Frectally speaking

This blog has explored issues from healthcare, to management, to technology over the last 10 years now and aimed to explore these at many levels.

If you are following the news in Ireland the story behind the attempts to build a new National Childrens Hospital, it presents an instructive example of a complex/change/healthcare programme going/gone wrong.

In brief, what started out many years ago as an aspiration to have a new Childrens Hospital decades ago, then became a political challenge around where to build it. While initial estimate costs were in the €400-600m range, it then jumped to about a billion euro, now in the last months up to €2billion, with no clear/good explanation of how things got so out of control.

When you look at it it appears a classic example of a complex systems challenge mismanaged. I have written before about the Simple/Complicated/Complex/Chaos in our lives and the misunderstanding many people have between complicated and complex challenges. Complicated challenges can be often handled with clearly defined plans.
Complex challenges need a more iterative exploratory approach.

Lets look at the essence of the National Children’s Hospital (NCH) aspiration/plan for a moment to understand some of the complexity involved. In Dublin there are at present 3 separate children’s hospitals of long standing and for many years those siloes have been seen as a problem, so the nation would be better served by one, integrated, national children’s hospital.

• Challenge #1 was always going to be the alignment of the people, processes and technology from 3 hospitals onto one new site.
• Challenge #2 was the oversight and coordination of this challenge, one of the biggest of its kind that the Irish State has taken on.
• Challenge #3 was the delivery of the related building programme, which was in large part, to be handled by “the Market”.

I call out the roles of the State and the Market early on here as we know that many of the challenges of our time are down to the politics & economics of the problematic relationship between Nations and Corporations (as we have explored in other posts).

We know that many states/governments talk about transforming this or that sector but often struggle with the organisational change involved. Many businesses/corporation/market forces face the same challenges, though may be able to keep their failings from the public eye.
Either way both the State and the Market fail to acknowledge that most change is evolutionary rather than revolutionary.

The rapidly escalating/out of control costs at Ireland’s National Children’s Hospital , now estimated at up to €2 Billion, show the limitations of both the State and the Market abilities to handle large scale Big Bang projects/programmes. While the State will get most of the blame, bear in mind that many leading business players from the Market have been brought in to help with this project and it is the tendering process to the Market and out of control costs post award of tender that are raising the alarm bells. There is a key lesson to be learnt here, that handing over the complexities of a programme from the State (government) to the Market (supplier) does not make the complexity go away.

You can foresee already that the key lessons to be learned here will involve people (esp leadership and governance issues) and process (around the project management/cost estimation/tendering of the work) issues, those recurring patterns will feature in the analysis.. that’s pretty much guaranteed amidst the complexity here..

It will be interesting to learn of the methods that were used to plan and cost the building of the Irish National Children’s Hospital. The Irish have been travelling around the world to help in the building industry for centuries, so regardless of the Celtic Tiger folly, this building challenge should have been manageable. As the investigations into what went wrong begin, keep an eye out for the use of Building Information Modelling (BIM) techniques to plan out the detail in each and every room of the projected build. There are varied levels to the detail available with BIM practice , including costs that could /should be included. Indeed the really important interplay between building designers and cost managers is nicely explored here.

I’m highlighting this #BIM discipline as it hasn’t been mentioned in coverage at all that I have seen, but as we know information is key to managing projects, so it could/should have been key to getting the costs right, down to the desks in the rooms, if it was done properly, iterating through designs/redesigns until design/cost agreement was reached, in advance of any tendering/ground being broken.

As it happens Ireland NCH was supposed to be a trail blazer of the BIM approach in Ireland (though I expect that either the initial designs were way off or the cost elements were not properly included for projecting the total building cost or else BIM just doesn’t work – either way there was a root cause issue here). This important approach has only just recently (2017) been recommended for use in projects across the State and it is clear there is a lot of learn about this on both the State and Market side.

Beyond the problematic building plans (Challenge #3, not #1), I’d like to bring attention to one of the most significant by products of the NCH cost problem now faced, that is the occasionally mentioned IT aspect of the project where we see these State/Market failures are being compounded.

It turns out that one of the addons to the project cost was €97 million that been put aside for IT in the NCH project. Whats €97 million in the context of €2 Billion I hear you say? 5%? Modest!
How didn’t they think of that before you may ask? The answer to that is tied up with the broader wider health reform plans such as the current thought leading SlainteCare programme and the related related (and risky) ask from eHealth Ireland for €875m to fund a 10 year Electronic Health Record (EHR) procurement/rollout plan.

What ever way you look at it, in the context of the Irish Healthcare system (which is largely paper based and stuck in the last century from an information management perspective) a potential investment of €97m is major, so all of HSE IT eyes are now trained on this opportunity for that investment.

Which is completely natural and understandable, until you consider that this NCH IT procurement of €97m focused on the acute paediatric sector is likely to consume/silo and skew the vast majority of the entire Irish Health IT spend and focus until now 2022/23 (i.e. until the NCH opens)… so just lets say the next 3/5 years.

In the context of the really really important stuff that Irish Healthcare needs (those major needs beyond a National Childrens Hospital), i.e. in the context of the SlainteCare programme of reform and improvement (whether you agree with it or not) around a patient centred healthcare system (based on need > ability to pay), this poses is a really big problem/risk.

Over the last couple of years I have been sharing information and ideas on how Ireland could /should embrace the challenging move to digital healthcare, as this is now the main focus of my work. In doing, so I have recently been warning of the risks of a waterfall style procurement towards a big bang spend on an EHR system/systems as the wrong way to do this. At this point in time, that’s exactly what the NCH IT programme looks set to do, another case of the State naivety of how to handle a complex challenge and hand the problem to the Market.

See Health Improvement in Ireland- for the Record(s) from 2016
and Irish HealthIT: It’s time to Innovate from 2017

As if that skewed NCH IT spend wasn’t problematic enough, the aforementioned Challenge #1 of the People (ie clinical staff from 3 independent hospitals) + Process ( 3 different ways to working across those 3 hospitals) + Technology (3 different tech landscapes) alignment between the hospitals hasn’t been done much at all, so a big bang change transformation is being teed up, that will force the alignment of organisational siloes, working practices and a ramp up of the information tech of the 3 independent hospitals, aimed at the promise of being “born digital“. I’m sorry to say it, but in my experience and opinion, this is a real recipe for a further big bang bungle.

You may not be believe me..
Well I’m afraid I’ve “been there, done that” during my 5 year time in the NHS as a medical doctor within the NHS National Programme for IT which spent up to £12 Billion (yes that’s billion not million) trying to bring Electronic Records to the NHS (between c. 2002-2016) and which floundered/failed on the acute hospital sector back in 2011.
Conversely, other work I later led in Leeds across the large multi-hospital Leeds Teaching Hospital group (which includes one of the UKs largest children’s hospitals) and then across the city of Leeds shows how this can be done better, at a fraction of the cost that is being considered here.

As a general rule, the answers to the challenges in 21st Century healthcare lie in clinically led, user/patient centred design and agile/iterative/evolutionary developments, rather than big bang programmes of revolutionary change.

We need to better understand how to tackle such complex challenges, so those in positions of responsibility within both the State and within the Market need to educate themselves on how to navigate and manage complex organisational change, where cooperation is as important as competition.

The story of the challenged delivery of the National Children’s Hospital in Ireland should be a wake up call in Ireland on that.