Monthly Archives: October 2014

No skin in the game

NHS England and other English health organisations have produced a five year ‘forward view’ [here]. The refreshingly short and precise document establishes a new approach to the

English: British National Insurance stamp.

“Skin in the Game” British National Insurance stamp. (Photo credit: Wikipedia)

English health service, something political reform has failed to achieve since perhaps the beginning in 1948, namely the realisation that top-down reform really doesn’t work. This is a bit surprising given how oftenNHS folk have travelled, particularly to the US, and other places, where the notion of a top-down approach is anathema. All these visits, reports and breathless commentary on lessons learned has really, it now seems, to have been for nought.

We also now have some explanation why the attempts to adapt lessons and approaches from other countries has failed — the heavy overarching deadweight of central control has stifled innovation. Given the additional volumes of studies of the NHS, think tank policy papers, round-table discussions and consultation, researchers, in the UK at least, seem to have been trapped within their own paradigm and failed to see the internal fault lines that pointed to this blind-spot.

Anyway, that said, we now see that Simon Stevens, head of NHS England, has not wasted his time in the US, as not only does the report quote Lincoln’s Gettysburg Address, but tacitly acknowledges that the US (and other countries, but not in the UK) favour decentralised experimentalisation with payer and service delivery flexibility.

Lawton Burns in his important book on healthcare innovation [The Business of Healthcare Innovation, 2005, @Amazon] notes that one reason the US dominates the health technology innovation space is precisely because of the flexibility to experiment, try new things in healthcare service development.

This report, together with the other surprising ‘discovery’ that the funding of healthcare and social care are also part of the problem, after decades of dysfunction, shows that there is now a window within which major changes can be achieved to remove perverse policy incentives, drop barriers to change and get rid of the zombie administriative rules that kill off good ideas.

So where might this all go? Yes there are some very good examples already in place and one hopes more to come. But putting the cat amongst the pigeons may have other rather interesting consequences.

If we see increased power shifting to cities, will we see Swedish-style county-council run healthcare? Such an approach has the merits of democratic accountability, and challengingly, puts funding options within local taxation strategies. Given years ago I advocated with the other big city in the UK a local-council run NHS which caused no end of criticism, I would be surprised if this doesn’t come back on the agenda.

The rising priority of prevention also highlights one weakness of the NHS.  Dating back to 1819, employers had legal duties imposed on them for the health and safety of their workers, a responsibility which the creation of the NHS in effect removed at least in respect of health.  The report notes that employers pay National Insurance as though that were sufficient motivation. What the report fails to add is that NI employer contributions are not experience-rated in terms of the health of the workers themselves. The NHS has flirted with workplace healthcare in the past, but the concept of “primary care in the workplace” has failed. Stevens will know (and others should) how many countries separate workplace health from general health. Some places call it “workers compensation” and it involves risk-based employer premiums, adjusted for actual workplace health, injuries and accidents. Countries with such systems include the USA, Canada, Australia, Japan, and others.  What taxation does is risk-pool, but that means it is hard to link individual behaviour to risk.

American Accountable Care Organisations and other similar approaches in other countries of long-standing, only work when organisations are free to associate in ways that make financial and healthcare sense. US ACOs are forming partly in response to the financial signals in healthcare legislation there, but these signals, coupled with systems of rigourous inspection (and a failure regime), focuses minds. Vertical or horizontal integration in the NHS is needed, and would serve to remove at a stroke the barriers that bedevil patients. I’ve seen how building primary care onto the ‘front’ of the hospital enabled speedy patient access to specialists (they simply came down from the wards) and avoided inappropriate admissions. Buying a nursing home added a step-down into the coummenity releasing pressure on in-patient beds. GP integration toward secondary care pulls diagnostic imaging and laboratory technologies toward the patient, and removes hospital monopoly control of what is the major cause of delayed diagnosis.

What Cognology says

The end result is in the UK, consumers, patients, employers, have no real skin in the game, which in these days of behavioural economics means that it is additionally challenging in the NHS to activate the essential incentives to align patients around their care, or employers around healthy workplaces other than through moral suasion.

