As a keen student of health informatics and how data can power better outcomes and accountability, it came as no surprise to me to find Care.data on the front pages of the broadsheets in recent months and weeks. Care.data is designed to capture and link data so it can be used by the NHS to analyse and improve outcomes. In the hands of the public, comparative data can support choice, transparency and accountability. Data enables innovation, efficiency and saves lives. Some headline!
But it is a minefield of Data Protection, Information Governance and privacy. Once exposed, a person’s most intimate concerns – their health – can’t be taken back. Patient confidentiality is paramount and any “Information Revolution” within the NHS must guard this principle to the end. Widespread concerns mean my former colleague from HM Cabinet Office, Tim Kelsey (now NHS England Director for Patients and Information) has extended the public awareness campaign for another six months.
Advocates of data should feel down, but not out. The truth is that we can’t run a £120bn health and social care system without use of more and better data. Winter pressures on A&E units showed that services are under severe strain from rising demand and tightening budgets. Without in-depth knowledge of which treatments are working, which services are underperforming, where systems are failing to join up or where patients feel their expectations have not been met, our world class health service will grind to a crushing halt. This is not about savings, it’s about survival.
Health is at the forefront of our public services in the degree to which data is already used to inform effective and efficient delivery. Whether collected by professionals, offered up by patients, open and freely available to the public, or closely protected, the potential of data within healthcare is huge.
The same principles apply to other public services and places. The City Growth Commission is interested in how cities can be empowered to create sustainable, inclusive economic growth. Much of the evidence we have received so far has focussed on fiscal devolution and linking public service reform with economic development at the city-level. Comprising up to 40% of cities’ expenditure, health and social care will be a crucial component of this and some (e.g. Bristol) are already starting to broaden their approach.
But what about education or infrastructure investment? How can cities securely link school destinations data with FE course completion and earnings data to tailor its skills offer? How can cities anticipate demand and install sufficient infrastructure capacity – whether utilities, energy, or housing? Data has the potential for cities for fine tune themselves as whole ‘systems of systems’.
Many cities, such as Birmingham, Manchester and Sheffield, are already looking to use Open Data released by government and public sector agencies, and not without challenge of accessing the data they need, whether public sector or from contracted suppliers. We’re at the start of this journey, with many complex issues to resolve along the way. As the Care.data example shows, maintaining personal privacy is vital for cities and services to maintain trust. But the prize for navigating the landscape is considerable; data is a critical enabler of better outcomes, productivity, and growth.
This blog has been written by Jennifer Barnes, intern with 2020 Public Services team
Today, the Healthcare Insurance Marketplace is going live. Its feels like a distant memory now, but in June of this year, Democratic Senator Wendy Davis stood up in her pink trainers and delivered an incredible 11 hour filibuster in the Texas Senate against a bill that would take us back decades (to before the landmark Roe V. Wade decision) in our fight for women’s health. After all of the media attention, the twitter support, and the hundreds of confiscated tampons, we seem to have forgotten about the impact the passing of this legislation will have on the lives of Texas women.
As a Texan woman currently on an internship with the RSA, I wanted to share insight into the Texan example of how policy making can result in perverse incentives and unintended consequences. I hope that this post is enough to pique your interest in the current happenings in Texas as well as the wider healthcare debate in America.
House Bill 2 disregards the challenges that women face when it comes to affordable health care by:
- banning abortions after 20 weeks
- requiring clinics providing abortions to raise to the surgical standards of outpatient surgeries (read about procedures in other states that are performed in both licensed and unlicensed clinics)
- requiring that a doctor be present when a woman takes drugs to induce an abortion (although there is no evidence or history of danger)
- requiring doctors practicing abortions to have surgical rights at a hospital within a 30-mile radius of the clinic
While Texas has become the 13th state to pass legislation banning abortions after the widely debated 20 week mark, it is arguably the latter three requirements that are most cause for concern. Presented in the rhetoric of raising standards, these stipulations instead eradicate options. The passing of this bill is predicted to close dozens of clinics across the state (with the highest closure estimates predicting all but 5 of the state’s 42 abortion providing clinics), most notably those in disadvantaged, rural areas where alternative healthcare options are limited.
“Governor Perry and other state leaders have now taken sides and chosen narrow partisan special interests over mothers, daughters, sisters and every Texan who puts the health of their family, the well-being of their neighbors, and the future of Texas ahead of politics and personal ambitions.”- Wendy Davis
To understand the likely impact of the changes that House Bill 2 will bring it is important to understand how medical services for women in Texas, and elsewhere in the US, are funded.
