Less Bureaucracy, More Innovation

By Gerrit Van Wyk.

Words of wisdom from an ex-British Columbia premier.

Glen Clark was a National Democratic Party (NDP) premier of British Columbia in Canada during the 1990’s, and spent the past 10 years as President and Chief Operating Officer of the Pattison Group, one of the biggest private companies in Canada. During a recent interview with CTV News, he made some interesting comments about health care worth exploring.

To begin with, he said health care cannot be run as a business, contrary to the prevailing wisdom and approach. No private company begins to approach the size of health care, businesses aim to maximize profit, but governments must reconcile multiple objectives, and it is currently run by an enormous unwieldy bureaucracy. Clark suggests trimming this bureaucracy to make it more responsive and flexible, using technology differently, and trialing pilot projects and implementing them quickly if they work as ways to solve the problem. The solution is not more money, but using low-cost improvements flowing from ongoing experiments and learning from them.

This echoes what front-line workers are saying. Administration staffing is increasing more rapidly than front-line staffing, individualized solutions for local conditions are dismissed out of hand, and leadership is out of touch with what goes on at ground level. They see many opportunities for cutting red tape and improvement, if only someone would ask them and empower them to make it work. Government understands the health care crisis, but responds by excluding front-line staff and limiting discussions to only politicians, administrators, and bureaucrats.

Needless to say, the BC health minister denies this, instead the current NDP government does not heed what Clark, who is still an NDP member and connected to the party, says. Although he may not know exactly why, his observations are spot on.

The essence of pragmatic philosophy is the truth is what works in practice, and Clark’s comments are based on his experience, hence it matters. Secondly, although Clark doesn’t see or comment on this, he recognizes what Drucker said many years ago, health care is the most complex industry around. Not only should we understand that, we should also understand what that means. Contrast this to the health minister, his administrators, and bureaucrats’ belief that health care works like a clock or machine and they can fix it better than anyone else.

Complexity means many parts interacting, from the interactions phenomena emerge that are both stable and unstable at the same time, everything within it affects everything else, even if in small ways, small events can have major consequences, and what goes on is not planned or under any sort of control. Upon reflection, that is a good description of our complex social world in general and health care particularly. It is an entirely different world from how the health minister, his administrators, and bureaucrats see it, but, paradoxically, are part of it like the rest of us. Ignoring it doesn’t make it go away.

In complex systems things change all the time, mostly in small increments but sometimes and unexpectedly in large ones, and one can’t predict when that may happen. We knew a big pandemic was due, but couldn’t tell when. It means we act, our actions change things, and we respond to that change without beginning or end. This is where Clark’s thousand experiments come in, we can act consciously, see what works and what doesn’t, and then act again, and learn from it. If it works, others can copy that, but only if it works for them. The notion that it will work for everyone everywhere is mechanistic and ignores the foundations of complexity.

Clark is also right that the people who should trial the experiments are those on the ground who know the problem and what may help, but also live the consequences of change. Most change managers pay lip service to participation. True participation, as Arnstein pointed out, is democratic which means you trust people and provide them with the means to implement the changes they designed. In health care, there is no trust in front-line workers, they are treated as if they are mentally challenged and untrustworthy, only the administrators and bureaucrats are smart, and, like a brain, must think for the rest of the very complex body.

Why is it that Glen Clark with all his political experience, business experience, and political and business connections can’t get his connections to listen to him? The answer is in the very social complexity we are talking about.

Ministers get authority from their appointment, and the belief they are in control. It is rare for minsters of health to have worked in the front-lines; hence they surround themselves with administrators and bureaucrats to maintain their authority and the illusion of being in control. But because they lack industry experience, they don’t control those they appoint, they are controlled by them.

Admitting you are not in control, because things are so complex, is frightening and likely career ending. Administrators and bureaucrats in turn invest lots of money and time getting educated as managers. What they are taught becomes part of who they are, and admitting what they were taught is not working becomes an attack on their selves, which, to maintain the image we have of ourselves, we all resist. You must be comfortable in your own skin to change how you think about the world, which, in turn, changes you as well.

But there is another underlying layer of complexity. Power in modern day politics is concentrated in the hands of the prime minister, one or two important ministers, and anonymous staffers in the prime minister’s office. They make the important decisions and everyone else marches to their tune. Not only must the health minister, his or her administrators and bureaucrats change their thinking and what they do, so must the prime minister and his or her staffers, and the psychological and social stakes for them is much higher. Unless there is some sort of political advantage to that, it won’t happen.

Voters don’t have much choice in the matter. If you vote out the existing government, all you do is replace them with a different one with the same mindset, controlled by the same administrators and bureaucrats, who are the constant as governments come and go. The game and rules remain the same.

Nassim Taleb talks about black swan events which are rare but have significant consequences. The possibility that a prime minister or minister of health will have a change of heart and tear up the hymn book, or their administrators, bureaucrats, or staffers will advise them to do so, is minuscule, but would change everything. It would mean they would take Glen Clark and his ideas seriously, which, without them knowing it, is academically and practically on solid ground. There are practitioners of the art of change in social complexity, and it works, but they are rare for now.

Our prime ministers, health ministers, and their administrators, bureaucrats, and staffers have two choices; continue on the current track and pray the train will not go off the looming cliff ahead, or, change how they think about the problem and surround themselves with people who can help them lay a different track. The first is a hail Mary pass, the second at least gives us a chance, and, as Glen Clark argued, it can work.