Questions about edge work

by Philip Boxer

The following questions were asked by Larry Hirschhorn about the blog on empowering the edge role, following which are my responses:

Larry: You say that edge work is breaking out almost everywhere. Can you give me an example?

Philip: We worked recently with the members of a clinic providing through-life care to patients with chronic conditions. The hospital managed the clinic’s activities in terms of treatment episodes, and budgeted the clinic according to their annual episode throughput. Because patients stayed with them long term, their budget tended to keep increasing because more patients were referred to them than died or left the area. But their budget couldn’t keep increasing. So instead patient care was rationed, the result being systematic under-use of the treatments available, to the long term detriment of the patients.

Larry: Where does ‘edge’ come into that?

Philip: As part of an acute care system, it made sense to treat the clinic as part of the centralised drive to provide cheap treatments. In these terms, the patients had to fit in with the hospital’s programming to provide the most efficient use of its resources. But the conditions in the clinic needed to be treated on a through-life basis, each course of treatment being designed to fit the particular patient’s condition. This meant the clinic’s (and behind that the hospital’s) resources fitting in with the programming of the patient’s treatment.

Larry: What made the project challenging?

Philip: First of all, although the clinicians had high situational awareness of their patients’ conditions, their ability to synchronise the behaviour of their own and others’ clinics around the needs of the patient were very constrained by the hospital’s internal processes of referral. Secondly, there was no way of holding the clinicians accountable for the way they aligned treatments (and costs) to patients’ conditions. Thirdly, the senior management used fixed budgets as a way of controlling the aggregate performance of clinics, there being no way of flexing them according to the mix of conditions different clinics were being asked to treat.

Larry: And how do you relate these challenges to the failings of bureaucracy?

Philip: Bureaucracy works by taking a big problem and breaking it down into little problems. The assumption is that if you solve all the little problems, the big problem will be solved too. This is called ‘deconfliction’ – each little problem is defined in such a way that it can be solved independently of the other problems. So the clinics with their associated budgets were defined on this basis, and as long as the levels of demand were stable and there had been enough time for patterns of treatment to settle down, things could work okay. This might have been true when both treatments and conditions were simpler, and the medicine less advanced. But it is not true now. The increasingly chronic nature of conditions, combined with the need for treatments aligned to the particular patient, means that treatments have to be adapted to patients and not vice versa. Bureaucracy can’t cope with this.

Larry: So what did you have to do differently?

Philip: There were a number of things. Firstly, we had to alter the way clinicians made referrals to each other so that authority to determine treatments was delegated as close as possible to the edge. Then we had to support the way the clinicians needed to manage treatments in a way that could also hold them accountable for the performance of those treatments. Thirdly, we had to change the way budgets were allocated so that they were based on the mix of patient conditions being treated. And finally, we had to secure funding on the basis of the cumulative cost of securing long term patient health outcomes instead of on the basis of the short term incidence of acute conditions.

Larry: Were you successful?

Philip: We proved that it was much cheaper in the long run to organise the clinic in this way in 6 different hospitals. But to sustain the changes it meant reallocating budgets on a different ‘edge’ logic across clinics. This the larger systems weren’t ready to do.

Larry: Would you say that it created more effective government due to edge work?

Philip: More effective government requires three things: the political will to do things differently, the ability to create value at the point of contact with the citizen/patient, and infrastructures sufficiently agile to make change practicable. We failed on the third count. Our brief was to make the edge work better, not to change the agility of the infrastructure. And I think that is the particular difficulty. To make the edge work better, you have to change the agility of the infrastructure, and the vested interests of the former are very different to those of the latter.

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