Contrary to popular perception, pregnancy terminations form a very small part of what the major women’s clinics actually do. For Planned Parenthood, for example, the organisation that runs the majority of abortion providing clinics, abortions are only 3% of the medical services provided. But they are financially crucial. 30-50% of Planned Parenthood’s surpluses are generated from termination services. What this means is that as the system currently stands, many of the cancer screening, sex-education, STD, pre-natal care and pregnancy prevention services that are accessible to low income women will potentially become more difficult to fund if the legislation succeeds in driving down the number of abortions.
Alternatively, if clinics are required to invest in expensive unnecessary upgrades to surgical standards to perform abortions, they will have to choose between closing or stopping their abortion provisions entirely. Planned Parenthood gets about half of its funding from government, but there are strict limitations on how it can be used. Title X funds are the only federal funds devoted to family planning and by law these funds cannot be used for abortions. If the state increases funding for family planning provisions outside of abortions, the clinics will likely survive, but will no longer offer terminations.
This funding atmosphere has created a complicated and unbalanced relationship between terminations and other women’s wellness provisions, and wrongfully reduces this conversation to one of economics, not value read more on ThinkProgress.
Pretend for a minute that you’re Cathy, a sexually active 16 year old girl in Texas living in a conservative town where everyone knows everyone and you all go to church together on Sundays. Your church and your high school teach abstinence-only and therefore your sexual education is lacking, but you become sexually active anyway.
If this is your reality, then the likelihood that you would be willing to buy condoms from the local pharmacy (where the pharmacist is friends with your father) is slim to none. It’s quite unlikely that you’ll go to the clinic for birth control and free condoms. If your closest clinic is up to two hours’ drive away, it becomes vanishingly unlikely. If you become pregnant and have spent the first few months working up the courage to face what’s happening, the 20 week mark will significantly limit your options even if you do make the drive.
This isn’t an unlikely story in many areas of rural Texas. Here, a young girl is strongly deterred from accessing birth control and receiving an abortion due to logistics and circumstances over which she is powerless. Here, the passing of House Bill 2 achieves the pro-life agenda and significantly reduces access to abortion.
Regardless of your thoughts on the morality of early termination, an alternate scenario is enlightening:
Now consider that you’re Julia, a single mother, working two jobs to pay your bills. You work part-time jobs without health insurance and you can only just afford the premiums even after the Affordable Health Plan takes effect. While you are eligible for the Texas Women’s Health programme, the doctors taking part in it have taken their quota of Medicaid patients so this option becomes almost worthless to you. Even if you have a health insurance plan, your deductible (the amount of money you must spend before the insurance company begins to pay for your health services) is enormous, leaving clinics like Planned Parenthood the only places you can go for affordable reproductive health needs and screenings.
The local clinic shuts down and you don’t have the time or energy to drive to the city for an exam when you start noticing mild symptoms. The gas money to get there is too much and the childrens’ schedules are too busy on top of your multiple shifts…so you ignore the symptoms. When the pain becomes too much to bear you hire a babysitter that you can’t afford and go to the closest clinic, 100 miles away. By then, it’s clear that you have advanced cervical cancer.
Supporters of this legislation ignore the reality that for many women, clinics like Planned Parenthood are one of their only affordable options for reproductive care. In many geographic areas, for those who earn too much for government Medicaid assistance but lack private insurance, Planned Parenthood truly is one of their only options. The story isn’t that Planned Parenthood supports pre-marital sex and abortions, the story is that Planned Parenthood supports women and their freedom over their bodies.
The passing of this bill limits women’s freedoms: freedom of choice is nonexistent when there are no options.
With a triple dip recession looming in the UK, it is increasingly clear that there is a need for fundamental reform of the UK economy. But there is little consensus about how to make this happen. The form of capitalism adopted by much of the West is predominantly based on the achievement of short term growth, with the banking crisis and the UK’s depressed economic performance arguably the result of short-term profit seeking with little regard for the longer term consequences. In the banking sector, retail banks have resorted to unsustainable tactics to make money from their customers, while the extreme financial incentives to increase profit in investment banking have led to dishonest dealings and collapsed markets. Likewise, on the high street, short term market incentives prompt grocers to squeeze their suppliers on cost while driving their customers to over-consume through carefully devised offers and by prompting impulse buying.
