Decision support to address the tragi-comedy of the Health Service Commons
Jack Dowie�London School of Hygiene and Tropical Medicine
Vije Rajput�Stonydelph Health Centre, Tamworth, UK
Mette Kjer Kaltoft�University of Southern Denmark
IHEA Basel 2019�
In Garrett Hardin’s original formulation, the tragedy of the commons - shared, public access lands - are over-grazed because individual farmers can send their livestock onto the land without restriction and at zero price. The tragedy occurs because overgrazing eventually reduces the ability of the land to provide fodder. Everyone suffers. To avoid this, ‘commons’ of all sorts - shared, public access facilities and resources – require management. Elinor Ostrom showed that a community management approach was workable under conditions of good communication, trust and reciprocity, but, in the likely absence of this ideal, the approach most likely to succeed was a mix of government regulation, market forces and community-based management. Daniel Cole and colleagues suggested the institutional structure is more complex, the tragedy arising from interacting resources and institutions. If the grass on the pasture had not been subject to appropriation, if the cattle had not been privately owned, or if property- and contract-enforcement institutions supporting market exchange had been absent, the tragedy of the commons would not have arisen, regardless of the open-access pasture.
Public health services such as the NHS are an archetypal example of the commons tragedy, currently advancing relentlessly towards its final act in the absence of good communication, trust, reciprocity, transparency and organisational incoherence, all driven by the attempt to sustain the mantra of ‘care based on need and free at the point of delivery ‘(or more recently "free at the point of use, based on clinical need and not an individual's ability to pay").
Abstract (hidden) 1
Maintaining these as an aspirational value, in the face of its operational impossibility, is taking the tragedy to tragi-comic levels. Along with undercover moves to increase charges, the tragedy is being fast-forwarded by the reckless application of financial fertiliser, at the expense of other public services (social care, education, transport, utilities, community services) that are being progressively stripped of resources in real terms. All this paper does is suggest a way in which the individual citizens who, as identified patients, benefit from the services provided – but also, as anonymous patients, suffer the opportunity harms - might be freed from the structural-symbolic violence they are subjected to by the maintenance of the NHS fiction. It involves alerting them at the point of care as to how the tragedy is leading to a denouement most will regard as disastrous.
In a multi-criteria preference-sensitive tool (Generic Rapid Evaluation Support Tool – GREST), designed to provide decision support for both clinicians and clinical commissioning groups, an equity criterion is introduced as one of six. The Ratings for the Equity criterion are based on Claxton’s WTP for a QALY and its Weighting for the specific case provided on a 0 - 100% scale; 0 indicates no concern for equity implications and 100 concern only with the. Providing an equity weighting is mandatory, but if it is assigned zero, GREST becomes a standard, equity-insensitive but otherwise preference-sensitive, tool, for use within the time and resources of clinical decision practice. A demonstration version is available online. The main predictable objections are discussed.
Abstract (hidden) 2
The ‘solutions’
Ostrom showed that a community management approach was workable under conditions of good communication, trust and reciprocity
Cole and colleagues suggested the institutional structure is more complex, the tragedy arising from interacting resources and institutions
The tragedy would not have happened, regardless of the open access pasture IF
The tragedy of the NHS commons
Public health services but particularly the NHS, are an archetypal example of the commons tragedy… or tragi-comedy
Currently advancing towards its final act despite efforts to sustain the mantra of ”care free at the point of use, based on clinical need and not an individual's ability to pay” …
… by applying more and more fertilizer to the commons
Q: Where does the fertilizer, being used in denial of the unsustainability
of the nhs mantra, come from ?
A: from other public services
such as education, care, benefits, crime and justice – resulting in
negative impacts on population health through its socio-economic determinants
the nhs commons�is unsustainable �� because
1. the increased fertiliser inputs are subject to rapidly diminishing returns - by any meaningful outcome criterion
2. the demands on it are ever- increasing as the associated fertiliser reductions elsewhere impact on the socio-economic determinants of health
“bullshit �is the �new �normal”�
Our organizations are flooded with empty talk. We are constantly "going forward" to lands of "deliverables", stopping off on the "journey" to "drill down" into "best practice".
André Spicer �Professor of Organizational Behaviour at City University �We need to call this empty talk what it is: bullshit.
Organizations have become vast machines for manufacturing, distributing and consuming bullshit.
The meaningless language of management has spread through schools, NGOs, politics and the media…. AND NHS
Pierre Bourdieu 1930-2002
“meets the needs of everyone, free at the point of use, based on clinical need”
Must NOT even be an ASPIRATION
Maintaining this as an ‘aspirational value’, in the face of its operational impossibility – indeed meaninglessness - is what is taking the tragedy to tragi-comic levels.
So individual citizens who, as identified patients, benefit from the services provided
But also, as anonymous patients, suffer the opportunity harms -
Must be freed from the symbolic violence they are subjected to by the perpetuation of the nhs mantra – our contribution to this is the decision support tool (GREST)
the �Settings�for� GREST�(Generic Rapid�Evaluation �Support Tool)
Local prioritisation of interventions, �replacing or complementing such tools �as the Portsmouth Scorecard.
Individual Funding Requests for an intervention on grounds of the ‘exceptionality’ of specific patient, for whom It is not available under existing policy
Clinical decisions including de-prescribing and non-prescribing, as well as re-prescribing
GREST �is equity-sensitive�and commons-sensitive
GREST is a ‘fast and frugal’ generic decision support tool
Based on Multi-Criteria Decision Analysis (MCDA)
Distinctive in including equity as a criterion and hence can produce an EQUITY-SENSITIVE opinion
The GREST options and criteria
The two OPTIONS in GREST are OLD (the current intervention, such as usual/standard/current care) and NEW (the contemplated replacement).
The six CRITERIA are:
Examples (https://ale.rsyd.dk Survey ID 1525)
Figure 1: a 1 year increase in HRQOL is the only gain from NEW; Equity is weighted 5%
Figure 2: Equity weight is now increased to 40% (above the equipoise point of 39%)
The heart of the matter
The decision maker is alerted to the commons issue by being required to assign a weight to equity – the impact on other commons users - in generating the GREST opinion.
It is arguably not ethical for the person as citizen to be allowed to opt into complete ignorance as to the impact on other persons of using common resources.
It is not for an individual profession to decide they need to be able to ‘protect our patients’ from concern with the impact on others in a commons setting.
Thank you for your attention
One can argue till the cows come home from the common
about the best metrics to be used in GREST…
but this should not be allowed to divert attention from the basic issue
Funding The software used was installed at https:// ale.rsyd.dk as part of a nationally funded project to develop decision support tools. SATS J.nr. 1-1010/116/27.
Conflict of Interest Jack Dowie has a financial interest in the Annalisa software when used commercially.
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