Watch Out for the Overshoot!

In 1972 a group called the Club of Rome published a report entitled “The Limits to Growth” that examined the possible global impact of our current obsession with competition and growth. They used Jay W Forrester’s computer models described in World Dynamics – models of global stocks and flows of natural resources, capital and people – and explored the range future possibilities based on the best understanding of current reality. Their conclusions were not encouraging – the most likely outcome they predicted if current behaviours continued would be global natural, economic and population collapse before 2100!

Their conclusions were discounted by governments, corporations and individuals as doom-preaching but it struck a chord with many and helped to fuel the growth of the global environmental movement.

Thirty years later the original work has been revised, updated and the original predictions compared with actual changes.

The original forecast proved to be prophetic – and revealed an alarming conclusion – that we may already be past the point of no return. It is now forty years since the original work and we have enjoyed the predicted boom years of the 1980’s and ignored the warnings so many options for avoiding a future global collapse have already been squandered. Even if we corrected all the errors of commission and errors of omission today it may be too late because we over-estimate our ability to solve problems and underestimate the effect of “overshoot”.

Suppose you are driving at night in freezing fog and you want to get to your destination as soon as possible so you press on the accelerator and your speed grows. You have not been on this particular road before but you have been driving for years and you trust your experience, skills, and reactions. Suddenly a red light appears out of the gloom – it is a stop light and it is close, too close, so you hit the brakes! You don’t stop immediately though – you are slowing down but not fast enough. The road is slippery, your tyres do not grip as well as usual, and your momentum carries you on. You are burning up the remaining tarmac fast and now you see other lights – white lights – coming from the right. A juggernaut is nearly at the crossroads and it has the green light and is not slowing down.  You are on a crash course – and there is nothing you can do – you have no options. The awful realisation dawns that you have made a fatal error of judgement and this is the end as you overshoot the red light and are crushed to a mangled pulp of metal and flesh under the wheels of the juggernaut!

The accident was avoidable – in retrospect. Was it avoidable in prospect? Of course – but only
– IF we were able to challenge our blind trust in our own capability and
– IF we were able to anticipate what could happen and
– IF we had set up trustworthy early warning signals and
– IF we had prepared contingency plans of what we would do if any of the warning bells rang.

Easy enough for an individual to do perhaps – but much more difficult for a group of individuals who have low regard for each other and who are competing to grow bigger and faster. Our mastery of  nature has given us the means to change global system dynamics – so our collective fate is sealed by our collective behaviour. We have the ability to achieve mutually assured destruction (MAD) without dropping a single bomb – and we are on course to do so not because we set out to – but because we did not set out not to. The error of omission is the stealth killer.

Is this global disaster scenario realistic? Is there anything that can be done? Are we collectively capable of doing it? The evidence suggests “yes” to all three questions – there is hope – but it will require a paradigm shift in thinking rather than a breakthrough in technology.

The laws of physics will seal our fate unless the laws of people adapt – and it may already be too late to avoid some degree of catastrophic decline – which implies billions of lives will be lost needlessly. Those of us in positions of most influence are already to old to expect to live to see the fruits of our collective error of omission – our children will bear the pain of our ignorance and arrogance.  What do you want carved on your gravestone … “Here lies X – who saw but did not act. Sorry.”

Limits to Growth – the 30 year update. ISBN 978-1-84407-144-9

Anyone for more Boiled Frog?

There is a famous metaphor for the dangers of denial and complacency called the boiled frog syndrome.

Apparently if you drop a frog into hot water it will notice and jump out  but if you put a frog in water at a comfortable temperature and then slowly heat it up it will not jump out – it does not notice the slowly rising temperature until it is too late – and it boils.

The metaphor is used to highlight the dangers of not being aware enough of our surroundings to notice when things are getting “hot” – which means we do not act in time to prevent a catastrophe.

There is another side to the boiled frog syndrome – and this when improvements are made incrementally by someone else and we do not notice those either. This is the same error of complacency and there is no positive feedback so the improvement investment fizzles out – without us noticing that either.  This is a disadvantage of incremental improvement – we only notice the effect if we deliberately measure at intervals and compare present with past. Not many of us appear to have the foresight or fortitude to do that. We are the engineers of our own mediocrity.

