Obama Heathcare Plan

What kind of nitwit (asks @RSessions ) would believe Obama's health care plan wants to kill the elderly? Roger cites a New York Times article, Obama Calls Health Plan a 'Moral Obligation' (20 August 2009).

Another way of putting this question is as follows. Within what frame or worldview does this outcome (killing elderly people) seem both likely and deliberate? And what are the characteristics of those people who view Obama's healthcare plan in this way?

One of the hotly contested frames is the religious one. Obama is specifically addressing the religious lobby, and is hoping to get the moral high-ground. Obama turns to faith leaders Josh Gerstein (Politico, 20 August 2009).

Care for the elderly has apparently become a focal point for opposition to the healthcare plan. Conservative religious leaders such as Dr Alveda King (niece of Dr Martin Luther King jr and supporter of John McCain in the recent presidential election) adopts the rhetorical trick of stringing emotive words together ("health reform ... unborn ... elderly ... genocide"), which may create the desired effect in some audiences without the need for detailed (and refutable) argument.

One of the interesting things here is the way a single word or phrase (in this case "elderly") becomes a substitute for a proper argument and well-articulated worldview. This is a very common phenomenon: the word acts as a totem, creating a frame around itself. The power of words.

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Sources

• Health reform fact check: Euthanasia of the elderly, Cindy House. Rocky Mountain Independent, 10 August 2009
• Fox & Friends crew frighten elderly viewers: health-care reform is 'a subtle form of euthanasia' David Neiwert Crooks and Liars Blog, 27 July 2009

See also

• Matt Frei, Washington diary: Making the sale, BBC News, 23 July 2009.
  
• Arnold Relman, The Health Reform We Need & Are Not Getting. New York Review of Books, July 2, 2009.
• Theodore R. Marmor and Jonathan Oberlander, Health Reform: The Fateful Moment. New York Review of Books, August 13, 2009.

Locking In

At the Tavistock Institute yesterday evening, to discuss some recent research on Service Design, presented by Paula Hyde based on her recent paper.

Paula Hyde & Huw Davies. Service Design, Culture and Performance: Collusion and Co-Production in Healthcare. Human Relations 57 (11). Available online until June 30

For a short discussion of this paper from a service-oriented perspective, see my Architecture blog.

Historically, the Tavistock Institute has played a leading role in understanding open systems from a sociotechnical perspective. One of the things I found striking about Paula's research was how closed the systems appeared to be, in the sense that the patterns of interaction were self-replicating and self-reinforcing, with no apparent room for external influence or innovation.

In the discussion, it was stated that prisons and mental health have made little or no progress over the past few decades although there has been significant progress in other areas such as healthcare and education. Why are some systems (more than others) incapable of learning? Why are some systems (more than others) locked-in to dysfunctional patterns?

Perhaps it is significant that the two systems that are most "locked-in" in a metaphorical sense are also those where not only the primary users of the service (patients, prisoners) but also the primary carers (nurses, prison officers) are physically situated behind locked doors.

Where the cybernetic community uses the term POSIWID, the Tavistock community uses the term "primary task". What is the system really trying to achieve? How should we evaluate the success of the system, and the success of interventions into the system?

In the case of both prisons and mental health, there is an ambiguity about the primary task: is it containment or care? When there is a fairly clear containment agenda (keeping people locked up) and a fairly vague care agenda (helping people return to being "good" citizens), it is not surprising if the clear agenda takes precedence over the vague agenda.

Hospital Superbugs

According to the Independent, citing a study by Professor Mark Wilcox (Leeds University, and a member of the Hospital Infection Society), hundreds of hospital wards are being closed, and the UK National Health Service is losing £160m a year because of the lethal bug Clostridium Difficile. 

Clostridium Difficile benefits from two interacting forces:

Overuse of antibiotics This produces stronger bacteria and weaker patients. 

Complex targets Government targets on hospital infections have focused on MRSA, which has led to other hospital infections being neglected. Furthermore, patients are shuffled around the hospital to satisfy healthcare productivity targets, which increases the rate of infection. Meanwhile, hospital cleaning is driven by cost targets.

