The connected world we’re building may resemble a computer system, but really it’s just the regular old world from before, with a bunch of microphones and keyboards and flat screens sticking out of it. And it has the same old problems.
Though the answer may be integration, we don’t always know what the question is.
Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:
Integration across any of primary, secondary and tertiary healthcare
Integration across health and social care (and education and housing and etc.) boundaries
Integration of resources and processes
Integration at the level of the individual.
As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.Mathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.
Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.
Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.
Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.
And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.
(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)
If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:
Integration is harder than differentiation – though there are limited tricks to make it easier
It gives a bigger picture across a wider area than a specific view of just one point in time or space
It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
Integration is a subtle, complex process that takes time and understanding to do.
Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.
Altogether, there are many examples of economists who change their minds, even when doing so involves repudiating their own previous research and policy positions. Maybe these economists are special and possess an inhuman lack of bias. But I doubt that.
Feel free to share examples of where you’ve changed your own mind, particularly when it comes to public service reform.
The perspective on disability the film brought was, I thought, excellent. It explicitly included reference to the impact Professor Hawking’s impairment had on his life and the people around him. From a practical view it showed the adjustments the Hawkings had to make in their lives, and the importance of good support that came from a range of different people.
Most satisfyingly, the film clearly captures the fact that Professor Hawking realised his ambitions and what he was capable of irrespective of the barriers – physical, attitudinal, practical – that could have prevented this.
This is perhaps best demonstrated in the sequence following his pneumonia in Bordeaux. A doctor proposes a tracheotomy, meaning Professor Hawking will not be able to speak; feeling that Professor Hawking may not survive a journey back home the doctor asks Jane Hawking to consider ending her husband’s life. Jane refuses and instead finds a way that means Professor Hawking can communicate in a different way. Eventually, of course, he speaks using a synthesized voice – something probably as closely associated with him as black holes.
Without necessarily recognising it, A Theory of Everything provides one of the best representations of the Social Model of Disability I can remember seeing.
(From a film point of view, I think Eddie Redmayne as Stephen Hawking and Felicity Jones as Jane Hawking are fantastic. If the Best Actor awards are a straight fight between Redmayne and Benedict Cumberbatch (for his role as Alan Turing in The Imitation Game) then Redmayne should win hands down. Put simply: Redmayne is Hawking, whereas Cumberbatch is Cumberbatch being Turing.)
Update: The Washington Post shares similar thoughts regarding the film’s portrayal of disability (via @angelamatthews4)
As far as I understand it (as someone who is neither medically trained nor well-versed in the associated literature) there is good evidence that the placebo effect exists: when a patient takes medication or does something they perceive will help their condition to improve, it does (in either their perception or actuality), even if the medication or thing done has no proven effects.
Thus, irrespective of the evidence base of Personal Health Budgets, if people believe having a Personal Health Budget will make them better or contribute to making them better, will the mechanism of a PHB contribute to making them better?
This seems like a straightforward question to answer, doesn’t it? Most primary school children could give you an answer, and even if they couldn’t they could quickly look it up in an Atlas.
But perhaps it’s not as simple a question to answer as we think. Scotland and Wales are countries, aren’t they(?), and yet they don’t appear on the list of countries recognised by the United Nations: the UN reckons there are 193 countries, including “the United Kingdom”. My Times World Atlas from 1986 says there were 173 countries. And football’s governing body, FIFA, currently has a list of 209 countries with football rankings.
So, in order to know how many countries there are we need to ask ourselves at least two prior questions: (1) What do we mean by a “country”?; and (2) Who are we asking?
Maybe the question is a bit complicated, so let’s ask ourselves an easier question by going up a level: how many continents on the world are there?
Erm, well. National Geographic reports: “By convention there are seven continents… [but] some geographers list only six [and] in some parts of the world students learn there are just five continents.” Which means the answer again depends on asking other questions, including: (1) What do we mean by a “continent”?; and (2) Who are we asking?
This “facts” business is tricky, isn’t it?
I share this by way of thinking about what we mean by “evidence” in the context of “evidence-based policy” and the recent example of Personal Health Budgets.
A significant announcement by Simon Stevens, the Chief Executive of NHS England, about Personal Health Budgets gave rise to some teeth-gnashing earlier this month.
The gnashing focused on the evidence base that underpins the effectiveness of Personal Health Budgets. Some folks, especially the well-known Ben Goldacre of Bad Science fame, are not convinced by the current status of the PHBs evidence. They think there should be at least a Randomised Control Trial (RCT) to test whether Personal Health Budgets work. Others, including advocates of personalisation in public services more generally, noted both the results of the existing evaluation of the Personal Health Budgets pilot and the value of all types of evidence, especially including the views of patients/users themselves.
Both groups therefore lay claim to “evidence-based policy”, which leads me to two reflections:
It’s hardly an original thought (indeed, there are entire disciplines dedicated to such questions) but we must remember there is value associated with all different types of evidence and research methods. The value derived, and of the associated evidence arrived at, depends on what types of answers you’re hoping to uncover, how questions are framed and what pre-questions and/or assumptions underpin the framing of those questions. Different people have different thresholds for evidence and research methods, quite aside from the fact that one type of evidence or research method that’s a gold standard in one discipline could be next to useless in another.
For me, this is the equivalent of the first pre-question we came to in considering countries and continents: What do we mean by “evidence”?
