Archivi del mese: Mag 2012

Servizi Sanitari Nazionali. Nel mirino.

Gavino Maciocco in http://saluteinternazionale.info/

È cominciato l’assalto ai sistemi universalistici europei.  Nell’arco di un mese in Inghilterra e Spagna sono state approvate leggi che puntano alla privatizzazione e al mercato: nel primo paese sul versante della produzione ed erogazione dei servizi, nel secondo sul versante del finanziamento. La crisi economica ha offerto ai governi conservatori il pretesto per introdurre radicali riforme liberiste. Difficile dar torto a Naomi Klein quando ha scritto: “Quelli che si oppongono al welfare state non sprecano mai una buona crisi”.


Non sono trascorsi nemmeno due anni da quando – nel giugno 2010 (a sole sei settimane dalla  costituzione del nuovo governo guidato dal conservatore Cameron, uscito vincitore dalle elezioni politiche)  – veniva pubblicato un Libro Bianco che annunciava una profonda riforma del NHS (National Health Service). Una riforma radicale che, pur mantenendo il finanziamento pubblico basato sulla fiscalità generale, consegnava interamente al settore privato e ai meccanismi competitivi del mercato la gestione e l’erogazione dei servizi sanitari, dalle cure primarie all’assistenza ospedaliera.  Eliminava inoltre dal NHS tutte le attività preventive (dalle vaccinazioni agli screening), affidandone la responsabilità alle autorità municipali.

La proposta venne considerata una specie di provocazione: chi avrebbe osato cancellare d’un tratto istituzioni pubbliche consolidate come i Primary Care Trusts (le nostre ASL) e le Strategic Health Authorities (le nostre Regioni), licenziando di conseguenza diverse migliaia di dipendenti?

Poi la proposta diventò disegno di legge (bill) e il ministro della sanità che lo sosteneva in parlamento fu paragonato a una specie di apprendista stregone (e disegnato come tale in una copertina del BMJ).  Ma più il mondo della sanità (medici, infermieri, manager) si indignava e insorgeva (Kill the bill!), più il disegno di legge camminava spedito, approvato prima dalla Camera dei Comuni, poi dalla Camera dei Lord e per diventare Legge dopo la firma della Regina, alla fine di marzo 2012.

I lettori possono trovare nel Dossier NHS l’intera documentazione di questa storia. Qui ci limitiamo a riportare in forma schematica il prima (Figura 1) e il dopo, ovvero la struttura del NHS uscita dalla riforma (Figura 2).

La  Figura 1 mostra come Strategic Health Authorities e Primary Care Trusts rappresentassero la colonna portante del sistema sanitario britannico. In particolare i PCTs erano i destinatari del finanziamento pubblico e svolgevano anche attività di committenza nei confronti degli ospedali, mentre alle SHAs era affidato il compito di controllo  e di valutazione dei PCTs su scala regionale.

Come abbiamo già accennato queste due strutture pubbliche vengono abolite (lo saranno formalmente dal 1° aprile 2013) e il sistema si riposiziona come descritto nella Figura 2.

Cliccare sull’immagine per ingrandirla

Cliccare sull’immagine per ingrandirla

I destinatari del finanziamento pubblico saranno delle organizzazioni private – Clinical Commissioning Groups (CCGs) – che sostituiranno le PCTs.  I titolari potranno essere medici di famiglia (General Practitioners, GPs) riuniti in consorzi di 100-200 unità o molto più probabilmente agenzie private (molto più attrezzate nella gestione di rilevanti mezzi finanziari) che assumeranno GPs come dipendenti.  Tali agenzie potrebbero sviluppare in futuro (la legge non lo dice) anche funzioni assicurative, diventando simili alle HMOs americane e realizzando così l’ hidden agenda di M. Thatcher.