How can an economic recovery take place in the context of such unsustainable market forces? The policy response has not proved very helpful. When these sustainability problems arise, the usual government response is to reach for new policy levers, regulation or sanctions. Sometimes industry captains get together to try to find an answer. In conference after conference, people discuss the change that needs to be seen, usually to little effect.
One of the problems is that incumbent players in an industry cannot alter their ‘basis for competition’ and no amount of top down pressure can change this. Professor Clayton Christensen of Harvard Business School explains in his research that innovation within an industry normally takes place to achieve incremental change rather than transformation. So transforming a market is extremely difficult. As a result, unsustainable factors which are inherent to industry models actually grow with the market themselves to become larger and larger challenges to society as a whole.
This is not just a private sector problem. In the UK, demand for healthcare has grown by four per cent every year since the inception of the NHS. Between 1997 and 2007, the NHS budget grew from £44bn to £96bn. This is 225 per cent more growth than the FTSE 100 index and 170 per cent more than GDP growth over the same period. The reason is that it is in hospitals’ interest to supply more services, even though they are a publically funded good. Yet this level of inflation in healthcare costs is definitely not sustainable, and represents a global challenge in the coming years. The incentives are backwards.
However, an anomaly to this is the technology sector. Unlike many other sectors, this industry consistently transforms itself, altering not only its own business models but also transforming how society functions. Why is this? Let’s consider some of the factors:
- The sector takes its inspiration from visionaries who have developed globally transformative solutions, starting from their garage. As Steve Jobs put it, it is the ones who are crazy enough to think they can change the world who usually do.
- Technology communities are well connected, allowing knowledge and communications to travel quickly, and enabling ideas to develop into solutions.
- The tech industry has enjoyed a disproportionate share of the global venture capital spend.
- Platforms such as Windows, Apple, and Google Android are making it easier for many people to develop applications for a mass market.
- Governments and organisations have set up technology hubs for entrepreneurs to test and grow their solutions.
For these reasons and many others, it has been possible for new people to enter the market and transform it from the bottom up. Better solutions and new business models have been able to displace those that don’t work as well. Yet if any link in this chain were removed, barriers would prevent this process. For instance, if VC finance were scarce in technology, then it would be harder for solutions to scale to the next level of development and incumbent players would maintain more control.
What has happened naturally in the tech markets is that the “right thing has been the easiest thing”. This has created a truly transformative, adaptive market. There are fewer barriers preventing someone from setting up an innovative global tech business than an innovative healthcare solution or a bank. Yet the sector has not collaborated at corporate levels, they have not looked to Davos for solutions and it has not been organised top down.
How can we apply this learning to other sectors? There are already some examples where markets have been rebalanced without the use of regulation. The Fairtrade movement has inspired innovation and sustainability in coffee, cocoa and many other supply markets where natural short term market forces were leading to unsustainability. Unsustainable supply is bad for growers, manufacturers, retailers and consumers; so the Fairtrade system has effectively a more balanced and prosperous outcome for all.
The same approach could be used in large corporations to solve endemic problems which conventional strategy fails to address. I have been working with The Fairbanking Foundation, an organisation that works with banks to create and certify new financial products that improve the financial wellbeing of their consumers. Some products make it easier for customers to make and reach savings goals; others help customers to better manage income and expenditure. Both improve market sustainability. And this type of innovation requires no regulation. It just uses the market.
Likewise, in healthcare, we are looking at the barriers that prevent ‘the right thing’ from happening. On this basis we are designing and implementing solutions to overcome these blockers. First, one of the most serious problems in healthcare is that health organisations are not assessed on the basis of the value they deliver to patients – that is, on the basis of positive patient outcomes for every pound spent. So we are developing a value based measure to make this easier. Second, healthcare organisations are unable to transform their service models to satisfy today’s needs. So we’re setting up public sector vehicles to test and scale new service models with the potential to better serve the needs of a target group. These come from healthcare practitioners, social carers or members of the community.
If market forces are causing a sustainability failure, then we must find solutions which alter the market dynamics in order to drive sustainability. The logic applies equally to private and state controlled markets, or to problems internal to corporations. All that is required is thinking differently about the problem. Instead of creating more regulation, what is needed is a strategy for taking away barriers for the market to correct itself. In other words, we need to find ways to make the right thing the easiest thing.