Competition Time?

This weeks BMJ has an expoloration of competition as a means to drive up quality. It turns out that the jury is still out as to the effectiveness.

I think it is pretty clear that competition does improve quality, take motor racing for example. If there was no Ferrari, would there be a Maclaren? Would Red Bull be quicker if there was no one to race? The answer is clearly no, the fact that there is someone to compete against means that the quality indicator of lap time is improved incrementaly year on year.

Stepping back from quality the piste appears less certain. Right now a formula one car costs $7 MILLION. Now I appreciate that this costs is exactly what is required to stay ahead of the competition and that the purpose of the car is to go faster than the competition, but ask yourself this one question- if Vettel and Hamilton were racing in Ford Mondeos then would we find out who was the faster? The answer is of course yes, we would know who was quickest, the competition could be won or lost and the purpose of F1 acheived.

You see competition comes in many dimensions, with many aspects and so when we argue that competition improves things we are correct, when we argue that competion makes some things worse we are also correct.

So is competition good or bad?- the answer is yes.

it's networks all the way down.

Network theory offers some insights and structure to the study of systems, whether random or complex. In particular scale free networks "webs without spiders" are particularly resonant when it comes to looking at the NHS.
Scale free networks consist of nodes and links, some links are unidirectional, others work both ways. Some nodes are massively well connected, others have few links.
So far so good, but when it comes to scale free networks there are some caveats, the networks are robust, non random creations, which obey some key principles including a power law for distribution of connections.
Look at the NHS, consider clinicians as the nodes of the network and patients as the links between clinicians, either as direct "please see this patient" or as patient related data, letters results, conversations.
Now sit and visualise your surgery, hospital, patients.
Imagine the lines flowing linking you with the services and clinicians that you refer to and share information with.
Think about how those who work in hospital interact over patients, the discussions, referrals and the vast web of links that is created.
So far so good.

Network theory suggests that the disappearance or failure of some of those nodes will mean that the links reform with other nodes and in many cases the network re-forms, however in some cases removal of a key node results in a cascade of failures, with each subsequent node being subjected to a load with which it cannot cope.

We know this intuitively, as we see this when the clinicians in the local AED are overloaded, the Trust goes "red" and sure enough, the nearest AED takes the load and sometimes fails.

So far the NHS has just about coped with "nodal failures " in general they have been escalating pressures, either seasonal or semi predictable.
Unfortunately there is a property of scale free networks which is unpredictable and undesirable, in that they are vulnerable to attack.

Deliberate removal of a key connector node causes isolation and fragmentation of the network with subsequent failure or isolation of the remaining network.

The NHS has not been subjected to a deliberate attack in terms of removal of nodes, but it is conceivable that change in the infrastructure of hospitals, their service delivery models, and key staff may function as an attack. The consequences cannot be foreseen but could be catastrophic. In some way this could be seen as justifying the maintenance of status quo, no changes to services etc, but in reality Network Theory provides us with a warning, the changes can be done, should be evolutionary and must be thought through.

Innovation or Novelty?

It’s a tough call commissioning new care processes.

Do you do the same as usual but faster? Do you do something different, by definition an untried process .

Doing something different is often described as an innovation, but is it really innovative?

A new contract to an existing supplier which is accomplished by the supplier in its current form is not innovation. It may have the novelty of newness, the frissant of freshness, but if the provider is just doing more of what it is set up to do, then there is no innovation. More of the same does not change the landscape and although novelty is amusing for  a while it soon fades and the system returns to normal.

Setting out to commission something which requires existing suppliers to change their processes and structures or which can only be fulfilled by a new provider is innovation. Beware that all existing pressures in our complex adaptive health system will attempt to force the new initiative into a shape that neuters the effect of innovation, so the emergent commissioning decision will need to be protected and steered to produce an innovation solution.

Why bother about innovation?

It is the nature of healthcare systems to be complex and adaptive. These systems want to revert to their current attractor state and the only way to move the system is a significant disruption. If you’re not ready to break it- and we’re not quite there yet with healthcare, the next best thing, possibly the best thing, is to innovate.

Go ahead, give it a try, but not as a novelty item.

What's in a name?- it's a Quantum Thing

People often talk about primary care, secondary care, General Practice, community care. But really what does it all mean?

Sometimes General Practice, which is strictly speaking General Medical Practice is used interchangably with primary care and equally community care is also blurred in the boundaries. 

The reality is that Primary Care is probably better thought of as a space rather than an organisation. A space in which multiple services operate providing care appropriate to deliver within "Primary Care".

Lets face it-there are Hospital Nurses who spend their days delivering primary care, being the first port of call for a child with diabetes, or a stoma patient, or specific illness. These nurses are by default part of the primary care approach, albeit operating from a secondary care base.

Equally most General Practitioners spend considerable amounts of time delaing with complex patients who have been through the halls of secondary care institutions and now need to return to some kind of normality.

I suppose my point here is that sometimes naming the process or issue, tends to fix the observed packet of care in place. It's probably best thought of as a quantum event, until you name it it is potentially everywhere, but once named it becomes fixed in time and space as a primary or secondary event.

The trouble with quantum observation is that it also changes the observer. Until the box was opened on schroedingers cat the observer wasn't happy or sad- not knowing if the cat was alive or dead.

Once opened, defined as dead, the observer is also "fixed" in sadness, so we also change who seek to define what should be in primary care, what is and isn't possible in each domain of care.

Perhaps we should seek less to define what should be done where and concentrate on the infinite possibilities that a quantum view of healthcare might provide.

What's the game?

Do you ever ask yourself why you are doing what you are doing?

Do you ever think that there must be a better way of doing things?

Do you then decide that sometime in the future you'll need to think about it?

You do!- Fantastic, you are normal, i.e. average.

Most of us do question our decisions in clinical practice, it's right that we should. But how often does this reflection prompt you to do more than justification in a post hoc kind of way?

The next time you feel that there must be a better way of doing the task, handling the patient or dealing with a problem just stop. Take a mental snapshot of the scenario, and later that day instead of wasting 30 minutes watching the latest Scrubs episode just sit and think about what the problem really was, not just the immediate task, but how did that task come about what really was the underlying reason that events transpired in the way they did. Ask the why, until you reach answers outside of the need to demonstrate some CPD or reading of a particular research paper.

You will not always get answers to your questions, but at least you will really start to understand the problem.