02 AProf Julian Rait - miiaa.com.au Julian Rait.pdf– Open East Africa to trade and settlement – Destroy the slave trade – Serve as an arm of imperial strategy to ... NHS told

MIIAA Annual Forum 2013 12 September 2013

Session: Advice to the Government 1

Policy pathologies: seeking better strategies for health care.

Julian L. Rait

Hannibal 218 BC

Hannibal needed to cross the Pyrenees, and many significant rivers to invade Rome.

In the Spring of 218 BC, Hannibal crossed the Pyrenees and reached the River Rhone before the Romans could take any measures to bar his advance.

Arriving at the Rhone in September, Hannibal’s army numbered 38,000 infantry, 8,000 cavalry, and 37 war elephants, most of which could not survive the harsh conditions.

Second Punic War



Hannibal’s invasion:

The ‘Lunatic Express’:

1895‐1901: 1000km railway from Mombassa, Kenya to Lake Victoria.



The Uganda Railway:

• George Whitehouse Chief Engineer

• Estimated cost 3M, actual cost 5.5M ($700M)

• 2498 workers died:– Most from sleeping sickness, malaria and dysentery

– Kedong massacre (> 500 killed by the Maasai)

– The Tsavo incident (135 taken by two lions)

• Numerous trestle bridges, enormous chasms

Great rift Valley:



Kikuyu escarpment incline:

Lord Salisbury:• The line would:

– Stimulate commerce

– Open East Africa to trade and settlement

– Destroy the slave trade

– Serve as an arm of imperial strategy to control Egypt and the upper Nile.



Tororo station, Uganda :

Three factors that distort political decision making:

• Inappropriate self‐interest

• Distorting ideologies

• Misleading memories

• Cognitive biases



Planning fallacy:• first proposed in a 1979 paper by Daniel Kahneman and

Amos Tversky*

• a cognitive bias whereby people tend to underestimate the costs, completion times and risks of planned actions, while overestimating the benefits of those same measures.

• such error is caused by a cognitive bias toward taking an “inside view,” where focus is on the constituents of the planned action, instead of an “outside view” of the actual outcomes of similar ventures that have already been completed or obviously failed!

* Kahneman, D. and Tversky, A., 1979, “Intuitive Prediction: Biases and Corrective Procedures.” In S. Makridakis and S. C. Wheelwright, Eds., Studies in the Management Sciences: Forecasting, 12 (Amsterdam: North Holland).

Reference class forecasting:

• Kahneman and Tversky concluded that disregard of distributional information, that is, risk, is perhaps the major source of error in forecasting

• RCF is a method of predicting the future, through looking at similar past situations and their outcomes.

• using distributional information from previous ventures similar to the one being forecast is the “outside view”

• in his 2011 book "Thinking, Fast and Slow," Kahnemancounsel to use reference class forecasting where possible, and add that "the single most important piece of advice regarding how to increase accuracy in forecasting”.



NHS told to abandon delayed IT project. The Guardian:“£12.7bn computer scheme to create patient record system is to be scrapped after years of delays”.

£12bn NHS computer system is scrapped... and it's all YOUR money that Labour poured down the drain! The Daily Mail:“Sum would pay 60,000 nurses' salaries for a decade”“Scheme can be replaced with cheaper regional alternatives”“Decision comes after report said IT system was not fit for the purposes of the NHS”.

Six reasons why the NHS National Programme for IT failed Computer Weekly

Alistair Maughan, partner, Morrison & Foerster (UK) LLP

• 1. Motives: "Top-down" politically inspired / motivated projects are much more likely to fail than "bottom-up" projects.

• 2. Buy-in: Few projects succeed over the outright opposition of the proposed users.

• 3. More haste, less speed: Rushing to award contracts without due diligence and a clear statement of the scope of works subsequently becomes a liability for the project.

• 4. Poor contracting process: more moderate, deliverable contracts are preferable to onerous ones with many legal risks.

• 5. Multisourcing: anything other than a "one customer, one service provider" structure is very difficult to operate.

• 6. Accountability: Avoid the “Mastermind factor”, i.e. the tendency amongst those involved in a project which isn't going well to dig in and adopt the "I've started so I'll finish" approach,



“e principles” of good policy:

• engagement

– communicates respect for stakeholders & their ideas

– encourages refutation & sharpens decision making

• explanation

– increases confidence that policy makers have considered options and implementation issues

• expectation clarity

– once policy agreed, there is a clear understanding of the scheme of implementation and what is expected.



What is fair process in health policy?

• when individuals feel recognised for their intellectual worth they are willing to:

– share knowledge

– feel inspired

– suggest ideas and share knowledge

– feel emotionally tied to the strategy

– engage in voluntary co‐operation

Why does fair process in matter?

