The  other day I was having my customary morning coffee in my usual place. As usual,  I was alone with the waiter. We started talking about everyday life and ended up conversing about financial facilities and the economy in general. His bank recently sent him a form that will allow him to acquire the  handsome sum of 4.000,00 € with just a simple signature and a not-so-simple annual interest rate of 15%! He was clever enough not to jump at the offer. But one thing led to another and we ended up wondering if anything would  prompt his employer to hire another waiter. He looked around and came to the conclusion that what his employer needed were more customers coming through the door, not more waiters attending one customer.

If the diagnosis is faulty, the cure will be useless in the best of cases and fatal in the worst case scenario. So, are we in a supply deficit scenario like most of our world leaders think? Or are we in a demand-deficit scenario as my waiter thinks? Sorry to say but I tend to think that what is lacking is demand and all and each of the measures that European Governments are taking are killing the little demand we have.

Let´s hope that sound economic thinking has not disappeared from the face of the earth and, just as in  the Dark Ages there  were niches of knowledge, today somewhere there are people with the knowledge to bring us back to economic health.

So far, we are witness to how society has approached the challenges posed by an ageing XXI century society with care processes designed in the XIX Century. All we have done is to provide the expert with tools, technological and pharmaceutical, to help in certain tasks of the care process. Very little has been done in the field of re-engineering the care process itself.

I see three main reasons for this sorry state of affairs. First, our focus is on caring for acute problems, not on preventing their occurrence. It is like the person who, seeing a banana peel on the sidewalk, is ready to help anybody who trips but is not capable of picking the peel off the ground. Even though different expertise is needed for each of the processes, anybody can see that it is cheaper to remove the banana peel than to heal the injured. As is often the case, the expertise for the solution of the problem, a street sweeper, is cheaper than the healing of the problem, a health care professional.

A second reason is that we are treating the human being as a sum of parts: health, social, economic, cultural, etc, with each “expert” dealing exclusively with his or her part, disregarding the interrelation with the other aspects of the person. The approach to the care process should be holistic. A human being is not a sum of parts; it is a whole in which whatever happens in one part greatly influences what happens to the other parts and to the whole. None of the parts should be treated separately. If my elder brother dies, I may fall into a depression, but most likely, the help of friends will be a lot more effective than Prozac.

And thirdly, and by no means lastly, we will not solve the issue of the well-being of an ageing society with processes based mainly on person-hours and equipment. We have to adopt the principles of modern management to re-engineering the care processes. We could learn from the, today not very popular, banking sector. Some ten years ago the process of sending a bank transfer followed a pattern designed in the XIX century. We would go to the bank and ask a teller to fill out a form by hand with the required information, then we would sign it, the teller would verify the signature in a card and, countersigning it, deposit the slip in an out-going tray. From there, a very complicated mechanism of human intervention and notations would end with a coded wire sent to the recipient´s bank. The reverse process would then be followed at the other end, finishing with a posted letter informing the recipient of the transfer. This process was first improved with the help of technological tools. Hand-written forms were substituted by machine formats. This is where the care sector is today. But then banks introduced a complete re-engineering of the transfer process. Today the customer, from home, sets in motion a completely automatic process to transfer money from account nº1 into account nº2, and in real time!

The banking system has re-engineered the transfer process by empowering their customers, allowing them to be in charge of managing their accounts. Today bank tellers have almost disappeared.

And, underlying all the previous reasons for our failure is the fact that the care sector treats people as cattle, not as human beings. Most caregivers treat their customers as property; they talk of “my patient”, “my client”, etc. This tendency to relate to people as if they were their personal property is in the basis of how they deal with them. Going back to the banking system, could you imagine if we had to go through a burdensome process to get a statement from our banks?   Well, this is what happens in most instances if we dare to ask for our health record. What’s more, they will produce an edited copy of it, never a full version with all the notations. There are two reasons for this. First, despite all public pronouncements to the contrary, professionals still think that my health record belongs to them. Secondly, they think that I am too stupid to understand anything, so what is the use of giving me information that I am incapable of comprehending?

If, on the contrary, care professionals started thinking about people as people, capable of understanding things if provided with the right information, things would change.

Let´s look at two “recent” examples of how care professionals should behave. There is a shoe repair shop in Madrid, established in 1948. There is a big sign in the workshop that reads “What is a client? The client is the most important person in this shop, no matter how he gets in contact with us, whether in person, in writing or by phone. The client does not depend on us, we depend on him”.