We may need to revisit how to use the NI contributions as co-payments to create the necessary financial incentives that serve to quantify risk to both patients and employers.

Of course, one should be grateful for small miracles, which is why this report is welcomed.

P.S. I suspect this can be done without new money.





Thinking like a virus

Ebola  is really quite a horrible little bit of DNA. Its route to humans is via the fruit bat and between humans through body fluids. So much for the public health model.

The virus is taking advantage of humans with poor lifestyle, illiteracy, folk medicine, weak healthcare systems and lack of awareness. If it is true a 2 year old is person zero, how did that come to be? The public health model wants to find the person, but what we really need to understand are the conditions for zero to become infected. That means mapping the ecology within which the virus operates.

Outbreaks, epidemics, pandemics should be understood as an ecology combining information, biological and social strands which track the infection production process.

We’re in the middle in the countries at risk of the Ebola outbreak, and at the beginning everywhere else (even a case or two does not a crisis make). Nigeria may now be coming out the other end. The key is to build into our response an anticipatory and first response capacity throughout.

The real test of how these three countries will emerge from the Ebola crisis depends on what they are now putting in place for the Post-infection phase. Typically, events such as these emerge, get dealt with quite quickly (as in the case of other Ebola outbreaks), but building in anticipatory and response capacity is not a resulting priority. Better organised healthcare systems will handle situations like this better.

The three at-risk countries have weak governance, score low on Transparency International’s corruption scale, and low on WHO’s Human Development Scale, all characteristics of failing states.  It is not inconceivable that these countries could collapse; the historical record shows that other civilisations have collapsed from disease.

Since weak healthcare systems are contributive to the problem, improving access to care and reducing the cash component would require improving the economic performance of the country itself. That comes with greater trust in government and confidence in the future. So there are tools and techniques that can be deployed to help.

Consideration should also be given to more integrated, ecological models of how viruses and infections work, what some call “conservation medicine”. Many of the problems of pandemics arise from unnecessarily narrow specialised focus and adoption of particular disease transmission paradigms that marginalise knowledge in related areas.

Without being too draconian in this respect, some rethink is appropriate of the prevailing public health driven model, characterised by high degrees of alarmist rhetoric and hyperactivity, to achieve a measure of integration particularly around pinch points in the flow of information for effective decision-making.  A ‘systems model’ would start with the likely inaccuracy of diagnostic tools (which both over- and under-report). There is also a general weakness in animal and human disease surveillance and corresponding weaknesses in subsequent information management.  What we know from thinking like a virus is that humans can be just as dangerous as the bats that originate the virus, but we use different logic when dealing with humans as with the bats.

Compounding he problem with Ebola and other zoonoses of that type is that our ability to collect information and act is slower than the pace of spread.

Obviously screening people at airports makes sense within the public health model, but makes little sense from the point of view of the virus itself. Regretfully, quarantining whole countries may need to contemplated. Screening at airports does little when the origin is people arising from stricken regions. What do they say about closing the barn doors after the cows have left?

But we must learn how to think more like the virus, so we react more quickly, and ensure the virus will not have the opportunity to spread.  After all, that is what the virus wants to do.

About the three most at-risk countries

The countries that are the core to the current Ebola crisis are Guinea, Sierra Leone and Liberia. Using WHO Human Development data (from here), we learn that these three countries are classified as low development countries: Liberia is ranked 175, Guinea 179 and Sierra Leone 183; there are 187 countries on the list. They spend less than 3.0% of GDP on education (closer to 5% is associated with higher education attainment levels) and with literacy levels below 50%. Expenditure on health as a percentage of GDP shows they are essentially cash-based systems, which given the relative poor human development means access to healthcare will be income rather than need linked — they have health systems for those who can afford it. Transparency International ranks these countries toward the bottom (more rather than less corrupt) with scores below 30 (see here). All very worrisome but indicative of national priorities at odds with the needs of the country. Many are more prone to conflict than care.

