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This page created April 2000 by Michael Wynne
This page describes social, psychological and political aspects to the process of change. These create pitfalls and challenges which are seldom confronted. The manner in which marketplace ideology has been imposed in health care illustrates many of the problems and the unfortunate consequences.
The Problems with Single Systems of Thought:- Change is so often the product of the efforts of a small number of people who develop insights by examining the criticised situation from an alternate point of view. These people are most valuable when they come from within the system because of the insight being involved provides.
The difficulty for any "reformer" is that their criticisms are usually based on another system of thinking. While this reveals the deficiencies it may misinterpret them. It may itself be flawed in designing alternatives because it too has limited frames of understanding. Ideas ported from other contexts, by people not directly involved may provide very useful insights but they are particularly at risk as they are not constrained by practical experience.
Owning Ideas:- There is a psychological problem too. People critical of a particular pattern of thinking are unwilling to accept any of its insights. Advocates come to own the ideas and invest their lives in them. Perhaps more accurately they are owned by the ideas and become advocates for them resisting and rejecting alternate understandings.
People become so convinced of the validity of what they are doing and their lives are so tied up in it that they are unable to accept that there are serious problems and identify failures in the system. They simply do not see problems when they develop. When their solutions do not work they rationalise reasons. They do not confront alternate points of view.
I find it disturbing that those pressing for change so often set great store on getting others to "own the concepts", and in marginalising critics. This is a very human response. It is effective and efficient. It increases motivation. It is a recipe for later problems. Behaviour in actual situations is interpreted and framed by theory rather than by the human interactions and context of that situation. Probems are consequently not identified.
Paradigms and the Political Process:- Political solutions are often based on a single paradigm of understanding or a belief system. This gives them a simple internal coherence. It allows them to be sold to the public and politicians.
To sell "reform" to politicians and to the electorate there can be no contradictions to create dissonance. Annas in analysing the collapse of the Clinton health care reforms concluded that they failed because they used more than one metaphor to assist in understanding. This made it difficult for Clinton to sell the system. It made it vulnerable to attack by its corporate opponents.
This need for simplicity and congruency creates problems in dealing with any complex activity such as health care. Experience with the Clinton plan shows why the political process is not a good venue for progressing health care changes.
"Modern" and "Postmodern" Thinking:- Marketplace models of health care are good examples of these processes at work and are typical of 20th century "modern" thinking. The theoretical system becomes the dominant determining factor and this is at the expense of the actual context where the theory is to be applied. Graeme Samuel sets out one such model in his speech to the World Bank. Postmodern thinking would initiate change from the actual situation and the real people involved - their understanding of the system and their interpretation of the theories. Community involvement and input, rather than any particular belief system become the focus for "reform".
Models:- Modelling within one or more
paradigms is an important tool for analysing possible positive and
negative outcomes of a particular set of proposals. Computers
contribute to this. Before accepting the results it must be shown
that the model is valid when applied to the situation. The model and
its results must be examined from alternate points of view.
Generating a model proposal within a single set of paradigms,
particularly one which sets out to discredit paradigms which provide
other insights is a suspect activity. The ideas which underpin the
model which Samuel proposed to the World bank misinterprets the
reasons for the failure
of professionalism and consequently
rejects important insights.
A health system embraces so many facets and so many paradigms provide insight that it simply cannot be subjected to the constraints of a single theory as market advocates propose. A more fluid approach in which incremental changes are made in a desired direction is much preferable. The insight from multiple paradigms can be brought to bear at each stage. Careful ongoing data collection is essential. The consequences of each step can be carefully evaluated. Constant review and even changes in direction may be required.
Different frames of understanding should be the tools used to craft the final product and the foundation for additional paradigms. It is not possible to make a chair using only a saw. Sound economic management is important and economists can provide valuable assistance but economic theory alone is not a valid tool for generating solutions for all human problems. As a cosmological belief system it is sadly deficient.
Clearly we must know where we are going and
what we want. There is an obvious need for a plan and objectives but
these must not be set in concrete. I believe that they should emerge
by discussion, consensus and compromise between groups which bring
multiple insights to the process. Market place advocates promote a
crisis and sell their systems as the solution. It is the proposed
solution and not the crisis which must be examined.
The market imposed its will:- The competitive health care marketplace has developed in a very different way. It has been imposed by true believers and market forces. The market has repeatedly ignored logical argument and clear evidence. Marketing and rhetoric have replaced logical process. Profit and success on Wall street have been taken as proof of benefit and almost every other consideration ignored. Tenet/NME, Columbia/HCA, Sun Healthcare and Aetna illustrate the way "innovation" and "reform" are accomplished in the market place. Any practices which were able to generate large profits were simply imposed. Their validity was decided by stock analysts and this was evaluated only on the profits generated or promised. Power, financial and political dictated to reason. If there were problems then it was because market principles had not been properly applied.
Examples of Market Thinking:- Market Analysts heaped praise on Tenet/NME because of its lucrative business practices, singling out its disturbing programmatic system of care for special commendation. Because it made money it was assumed to provide good care.
Columbia/HCA's Richard Scott's integrated "Macmedicine" was a marketplace "turn on" as it promised and generated vast profits fuelling meteoric growth. Its integrated systems were considered to be the benchmark for excellence.
Andrew Turner's totally uninformed claim that there was fat in the aged care system which could be "cut" to increase profits was music to the market. Emerging evidence now indicates that this caused a vast amount of needless pain and suffering as well as thousands of premature and unnecessary deaths
Managed care's ludicrous claims to provide more for less and still make a profit was accepted without question. It was implemented by the business community across the system without any effective discussion or ongoing monitoring. Evidence which should be there is simply not there. It is the cries of pain from the community which have exposed its deficiencies rather that the hard data which should have been collected.
This is not the way to make changes. It is
certainly not reform and must never be allowed to happen again.
It is easy to predict that once the health system is fully opened to the market in Australia or in any developing country, the market will dictate and impose its own practices and solutions in exactly the same way it has in the past. Patient care will be decided in board rooms and dictated by the demands of Wall street. We are likely to have a replay of what has happened in the USA but with an Australian rhythm. That any government could control what will happen in a global marketplace in any significant way is a delusion. In the new world the only control will be the World Trade Organisation. This is not an organisation which would on its current performance fill anyone with confidence.
SAMUEL'S PLAN:- I am concerned about the nature of that plan, the ultimate objectives and the intended and unintended consequences of the processes used to accomplish those objectives. Any sensible plan for change must be incremental, based on carefully evaluated steps. Ideally it should start from something which is known to work in health care and adjust this to meet the changing situation. This www site shows that the health care market does not qualify. Evidence and unanticipated outcomes must be sought and carefully examined. These processes must be shielded from pressures generated by self interest. I doubt the market's ability to do this.