Perhaps we should manage the health services a little more like a metropolis such as New York City than like an enterprise such as Toyota?
Photo: Einar Nilsen
«What was needed to plan something like this?» my travel companion asked me as I slumped exhausted on to a bench after having strolled the streets of New York City for hours on end during my first visit there. The city is a breathtaking experience, a whirl of impressions: astonishing, sumptuous, banal, disgusting, exclusive, threadbare and quite ordinary – all at once.
But there is order in the chaos, of course. One discovers this on repeat visits. At the micro level, nearly everything has changed. The newspaper seller, your favourite café, the amusing antiques dealer and the lively jazz club are no longer where they used to be. However, the city remains just as eventful and dynamic, and you can find everything you need – and much more besides. The atmosphere and the dynamism are unchanged. You become just as surprised, exasperated and enthusiastic. Some things remain where they always were, and with the same function: Times Square, Brooklyn Bridge, Central Park and the Grand Central Terminal. The Twin Towers are gone, but in spite of the tragic reason, it makes little difference to the city as a whole.
In this manner, New York City resembles other metropolises. They are diverse, dynamic and adaptable. They provide what their inhabitants and visitors need and want. They change, but remain true to their character.
How does such a city come to be? Can it be planned? Hardly, at least not in any detail. But this does not mean that everything is in flux and that nothing has been structured, planned or predetermined. On the contrary: for a complex and multi-faceted metropolis to function, there must be a solid infrastructure and clear frameworks: Roads and public transport, waste disposal, a fire department, laws and regulations (and people to enforce them), to mention but a few. There must be day-care and schools – and a safety net for those who cannot take care of themselves. Moreover, there must be institutions that make decisions and collect money for shared objectives on behalf of the population – i.e. politicians. In brief, a large amount of structure and planning is required in order for a city to appear as spontaneous, dynamic, diverse and chaotic.
However, the New York City authorities do not decide how many theatres there should be on Broadway or what plays they should perform. They have no detailed plan for what restaurants should be located where or what they should have on the menu. They have, however, clear views on building standards, hygiene requirements, escape routes and statutory conditions of employment. They also have an impact on life in the city through the prices, timetables and public transport safety, through streetlights and maintenance of public parks, property taxes and the presence of police on the streets.
On the other hand, if one sets out to produce the world’s best nails, chocolate bars, MRI scanners or drugs, the process must be planned in detail within a streamlined manufacturing enterprise. This will make it better, cheaper and more efficient than if the same items are produced more or less ad hoc. Even health services can be produced in this manner, the precondition being that there is full agreement regarding the services that are to be provided. «Standardised package pathways», or standardised patient pathways, which Bent Høie, Minister of Health and Care Services, referred to as one of the main initiatives in his hospital speech on 7 January 2014, are examples of this approach. This means that patients with well-defined conditions follow similarly well-defined treatment pathways. Many diagnostic procedures and drug-based or surgical interventions are being planned and «mass produced» in this manner – with excellent results.
Problems arise, however, when one attempts to plan the entire health service in detail, modelled on a gigantic industrial enterprise. The bulk of the activities cannot be mass produced, and only selected patients or groups of patients will be eligible for «package pathways». Moreover, medical science is developing, and so are the patients’ preferences. Any long-term plan will therefore be outdated as soon as it is formulated. Furthermore, manufacturing enterprises provide few incentives for innovation. State-owned manufacturing enterprises have the additional disadvantage (for the users) of not being shut down even when they produce inferior or unnecessary goods.
Perhaps we should take the chance on planning and managing the health services more like a metropolis such as New York City than in the manner of a successful enterprise such as Toyota? That is, more like a structure intended to fulfil a diversity of needs and be in continuous development than like an enterprise designed to produce pre-defined goods and services? What would this require?
The key issue would be to have a firm grasp of what the public sector must operate and finance itself, i.e. the essential infrastructure. Which parts of the health services correspond to roads, public transport, disaster response services, streetlights and the police? All emergency medical services, I would say, and all treatment and care for rare and costly diseases, but what else? Perhaps education and research? It’s debatable. It is equally important to have clear and predictable frameworks for all diagnostics and therapy that do not necessarily have to be provided by the public sector, but where society has clear, overall notions of what should be provided and at what level of quality. Defining frameworks does not imply that one must finance the services, but that one can do so, for example in the way the regular GPs are financed today. One can also be content to decide the frameworks for how things should be run – in the way the Broadway theatres operate.
Such management provides more flexibility and better opportunities for customising and development. On the other hand, of course, this also means less predictability for those who work there. If this is to function, however, one must take the risk of doing it wholeheartedly, rather than creating a «quasi-market», as was done with the Enterprise Reform. This will soon result in the worst of all worlds.
It is easy to argue how wrong it would be if not all hospital staff members were public-sector employees. This works extremely well in most other countries, though. And this was exactly what was done in the primary health services with the introduction of the regular GP scheme.