I have an even “more recent” example. It relates to a certain Rufus of Ephesus living in Ephesus (today Turkey) in the late 1st century. His teachings emphasized the importance of anatomy, and sought pragmatic approaches to diagnosis and treatment. He wrote, “The patient must be interviewed. By means of these questions, it is possible to learn a great deal concerning the illness, which enables a better treatment. The time that an illness began is also important. In addition, one should inquire as to patient’s attitude toward life and general mental state. In this way, the patient’s mental health can be assessed.” I would like to emphasize the part that reads “one should enquire as to patient’s attitude towards life”; no comments.

My point is that we need to re-engineer the care process and move beyond today’s focus, which only means wasting more person-hours and more gadgets on an obsolete process. We really need to think about the people we are serving. We need to empower them by realizing that they are able, intelligent people, capable of taking their own decisions if only they have the right information.

If we could keep in mind those three + one paradigms we may be able to move away from the pilot trap towards efficient processes. Then we would have achieved: preventive actions, with a holistic vision; care processes designed for today’s economic and demographic environment, and which empower people to have complete control of their lives.

Focusing now on active and healthy ageing or AAL, there are a couple more things that we have to take into consideration before plunging into re-engineering the care processes.

First, let´s consider lifestyle. Overweight and obesity, social exclusion, lack of physical exercise, bad eating habits, etc. are all cause for future medical conditions that will jeopardise our well- being as years accumulate. I want to emphasise future because things rarely happen overnight. It is through years of stuffing ourselves with spaghetti a la carbonara that we easily become overweight and most likely will develop some cardio-vascular disease.

So, what is the chance of having any success with a target population that has not been aware for years of the need for controlling its habits? Of convincing them that the time has come to change? Do we really believe that a person in his or her seventies will suddenly introduce radical lifestyle changes, learning how to eat more healthily or how to use a new gadget? Can’t we recognise the fact that what we are subtly transmitting to that seventy-year-old is: now, now, you are really old and frail; the time has come to surround you with machinery that will make sure you are not going to do anything stupid.

Let’s look at who exactly is our real target population. Consider that from the time somebody has an idea to the time that the product gets to the market, seven to ten years can pass. One or two years for inception, three to five  years for research, and three years, more or  less, for production.

With this time frame, we should be designing for people like myself. I am almost sixty years old and I will probably need something in ten years time. Whatever we design should build on the lifestyle of today’s average 60-year-old, so that I don’t suddenly feel that I am old. What’s more, my needs will evolve over time. I really don’t want to keep adding changes to my lifestyle or gadgets to my house that require a new learning process; I would like to have a simple ubiquitous interface with whatever I need.

There are two clear candidates for taking up the role of interfaces.

My first candidate is the mobile phone. The figures from Eurostat reflect the use of the mobile phone among persons in the 55-74 age range. In most countries, more than 60% of the population in the 55-64 age range uses the mobile phone.

The other gadget which a large proportion of the population is familiar with is the PC, laptop or tablet, whatever you prefer. Taking advantage of one of their many features, the internet, let’s see how popular it is according again to Eurostat. Obviously internet  is not as popular as the mobile phone, but among the big EU countries, only Poland is under the 10% threshold in everyday use of the internet for the similar age range.

Summing up, we should aim at re-engineering the care process by developing an information management system, which would serve as the sole interface between the citizen and the rest of the world. It should allow access to all health, social, family, financial, and any other information the citizen needs for his or her decision-making. It should also be the interface for command and control of equipments that are meant to assist in activities of daily life and independent living. It should be modular so that every person can choose which modules better adapt to his or her particular needs, facilitating a smooth transition from middle age to old and to older. It should empower people by refocusing the care process on the person and not on the professional.

Let me finish the way I started:  with a quote. This time it is from the well-known American radical feminist activist, writer and poet Ms. Robin Morgan:

“Knowledge is power. Information is power. The secreting or hoarding of knowledge or information may be an act of tyranny camouflaged as humility.” Robin Morgan.

Cutting social expenses is how most governments are reacting today to the budget deficit problem. And to be honest, this provides quick results. These cuts have another advantage: although they may affect a certain number of voters, why should we care?  Most of those affected are public workers anyway, and we all know that they are not exactly the most cost-effective workers on earth, don´t we? So, the logic follows, the effect on the rest of the population/voters will be minimal or even positive.

But maybe we should consider the medium and long term effect of those cuts. If social care processes remain unchanged, the logic says that, by reducing inputs, the output will be negatively affected. This is true unless, miraculously, the till now inefficient public worker suddenly becomes efficient and maintains the previous output. As I do not believe in miracles of that kind, this reaffirms my conviction:  there will be a reduction of the output.

A reduction of the output is immediately felt in some of those services. Probably that is the reason why we have seldom heard of cutting the police force. But there are other services in the social menu in which the reduction in output will be felt mostly in the medium or long term.  But since we won’t have to worry about that until the next election, who cares?

