Wednesday, 11 January 2006
The Wisdom of Crowds and the National Health Service
I finished "The Wisdom of Crowds" by James Surowiecki (Abacus £7.99) on January 2nd and wondered what his conclusions meant for the National Health Service. The book is sub-titled 'why the many are smarter than the few' and is a useful challenge to the idea that medical matters are too complex and important to be left to the patient.
The reputation of a hospital or indeed a school is something that the many construct. Surowiecki makes the point that their conclusions are likely to be much better than the view of a smaller but more skilled group - the experts. He is also strongly sceptical about targets.
How does this play out in a health service? For my purposes today, I will characterise the health service - managers and clinicians - as the experts and the service receivers as the crowd. Expertise is exercised over a very narrow scope of reference - one example would be chess experts focusing all their skills on the board. Can anyone really claim that same degree of expertise in broad areas such as 'policy', 'strategy' or 'decision making'?
Studies show that experts' judgements to be neither consistent with the judgements of other experts in the field nor internally consistent. The book quotes a study where "the internal consistency of medical pathologists' judgements was just 0.5, meaning that a pathologist presented with the same evidence would, half the time, offer a different opinion." We in the UK have recently had some headline court cases where expert opinion has been held to be seriously flawed. Experts routinely overestimate the likelihood they are right with another study showing that "physicians, nurses, lawyers, engineers, entrepreneurs and investment bankers all believed that they knew more than they did". So it is not simply that experts get it wrong: they also don't have any idea how wrong they are.
Politicians do not do any better. The kitchen cabinet form of government where a small group in Number 10 formulate policy which is then sold to others suffers from the same failings as the small group around President Kennedy who planned the Bay of Pigs invasion of Cuba. Small homogenous groups fall prey to groupthink. They become more cohesive more easily and more rapidly than more diverse groups and as they do so, they become more dependent upon the group and more insulated from outside opinion. Arthur Schlesinger Jr. the great historian of the Kennedy years and a participant in that ill-fated venture wrote "Our meetings took place in a curious atmosphere of assumed consensus". The administration took no serious advice from anyone sceptical of the prospects of success. They became believers in their own success and could not look on the faces of any dissenters.
Here politicians or indeed any leader in charge of a system which is very large and with huge bets riding on future patient and public behaviours and their ailments and needs have to be believers. The only other alternative would appear to be admitting that no one has a clue which would be very scary and dangerous for politicians who need to get elected or chief executives who want to keep their jobs. They often therefore get very tough when enforcing their vision of the future on health care workers using the targets technique. In doing so, the target setters are inciting what one writer has called "inauthentic behaviour" within the organisation they want to control ie people telling bosses what the bosses want to hear and doing the things bosses ask them to do even if they think they are stupid and wrong. Targets distort behaviour and institutionalise lying about what is actually happening.
So who to trust? The crowd that's who -the aggregated opinions of the individuals making their views known to suppliers at the point of delivery. The suppliers can only respond if they have the money to do so. But the money emerges from a system run by experts, politicians all engaging in groupthink guessing what the crowds' needs would be when they drew up budgets last year or the year before that. Users - individuals or in groups - know nothing of these plans. They are only aware of their frustrations when their needs cannot be met.
Read the book and email us with your views on how the argument in it could be applied to improve the health service. It was interesting to see in today's (11/01/06) newspapers the Health Select Committee's view that ministers should have allowed the trusts (PCTs) "to develop organically and adopt a managed approach to sharing best practice in commissioning" instead of responding to central directives that the committee characterised as "clumsy and cavalier".
The Wisdom of Crowds James Surowiecki £7.99 Abacus ISBN 0-349-11605-9