There is an alternative though – it is called improvement-by-design. The difference from improvement-by-increments is that with design you deliberately plan to make a big beneficial change happen quickly – and you can do this by testing the design before implementing it so that you know it is feasible.  When the change is made the big beneficial difference is noticed – WOW! – and everyone notices: supporters and cynics alike.  Their responses are different though – the advocates are jubilant and the cynics are shocked. The cynics worldview is suddenly challenged – and the feeling is one of positive confusion. They say “Wow! That’s a miracle – how did you do that?”.

So when we understand enough to design a change then we should use improvement-by-design; and when we don’t understand enough we have no choice but to do use improvement-by-discovery.

July 5th 2018 – The old NHS is dead.

Today is the last day of the old NHS – ironically on the 70th anniversary of its birth. Its founding principles are no more – care is no longer free at the point of delivery and is no longer provided according to needs rather than means. SickCare®, as it is now called, is a commodity just like food, water, energy, communications, possessions, housing, transport, education and leisure – and the the only things we get free-of-charge are air, sunlight, rain and gossip.  SickCare® is now only available from fiercely competitive service conglomerates – TescoHealth and VirginHealth being the two largest.  We now buy SickCare® like we buy groceries – online and instore.

Gone forever is the public-central-tax-funded-commissioner-and-provider market. Gone forever are the foundation trusts, the clinical commissioning groups and the social enterprises. Gone is the dream of cradle-to-grave equitable health care  – and all in a terrifyingly short time!

The once proud and independent professionals are now paid employees of profit-seeking private providers. Gone is their job-for-life security and gone is their gold-plated index-linked-final-salary-pensions.  Everyone is now hired and fired on the basis of performance, productivity and profit. Step out of line or go outside the limits of acceptability and it is “Sorry but you have breached your contract and we have to let you go“.

So what happened? How did the NHS-gravy-train come off the taxpayer-funded-track so suddenly?

It is easy to see with hindsight when the cracks started to appear. No-one and every-one is to blame.

We did this to ourselves. And by the time we took notice it was too late.

The final straw was when the old NHS became unaffordable because we all took it for granted and we all abused it.  Analysts now agree that there were two core factors that combined to initiate the collapse and they are unflatteringly referred to as “The Arrogance of Clinicians” and “The Ignorance of Managers“.  The latter is easier to explain.

When the global financial crisis struck 10 years ago it destabilised the whole economy and drastic “austerity” measures had to be introduced by the new coalition government. This opened the innards of the NHS to scrutiny by commercial organisations with an eager eye on the £100bn annual budget. What they discovered was a massive black-hole of management ignorance!

Protected for decades from reality by their public sector status the NHS managers had not seen the need to develop their skills and experience in Improvement Science and, when the chips were down, they were simply unable to compete.

Thousands of them hit the growing queues of the unemployed or had to settle for painful cuts in their pay and conditions before they really knew what had hit them. They were ruthlessly replaced by a smaller number of more skilled and more experienced managers from successful commercial service companies – managers who understood how systems worked and how to design them to deliver quality, productivity and profit.

The medical profession also suffered.

With the drop in demand for unproven treatments, the availability of pre-prescribed evidence-based standard protocols for 80% of the long-term conditions, and radically redesigned community-based delivery processes – a large number of super-specialised doctors were rendered “surplus to requirement”. This skill-glut created the perfect buyers market for their specialist knowledge – and they were forced to trade autonomy for survival. No longer could a GP or a Consultant choose when and how they worked; no longer were they able to discount patient opinion or patient expectation; and no longer could they operate autonomous empires within the bloated and bureaucratic trusts that were powerless to performance manage them effectively. Many doctors tried to swim against the tide and were lost – choosing to jump ship and retire early. Many who left it too late to leap failed to be appointed to their previous jobs because of “lack of required team-working and human-factor skills”.

