Thursday, 28 July 2011

Nigel Crisp - Turning the World Upside Down

(This review will be published in "The Eagle 2011", the annual year book of St John's College Cambridge)

What happens if you turn the world upside down? Well, things are starting to look very different. And a different perspective is needed as the world is changing, and so are the demands placed on health services all over the world. Firstly, the world has become more interdependent. Disease travels faster - SARS for example, which had started in rural Asia, reached over 30 countries within just a few months and caused severe disruptions in the economy, travel and trade. Borders between rich and poor countries are blurring; health has gone global.

Secondly, patterns of disease are changing, partly due to demographics, and costs are rising. This is particularly a problem in the developed world. The 19th and 20th century, when our health systems were developed, were characterized by a fight against acute disease. But, the challenge of the 21st century is an epidemic of non-communicable chronic disease. Thus, a shift is needed – from focusing on treating disease to allowing people to lead lives which are as healthy as possible. While the developing world is still largely plagued by acute and communicable diseases, it has a pragmatic and more holistic view on health which could hold the key for the problems of the developed world.
Lord Crisp uses his wide-ranging experiences to provide an insight into these challenges for health care and ways to solve them. Having read philosophy at St John’s, he went on to become the only person so far to simultaneously hold the posts of Chief Executive of the NHS, the largest health organization in the world, and Permanent Secretary of the UK Department of Health. Lord Crisp left these posts in 2006 and is now an independent cross-bench member of the House of Lords. His particular area of interest is international development and global health. He authored the report “Scaling Up, Saving Lives” which set out practical ways to increase the training of health workers in developing countries. Among other projects, in 2007 Lord Crisp co-chaired an international task force on increasing education and training of health workers globally; and in 2009 he co-founded the Zambia UK Health Workforce Alliance to increase number of health workers trained in the country.

“Turning the World Upside Down” sets the stage by discussing the links between health, wealth and social change. Lord Crisp does so by first looking at the developing world and then contrasting and comparing its challenges with the developed world. He shows how health cannot be seen in isolation, but is rather a deeply contextual issue – a key insight that leaders should keep in mind when designing interventions and programmes. Lord Crisp goes on to examining the status quo of links between rich and poor countries, and concludes that there is an unfair trade occurring in both directions. Poor countries are exporting the scarce resource of health workers to rich countries and in exchange importing ideas and ideologies which might not fit their societal context. Health workers are critical to any health system and understaffing is a global problem. Better remuneration, living conditions and facilities as well as safer environments draw health workers from poorer countries to richer ones. Several countries have enacted policies of ethical recruitment, but Lord Crisp argues that the extent of the problem also warrants more fundamental questions. Understaffing means a smaller supply than demand. Yet what is meant by demand? Does it mean workers needed to achieve a medically desirable level of care, or the level of care which a society can afford? If the latter definition is employed, the landscape of over- and undersupply changes dramatically.

 Lord Crisp continues to turn the world upside down in the following chapter and looks at what rich countries can learn from low and middle-income countries. These lessons fall into three broad categories: different ideas, attitudes and approaches to health; specific innovations in policy or treatment; and working together. He argues that pragmatism, creativity and vision, often born out of the lack of resources, can complement Western thinking. For example, many developing countries address their shortages of health professionals by basing their health system on workers who are not as extensively trained. Instead, these community health and mid-level workers receive specific training which is determined by local need instead of oriented along professional lines. Lord Crisp goes on to look at the practical implications of the health challenges of the 21st century – what role do science and systems play? And who is really in charge: the professionals or the patients? In the final two chapters he summarizes the need for a paradigm shift to global health and what action is needed to confront the challenges of health in the 21st century. Lord Crisp argues that transition will inevitably occur due to the burden of cost, which will become unbearable. Amongst others, it will be necessary to move clinical and public health closer together in order to shift from a focus on curing disease to one on keeping people healthy. This will have to be linked to new business models and financial incentives, as well as a need to rethink training and deployment of staff according to tasks instead of professions.

Lord Crisp provides a fascinating insight into the links between health in the developed and the developing world. He challenges a one-size fits all approach and argues for the need of a systemic view. He also challenges ideological preconceptions to developmental work. Lord Crisp argues that it is about economic growth, not aid, and that as aid builds dependency, the true goal should be empowerment. His experiences of working both in the developed and developing world allow a first-hand insight and lead to a pragmatic look at issues. Lord Crisp argues convincingly that both sides can learn from each other – let us hope that they are listening.

Monday, 25 July 2011

Making Health Care Safer - Summary

I only summarized the main plenary sessions so far but the conference had so much more to offer - lots of interesting posters and several very interesting talks in the parallel sessions. A big well done to the organizers for assembling such an interesting program.

I think what I take away from the conference are a couple of main themes:

  • context-dependency - this was raised over and over again, one size fits all just don't work but more importantly what works in one place might not necessarily work in another. Is decentralization key to addressing this? But how can we then ensure quality and uniform standards?
  • emotion - Justin Waring mentioned this and I also came across it in my reseach. Health care services are dealing with people and people are not (always) rational. Surprise, optimism, fear or anger are all strong emotions which will influence how people react in certain situations. So far this has not been addressed at all.
  • complexity
  • knowledge
  • organisational hurdles
The amazing thing is that these are themes which also surfaced in my own work - thus I seem to be on the right track. Makes me a bit more optimistic (speaking of emotions) about my viva :)

Making Health Care Safer – More Plenary Talks

I really liked Denis Fischbacher-Smith’s talk. He talked about the report Organisation with a Memory which he worked on. This was based on the premise that organisations should learn from adverse effects in order to prevent future systems failures. 
He identified three main obstacles to learning 
  1. organisations driven by short term imperatives
  2. high management turnover and
  3. involvement of politicians.
He stressed the difference between passive (lessons are identified but not put in practice) and active learning (lessons become embedded in organisational culture and practices) but also pointed out the communication problems across disciplines and between medical and management functions. Other points he touched upon where the importance of culture and the problem that organisations tend to manage what they can measure. All in all his talk was fairly pessimistic (some might say realistic) about organisational learning. But perhaps this is just another example that we really need new ideas and approaches in health care which are compatible with the existing culture and hopefully can shift it towards being more receptive to learning in the long run.

The first talk on day two brought the focus back on patient safety. Teun Zuiderent-Jerak who looked argued that while safety is a system property, there are several ways a problem can be framed and approaches. He used medication safety as an example, where the classical approach is to control medication behaviour and report errors, while an alternative approach is to see errors and safety as synonyms. The first approach would seek to standardize dispensation while the second one focuses on fostering resilience. Such a shift from control to delegation would have impacts on multiple levels – and would raise very different questions when it comes to spreading and sustaining change than the first approach of standardization.

The last plenary talk was by Justin Waring who first summarized where he sees the field of patient safety. He felt that the scale of the problem, its sources and potential solutions have been well researched in the past years. But there are still gaps that future research will have to address. To do so, he identified three critical perspectives: knowledge (which seems to be sticky when it would need to be slippery and vice versa), cultures (how ideas are lives and breathed) and power and organization (resistance to change and unintended consequences). 
He went on to identify four concrete gaps: 
  1. Sources of safety
  2. Roles of professional practice networks
  3. Role of emotion and
  4. Spaces between care processes.

Slides for many of the plenary (and parallel sessions) can be found here: