Setting out the New Year for HaCIRIC and healthcare research

Posted: 7 January 2013 by James Barlow

Francis Spufford’s novel ‘Red Plenty’ follows a cast of characters – economists, computer programmers, biologists, writers, fixers and others – around the Soviet Union of the 1950s and 1960s. This was time of optimism, where the planned economy would become, in Spufford’s phrase, “its own self-victualling tablecloth.”

One of those characters was Vasily Nemchinov, architect of the scheme to reform the Soviet economy mathematically. ‘Cybernetic’ institutes were established, mathematical and linear programming models were developed for balancing supply and demand over the short and long-terms, for different economic sectors and on local, regional and national scales.

Of course, it proved an impossible task. Next year’s planning and purchasing decisions were being made on imperfect information at the same time as planners were still working on this year’s (massively complex) calculations. In 1964 it was predicted by some reformers that by 1980 the entire Soviet population would have had to work full-time on balancing supply and demand in the National Plan.

So what does this tell us about healthcare and the NHS? Like the Soviet economy, it is a complex system and a complex problem. And it is a system that is already fragmented and – arguably – fragmenting further. It is an environment in which we know little about cost or value, so we lack the knowledge to improve resource allocation or eliminate activities that don’t improve patient outcomes.

How does HaCIRIC fit into this? A theme running through HaCIRIC’s work from the outset has been the problem of planning and delivering health services, technology and infrastructure, where the lifecycles of each of these are mismatched.  We have researched many aspects of the relationships between these essential elements of a health system, providing answers to questions with immediate practice or policy impact.

But much of this work could be described as ‘micro solutions’ for ‘macro problems’. We are good at tackling the detailed issues such as, for example, the way the design of hospital wards impacts on the spread of infections or the impact of a technological innovation on patient flows. We now need to look at the big picture – the macro questions.

So what are these big questions and, in particular, what the researchable big questions? Asking the right questions is harder than doing the research to provide answers. It can be hard to formulate questions that inspire answers we can’t possibly predict, but I believe these relate to the planning and coordination problems I’ve just described.

Chris Evennett and I have been doing some work for NHS National Commissioning Board, building future scenarios of what NHS might look like in 2030. Two dimensions are seen as particularly important. The first is technology innovation – to what extent do we grasp the possibilities offered by all the technology innovations that will emerge over the next 20 years? The second concerns the public – how much power and responsibility will they take? One can imagine variations: powerful and motivated users and communities taking responsibility for their health, exercising choice and control over services. At the other end, there may be passive users, content to be guided by professional influence. Likewise, one can image radical use of all technology or more incremental use of it.

We have created four different futures, tested on a range of experts. Some involve the NHS as it is now and some are radically different in the way organisations deliver health, the way they are paid, the way they deliver, the way we are involved. All these futures are plausible.

Healthcare in the UK in 2030 will probably embrace elements of at least one of these scenarios. We need to be asking – today – what they mean for patients, for health gain, for health inequalities, for infrastructure, for the taxpayer. And we need to think about how these ‘big questions’ translate into researchable questions, with findings that meet both the needs of universities to publish in the best possible journals and the needs of policy makers and the healthcare sector to find practical answers.

So here are a few questions that spring to my mind – in no particular order.

- I would suggest that fixing the acute sector is actually relatively easy – a 10-20 per cent productivity gain would address much of the upcoming cost pressure. We know that we do too much work in the hospital sector and such productivity gains are possible, drawing on existing knowledge about what works best. The truly ‘wicked’ question, however, is how to fix the rest of the care system – the organisation of better social care, its relationship with health services, and how to pay for it all.

- How do we ensure that technology innovation does not simply allow us to do what we currently do, but just do it more efficiently? We need to make sure that innovation disrupts current practice – where it needs disrupting – and is not simply overlaid on an already inefficient system.

- Driving out waste and non-value-adding activities through ‘lean’ thinking is part of the productivity story, but how do we balance such highly engineered approaches against views of healthcare as a ‘complex adaptive system’, with many interdependencies across different scales which evolve in response to policy and other levers?

- Patients want to be at the centre of the care system – how do we customise health and social care delivery by systematising it but without standardising it? What does a ‘mass-customised’ model of care delivery look like and what are the business models that work?

- What does a ‘strategy for ageing’ look like rather than a ‘strategy for the elderly’? For a start, it would mean thinking about ageing right from the moment someone is born and ensuring that the right financial mechanisms are in place to provide support throughout their life.

- Finally, back to the issues that plagued the Soviet Union. How do we control, coordinate and manage health and social care systems under the different possible scenarios? The need for ‘whole system thinking’ is often trotted out like a mantra, but what this means and how to deliver it is as unclear as ever.

Professor James Barlow is Principal Investigator and Co-Director, HaCIRIC