Case Study: Rethinking Healthcare
Editor | On 19, Aug 2018
I picked up my newspaper today and found the word â€˜crisisâ€™ written over 40 times. Six of them as part of a headline. Debt crisis, NHS budget crisis, obesity crisis, KFC crisis, Brexit crisis, weather crisis, plastic crisis. You name it, its in crisis. To say the word has become somewhat devalued would probably be an understatement. What I think it actually means is â€˜has hit a contradictionâ€™. Which, maybe, if you donâ€™t know about TRIZ is precisely the same thing as a crisis, but if you do know some TRIZ, you know that crises can be solved once we give ourselves permission to start solving contradictions.
Some contradictions, though, are perhaps more important than others. Both in terms of the extent of the problems they create. But also in terms of their potential for starting a forest-fire of contradiction-solving practices elsewhere. Anything to do with the healthcare system falls into this category. In the UK, the National Health Service now accounts for over 12% of the countryâ€™s GDP. Thatâ€™s a lot of money. And, the amount only ever seems to go up. British people are very proud of the NHS. When it claims to be short of money â€“ as it is again this year â€“ we always bail it out. Maybe thatâ€™s its biggest contradiction of all: no incentive to be efficient because we always throw more money at it? But then again, if we look at the other figures, the ones relating to patient health, or lack thereof, thereâ€™s probably a much bigger contradiction: people are getting sicker and sicker despite the increased spending. This is especially so when it comes to some of the more emotion related illnesses such as stress and depression. Throwing more money and more drugs at this problem, if anything, seems to be making the problem worse. Maybe this is the contradiction that should find itself at the top of the priority list?
If it was me responsible for this problem, Iâ€™d look to map it onto the new Business Matrix. Iâ€™d map it as a Negative Intangibles versus Support Cost conflict. If I did that, the Inventive Principle suggestions Iâ€™d get back are currently, in descending order of priority:
Principle 25 â€“ Self-Service
Principle 40 â€“ Composite
Principle 3 â€“ Local Quality
Principle 10 â€“ Prior Action
Principle 35 â€“ Parameter Changes, and
Principle 13 â€“ The Other Way Around
After I made this analysis, I did something quite strange. I am in no position to do anything tangible to deploy these Principles in the NHS. We do work with them, but our job tends to be PanSensic â€˜measurement stuffâ€™ rather than solution implementation stuff. But this doesnâ€™t mean I canâ€™t look around the various parts of the NHS to see if thereâ€™s evidence of anyone using strategies relating to these Principles.
It didnâ€™t take me long to find this:
It could, if the results stand up, be one of the most dramatic medical breakthroughs of recent decades. It could transform treatment regimes, save lives, and save health services a fortune. Is it a drug? A device? A surgical procedure? No, itâ€™s a newfangled intervention called [Principle 40] community. This week the results from a trial in the Somerset town of Frome are published informally, in the magazine Resurgence & Ecologist. (A scientific paper has been submitted to a medical journal and is awaiting peer review). We should be cautious about embracing data before it is published in the academic press, and must always avoid treating correlation as causation. But this shouldnâ€™t stop us feeling a shiver of excitement about the implications, if the figures turn out to be robust and the experiment can be replicated.
What this provisional data appears to show is that when isolated people who have health problems are supported by [Principle 25] community groups and volunteers, the number of emergency admissions to hospital falls spectacularly. While across the whole of Somerset emergency hospital admissions rose by 29% during the three years of the study, in Frome they fell by 17%. Julian Abel, a consultant physician in palliative care and lead author of the draft paper, remarks: â€œNo other interventions on record have reduced emergency admissions across a population.â€
Frome is a remarkable place, run by a [Principle 3] Â independent town council famous for its democratic innovation. Thereâ€™s a buzz of sociability, a sense of common purpose and a creative, exciting atmosphere that make it feel quite different from many English market towns, and for that matter, quite different from the buttoned-down, dreary place I found when I first visited, 30 years ago.
The Compassionate Frome project was launched in 2013 by Helen Kingston, a GP there. She kept encountering patients who seemed defeated by the medicalisation of their lives: treated as if they were a cluster of symptoms rather than a human being who happened to have health problems. Staff at her practice were stressed and dejected by what she calls â€œsilo workingâ€.