A distanza di un mese dalla firma di una Regina viene emanato in Spagna un Decreto Reale,  che per entrare in vigore non ha bisogno dell’approvazione  parlamentare.  La legge, voluta dal nuovo governo conservatore di Mariano Rajoy, ha lo stesso effetto deflagrante sul servizio sanitario nazionale di quella approvata in Inghilterra, in questo caso però sul versante del finanziamento. Il provvedimento legislativo spagnolo, adottato con grande urgenza, sostituisce il classico modello universalistico basato sulla fiscalità generale con un modello basato sulle assicurazioni[1].

Le due leggi hanno diversi punti in comune.

  1. Nessuna delle due era stata prevista nel programma elettorale dei partiti vincitori delle elezioni e la loro successiva irruzione è stata motivata con motivi di urgenza legati alla crisi economico-finanziaria;
  2. Le leggi sono state accompagnate da pesanti tagli alla sanità: 20 miliardi di sterline entro il 2015 in Inghilterra[2], 7 miliardi di euro in Spagna, pari al – 10%  del budget del 2011, con forti aumenti nella compartecipazione alla spesa e drastica riduzione dell’assistenza agli immigrati irregolari[3];
  3. Entrambe le leggi hanno una forte impronta liberista: sul versante della produzione/erogazione dei servizi  in Inghilterra, su quello assicurativo in Spagna.

La crisi economica ha offerto ai governi l’opportunità che capita una sola volta nella vita. Come Naomi Klein ha descritto in molte differenti situazioni, quelli che si oppongono al welfare state non sprecano mai una buona crisi (vedi il Post assalto all’universalismo).

Bibliografia

  1. Rada AG. New legislation transform Spain’s health system from universal access to one based on employment. BMJ 2012;344:e3196 doi: 10.1136/bmj.e3196
  2. Butler P. NHS reform bill passes with government bloodied, but unbowed. The Guardian, Tuesday 20 March, 2012.
  3. Casino G. Spanish health cuts could create “humanitarian problem”. The Lancet 2012; 379

Andrea Silenzi, MD, MPH, PhD

Doctor House
SOCIETÀ di Monica Piccini

22 maggio 2012 – 17:58Bello e sfuggente, il dottor Gianmarco B. ha 38 anni e uno sguardo da cui già a prima vista traspare difficoltà a relazionarsi con gli altri. Quando si rivolge allo psicologo del Sert di Brescia, mostra soddisfazione per aver conseguito la laurea e la specializzazione in ortopedia e traumatologia. Il percorso da studente modello comincia a sgretolarsi dopo aver vinto un concorso ed essere stato assunto dalla Croce Rossa della sua città. La cocaina lo aiuta a sostenere l’ideale iperlavorativo. Nei momenti di pausa sniffa in studio. In questo modo, non sente la fatica e può protrarre la giornata a suo piacere. Frequenta una collega, separata con figli. La relazione diventa totalizzante e a un certo punto lei lo lascia.

Non trovando conferme nell’ex compagna, il dottore le cerca nella dipendenza. Diventa aggressivo e ben presto comincia ad assumere cocaina anche durante…

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Live & Learn

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Thank you Rolly for sharing this inspiring video…

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Innovation in research methods and dissemination – ensuring best practice @bmj_latest

The Association of the British Pharmaceutical Industry (ABPI) and BMJ Group held a joint conference at BMA House yesterday entitled ‘Innovation in research methods and dissemination – ensuring best practice’. The event brought in some big names, including our very own Dr. Fiona Godlee (Editor-in-chief, BMJ), Professor Sir Alasdair Breckenridge (Chairman, Medicines and Healthcare products Regulatory Agency/MRHA) and even Jimmy Wales (Co-founder of Wikipedia).

The conference was essentially a get-together of the ‘movers and shakers’ of the pharmaceutical and health regulatory industries, focussing on policy and future practice relating to drug development. With pharmaceutical outputs falling in recent times despite more funding, questions are being asked about the effectiveness of current methods.

Some of those present, including and especially Professor Breckenridge, were keen on imposing PM David Cameron’s wish for ‘every willing NHS patient to be a research patient’, with the entire consortium of NHS hospitals in the UK effectively serving as one single clinical trials unit. Indeed, others present at yesterday’s conference generally went along with this, with some issuing a word of caution about the obvious problem of patient participation.