As with many complex ecosystems, there are some winners and losers. Does that mean the purpose of this complex system is to promote the interests of Clostridium Difficile? What does POSIWID tell us about the possibility of effective interventions into this complex system? 

 

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Update. My original post cited a news item from the Independent (June 8th, 2005), but this has now disappeared. Here is a later story from the same source. 

Jeremy Laurance, Hospital superbug threatening to spread through community (Independent, 21 December 2005)

My post also included a picture How Clostridium Difficile wins by default, but this has got lost.

Previous post on Innovation and MRSA: When Knowledge is Free (September 2004)

Target-Setting

WYMIWYG - What You Measure Is What You Get

This is another very important system principle. Systems are distorted by the presence of targets, which increasingly fail to measure what they were supposed to measure. 

Here is a well-known example. If you test, measure and analyse the ability of school-children, this may tell you all sorts of useful things about the socio-geographic distribution of ability, about the success of different teaching methods, and so on. But if you set targets for the scores achieved on these tests, this will motivate some changes in behaviour among teachers, parents and children. Teachers will "teach to the test", while many middle-class parents will send their children for special coaching. (Indeed, for many schools, the excellent results achieved in the school league tables are in large part due to the huge amounts of extra tuition received by children outside school, and bears little relationship to the amount of added-value provided by the school itself.) While this may indeed improve the scores, it seriously undermines your ability to learn anything useful about the ability of school-children, or to make any systematic changes. 

Another interesting example came up in the UK election. Given a reasonable-sounding goal that health clinics should try to see patients within 48 hours, the government had imposed a target. It emerged (on live television, to the surprise and embarassment of the Prime Minister) that in order to reliably achieve this target, some clinics had changed their appointment policy and were now refusing to book appointments more than 48 hours in advance.

Jenni Russell When you can't see a GP (Guardian, April 30th, 2005)

The present Labour government is often criticized for its obsession with targets, but it should be remembered that this obsession was shared by the Conservative government under John Major. The desire to set measurable targets often comes from quite sincere motives, but these targets have dysfunctional effects. This is especially true when targets are set by politicians under political pressure without proper systems analysis.

• Setting isolated targets for improving the things you are unhappy about, while failing to set targets for maintaining the things you are happy about.
• Setting sample targets as illustrations of the things you could improve, which then receive disproportionate amounts of attention and resource. ("We will cut waiting times for breast cancer" ... hang on, what about other forms of cancer such as prostate?)

And of course target-setting is not just a disease of politicians. It is also an occupational hazard of managers within organizations. We cannot reasonably demand an end to targets, but we need to work on developing wiser targets. 

 

POSIWID - Purpose of System Is What It Does

At one level, POSIWID shows us how complex systems resist simplistic attempts to change them, or sometimes even to monitor them. The education system contains a testing subsystem whose purpose is to achieve high scores. Tracing how the testing subsystem actually achieves high scores reveals some important dependencies: the test results are dependent on the coaching subsystem, which in turn is dependent on the social system of the parents. 

If we want to make meaningful changes in the education system, it is very useful to carry out this kind of dependency analysis, because it helps us to predict several things:

1. How successful a given initiative will be.
2. How quickly this success will become visible.
3. How unequally this success may be distributed in different areas.
4. How quickly this success may be eroded or undermined by other system effects.

At another level, we can ask about the POSIWID of the target-setting system itself. The avowed purpose of target-setting is usually something to do with accountability or performance or both. The actual effect is often to make things more complicated and more bureaucratic, achieving local accountability or performance only at the expense of accountability and performance elsewhere in the larger system.

It is possible to intervene into this system too, but it needs an intervention at the right logical level. Perhaps incredibly, the quality standard ISO 9000 (dismissed by many people as hopelessly bureaucratic) contains a defined point where you can plug in a control loop that will limit or even reverse the growth of bureaucracy. I really enjoy that kind of intervention - it's like one of those martial arts where you simply redirect the energy of your opponent. 

 

See also On the performativity of data (August 2021). More posts on target-setting.