By Gerrit Van Wyk.
We’re going to the moon.
On May 25, 1961, US President Kennedy announced that America would send a man to the moon by the end of the decade. In doing so, he gave the country an idealized vision of the future to strive for. On July 20, 1969, Neil Armstrong became the first human to set foot on the moon, which showed ideals, no matter how high, are achievable.
Ackoff made a distinction between goals, objectives, and ideals. A goal is something we will likely achieve shortly, an ideal is achievable but takes longer, and an ideal has a long time span and may never be achieved, but we can keep making progress towards it. By analogy, they say you eat an elephant one bite at a time; you are likely to get distracted along the way, but if you keep biting, eventually, like achieving an ideal, you may get there.
Getting my blood pressure down and maintaining it at normal level with lifestyle changes and medication, is a goal, reducing the health care budget by 10% over 5 years is an objective that is achievable, but much can happen along the way, and changing the way we practice health care is an ideal we may never achieve, but we can keep making progress towards it. Hence an ideal is a picture or story of a different future that, to be achievable, must be feasible, affordable, and possible.
During the marshmallow test for delayed gratification, a child is offered a marshmallow or pretzel immediately, or can get two if it can wait for 15 minutes. The researcher then leaves the room and observes what happens. Unexpectedly, it turns out children able to delay gratification tend to have better life outcomes along several parameters. I suspect there is a correlation between goals, and instant gratification, and ideals and delayed gratification. People in North America tend to be goal driven, hence want their pretzels and eat it now, which is not good for health care.
This may sound overly philosophical but has profound implications for health care. The problem with goals and objectives is, once achieved, you start hunting about for the next one, running on a sort of hedonistic treadmill. Most change in health care is short term and mostly cosmetic, which leaves the superstructure intact.
If you think about it, the health care processes we use were designed around 150 years ago for a very different era. Since then, we have been renovating it, and the question becomes, do we want to keep it as a historic relic, or knock it down and build something new, better aligned with today’s conditions?
Many think health care in Canada is in trouble, with two issues constantly cropping up; we need more money to pay for it, and more doctors and nurses to staff it. We’ve known for many years about a coming demographic crisis, and had ample time to prepare for it, but goals or objectives planning didn’t solve it, so nothing was accomplished. That moment has now arrived.
After World War 2, there was a boom in births which tailed off, and in many first world countries is now below 2 per family, or replacement. Many of my ancestors died at an early age, but with improved treatments for the infections, cardiovascular, disease, cancers, etc., that killed them, the so-called baby boomers live longer. Populations still grow not because more babies are added, but because fewer elderly are subtracted.
In Canada, where health care is tax funded, it means younger economically active people pay towards the expenses of retired, no longer economically active older people. Older people have more health needs and most of the costs we incur in our lives happen towards the end. What we have now is more old people with more health needs driving up costs, and fewer younger people to contribute taxes. Amongst the elderly are also increasing numbers of doctors and nurses retiring who need replacing by a smaller pool of young people, which is not possible.
It means the fantasy goal that more money, doctors, and nurses will save health care is impossible in practice, which means we must use those resources differently, and current practices don’t support that. The way out is fundamentally redesigning health care practice to match these practical realities and constraints. Another fantasy is experts or committees can do so, but there is ample evidence they are incapable of solving complex problems of this kind. Hence we find ourselves in a double bind; an exploding demographic time bomb, and the failure of short-term thinking to solve it, and the only way out is to change how we think about the problem.
People who do the work like doctors and nurses are indoctrinated into believing the existing model is best, and somehow works if you ignore reality, and without changing their beliefs nothing will change. The only way to change beliefs is for people to discover for themselves what works and what not in practice, and for them to come up with what must be changed through trial and error. Allowing them to do so requires an approach entirely different from what we’ve been doing so far.
There are significant barriers to such an idealized redesign of health care. Many medical professionals have incentives to keep things as they are, even though they know it’s broken, resources are controlled politically with little incentive to embark on something that will take many election cycles to realize, and by health care bureaucracies with little incentive for radical change, and the number of planners not goal or objectives orientated with a deep understanding of bottom-up complex change are few and far between. Those who are, are mostly ignored as different and outsiders by goals/objectives planners, which excludes them from the conversation. They must be brought into the tent for things to change.
Starting an idealized redesign of health care is scary, but there is good evidence it can work with the right people to mentor and steer it. It is as big as putting a man on the moon, and there is a many-marshmallow reward and a better long-term outcome if we can quit looking for instant gratification. What we need is for someone with vision to articulate the ideal that health care can be done differently, rather than just another unachievable objective.