A significant development that did stand out was the coming change in drug development schedule. The current model is an ‘all or nothing’ linear scheme, from screening to development, phase I-III clinical trials, etc. This is expensive, time-consuming, and generally inefficient. However, by 2020, there will be increased focus on molecule development and pathophysiology, leading to a shorter clinical development schedule and early approval. But that’s not where it ends. Increased focus on post-marketing safety and effectiveness will also be a key part of the plan.

Professor Breckenridge was also keen to shift attitudes about drugs from looking at ‘safety’ to considering the ‘risk-benefit balance’. ‘If you think about it, we don’t actually look at safety. We look at the risk-benefit balance. Anti-HIV drugs, for example, may not be safe, but their benefits far outweigh their risks, so we use them’, he said.

There was more focus on the sluggish pace of drug development in the UK. ‘We take nearly two months longer than some other countries, and the biggest obstacle still seems to be NHS R&D approval’, said Dr. Tony Whitehead, Medical Director at Sanofi. He also stressed that we should continue to press forward in the most successful areas of the industry, including oncology and translational research/personalised medicine. In order to ensure tighter restrictions on time frames, Dr. Whitehad also suggested a ‘more formal business relationship between pharmaceutical companies and NHS trusts’.

The general vibe at this meeting was a positive one, but this was undermined ever so slightly by startling data relating to a lack of reporting from clinical studies. Dr Trish Groves, Deputy Editor of the BMJ revealed that up to 50% of data may not be reported, with approximately 60% of studies having more than one primary outcome changed prior to publication. It was stressed that incomplete reporting is a serious misconduct, essentially half-way between making an incorrect observation and frank fabrication of data. This may come as as surprise to many, as the retention of data by labs is notoriously ubiquitous.

But what about quality control? ‘There is quite a lot of misinterpreted data out there’, said Dr. Carl Heneghan of the Centre for Evidence-Based Medicine (CEBM) in Oxford. He used the recent example of rosiglitazone and the well-known thalidomide controversy to illustrate his point. On the contrary, he also reported that pharmaceutical companies are now providing data to CEBM so that it can be checked.

Cue a coffee break, and then a sudden influx of young adults from BMA House into the conference room. Most had left their desks just for this bit. Jimmy Wales received a round of applause before he had even said anything – not surprising for a man who created a website that clocks around 10 billion page views per month (according to h-online.com).

Jimmy’s focus was on open access publishing and access to the results of research. ‘Taxpayers pay for research, so shouldn’t they be able to access it? It would be good if intelligent non-researchers can access all the research in the world’. One attendee asked the obvious question of quality control. ‘We obviously know a lot about this!’, said Jimmy, followed by an explosure of laughter from the attendees. ‘We need to focus on how reliable sources are and involve academic experts as much as possible.’ He also dismantled the notion that academics hate Wikipedia – ‘For people who hate it, they sure use it a lot’. Then followed a debate about the issues involved with open access publishing, namely privacy and confidentiality issues. The fact that labs will obviously want to publish their own data in a journal first was also an issue that was highlighted.

All in all, this was a hugely enjoyable conference with some very interesting developments noted. ‘Healthcare innovation’ is a term that is being thrown about a lot these days, but it was fruitful to see just what this means in the context of policy within the pharmaceutical industry.

http://bit.ly/LzF8bJ 

Viva i vecchi

Andrea Silenzi, MD, MPH, PhD

Nella campagna per la rielezione, il presidente uscente Obama sfrutta ancora una volta, e se possibile con ancor maggiore competenza, il mondo dei blog e dei social media. Coi “social objects”, divertenti, si punta a raggiungere il pubblico più giovane, mentre facebook ormai è per persone più “mature”.