Let’s not even get into the “policy” bit of “evidence-based policy”. For example, when has policy ever been based on evidence anyway? Does policy making happen in a rational, evidence-led vacuum that is protected from the whims of politicians and public opinion which, heaven forfend, may not be evidence based? Notwithstanding questions of what we mean by evidence, it’s safe to say that not all policy is based on what evidence there is. This is therefore the equivalent of the second pre-question we came to in considering countries and continents: Who are we asking what we mean by “evidence”?
The up-shot of this in the context of the evidence base for Personal Health Budgets is that Ben Goldacre and advocates of personalisation are both right, and they’re both wrong. There cannot be a definitive answer to the question of whether Personal Health Budgets are effective until some other, perhaps unanswerable questions, are considered.
That’s right. Adding all of the positive integers to infinity equals a small, minus fraction (and thus the joke of the tweet at the start of this post).
If you’re interested in how/why, the video below is a good starter .
Without wishing to make too much of a leap, I think this has two contradictory lessons when it comes to personalisation in adult social care.
If you follow rules and/or processes absolutely rigorously then what you might end up with could confound nearly everyone and what they would sensibly or understandably expect. In some cases, it would be reasonable to suggest things like Resource Allocation Systems could also fall into this category.
If you pursue something in an open-minded way, trusting the way in which you go about it and where the process takes you, then you might end up with a surprising, unexpected, but still wonderful and valid result. Again, in some cases, it’s reasonable to say things like co-production fall into this category.
[I]t has happened that so many of the twentieth century’s political tragedies have flown the banner of progress, emancipation, and reform… If I were asked to condense the reasons behind these failures into a single sentence, I would say that the progenitors of such plans regarded themselves as far smarter and farseeing than they really were and, at the same time, regarded their subjects as far more stupid and incompetent than they really were.
A nice summary of Scott’s overall argument is given here by Brettany Shannon.
I like the word metis, meaning knowledge that comes only through practical experience and/or local understanding, that Scott uses. Handy for capturing the importance of, for example, users in public service design and delivery.
The consistently thoughtful Stefan Czerniawski (also known as @pubstrat) posted an excellent set of reflections on Remote: Office not required yesterday, itself a book which “shows both employers and employees how they can work together, remotely, from any desk, in any space, in any place, anytime, anywhere.”
I thoroughly recommend you read the whole of Stefan’s post and the excellent discussion in the comments that follow [not often you say that – ed]. Of many excellent parts, how about:
Although few like to admit it explicitly, many managers do not have that trust or, more generously, have not needed to develop a management style which is based on trust.
Stefan also points to an excellent video from the RSA on Re-Imagining Work, which animates a talk from Dave Coplin (we won’t hold the fact he’s from Microsoft against him). It’s well worth 9 minutes of your time.
I’m not quite sure where I am on this. Drawing on my own experiences I’ve worked in places that are the extremes of both office-based working and remote working. Neither really worked for me. Then again, when I worked in a place that was generally trusting and so had a flexible approach to where you based yourself on any given day or week, this didn’t really work for me either. In this case there were different reasons at play: it was less the location of people’s working but more other organisational cultures (grappling with silos, funny enough) which made things difficult.
Inevitably, I don’t think there’s a general conclusion we can draw on where people should work. I know the balance is currently too far in the direction of traditional work models, but equally think the correction shouldn’t be taken too far in the other direction. Let’s work first on trust and approaches to management that are appropriate and relevant to the function of an organisation, and then figure out the form that follows.
Addendum: The opening of Dave Coplin’s talk really hit home with me about people who get the collaborative, networked approach we are moving to now, and how this differs from traditional views of management and work. My (admittedly silly) working theory is both that (a) those people who are more naturally collaborative will more often attribute where their tweets, references or thinking cites others, and (b) they will cite in less traditional ways, using @usernames and links rather than referencing according to the Harvard system or using footnotes.
(George Julian had some interesting reflections on an associated topic – the Modified Tweet – which you can read here and here.)
John Gray’s writing is challenging. It makes difficult points about doctrines we as humans hold of humankind – our progress, our religion, our place in the universe – and does so in a straightforward way.
For example, in his latest book, The Silence of Animals, we have:
Allowing the majority of humankind to imagine they are flying fish even as they pass their lives under the waves, liberal civilization rests on a dream.
Gray’s main point in this and his other books is that we are bound by our nature to repeat mistakes of the past. What’s worse, we think we have the capacity to get better, to improve, to progress, when history shows we have no such capacity.
Human progress is no such thing.
His argument has developed a little since Straw Dogs, in recognising that some forms of progress have indeed happened – in science and technology, for example. But he notes that the knowledge we gain from the recurring dilemmas of ethics and politics is not cumulative in the way it is in science. Instead, we are not capable of learning from past experiences of previously attempted solutions.
Gray concludes that we will not be different in future from how we have always been. Further, he argues that to think of progress as leading towards a future, attainable goal is wrong:
History shows history to have no goal.
But in this there is the possibility of freedom – a freedom that comes from the world having, in fact, no meaning. Thus, if there is nothing it “opens to us the world that exists beyond ourselves”, and that we can be “liberated from confinement in the meaning we have made”.
This is a similar point to the one made by Albert Camus in the Myth of Sisyphus. He concludes we must find Sisyphus, a man “condemned to ceaselessly roll a rock to the top of a mountain, whence the stone would fall back of its own weight”, happy. Camus says:
Sisyphus’s passion for life won him that unspeakable penalty in which the whole being is exerted toward accomplishing nothing… I leave Sisyphus at the foot of the mountain! One always finds one’s burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man’s heart.
Many find John Gray’s writing pessimistic. I find it redemptive, and recommend to you his work.