So, with the help of the NHS group Health Connections Mendip and the town council, her practice set up a [Principle 10] Â directory of agencies and community groups. This let them see where the gaps were, which they then filled with new groups for people with particular conditions. They employed â€œhealth connectorsâ€ to help people [Principle 25] plan their care, and most interestingly trained [Principle 25, 13] voluntary â€œcommunity connectorsâ€ to help their patients find the support they needed.
Sometimes this meant handling debt or housing problems, sometimes joining choirs or lunch clubs or exercise groups or writing workshops or menâ€™s sheds (where men make and mend things together). The point was to break a familiar cycle of misery: illness reduces peopleâ€™s ability to socialise, which leads in turn to isolation and loneliness, which then exacerbates illness.
This cycle is explained by some fascinating science, summarised in a recent paper in the journal Neuropsychopharmacology. Chemicals called cytokines, which function as messengers in the immune system and cause inflammation, also change our behaviour, encouraging us to withdraw from general social contact. This, the paper argues, is because sickness, during the more dangerous times in which our ancestral species evolved, made us vulnerable to attack. Inflammation is now believed to contribute to depression. People who are depressed tend to have higher cytokine levels. But, while separating us from society as a whole, inflammation also causes us to huddle closer to those we love. Which is fine â€“ unless, like far too many people in this age of loneliness, you have no such person. One study suggests that the number of Americans who say they have no confidant has nearly tripled in two decades. In turn, the paper continues, people without strong social connections, or who suffer from social stress (such as rejection and broken relationships), are more prone to inflammation. In the evolutionary past, social isolation exposed us to a higher risk of predation and sickness. So the immune system appears to have evolved to listen to the social environment, ramping up inflammation when we become isolated, in the hope of protecting us against wounding and disease. In other words, isolation causes inflammation, and inflammation can cause further isolation and depression.
Remarkable as Fromeâ€™s initial results appear to be, they shouldnâ€™t be surprising. A famous paper published in PLOS Medicine in 2010 reviewed 148 studies, involving 300,000 people, and discovered that those with strong social relationships had a 50% lower chance of death across the average study period (7.5 years) than those with weak connections. â€œThe magnitude of this effect,â€ the paper reports, â€œis comparable with quitting smoking.â€ A celebrated study in 1945 showed that children in orphanages died through lack of human contact. Now we know that the same thing can apply to all of us.
Dozens of subsequent papers reinforce these conclusions. For example, HIV patients with strong social support have lower levels of the virus than those without. Women have better chances of surviving colorectal cancer if they have strong connections. Young children who are socially isolated appear more likely to suffer from coronary heart disease and type 2 diabetes in adulthood. Most remarkably, older patients with either one or two chronic diseases do not have higher death rates than those who are not suffering from chronic disease â€“ as long as they have high levels of social support.
In other words, the evidence strongly suggests that social contact should be on prescription, as it is in Frome. But here, and in other countries, health services have been slow to act on such findings. In the UK we have a minister for loneliness, and social isolation is an official â€œhealth priorityâ€. But the silo effect, budget cuts and an atmosphere of fear and retrenchment ensure that precious little has been done.
Helen Kingston reports that patients who once asked, â€œWhat are you going to do about my problem?â€ now tell her [Principle 13] , â€œThis is what Iâ€™m thinking of doing next.â€ They are, in other words, no longer a set of symptoms, but people with agency. This might lead, as the preliminary results suggest, to fewer emergency admissions, and major savings to the health budget. But even if it doesnâ€™t, the benefits are obvious.
If there really is such a thing as â€˜clinical evidenceâ€™ in the healthcare system, I think there is a lot in the Frome story that could and should be transferred elsewhere. But then again, in the spirit of Inventive Principle 13, Iâ€™m inclined to suggest society as a whole uses their example to turn the whole system around and take their own â€“ community â€“ initiative. More friends, less pharmaceuticals, whatâ€™s not to like? I reckon we could have NHS costs below 10% of GDP before the end of the decade. Big Pharma or no Big Pharma.
More generally, I think thereâ€™s also a lesson here about using the Matrix and the Inventive Principles â€˜the other way aroundâ€™ to help find the someone, somewhere who already used them to solve a problem like yours.