My second paper: "Why are healthcare services fuzzy?"

My second paper just got published in AMJ, an open access journal. Below the abstract and the link to the journal. Very excited to see this finally happen.

Why are healthcare services fuzzy?

Abstract

Background
Healthcare organisations are an enigma to many people in- and outside the service. Organisational fuzziness is a common state, characterised by a lack of clarity, lack of awareness, lack of organisational knowledge, and the reliance on practice and custom instead of transparency.
Aims
The objective of this study was to obtain a better understanding of what causes this fuzziness and provide an actionable description of fuzzy organisations. Such a description is essential to managing and preventing organisational fuzziness.
Method 
We used a longitudinal case study in an integrated health- and social care organisation to obtain a thorough understanding of how the organisation functions. These in-depth insights allowed the identification of three generators of fuzziness.
Results
We found that the three main generators of organisational fuzziness are change, informal organisation and complexity. Organisational fuzziness is thus partly due to the inherent complexities of human systems. However, also continuous change and the inability of the system to adapt its formal structures resulted in structures deteriorating or no longer being appropriate.
Conclusion
Existing approaches to explain unclear or absent structures in healthcare organisations by describing these organisations as complex adaptive systems (CAS) are too simplistic. While aspects relating to people and their interactions are indeed complex, fuzziness of structural aspects are often the result of continuous change and insufficient organisational capacity to adapt to it.

http://www.amj.net.au/index.php?journal=AMJ&page=article&op=view&path[]=1857

Paper now open access

Just to let you know, my paper on the contributions of carers and staff in service design is now available as open access:

http://onlinelibrary.wiley.com/doi/10.1111/hex.12107/pdf

Thanks to the CLAHRC for making this happen :)

The final reckoning: how much should end of life care cost?

This is a repost from a blog article I was invited to write for the Gates Scholars Blog

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The big innovation in the 19th and 20th century was the acknowledgement that health is a systemic issue. If people do not seek medical advice for small problems due to economic reasons, these small problems can become big problems and cause further poverty. This realisation led, for example, to the establishment of the NHS in 1948.

Nowadays we are facing the sustainability challenge: will we be able to keep affording the systems set up as a result? One problem is the ageing populations of many developed nations – it is estimated that in the US on average between 25% and 56% of healthcare spending occurs in the final 12 months of life. A second problem is, ironically, continuing progress in the medical sciences which allows us to treat more diseases and prolong lives. But the associated costs are spiralling out of control. Also, scientific progress creates illusions regarding what it possible and feasible. Combined with the lack of a culture that discusses death as a part of life many doctors find themselves under pressure to do whatever is possible, regardless of quality of life – or costs.

The latter point – placing a monetary value on life – might sit very uncomfortably with some readers. However, when we look at health as a systemic issue the question of money is bound to arise in one form or another. Every dollar or pound can only be spent once. A cancer treatment that prolongs life for a couple of months (at often a pretty terrible quality of life) can cost £40,000, which could also pay the annual salary of a palliative nurse. In the United Kingdom the discussion is open. The National Institute for Clinical Excellence (NICE) makes decisions about which treatments are covered by the National Health Service (NHS) based on the calculation of quality-adjusted life years. But systems which do not have this transparency, such as the fragmented German system of different public and private payers and various associations representing healthcare providers, also have to make decisions regarding which treatments are considered effective and value for money in order to contain costs and kept health insurance affordable.

Another issue which affects the sustainability of our healthcare systems is the human side. Organisational structures are filled by people, both staff and patients. As the people in them change structures have to adapt and vice versa. A system in which structures and people are out of synch will not work in the long run. A popular contemporary line of argument is that because healthcare is fundamentally an interaction between people, it is complex and non deterministic. Other arguments for this complexity model are based on the enormous variety of issues faced by healthcare providers, although this is strictly speaking not a characteristic of complexity but rather indicates a complicated problem. Semantics aside, the focus on complexity are as one-sided as the earlier models of rational technocratic top-down blueprints which the complexity model seeks to supersede. It is not a question of one or the other, but rather ‘horses for courses’.

A climbing rose is a good simile for how organisational success depends on interactions between staff and structures. A climbing rose (staff) requires a scaffold (structures) to reach its full potential. The shape of the scaffold will have a key influence on the shape of the final rose bush, but it is not possible to completely determine the shape of the bush from the shape of the scaffold and sometimes it becomes necessary to change the shape of the scaffold. On the other hand, the best scaffold in the world is worthless without the right, good, healthy plants.

I think the challenges we face are so big that a more open discussion regarding end of life care will be inevitable. On the other hand, a new direction in the policy debate that seeks to reconcile technocratic approaches to structures with insights about the complexity of human interaction should help to ensure a system that can adapt to changing environments and new challenges.

Paper: What can carers contribute to service design?

My paper is finally out - I submitted it last year in June and it was published as early view this July. I carried out a study with three groups of stakeholders and assessed to which degree they agree on priorities for service design.

Of course I am biased, but I think this is really important and interesting research as it is the first time that we can quantify the contribution of different stakeholder groups which historically had different amount of influence on the service design process. For example, experts and policy makers usually have a lot of influence, carers (and patients, but unfortunatly I was not able to include them) usually have much less. One of the reason why they have so much less influence is because those with the power over the process doubt how useful their contribution can be (I guess you can call this a certain degree of professional arrogance) and this is exactly where my work chimes in. I can actually show that they can contribute new idea which established stakeholders recognize as valuable.

The article is available as open access:
http://onlinelibrary.wiley.com/doi/10.1111/hex.12107/abstract

Exploring the boundary of a specialist service for adults with intellectual disabilities using a Delphi study: a quantification of stakeholder participation

Eva-Maria Hempe, Cecily Morrison, Anthony Holland

 

Background

There are arguments that a specialist service for adults with intellectual disabilities is needed to address the health inequalities that this group experiences. The boundary of such a specialist service however is unclear, and definition is difficult, given the varying experiences of the multiple stakeholder groups.

Objectives

The study reported here quantitatively investigates divergence in stakeholders’ views of what constitutes a good specialist service for people with intellectual disabilities. It is the first step of a larger project that aims to investigate the purpose, function and design of such a specialist service. The results are intended to support policy and service development.

Study design

A Delphi study was carried out to elicit the requirements of this new specialist service from stakeholder groups. It consisted of three panels (carers, frontline health professionals, researchers and policymakers) and had three rounds. The quantification of stakeholder participation covers the number of unique ideas per panel, the value of these ideas as determined by the other panels and the level of agreement within and between panels.

Findings

There is some overlap of ideas about of what should constitute this specialist service, but both carers and frontline health professionals contributed unique ideas. Many of these were valued by the researchers and policymakers. Interestingly, carers generated more ideas regarding how to deliver services than what services to deliver. Regarding whether ideas are considered appropriate, the variation both within and between groups is small. On the other hand, the feasibility of solutions is much more contested, with large variations among carers.

Conclusions

This study provides a quantified representation of the diversity of ideas among stakeholder groups regarding where the boundary of a specialist service for adults with learning disabilities should sit. The results can be used as a starting point for the design process. The study also offers one way to measure the impact of participation for those interested in participation as a mechanism for service improvement.

US Health Care Spending

Two interesting links, explaining why US Health Care costs are so high (also in comparison to other developed countries). In a nutshell: lack of transparency about costs + inherent power imbalances = a flawed market.

Time Magazine - "Bitter Pill: Why Why Medical Bills Are Killing Us"
http://content.time.com/time/magazine/article/0,9171,2136864,00.html

8-minute video. "Why Are American Health Care Costs So High?"
http://www.youtube.com/watch?v=qSjGouBmo0M

Applicability of Engineering Design Processes in the Design of Integrated Intellectual Disabilities Services in England

I have been quiet for an aweful long time - and a lot has happened since. Most importantly: my thesis is all done, approved and on the shelves of the Cambridge libary, so I am now a doctor (yeah). I since moved back to Germany and for the last 14 month I have been working as a consultant in Munich, with a focus on health care projects.