What Cognology says

Dear Virus

There are some excellent countries for you to consider: poor literacy, poverty, unhealthy population with low life expectancies (under 50 years or so), internal strife and conflict, corruption.

Guinea: spends 6% of GDP on health, of which 67.4% is cash

Sierra Leone: spends 18.8% on health, of which 74.9% is cash

Liberia: spends 19.5% on health of which 17.7% is cash (best of the three in that respect)

Want to know more?

Laurie Garrett’s The Coming Plague, 1994. See here at Garrett’s website. And they say prophecy is dead.

Who thinks these things up?

Right now, there is the proposed NHS Reinstatement Bill, a lobby document which lays out a way to reverse many NHS reforms.

This lobby document, which is what is it, is familiar reading, and brings back various structures that in the past have failed. You can find information on it at this link.

What is interesting about this approach is the aura of respectability that it wraps itself in, by proposing the changes as a legislative draft, almost as though it were ready to go to committee.  This is, obviously, an influencing tactic designed to force debate onto the topics covered in the proposed bill, and disarm critics who don’t agree that the points in the lobby document are the right starting points. In that respect, the lobby document polarises positions, particularly against current policy direction.

The whole lobby document’s comments and notes identifies proposed changes to a variety of existing legilsation. What we don’t find, though is any evidence that the authors were in any way persuasive  or influential during public consultations at the time. We call that ‘sour grapes’.

Approaches such as this suffer from the following:

  1.  a belief that the fundamental values underpinning the health service can only be protected in a particular way and these are the ways things used to be.
  2. a belief that the changes that have been made have violated these values; moreover, that the solutions have made things ‘worse’ as they see it.
  3. selective use of academic research to support the positions that one wishes to avoid changing.

New PublicManagement as reform of government itself must sit uncomfortably with this regressive thinking.

For the authors, they would no doubt point to market failure logic to prove that the NHS should not be ‘marketised’ as they put it, forgetting that a greater fear is ‘government failure’, for which there is ample evidence, not just with the NHS but a whole host of other public initiatives and legislation that has wasted public money.

Healthcare systems are complex and by trying to overlay what they see as simple solutions to the problems they claim arise from the reform agenda of past years, they misrepresent what the actual problems are. As messy, or complex/wicked, challenges, the authors believe that by taking away that messiness, they’ll also take away the problems. But they know just as well as anyone, that their solutions will only create, perhaps even recreate, the very problems that led to reform in the first place, except now they will be today’s problems, not yesterday’s.

One might argue that the authors are committing a type 3 error, of unintentionally solving the wrong problem well, but that would assume that they have are not clear in their minds what they are proposing. Therefore, it appears they are do know better and are committing a type 4 error, of intentially solving the wrong problem well because that fits with their policy preferences, or prejudices.

That’s why this is a lobby document, designed to intensionally convince, (is mislead too strong?) others of their definition of what the NHS problem is.

What Cognology says

The lobby document and the authors are caught by a fundamental policy trap: of solving the wrong problem.

Want to know more?

Government failure in the UK is examined in Anthony King and Ivor Crewe, The Blunders of Our Governments, 2013 (@Amazon) and in Richard Bacon and Christopher Hope, Conundrum: Why every government gets things wrong and what we can do about it, 2013. (@Amazon)

New Public Management was originally conceptualised by Christopher Hood, in 1991, A Public Management for All Seasons. Public Administration, 69 (Spring), 3-19. Some (Dunlevey et al) argue that New Public Management is dead and that governance in the digital era requires greater, not less, government. That may be the case for some, but if you actually look at the tools that are available to government in a digital world, you’d find that there is little reason for government to own or run very much. See Christopher Hood and Helen Margetts, The Tools of Government in the Digital Age, 2007. (@Amazon)

I have found Leslie David Simon’s book, (Woodrow Willson Centre, 2000) an early, and compelling way of laying out the digital agenda in a policy context really well. (@Amazon)

I would also recommend Vito Tanzi, Government versus Markets: the changing economic role of the state, 2011. (@Amazon)