NEW YORK – “Social objects”. È questo il principale strumento su cui scommette il team elettorale di Obama per coinvolgere i giovani e rivitalizzare il popolo del “Yes we can” rappresentando il presidente in carica come il candidato del popolo, contrapposto all’uomo dell’establishment Mitt Romney. Definiti in marketing come nodi attorno ai quali si sviluppa una conversazione sulle piattaforme digitali, sono per esempio “social objects” il grafico dell’andamento della disoccupazione postato dalla squadra di Obama sul Tumblr blog a inizio maggio, il filmato in cui il presidente spiega i passi in avanti sulle politiche ambientali, pubblicato su Facebook il 22 aprile, e…

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Brian Goldman: I medici commettono errori. Possiamo parlarne? @muirgray @Medici_Manager

Ogni medico commette errori. Ma, come dice il medico Brian Goldman, la cultura medica della negazione (e della vergogna) impedisce loro di parlarne o di sfruttare gli sbagli per imparare e migliorare. Raccontando aneddoti della sua lunga pratica, fa appello ai medici perché comincino a parlare dei propri errori.

http://www.ted.com/talks/lang/it/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

Brian Goldman is an emergency-room physician in Toronto, and the host of CBC Radio’s “White Coat, Black Art.” Full bio »

Translated into Italian by Anna Cristiana Minoli
Reviewed by Chiara Di Felice
Comments? Please email the translators above.

More talks translated into Italian »

The redefined physician is human, knows she’s human, accepts it … and she works in a culture of medicine that acknowledges that human beings run the system.” (Brian Goldman)

Pazienti, cittadini, utenti, clienti, consumatori… @GIMBE

Attenzione a non essere troppo ideologici nel rifiutare le parole consumatore e cliente di servizi sanitari!

Milton Friedman, premio Nobel per l’economia ha scritto:  “La Costituzione degli Stati Uniti mi va bene, ma vedrei di buon occhio un suo minimo aggiornamento. Sostituiamo la parola cittadino con quella di cliente. Infatti, un cittadino puo’ essere vessato, un cliente no”.

dal Blog di Nino Cartabellotta http://www.ninocartabellotta.it/

10-13 maggio: quattro giorni di duro lavoro per preparare i materiali didattici del nuovo corso Coinvolgere gli utenti nei servizi sanitari e accorgersi poche ore prima dell’inizio che il titolo potrebbe essere inadeguato…

Destreggiandomi tra riferimenti normativi, evidenze scientifiche e linguaggio comune, la domanda è sorta spontanea: è un utente il soggetto da coinvolgere attivamente per migliorare la qualità dei servizi sanitari?

Il Cochrane Consumer Group sceglie il termineconsumatore per identificare “un paziente, un soggetto che presta assistenza o un familiare che ha una esperienza individuale su una specifica condizione medica”. Accanto a questa definizione, precisa inoltre che in altri contesti/culture vengono utilizzati altri termini con lo stesso significato: utente, paziente, cliente, membro del pubblico, cittadino, soggetto laico, etc.

Mi illumina un recente articolo dell’amico Marco Geddes da Filicaia, secondo il quale il Servizio Sanitario Nazionale è a disposizione delle persone perchè, con l’articolo 32 della Costituzione, tutela la salute come diritto fondamentale dell’individuo (e non del cittadino). Ciascuna persona all’interno del sistema sanitario può assumere ruoli diversi:

  • paziente, quando viene preso in carico dal servizio per problemi assistenziali
  • utente, quando si rivolge alle per informazioni, transazioni, certificazioni, etc
  • cittadino, quando contribuisce con il proprio voto alle scelte sanitarie

Ad eccezione del cittadino preso in carico dal SSN per strategie di prevenzione primaria (ad esempio screening oncologici) che non avrà voglia di essere etichettato paziente, la proposta di Geddes è molto convincente.

Non avendo le idee chiare su come modificare il titolo del corso, confido nei feedback dei 23 partecipanti. Sicuramente, se Geddes consiglia di lasciare il termine cliente al mondo del consumismo, personalmente metto al bando quello di consumatore, proponendo alla Cochrane Collaboration di ribattezzare ilCochrane Consumer Group.