• if people’s worth is not recognised:

– they will feel angry

– not invest their energy in participating

– drag their feet and apply counter measures

• commitment, trust and voluntary co‐operation = intangible capital of health policy.

• committed engaged practitioners can ignore self interest in the pursuit of policies that enhance patient care and safety.



Problems with healthcare:

• the leadership

• the cost drivers

• a system that is fragmented and disorganised



Problems with the leadership:

• Baby boomers!

• Focus on the medical needs of each patient.

• Adopts high personal standards to achieve quality.

• Worries little about costs.

Problems with cost drivers:

• many new drugs

• new tests

• new devices

• new ways of using them

• often incremental cost : benefit advantages



Problems with ‘the system’:

• accidents and errors are usually by‐products of a system’s poor design and normal function

• patients often receive inconsistent and contradictory messages from providers

• frequently chaotic co‐ordination of care between hospitals/units/specialists/GP

• patient distress and errors are frequent

Advice/solutions required:

• a new style of leadership is required

• we need to re‐organise systems:

– hospitals

– medical centres

– Doctor’s practices

– the National registration scheme ?

• we need to focus on performance.



Why performance matters:

• clinicians are altruistic

• clinicians are hard workers

• …..but what matters is results:

– how do patients fare?

– do patients survive/recover from their illness?

– are the emotional needs of patients being met?

What is value in healthcare?

• achieving good outcomes as efficiently as possible

• making meaningful comparisons between providers

• creating a safety culture that continually re‐engineers the tools, tasks and operating environment of providers



Organising for performance:

• superior co‐ordination of care around specific patient conditions

• more harmonious relationships between doctors, administrators and regulators

• information sharing / e‐health strategies

• reward providers for quality and safety as well as quantity of services

• discouraging unhelpful system design/behaviours

• encourage sound teamwork



What could these threepeople have in common?

Nice guys finish first!D. Goleman Working with emotional intelligence 1999, p 189.

- the best US Navy commands were run by “nice guys”:Superior leaders:

positive & outgoing

emotionally expressive

more appreciative

warmer, more sociable

Mediocre leaders:

legalistic & negative

authoritarian

disapproving

cold and aloof

‐ i.e. an authoritarian emotional style didn’t work – even in the military !



Competencies and Patterns of Behaviour:

TECHNICAL EXPERTISE

Recognising conditionsamenable to

surgery Maintaining dexterity

& technical skills

Defining scope of practice

COMMUNICATIONGathering

& understanding information

Planning ahead

Communicating

effectively

JUDGEMENT & DECISION-MAKING

Considering options

Selecting &communicating options

Implementing & reviewingdecisions

COLLABORATION & TEAMWORK

Documenting & exchanging information

Establishing a shared understanding

Playing an active role in clinical teams

SCHOLARSHIP & TEACHING

Showing commitment to lifelong learning

Teaching, supervision & assessment

Striving for surgicalexcellence

MANAGEMENT & LEADERSHIP

Setting & maintaining

standards

Leading that inspires others

Supporting others

HEALTH ADVOCACYCaring with compassion & respect for patient rights

Meeting patient, carer & family needs

Responding to cultural & community needs

PROFESSIONALISMHaving awareness, &

insight

Observing ethics & probity

Maintaining health & well-being

MEDICAL EXPERTISE

Demonstrating medical skills & expertise

Monitoring & evaluating care

Managing safety &

risk

Framework:

Behavioural Markers: Example 1

Competence: Management & Leadership

Pattern of behaviour: Supporting others

Behavioural markers:

Good: provides constructive criticism to team members

Poor: puts down junior staff or other hospital workers who don’t know issue



Behavioural Markers: Example 2

Competence: Communication

Pattern of behaviour: Communicating effectively

Behavioural markers:

Good: demonstrates empathy and compassion when breaking bad news

Poor: is discourteous to staff and/or patients

How to facilitate change:

• articulate rationale for change via the 3 “E’s”

• convey understanding of altruistic values that can resist change

• appeal to the need to “do the right thing”

• be direct about measures needed to succeed

• define strategy around patient’s needs

• explain that performance measurement is a tool leading to satisfied patients



Building effective teams:

• heroic healers vs team players

• commitment to reduce errors and waste

• physician autonomy is not always synonymous with quality

• build competence AND performance

Conclusion:

“If you don’t like change then you are going to like irrelevance even less”

‐ Eric Shinseki

Documents

02 AProf Julian Rait - miiaa.com.au Julian Rait.pdf– Open East Africa to trade and settlement – Destroy the slave trade – Serve as an arm of imperial strategy to ... NHS told