If it looks like a duck, waddles like a duck, quacks like a duck, and swims like a duck–  it’s probably a duck!  This is an example of abductive reasoning which is a form of logical inference which starts with an observation or set of observations then seeks to draw the simplest and most likely conclusion   Yes, but what’s the relevance to health reform?

Those working in PHNs are often challenged to commission health services in the absence of complete information.  Time pressures, incomplete datasets and conflicting analyses means that we find ourselves making educated guesses about what the best way forward might be.  We look to apply common sense in the hope that what we do will satisfy even if we can’t be sure that it is optimal.  In the first instance it needs to ‘look right’ if we want to get buy-in from key stakeholders. In other words it needs to pass the ‘duck test’ with enough people believing that the change will actually ‘fly’!

Nobel laureate Herbert A. Simon’s  research into problem solving showed that we operate within what he calls bounded rationality– with the rationality of decisions influenced by the tractability of the problem, the cognitive limitations of the decision-makers, and the time available to make the decision.  He also coined the term ‘satisficing’, which denotes the situation where people seek solutions or accept choices or judgments that are ‘good enough’ for their purposes, while acknowledging that they are not perfect and can most likely be improved. 

PHNs work in a real world with real-life constraints and as such we need tools to help us make ‘satisficing’ solutions to maintain forward change momentum while learning as we go.

 This article in a nutshell:

This article looks at some of the approaches that Health Service Commissioners employ to sustain progress in spite of the absence of certainty in decision-making processes.  It looks at approaches such as:

• Heuristics
• Ockham’s razor, and;
• Abductive Reasoning (also known as the ‘Duck Test’)

The article considers what application these approaches may have in the design and implementation of reforms such as new models of patient care including Health Care Homes.

About heuristics – applying ‘the rule of thumb’!

Heuristics are simple, efficient rules, learned by experience, that have been proposed to explain how people make decisions, come to judgments, and solve problems typically when facing complex problems or incomplete information.  When you hear people refer to things like the ‘rule of thumb’ or applying ‘common sense’ these are heuristic constructs.

To illustrate, General Practice fee-for-service MBS, that sees GPs best rewarded financially for seven minute consultations, is not going to be good for patients with complex multi-morbid chronic conditions.  Our ‘common sense’ tells us that this will result in insufficient time for a GP to examine the patient, fully appreciate their complex clinical status and respond appropriately.  As such we know that a different payment mechanism is needed for disease-difficult patients although we might not know what this should look like. Heuristics can therefore be useful for indicating the need for and the direction of change but not necessarily the specifics.

Ockham’s razor – and the cut-through on health reform

Ockham’s razor, also known as the ‘law of parsimony’ is the problem-solving principle that, when presented with competing hypothetical answers to a problem, one should select the answer that makes the fewest assumptions. The idea is attributed to William of Ockham (c. 1287–1347), who was an English friar, scholastic philosopher, and theologian.

So what would William of Ockham make of the hypothetical question as to whether the Australian healthcare system of the 21st century will survive in its current form? One needs to make very few assumptions to conclude that it is unsustainable given its spiralling costs and growing misalignment with the changing needs of the Australian community. Conversely, to conclude that our  current health system is in fact sustainable we would need to make a lot of assumptions.

• We would need to assume that the economy will grow at a rate sufficient to fund the projected growth in health expenditure
• We would need to assume that we can build bigger and better hospitals fast enough
• We would need to assume that we can grow and train the health workforce quickly enough to staff these newer and larger hospitals
• We would need to assume that Australians will make better lifestyle choices to reduce the increasing prevalence of chronic illnesses like diabetes

The application of Ockham’s razor points conclusively to the need for change, but once again, does not provide the specifics- just a general sense that the health system of the future needs to :

• be geared for an ageing population
• provide for high numbers of people with complex chronic conditions
• maintain access for a large proportion of the population in need of affordable healthcare
• support people to maintain good health outside of formal healthcare delivery arrangements  i.e. better self-care

Ockham’s razor helps us to be more incisive – cutting through fanciful thinking and rejecting false hopes based on dubious if not spurious assumptions.

Healthcare reform and abductive reasoning

Now, back to the ‘duck test’ !

You will recall from earlier in this article that when we apply the ‘duck test’  we are using a form of logical inference which starts with an observation, or set of observations, then seeks to find the simplest and most probable conclusion.

The insight here is that when PHN’s look to develop and implement new models of care we need to be mindful that others will be applying the ‘duck test’ deciding whether the new model of care ‘is going to fly’ or not.  The ‘duck test’ might include such things as:

• Whether it looks like the model of care will deliver better care for patients
• Whether it looks like enough GPs and other clinicians will want to work the new model of care
• Whether it looks like there is going to be enough money to support the new model of care
• Whether it looks like there will be enough political resolve to overcome those seeking to impede change

Understanding the duck test, and the optics that key stakeholders will use, allows us to anticipate how others will view the reform. This can be used to:

• Guide the model-of-care design processes
• Test the feasibility of the proposed model- operational, technical and financial
• Help formulate the change management plan
• Shape the marketing strategy

The ‘duck test’ applied to the Health Care Homes Pilots

While talking to a friend and colleague a few weeks ago he expressed the view that the Health Care Home initiative was a ‘dead duck’.  The reasons he gave were insightful.  He said that the GPs had concluded that it looked like there was not going to be enough of a financial incentive to warrant their participation.  They weren’t waiting for the outcome of the pilots- the model didn’t lool like it was going to fly.

I myself have insufficient information on the status of the HCH initiative to offer an opinion.  I do however suggest that should the Commonwealth and PHNs need to ‘reboot’ the initiative we should invest the time and resources to better understand the ‘optics’ that GPs will use and tailor the reform so that it at least looks like the new model of care will in fact be implementable at scale.

A summary of this article would be:

• PHNs need to make decisions in the absence of certainty as to the outcomes- a fact of life!
• Trial and error is one way of learning and PHNs shouldn’t be afraid to acknowledge when they are ‘feeling their way forward’!
• Reforms need to look like they will work before people will take them seriously.
• You can learn from a lame duck but a conversation with a dead duck is less fruitful.