FonteGeddes da Filicaia M. Cliente, paziente, persona. Ricerca & Pratica 2012

A Breakthrough Opportunity for Global Health

Portrait of Joseph E. Stiglitz

Joseph E. Stiglitz, a Nobel laureate in economics, has pioneered pathbreaking theories in the fields of economic information, taxation, development, trade, and technical change. As a policymaker, h Full profile

http://www.project-syndicate.org/commentary/a-breakthrough-opportunity-for-global-health

NEW YORK – Every year, millions of people die from preventable and treatable diseases, especially in poor countries. In many cases, lifesaving medicines can be cheaply mass-produced, but are sold at prices that block access to those who need them. And many die simply because there are no cures or vaccines, because so little of the world’s valuable research talent and limited resources is devoted to addressing the diseases of the poor.

This illustration is by Paul Lachine and comes from <a href="http://www.newsart.com">NewsArt.com</a>, and is the property of the NewsArt organization and of its artist. Reproducing this image is a violation of copyright law.
Illustration by Paul Lachine

This state of affairs represents a failure of economics and law that urgently needs to be corrected. The good news is that there are now opportunities for change, most promisingly through an international effort headed by the World Health Organization that would begin to fix the broken intellectual-property regime that is holding back the development and availability of cheap drugs.

Two main problems limit the availability of medicines today. One is that they are very costly; or, more accurately, the price charged for them is very high, though the cost of producing them is but a fraction of that amount. Second, drug development is geared toward maximizing profit, not social benefit, which skews efforts directed at the creation of medicines that are essential to human welfare. Because the poor have so little money to spend, drug companies, under current arrangements, have little incentive to do research on the diseases that afflict them.

It doesn’t have to be this way. Drug companies argue that high prices are necessary to fund research and development. But, in the United States, it is actually the government that finances most health-related research and development – directly, through public support (National Institutes of Health, National Science Foundation), and indirectly, through public purchases of medicine, both in the Medicare and Medicaid programs. Even the part that is not government-financed is not a conventional market; most individuals’ purchases of prescription medicines are covered by insurance.

Government finances health-care research because improved medicines are a public good. The resulting knowledge benefits everyone by stopping epidemics and limiting the economic and human toll of widespread illness. Efficiency requires sharing research as widely as possible as soon as it is available. Thomas Jefferson compared knowledge to candles: when one is used to light another, it does not diminish the light of the first. On the contrary, everything becomes brighter.

Yet, in America and most of the world, drug prices are still exorbitant and the spread of knowledge is tightly limited. That is because we have created a patent system that gives innovators a temporary monopoly over what they create, which encourages them to hoard their knowledge, lest they help a competitor.

While this system does provide incentives for certain kinds of research by making innovation profitable, it allows drug companies to drive up prices, and the incentives do not necessarily correspond to social returns. In the health-care sector, it may be more profitable to devote research to a “me-too” drug than to the development of a treatment that really makes a difference. The patent system may even have adverse effects on innovation, because, while the most important input into any research is prior ideas, the patent system encourages secrecy.

A solution to both high prices and misdirected research is to replace the current model with a government-supported prize fund. With a prize system, innovators are rewarded for new knowledge, but they do not retain a monopoly on its use. That way, the power of competitive markets can ensure that, once a drug is developed, it is made available at the lowest possible price – not at an inflated monopoly price.

Fortunately, some US lawmakers are taking a strong interest in this approach. The Prize Fund for HIV/AIDS Act, a congressional bill introduced by Senator Bernie Sanders, is just such an initiative. His bill also contains an important provision aimed at encouraging open-source research, which would move the current research model away from secrecy toward sharing.

But, globally, our innovation system needs much bigger changes. The WHO’s efforts to encourage broad reforms at the international level are crucial. This spring, the WHO released a report that recommends solutions similar to those proposed in the US Senate bill, but on a global level.

