Refactoring the Healthcare System

Outgoing Health Minister Leo Varadkar made quite an odd statement there a few weeks ago, referring to the shortage of beds and other resources in the public health system. It caused much rancour on my twitter feed and I have to wonder if he actually believed it himself, or it was a party line he was relaying, safe in the knowledge that whether it was utter nonsense or not he would retain his seat. It turns out that he was right, about his seat. But anyway, the statement:

“What can happen in some hospitals is sometimes, when they have more beds and more resources, that’s what kind of slows it down.”

When asked why, he replied: “Because they [hospital staff] don’t feel as much under pressure.
“When a hospital is very crowded, there will be a real push to make sure people get their x-rays, get their tests and, you know, ‘lets get them out in four days.’

“When a hospital isn’t under as much pressure, you start to see things slowing down and it might take five, six, seven days to get the person discharged and that’s [the] length of stay, so it’s all these different factors come into play all the time.”

I suppose there is a certain logic to this … yes, if there is a shortage of beds it does add an additional reason to turn patients over and get them out the door. I’d question why though, this turnover is necessarily seen as a measure of productivity; there’s an implication in his statement that patients staying an extra few days is down to some inefficiency – surely not “laziness” – but perhaps a lack of motivation on the part of the hospital staff.

But perhaps there are other reasons why a patient could be kept in a little longer: Perhaps it’s simply too soon for them to be discharged? Maybe it’s simply in the interest of the patients to stay in for observation a day or two more. But in any case, surely there are better ways to ensure “productivity” than limiting available resources. Roughly speaking it’s kind of like say taking a player off your football team and expecting them to “play harder” with ten men (you lose the match), or restricting the flow of petrol to your engine to increase fuel efficiency (you most likely damage your engine).

Anyway, I am obviously not a healthcare professional, nor a political actor, and while these remarks caused me some concern as a taxpayer and potential health system user, they didn’t really anger me. I see a healthcare system that is a black hole for money, a government whose whole policy is putting a rein on public spending, and a minister trying to put lipstick on the pig. For all I know Leo knew full well what he was saying was stupid, and he may have even been making a discordant statement on the sisyphean absurdity of being an impugned vassal state trying to pay off a debt with money loaned by creditors.

But it did get me thinking about the whole dynamic of “productivity” vs “utilisation”, and how such statements effectively confuse these two terms. I have a small bit of knowledge on such things rattling around in my head from my undergraduate days (specifically relating to network switches, but abstracted as “systems” a perfectly suitable analogue). In a nutshell, you can run around in a circle all day and you would be fully utilised yet you would have got nowhere so your productivity would have been effectively zero.

For a network switch, if it has a maximum capacity of 1 Gigabit per second, and you are relaying 900 Megabits per second then your utilisation is 90%. It’s generally a good thing, but then again if you relate the “value” of this data directly to this number then you only have that remaining 10% capacity to get more value out of your network before you have to buy a new switch. Then what happens if you have a spike in traffic?

As a software engineer, I sometimes find myself faced with these problems. In the rush to get to market short cuts are taken and sometimes the implementation isn’t optimal and sometimes that needs to be fixed. This often involves a broad system-level analysis to determine specific bottlenecks, and then a root and branch analysis of particular elements. Often times a one-line fix here or there is sufficient to get a significant improvement, other times an element needs to be reorganised, or even the whole system needs to be re-orchestrated – obviously the first of these options is the best but sometimes you just need to upend things, and swallow the associated risks.

This kind of pragmatism is often scoffed at by commercial personalities “why bother when you can just buy more hardware?” or “increase resource allocation on [cloud platform]?” which is in the near-term much cheaper than paying for expensive engineering time. Bjarne Stroustroup’s answer to this is that “If you’re dealing with a server farm, doubling your resource retention means you need another server farm. They aren’t cheap, and they’re not cheap to run”. There are times when you need to look at application efficiency (productivity basically), not all the time, but there are critical instances where it very definitely is commercially necessary.

So when you look at your switch running 90% utilisation and you want to get more value from it, without buying a new switch then what are the options? You need to get more value for that 90%. You look at the traffic going through it and see what you can do with that. You could add some compression to some of the applications using it; perhaps identify and throttle some high-volume activity; there may even be some unnecessary activity on there, or some misbehaving applications that need tuning.

Now you’ve still spent money in terms of expensive engineer hours rather than a shiny new switch. There is some comfort in owning your switch, since people are fickle but you would have had to pay somebody to install the switch anyway. If you got your utilisation down to 45% now you’ve got twice as long before you have to buy a new switch and when you do that it will last twice as long again (factor in ever-plummeting equipment costs and you can put the depreciation value in your pocket too).

So where does this leave Leo and his under-productive but over-utilised health service? Well after hearing what he said I felt some correction was in order so I googled “utilisation vs productivity” and came up with this beautiful article. I still haven’t finished reading it yet, but it has so much good stuff in it that I can directly relate to from my days as a junior engineer. You could pretty much take the terms “Product Development” and replace them with “Healthcare”. It covers some of the common fallacies of management seemingly reapplied rote from a widget-manufacturing context, ala Adam Smith.

Leo isn’t in a position where he can “buy a new switch” to increase capacity. Even if additional healthcare workers were readily available there is a reluctance to splurge extra money when during the nineties we did just that and just ended up making things worse. To wheel out yet another oft neglected software engineering trope “adding manpower to a late software project makes it later”.

So again what is he to do? When there’s nothing he can buy, and he can’t throw money at it anyway … when conventional business wisdom fails but he needs to get more bang for his buck??? Rather than treat it as a black box (money goes in, productivity – whatever that is – comes out) he might employ a more enlightened “white box” approach.

Just like sometimes a business needs to concede that good old fashioned sciencing is vital, he could start by consulting actual HSE staff. Some of the smartest people in the country work in medicine – it couldn’t possibly be the case that they have no idea how things could be done better.

The “box” is populated with many highly qualified, motivated people who would be only too happy to offer their advice and insight if only somebody would ask. I think traditionally it was the role of the unions to channel the concerns of workers, but that kind of process is more to protect workers than endow businesses, so I don’t think these organisations have that capability.

There is this gaping chasm in terms of cross organisational communication and for my money I think addressing that would be the best place to start. A cross disciplinary convention (similar to the constitutional convention) of HSE staff could be a good place to start getting soundings before embarking upon some subtle organisational transformations. Though perhaps reforming such a gigantic organisation would be a herculean and politically toxic task – that being the case maybe it’s time to apply another popular engineering method and start breaking the big problem down into smaller simpler parts.


I suppose it is worth noting, for the benefit of more pedantic readers, that depending on what happens over the next few weeks it may not end up being Leo’s problem at all. But seeing as I started the narrative with his statement it made sense to make him continue pushing the rock uphill throughout 🙂

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