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Analysis Essay

Reform reform: an essay by John Oldham

BMJ 2013; 347 doi: (Published 20 November 2013) Cite this as: BMJ 2013;347:f6716

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Re: Reform reform: an essay by John Oldham

Sir John Oldham nicely recapitulates my thesis that competing demands and unchecked complexity underpin our failure to reform many aspects of the health system[1]. As I pointed out back in 2011, we should give this state a name, and ‘system inertia’ seems as good one to pick as any.

System inertia can appear perplexing in a world that is in the midst of such constant change. It seems hard to reconcile the rapid growth in technology that we all experience with the equally slow pace of effective health reform. Change happens where there is headroom and spare resource, and industry creates that headroom by cannibalizing its own. Old companies and technologies are cast aside remorselessly.

There is something in the nature of healthcare that leads us not to rapid change but rather to organizational inertia – because we find inertia in health systems built on a commercial private model, as in the US, as well as in the strong publically funded model of the NHS, and mixed public-private system in Australia.

Oldham ascribes system inertia to a “bias to status quo” driven by the sectional views and interests of the different guilds and professions. This is no doubt true, but I think somewhat confuses a system behavior (inertia or a tendency to the status quo) with the structural causes of the behavior. The culprit is indeed excessive competing demands and the system complexity that they create. The explanation that I favor for their accretion is the tendency for health systems to accumulate variation, firstly because of natural statistical variation in practice. It is also due I think to a pro-innovation bias that values and rewards the introduction of innovations, but never values the equally hard task of decommissioning to create head room for the innovation.

It therefore becomes necessary to ask - “what strategies do we have to reduce competing demands, and hence complexity?”.

My suggestion from 2011 still stands – that whenever we innovate we must also look to programmatic decommissioning of services and service elements to create headroom for innovation to take hold - you don’t get to add anything without eliminating something of equivalent or greater complexity. The rules for such health system “apoptosis” remain to be developed. Importantly, “apoptosis is not excision”, which means that simply cutting and restructuring without a deep understanding of interconnection, and interdependency, is likely to lead to more harm than good.

We also need to reconsider the role of standards. As I pointed out then, one logical consequence of requiring ever increasing compliance with standards and guidelines is ultimate non-compliance. To paraphrase Herb Simon, “a wealth of standards will lead to a poverty of their implementation”.

Too often standards adoption is seen as an end in itself. There seems little work examining the effect of standardisation on system behaviour. There seems to be no work on the core questions of when to standardise, what to standardise, and how much of any standard one should comply with [2].

Sir John calls for rebalancing healthcare, with more support for the management of multimorbidity and generalists, which is a worthy goal. We cannot however lose sight of the underlying systems problem which is driving inertia, and that is accreting complexity and competing demands. No new structure or model of care is immune to it. Indeed it should in principle be possible to design a low complexity health system focused on specialization that is more effective than an overly complex attempt focusing on multimorbidity. It is the complexity that seems to get us, not necessarily the structures that we choose.

1. Coiera E. Why system inertia makes health reform so hard. British Medical Journal 2011;343:27-29.

2. Coiera E. Stasis and Adaptation. Studies in health technology and informatics 2013;194:11-19.

Competing interests: No competing interests

26 November 2013
Enrico Coiera
Centre for Health Informatics
Australian Institute of Health Innovation, University of New South Wales