If we stand by today’s care processes while cutting inputs, the health of the population will be affected in the long run; there will be fewer resources for prevention because acute problems will absorb the remaining resources. The same goes for education; teachers will dedicate their efforts to the brightest of the class, leaving behind those less naturally gifted, thus reducing the average level of
education in the population as a whole. And so forth and so on.

If our leaders could for a moment think about their constituency and not about getting re-elected, then maybe they would realize the obvious: there are no shortcuts. The only way of reducing cost while maintaining the quantity and the quality of the output is by re-engineering the processes in which social services are provided. But then that requires leadership and time!

Almost everybody will agree that if I address somebody as that person, the implication is that I don’t think very highly of him or her. Shopkeepers will treat people who enter the shop differently if they think about them as buyers –they should come, buy and leave- than if they think about them as clients –they are here to be served and will come back-.

If we assume  the above, why is it that in the health sector we keep insisting on calling people patients? According to the Free Online Dictionary (and I assure you very similar definitions will be found in any other dictionary) the definitions  for “patient” are:

adjective

1. Bearing or enduring pain, difficulty, provocation, or annoyance with calmness.

2. Marked by or exhibiting calm endurance of pain, difficulty, provocation, or annoyance.

3. Tolerant; understanding: an unfailingly patient leader and guide.

4. Persevering; constant. “With patient industry, she revived the failing business and made it thrive”.

5. Capable of calmly awaiting an outcome or result; not hasty or impulsive.

6. Capable of bearing or enduring pain, difficulty, provocation, or annoyance: “My uncle Toby was a man patient of injurie” (Laurence Sterne).

noun

1. One who receives medical attention, care, or treatment.

2. Linguistics: A noun or noun phrase identifying one that is acted upon or undergoes an action. Also called goal.

3. Archaic: One who suffers.

A neutral reader will see that most of the definitions refer to suffering or calmly enduring something. Does this not say a lot about how the health sector regards what should be, and are, its clients?

Unless health professionals start thinking about people in need of health advice as clients, and calling them clients, I think there is little hope for an effective re-engineering of the heath processes that will result in the necessary sustainable health and social system. Anything less is just plugging holes in an antiquated social and health provision system.

I made a presentation on a project in La Fuenfría Hospital in Madrid. Its aim is improving the security of patients in relation to mobility and food and medicine intake. But about this subject I will comment at another time.

Today I only would like to express my gratitude to a sentence by Professor Heinz Wolff (Brunel University) that to me was worth the whole trip. He started a presentation in the morning of the 29 saying something like “You are all wrong, you have not realized that we are in a war economy!”

That sentence says a lot to me and it should say a lot to those who are involved in the advancement of how society provides services to its citizens. For one thing, it shows how misled governments are in trying to reduce deficits by cutting services: fewer doctors or fewer teachers simply results in a deterioration of the level of health or education of the population, and in the long run will produce a bigger deficit. The population will be in worse shape (will need more care) and will be less productive (will pay less taxes).

What is really needed is a radical change in the processes by which society is delivering its services. It is not fewer doctors that we need, it is a more efficient process in delivering health care, as well as education, social care, security, etc.

Only by focussing on processes and re-engineering them will society be able to reduce its economic imbalances and, at the same time, deliver the services that will keep it productive and able to continue to pay taxes.

Solamente si todos los que tienen algún interés en la organización han asumido que la confianza en la organización es el mayor de sus activos, se puede llegar a prevenir la ocurrencia de eventos indeseables.

Si los empleados, los proveedores y los clientes han interiorizado que su bienestar a largo plazo depende del buen hacer de la organización, cualquier desviación de la norma será detectada antes de que la desviación suponga daños irreparables.

El proveedor no intentará corromper al departamento de compras, el cliente utilizará el producto o usará el servicio sin pervertir el fin para el que está diseñado, el empleado seguirá los procesos de producción adecuadamente.

La organización que consigue poner en el centro de su estrategia la creación de confianza en la misma, tiene una ventaja competitiva obvia respecto a sus competidores. Por lado tiene un poderoso imán para atraer a los mejores, por otro lado, en el caso de la ocurrencia de eventos indeseables, su reacción es creíble por la sociedad.

Crear confianza en la organización es, pues, el eje central de la gestión de una crisis. Implica la detección precoz y la reacción creíble y por ello mismo eficaz. Basándose en estos dos pilares de la gestión de crisis, la organización puede transformar una crisis en una oportunidad y acrecentar, de paso, su capital de confianza.

My feeling is that the reason for such an state of things lays in the fact that most research into the field has being carried out by the mobile telecom sector and not as part of an strategic drive to make health care more efficient. In a more mundane wording, we have put the cart before the horse.