And the public have fared no better than the public-servants. The service conglomerates have exercised their considerable financial muscle to create low-cost insurance schemes that cover only the most expensive and urgent treatments because, even in our Brave New NHS, medical bankruptcy is not politically palatable.  State subsidised insurance payouts provide a safety net  – but they cover only basic care. The too-poor-to-pay are not left to expire on the street as in some countries – but once our immediate care needs are met we have to leave or start paying the going rate.  Our cashless society and our EzeeMonee cards now mean that we pay-as-we-go for everything. The cash is transferred out of our accounts before the buy-as-you-need drug has even started to work!

A small yet strident band of evangelical advocates of the Brave New NHS say it is long overdue and that, in the long term, the health of the nation will be better for it. No longer able to afford the luxury of self-abuse through chronic overindulgence of food, cigarettes, and alcohol – and faced with the misery of the outcome of their own actions –  many people are shepherded towards healthier lifestyles. Those who comply enjoy lower insurance premiums and attractive no-claims benefits.  Healthier in body perhaps – but what price have we paid for our complacency? “

On July 15th 2012 the following headline appeared in one Sunday paper: “Nurses hired at £1,600 a day to cover shortages” and in another “Thousands of doctors face sack: NHS staff contracts could be terminated unless they agree to drastic changes to their pay and conditions“.  We were warned and it is not too late.

The Seven Flows

Improvement Science is the knowledge and experience required to improve … but to improve what?

Improve safety, delivery, quality, and productivity?

Yes – ultimately – but they are the outputs. What has to be improved to achieve these improved outputs? That is a much more interesting question.

The simple answer is “flow”. But flow of what? That is an even better question!

Let us consider a real example. Suppose we want to improve the safety, quality, delivery and productivity of our healthcare system – which we do – what “flows” do we need to consider?

The flow of patients is the obvious one – the observable, tangible flow of people with health issues who arrive and leave healthcare facilities such as GP practices, outpatient departments, wards, theatres, accident units, nursing homes, chemists, etc.

What other flows?

Healthcare is a service with an intangible product that is produced and consumed at the same time – and in for those reasons it is very different from manufacturing. The interaction between the patients and the carers is where the value is added and this implies that “flow of carers” is critical too. Carers are people – no one had yet invented a machine that cares.

As soon as we have two flows that interact we have a new consideration – how do we ensure that they are coordinated so that they are able to interact at the same place, same time, in the right way and is the right amount?

The flows are linked – they are interdependent – we have a system of flows and we cannot just focus on one flow or ignore the inter-dependencies. OK, so far so good. What other flows do we need to consider?

Healthcare is a problem-solving process and it is reliant on data – so the flow of data is essential – some of this is clinical data and related to the practice of care, and some of it is operational data and related to the process of care. Data flow supports the patient and carer flows.

What else?

Solving problems has two stages – making decisions and taking actions – in healthcare the decision is called diagnosis and the action is called treatment. Both may involve the use of materials (e.g. consumables, paper, sheets, drugs, dressings, food, etc) and equipment (e.g. beds, CT scanners, instruments, waste bins etc). The provision of materials and equipment are flows that require data and people to support and coordinate as well.

So far we have flows of patients, people, data, materials and equipment and all the flows are interconnected. This is getting complicated!

Anything else?

The work has to be done in a suitable environment so the buildings and estate need to be provided. This may not seem like a flow but it is – it just has a longer time scale and is more jerky than the other flows – planning-building-using a new hospital has a time span of decades.

Are we finished yet? Is anything needed to support the these flows?

Yes – the flow that links them all is money. Money flowing in is called revenue and investment and money flowing out is called costs and dividends and so long as revenue equals or exceeds costs over the long term the system can function. Money is like energy – work only happens when it is flowing – and if the money doesn’t flow to the right part at the right time and in the right amount then the performance of the whole system can suffer – because all the parts and flows are interdependent.

So, we have Seven Flows – Patients, People, Data, Materials, Equipment, Estate and Money – and when considering any process or system improvement we must remain mindful of all Seven because they are interdependent.

And that is a challenge for us because our caveman brains are not designed to solve seven-dimensional time-dependent problems! We are OK with one dimension, struggle with two, really struggle with three and that is about it. We have to face the reality that we cannot do this in our heads – we need assistance – we need tools to help us handle the Seven Flows simultaneously.

Fortunately these tools exist – so we just need to learn how to use them – and that is what Improvement Science is all about.