Importantly, the report, “Research and Development to Meet Health Needs in Developing Countries,” recommends a comprehensive approach, including mandatory funding contributions from governments for research on developing countries’ health needs; international coordination of health-care priorities and implementation; and a global observatory that would monitor where needs are greatest. In late May, the international community will have a chance to begin implementing these ideas at the WHO World Health Assembly – a moment of hope for public health around the world.

Reforming our innovation system is not just a matter of economics. It is, in many cases, a matter of life and death. It is therefore essential to de-link R&D incentives from drug prices, and to promote greater sharing of scientific knowledge.

For America, the Sanders bill marks important progress. For the world, the WHO’s recommendations represent a once-in-a-generation opportunity to remedy a long-standing and egregious inequity in health care, and, more broadly, to set a model for governance of global public goods befitting an era of globalization. We cannot afford to let this opportunity pass us by.

In health care, cheaper can mean better

DR. DONALD M. BERWICK nel Boston Globe http://b.globe.com/KpLt5g 

An Irish adage says: “When you come to a wall that is too high to climb, throw your hat over the wall, and then go get your hat.” That’s what Massachusetts started with its 2006 law requiring just about everyone to get coverage and arranging to make that coverage affordable. Now, it’s time to get the hat.

Legislation to contain costs is the necessary sequel. Reducing costs won’t just rescue health care; it will also help rescue our schools, our roads, our museums, our wages, and the competitiveness of our corporations; that’s because every additional nickel we spend on health care comes from somewhere else — somewhere also important.

Can Massachusetts’ health care be universal, excellent, and far less expensive?

Absolutely. The route is simple: improve care. In a study in the Journal of the American Medical Association, my colleague Andy Hackbarth and I estimated the amount of pure waste in American health care — overtreatment that helps no patient at all (like treating viral infections with antibiotics), errors and injuries from unsafe care, failures in coordination (such as sending people home from hospitals without supports), needless administrative complexity, failures of price competition, and fraud. The lowest estimate of total waste in these six categories was 21 percent of health care costs; the highest was 47 percent; and the midpoint was 34 percent.

When we are wasting $1 in of every $3, it makes no sense to say we cannot afford to make health care a human right without rationing. Don’t cut care. Cut waste.

Easy to say, but hard to do. Every form of waste in health care has deep roots in the current system. Fee-for-service payments have trained hospitals to keep their beds full; they therefore underinvest in the coordination of care that can help keep patients home, where they would rather be. Prices are not transparent to doctors or consumers, so price competition is weak. Neither hospitals nor doctors are taught how to standardize care in accordance with the best science; the result is illogical and harmful variation in care.

Better care at lower cost already exists. For example, last month, the “Nuka” system of team-based, health-oriented care that serves Alaska Natives in Anchorage won the Malcolm Baldrige National Quality Award, the nation’s highest recognition for quality in any industry. Nuka started with both a needier population and far lower costs than in Massachusetts, but it has further reduced emergency room visits by 50 percent, hospital bed-days by 53 percent, specialty consultations by 60 percent, and primary care visits by 20 percent, while achieving first-rate scores for quality, outcomes, patient satisfaction, and staff morale. Nuka makes care affordable by making it excellent.

Eliminating waste in Massachusetts health care will require large-scale changes in delivery that will be temporarily uncomfortable for most providers. And even though patients, families, communities, employers, wage-earners, and doctors themselves would be much better off, the pace of change is much too slow. Our elected leaders must press the issue, because our health care delivery systems are unlikely to summon the will on their own. The changes are just too hard for most to face.

Bills now before the Massachusetts House and Senate can provide that will in the form of a cost target, and by creating consequences for missing it. The House would limit the growth of health care costs to the growth rate of the Massachusetts economy starting now, and then to 0.5 percentage points lower than the overall economic growth rate starting in 2016. The Senate is less ambitious; it would set a limit of 0.5 percent above economic growth until 2016, and then equal to it thereafter. Neither matches the bolder goal proposed last month by both the Associated Industries of Massachusetts and the Greater Boston Interfaith Organization: 2 percentage points lower than the overall growth rate.