Probably a more long term and efficient approach would be to start by redesigning the way health care is delivered. By this I mean integrating preventive health care into the more traditional health care of responding to acute problems or urgent needs.

In my opinion, it is in preventive health care where mHealth could prove more useful. This feeling rests in the fact that, in most cases, an individual is a lot more active (*) when he/she belongs to the population group where prevention is important and should be targeted, than when the person has moved into a chronic situation or is suffering an acute health event.

Focusing on preventive health care we will have a big enough population to allow the development of a proper business model to support the functioning of a mHealth based preventive system. Note that I am talking about a business model for preventive health care using mHealth, and not a business model for mHealth.

(*) in this context I am using “active” to mean someone  more aware of his/her surroundings; ITC user literate; open to new ideas; etc.

Sin embargo, esa presencia a nivel anímico no se traduce en una presencia a nivel de gestión empresarial. Sea unas veces porque pensamos que somos “demasiado pequeños como para que se nos note”, o tal vez que lo mejor es ignorar el problema, “el tiempo lo cura todo”.

Pero hoy incluso la más pequeña de las organizaciones se puede encontrar examinada en la Web. Cada ciudadano es un difusor potencial de noticias y nadie es demasiado pequeño. El antiguo boca en boca, hoy es golpe de ratón. La gran diferencia es que la voz tiene un alcance limitado en el espacio y en el tiempo y el golpe de ratón tiene un alcance universal y permanente en el tiempo.

Por eso, no importa las características ni el tamaño de la organización: hay solamente tres posibles caminos: a) Hacer como si hiciéramos algo; b) Hacer algo que corrija los efectos del incidente; y c) actuar en previsión de crisis y que incidentes que puedan poner en peligro la reputación, y por ende los resultados o la supervivencia, de la organización no puedan ocurrir y si ocurren, toda la organización sepa cómo responder y responda.

Es obligación de la máxima dirección de la organización decidir qué camino quiere emprender.

A person who develops a chronic disease is faced with the shock of suddenly having to make drastic changes in lifestyle. Then the same person confronts another shock:  having to deal with an array of devices supposedly geared to help in the treatment of the health problem using eHealth solutions.

On top of the necessary adjustments involved in incorporating periodic controls and check-ups, medicine intake, diets, etc, the person will have to learn how to use and live with an array of gadgets. These may vary from the less intrusive sensors to computers and the like, of which a normal older person may know next to nothing.

A more rational approach would be to follow the path of preventive medicine. Just as preventive medicine identifies target populations that have to be monitored, why don’t we provide the healthy person, within a target population, with those gadgets designed to prevent the deterioration of health. This way, eHealth becomes an integral part of   preventive health care, with the person directly involved in the process.

As the process of deterioration continues, so will the person´s health care and eHealth requirements. But if we involve people in the process of preventive health care early enough, we help them ease the transition from a healthy person to a not so healthy one helped by preventive medicine and what we could call preventive eHealth.  An additional asset to this approach is the increased efficiency of health care derived from the use of prevention instead of relying mainly on acute care.

Que estamos en una crisis es una realidad que ya nadie puede negar. Que para salir de la crisis alguien tiene que hacer algo es una verdad de Perogrullo. La dificultad viene cuando hay que empezar a identificar quién tiene que hacerlo. Aquí la mayoría mira hacia el Gobierno, incluso aquellos que se declaran abiertamente liberales. Sin embargo tal vez sería conveniente dejar de buscar la paja en el ojo ajeno y darse cuenta de que la viga está en el propio.

Supongo que el señor Amancio Ortega tiene algún arma secreta como para en plena crisis haber aumentado la facturación un 14% y los beneficios un 42% y todo ello con el mismo Gobierno que, al parecer, a otros les está partiendo por la mitad y no hace nada para mejorar la situación o cuando lo hace es tarde y obligado.

Y en plenas crisis mundial o mejor dicho de países desarrollados, léase USA y Europa, hay sin embargo países con estructuras socio-económicas no muy diferentes  a la de España que, por decirlo de forma coloquial, van como un cohete. ¿Qué tendrá Alemania que no tengamos nosotros?

Lo que identifico como claramente distintivo es la existencia de los llamados Mittelstand: PYMES que en un 90% de los casos realizan sus operaciones business-to-business, no dependientes directamente del consumo de los particulares, y que en un 70% se localizan fuera de las grandes zonas industriales, favoreciendo la relación entre la propiedad y sus profesionales. Además no se dedican a hacer lo que otros pueden hacer, sino que se caracterizan por haber encontrado un nicho de mercado en el que son los mejores.

Un corolario se me ocurre, antes de buscar culpables en el más allá, identifiquemos qué podemos hacer nosotros por nosotros mismos y dejemos de buscar que pueden hacer otros por nosotros.