Healthcare Institutions Prevent Healthcare Problems From Being Solved

By Gerrit Van Wyk.

The Shirky Principle.

Clay Shirky in a talk said institutions preserve the problem they must solve, which Kevin Kelly labelled as the Shirky Principle. It means we focus on solutions emerging from past problems to the exclusion of solutions to new problems. Kelly uses the example of unions arising to counter exploitation of workers. Over time, unions need management to manage their increasing complexity, to which companies respond with more management of their own, which then locks the two into a co-dependent relationship. The problem and solution become a problem system.

Innovation, and seemingly innocuous disruptive technologies, arise from the margins of industries in response to what seems like irrelevant problems, hence we ignore it. We focus instead on existing, or historical problems, consequently the problems we try to solve end up defining us. It means to make a difference, we must let go of old problems and attend to marginal solutions that may better solve current problems. In Kelly’s example, car manufacturers had no interest in Honda’s electric bicycles, which became motorcycles, and in turn small efficient motor vehicles, which then disrupted traditional motor vehicle manufacturing. They couldn’t see existing practices becoming a problem.

Shirky’s gave a talk titled, “A Group Is Its Own Worst Enemy”, which starts with Bion’s observation that groups in therapy conspire to defeat the therapy the group was designed for, without planning or control. Groups unconsciously protect something emerging from their interaction, which, often, is not that which they are officially there for, to satisfy emotional needs, in response to real or imagined enemies or threats, or to protect valued beliefs. In a similar way, experts eventually define their jobs in such a way that it obstructs solutions, and generals are there to make war, not prevent it. The only way out of the dilemma and bypass the resistance is creating rules to formally structure group activity.

The same thing happens when we innovate. Innovation is killed on the inside for Bion’s reasons. We design solutions assuming we know how users will behave, they don’t behave like that, and we then discover our solution and social issues are interlinked. We respond by creating rules and making rules about making rules to control the dilemma.

Shirky makes the point innovation comes from small groups (by Belbin’s research no more than about ten people), who can rapidly come up with ideas and trial it to see what works, and adapt based on that feedback. If it works, it has the potential to change everything rapidly and radically. There will be many failures, that’s part of learning, but the point is we can’t predict what will or will not work, nor whether people will find it useful; designers are not the users. And the solution doesn’t have to be perfect, just good enough.

A reading of Starr’s “The Social Transformation of American Medicare” provides a useful basis for understanding the interconnectedness of historical problems the healthcare industry faced, and the institutions and organizations formed in response to solve them. It paints a picture of interconnected groups and organizations competing and responding by creating more organization and complexity, tightening the noose. On could say, healthcare is a prime example of the Shirky principle. We cannot solve today’s problems because of the solutions to yesterday’s problems.

Creative innovators find themselves on the margins, because, as Belbin also pointed out, a feature of bureaucracies is similarity and conformity, hence such people are either not hired, or quickly ejected. It means the solutions we need in healthcare won’t come from tradition and the inside.

Secondly, the purpose of leaders, managers, experts, consultants, etc., in bureaucracies is to maintain status, influence, and dominance, and the jobs, salaries, and contracts accruing from that social advantage. Battle plans, reports, strategies, initiatives, etc., are not there to solve problems, they are there to support the narratives, or stories, justifying the roles and making them legitimate, which feeds back into maintaining historical structures and solutions.

The plans presented to us by commissions and experts contain no leeway for experimentation, adapting, and failure, just certainty that with the right amount of control, success is guaranteed, and they are not creative, just variations of solutions that didn’t work in the past, confirming Shirky’s principle. The danger is large bureaucracies and organizations are incapable of adapting, and, if disruptive change comes, and, eventually, it will come in healthcare, they fail spectacularly. One could say the covid-19 pandemic was a harbinger and warning of that.

As per Bion, large healthcare institutions and bureaucracies are no different than small therapeutic groups, they sabotage any possibility of innovative change for the same reasons individuals in small groups do; to satisfy emotional needs for status and self-esteem, to which innovation, creativity, and disruption are imagined enemies or threats to the status quo, and to protect the underlying valued beliefs, norms, and ideologies bureaucracies are founded on.

It means the innovation and experimentation needed in healthcare must come from the margins, and we need opportunities and financing to stimulate that. We need to bypass existing structures. The danger, of course, as Shirky pointed out, is that as solutions grow, the same cycle of rule making and management complexity repeats again, which is almost inevitable.

Governments and private donors individually or together can provide the funding and infrastructure needed to stimulate and incubate. Governments also can cascade what works through the healthcare system. But, in terms of the Shirky principle, what prevents them is their interconnectedness with the institutions and bureaucracies perpetuating old problems, which makes them part of the problem.

I spent 43 years in healthcare, and during this time observed and experienced the Shirky principle; the more things changed, the more they stayed the same because of the institutions and bureaucracies I worked in. Ambrose Beirce said a cynic is a blackguard who sees life as it is, not how he ought to see it. Those years made me cynical that we’ll ever solve the healthcare problems we are faced with, until, like when the Berlin wall came tumbling down, something small unpredictably and unexpectedly tips everything out of alignment.