In case you are interested, I pasted the abstract of my thesis below. If you want to read the full thing, drop me a message (ideally with a bit of beackground on what you do and why you are interested in my work) and I can send you the pdf.

Applicability of Engineering Design Processes in the Design of Integrated Intellectual Disabilities Services in England

This dissertation investigates the applicability of engineering design processes for the design of integrated intellectual disabilities (ID) services in England. It aspires to contribute to the development of an engineering-design-style (ED) design process for a particular integrated health and social care organisation. Healthcare services in the developed world are faced with challenges arising from a growing burden of chronic disease and aging populations. In order to address these challenges, a more holistic understanding of health that also considers social factors is needed. A local integrated care service for people with intellectual disabilities constitutes an interesting case study as these intellectual disabilities services have several decades of experience in integrating health- and social care.

This study contributes to knowledge by elicitating the need to combine the engineering tradition of design as problem-solving with the tradition of design as enquiry. The applicability of engineering design processes in an indisputably complex domain, such as integrated ID services, also helps clarify of the concept of complexity within engineering design. Methodological contributions are made by developing and applying a research framework for exploratory design research and by demonstrating the utility of engineering design tools outside engineering. Furthermore, this study also provides important insights for the healthcare management literature by suggesting an approach to distinguishing complicateness from complexity, demonstrating the value of contributions of currently marginalised stakeholders and showing the applicability of a mathematical technique for pre-structuring service user involvement.

The research is guided by a framework developed specifically for exploratory design research into the care service domain. An initial exploratory study investigates design-related issues faced by the local service and to which degree engineering design is applicable. The predominantly qualitative data is analysed in diagrammatic form. It emerges that the formal, structural aspects of the organisation are complicated and suited to an engineering design approach. However, complex informal aspects, such as customs or personal relationships, surround the formal structure and are beyond the current scope of ED design processes but can be addressed by approaches in the design as enquiry tradition. Four issues are identified which will require amendments to the ED design process: organisational settings, knowledge management, the lack of a clear role, and neglected stakeholders.

The exploratory study is followed up by a detailed study which uses a Delphi approach to investigate whether the confusion about the role of specialist services is a general problem in the ID field. It further characterises key stakeholder groups in ID services in terms of their expertise and level of agreement or disagreement. The findings outline requirements for new design approaches that bridge the traditions of design as enquiry and design as problem-solving.

Very interesting article about patient demand for life-extending interventions ...

... and how those who know what these interventions really mean, physicians, have a completely different opinion:

http://thesocietypages.org/socimages/2013/06/24/how-do-physicians-and-non-physicians-want-to-die/

Anatomy of an unsafe abortion (repost)

Another of these stories which brings home the point that all those decisions we are making about health systems are ultimately about people's lives:

http://drjengunter.wordpress.com/2012/02/11/anatomy-of-an-unsafe-abortion/

Health Systems Strengthening - what others thought

Jocalyn Clark blogged about my workshop on PLoS Medicine:
http://blogs.plos.org/speakingofmedicine/2011/11/25/what-is-health-systems-strengthening/

I also received a summary of the feedback forms and people really enjoyed the day, particularly the two part format with an overview of the theory in the morning and experiences from the field in the afternoon. And almost everyone said what they learned will affect their practice :) Really chuffed and happy that people found the workshop useful. Thanks again to my speakers and Anne Radl for her support - I wouldn't have been able to do this without you :)

Doctors and Critical Care - or: Quality, not Quantity

Interesting piece on the procedures (and more important lack thereof) doctors chose for themselves shall they become critically ill - and the (complex web of) drivers that lead to very different decisions for their patients:
http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/

Health Systems Strengthening

As some of you might know, I organised and led a workshop on Health Systems Strengthening this weekend. I got interested in how the systemic view, which I took on the UK health system in my PhD, applies to the developing world following a Gates Distinguished Lecture last year. The more I read about it, including Nigel Crisps book (a review here), the more intrigued I got. By chance I met Anne Radl from the Cambridge Humanitarian Centre and she encouraged me to share my knowledge.

