Frankenstein Healthcare

By Gerrit Van Wyk.

Reports, reports, and more reports.

Mary Shelley published Frankenstein: or, the modern Prometheus in 1818, which is a horror story about a scientist who created an artificial man by combining parts of different bodies. It was a monster because the parts didn’t fit together well, and, because nobody loved it, the monster turned on its creator, leaving a trail of destruction behind.

The C.D. Howe Institute last week released a 13-step plan for reforming Canada’s healthcare system, which, like Frankenstein, is a creature stitched together from different parts, which will be unloved, and eventually turn on us. Since the 1980’s, a never-ending stream of similar reports started appearing, all claiming to have solutions for Canada’s healthcare, and all now buried in a graveyard of failures that never seems to get full.

Starting with Hall’s Health Services Review in 1980, I count no less than 37 Commissions and reports provincially and federally on Health Canada’s website, ending with Saskatchewan’s For Patients’ Sake in 2009. This excludes plans and reports from think tanks, and other sources, and reports after 2009, which is a staggering amount.

So much wasted time, money, and effort, so many experts, so few results. And no-one bothers to ask the obvious question: why do we keep failing, and what can we do differently?

I distinguish between beliefs, which are just that, and facts, and will argue, based on fact, all these commissions and reports failed for the same two reasons: they all took a simplistic mechanical perspective of what Drucker called the most complex biological, technological, and social industry on the planet, and they all failed to comprehend the social complexity of implementing their plans, and that’s a fact. They all bravely sailed off to a new dawn, to be caught in a hurricane of social complexity throwing them on the rocks, and leaving destruction and casualties behind. As long as we cling to this outdated and useless perspective, we’ll keep whistling in the wind.

Roadmap for Reform is written by four healthcare experts, with the input of an additional 23 expert reviewers and a literature search. It says it is designed for more effective reform, and states it represents a consensus of viable options. Canadians fear change to Medicare and that healthcare may become as expensive as in the US, which must be overcome to make the system more effective, efficient, productive, and affordable, and for a more holistic and comprehensive reform agenda. Although the primary focus is on improving service, it will also save costs.

The 13 steps are: a foundation of better data collection, analysis, and reporting, and health workforce planning; team-based care, expanding scopes of practice, changed funding models, and regionalization, which must happen now; better long-term care, digital health services and solutions, facility redesign, improved accessibility, and more emphasis on health promotion in the future; and private funding and broadening coverage, on which there is no consensus.

The moment you see “13 steps”, you know the point of departure is a mechanistic perspective of reality, and therefore a belief healthcare, like a machine, can be designed from the outside by “experts”, a belief the design will improve it, and you have some control over the process and outcome. That’s the exact opposite of complexity. If, as I argue, healthcare is complex, you don’t know how many steps, if any, there are, because complex change is ongoing and is based on continuous action, observation, and adapting. You must interact with the problem, from which necessary further steps emerge, you don’t know for certain what the outcome will be, and no-one controls complexity, and therefore the process. Language of effectiveness, efficiency, productivity, affordability, and comprehensiveness is mechanistic, and the claim by the “experts” that their approach is “holistic” therefore does not bear scrutiny.

A second, related problem, is the notion there are people with superior knowledge about something as complex as healthcare, recognized socially by the title and role of “expert”. McIntyre and Popper argued the problem with that role and status is it limits one’s ability to escape the silo thinking associated with being an expert without risking losing your status as expert, which becomes a problem when interacting with complex phenomena. Even an “expert” perspective only contains a sliver of knowledge about a complex situation, such as healthcare, which means about it, there are no “experts”.

It then becomes critical to solicit and include multiple other equally valid perspectives to build a more complete picture of the problem space, which this plan neglects. All it is based on is the limited perspective of a group of “experts”, which, from a complexity perspective, limits its value. Theirs may be an “expert” consensus, as it states, but many others who are affected by the plan, but have no voice, will disagree.

A third, and very significant issue, is this report, like all others of the same kind, ignores the implementation problem, hence its chance of succeeding, if adopted, is 5-15%, which is abysmally low. The mechanistic approach to implementation, as taught academically, is find early adopters to promote the plan, get rid of resisters, and the flock will follow. If that doesn’t work, coerce people by mandating their cooperation. What happens in practice is the voiceless who disagree but were not consulted resist, which is why most change initiatives fail.

In the real world, plans are implemented by people within a context of very complex interrelationships and interactions. I know only one approach acknowledging that complexity, and it succeeds 85% of the time, which I take as proof that paying attention to the social complexity of healthcare is critical. Employees in the trenches know 13-step plans don’t work, and you cannot come up with anything better without engaging them in conversation and dialogue. The 13-step plan doesn’t intend doing so, hence, predictably, it will fail if implemented.

Some of the recommended steps are not unreasonable, but the perspective on them is very simplistic and likely to have unintended consequences. Better data collection, analysis, and reporting is indeed necessary, but we lack the IT backbone to do that in Canada, and whether we ever will have it, is debatable. The idea one can plan for a workforce is mechanistic, and without their cooperation, turns workers into objects. Team-based care does not reduce workforce requirements, it increases it, thereby worsening shortages of physicians, nurses, etc., extending scope increases jockeying for privilege amongst professional groups, and funding creates incentives to which people respond unpredictably. Long-term care is impacted by changing social values and the boomer grey tsunami which will eventually wash away, and diverting resources to under serviced groups and communities is not a simple matter. Private funding increases expenses and costs and diverts resources to low hanging fruit, and broadening coverage is commendable, but must traverse the alligators in a political swamp. In short, Roadmap to Reform is better served as a discussion document than a 13-step plan.

Healthcare is political and no conversation about healthcare can therefore ignore a discussion about politics, particularly here in Canada, which Roadmap to Reform ignores. Politics is a complex social game about social power, and no healthcare reform will take place without understanding and playing that game.

Albert Einstein said you cannot solve problems with the same thinking that created the problems in the first place, and Jamshid Gharajedaghi that creating different games based on the same rules creates games of the same kind, no matter how different you think they are. The thinking behind Roadmap to Reform is the same as the 37 official Commissions and reports that failed before it, and based on the same rules. They all are firmly rooted in mechanistic thinking, which created the very machinery that dug the hole in which healthcare is now, and designing different machinery of the same kind won’t fill in the hole, it will dig it deeper. What we need is to view the problem from a different hilltop and take a fresh and different approach. There is one readily available; to think about healthcare and how to solve it as a complex problem, the question is, when will we recognize its value and take it?