I opted for a 2 part design - in the morning I led a 2h session, supported by Jocalyn Clark, a PloS Medicine editor from Toronto who had been in charge of a recent series of HSS articles. In the 2h I tried to cover the basics - what is health systems strengthening, why do we need it and how can we do it. We had a great group of participants, who shared their experiences of working in places like Ethiopia, Bangladesh or the Gulf region - this really enriched the session. Over lunch there was some time for more informal exchange and networking and I was really impressed by the diverse and interesting backgrounds.

In the afternoon we had three speakers who shared their field experience and brought the concepts which we had we covered in the morning to life. First, Egbert Sondorp joined us via videolink from Amsterdam and shared his experiences of trying to rebuild the Afghan health system after the end of the rule of the Taliban. He stressed the importance of small steps and a long-term strategy. In Afghanistan the strategy was trying to ensure the delivery of a basic set of services as a starting point, but it is clear that other building blocks, such as stewardship and sustainable financing, will have to follow. Next was Geoff Walsham of the Cambridge Judge Business School, an expert in information and communication systems and technologies. He shared insight obtained while carrying out work in India and stressed that information technology can only be one part of the story. Our final speaker was Bruce Mackay from HLSP, a health sector consultancy. His field experiences were Bangladesh and Mozambique. He also stressed the importance of the private sector, particularly for the poor in developing countries. The WHO reports that in Bangladesh about 75% of health service contacts are with non-public providers, yet most health system plans hardly mention these providers at all.

Each of the presentations had been followed by a short Q&A session, so that after a short coffee break there was a chance to have a more general discussion between the two speakers who were present in person and the audience. All in all, I think it was a very successful day - and from what I have seen of the feedback forms the participants shared this view. Thanks to Anne and my speakers for making this possible.

If you're interested in my handout, you can find it here.

I also got an email from the World Bank, suggesting some further references:
Roberts et al, "Getting Health Reform Right" published by OUP (a text book the World Bank uses for teaching about health systems strengthening and sustainable financing)
and even more at this link.

Figure of the day (2)

In 2008 the 5% of the population with the highest health care expenses accounted for 47.5% of total health care spending.

On the other hand, the 50% of the population with the lowest expenses only accounted for 3.1% of total health care spending.

Source: Kaiser Family Foundation
http://facts.kff.org/chart.aspx?ch=1344

Preventing NCD for US $1.20 per person per year

The WHO just published a report investigating low-cost interventions to prevent non communicable diseases and/or lessen the economic impact of NCDs. I find it interesting and encouraging that the recommendation span both individual intervention such as screening but also large-scale population-based interventions (e.g. action against tobacco use or campaigns for better nutrition).

Expert Comment - Part 2

On September 16 I blogged about an expert comment by Dr Sudeep Chand of Chatham House about the UN meeting on non-communicable diseases. In a follow-up he assesses the outcomes of the meeting.

Unfortunately, it seems a chance was missed to address the global challenge of health in a global, coordinated way: "There is little in the declaration that is specific on international cooperation or coordination. [...] Health system development, the regulation of industry, and key interventions across sectors such as education, environment, agriculture, and transport remain areas for intervention at the national level."

Competition in health care

Interesting article in the Guardian about what competition means in health care:

"Competition is the supreme example of waste in health services. Private health and health insurance systems generate enormous transaction costs."

http://www.guardian.co.uk/commentisfree/2011/oct/09/nhs-nightmare-choice-competition