Alarms are sounding. Massachusetts hospitals and other providers are warning that too stringent a target will harm care — and harm the state’s economy when unemployment is already high.

Undoubtedly, this transition will be wrenching. But no healthy industry can maintain jobs that depend on continuing services that add no value. Health care costs are hurting the economy now, because they keep employers and consumers from spending on other priorities. Massachusetts has among the nation’s highest costs per capita. Waste levels here likely exceed the average, and surely exceed 20 percent of what we are all paying. The more ambitious AIM, GBIO, and House proposals are on the right track; health care can and should begin to return money to other uses, starting now.

The one outcome we must avoid is the stalemate that plagues Washington. Massachusetts led the nation in making health care universal, and it should lead now in cost control through waste reduction. Bold goals will help. If any state can, Massachusetts can ignite the intellectual firepower to reduce costs without harming a hair on any patient’s head.

Dr. Donald M. Berwick is the former president of the Institute for Healthcare Improvement and the former administrator of the federal Centers for Medicare and Medicaid Services.

 

Nine Things Successful LEADERS Do Differently

Very few people can say that they are a truly great leader in every sense of the word.  Chances are good that you are a terrific leader in some respects, and could use a little help in others, and you aren’t really sure why you can’t seem to master the whole package. The intuitive answer – that you are born blessed with certain leadership skills and talents, and born lacking in others – turns out to be, from a scientific standpoint, utterly wrong.
Decades of research on achievement paint a very clear picture: Successful people (including successful leaders) reach their goals not because of what they are, but because of what they do.  You can learn to give feedback that motivates, create work environments that bring out the best in your team, and more effectively reach your own goals while teaching your employees how to reach theirs – but only if you have the right information to help you get the job done.   Here are nine simple and scientifically-proven strategies you can use improve your game.
#1   Successful Leaders Get Specific.  Very Specific.
Whether you are setting yourself a goal, or assigning a goal to a member of your team, try to be as specific as possible.  “Increase sales by 10% in 2012” is a better goal than “increase sales,” because it gives you a clear idea of what success looks like.  Knowing exactly what you want to achieve keeps you motivated until you get there.
Specificity is also important when it comes to giving feedback. Make sure you provide clarity not only about what needs improvement, but also what exactly can be done to improve.  When you are a leader, helping your employee figure out how to do itright is just as important as letting them know what they are doingwrong.
#2   Successful Leaders Seize the Moment to Act on Their Goals.  Given how busy most of us are, it’s not surprising that we routinely miss opportunities to act on our goals.  Did you reallyhave no time to check in with your team today?  No chance at any point to return that email requesting guidance?  Achieving your leadership goals means grabbing hold of these opportunities to be a great leader before they slip through your fingers.
To seize the moment, decide when and where you will take each action you want to take, in advance.  Again, be as specific as possible (e.g., “If it’s Friday, then I will check in with each member of my team before lunch.”) Studies show that this kind of planning will help your brain to detect and seize the opportunity when it arises, increasing your chances of success by roughly 300%.   Whenever possible, encourage your employees to use this same technique to execute their own projects as well.
#3  Successful Leaders Know Exactly How Far They Have Left To Go.  Achieving any goal also requires honest and regular monitoring of your progress.  You need it, and your team needs it.  If you don’t know how well you are doing, you can’t adjust your behavior or your strategies accordingly.  And research shows that we lose steam when we don’t have a clear sense of how far we are from the finish line. Check your progress (and theirs) frequently – weekly, or even daily, depending on the goal.  Encourage the members of your team to monitor their own progress, too.
#4  Successful Leaders Are Realistic Optimists. When you are setting a goal for yourself or your team, by all means engage in lots of positive thinking and talking about how likely you are to achieve it.  Believing in our ability to succeed is enormously helpful for creating and sustaining motivation.  But whatever you do, don’tunderestimate or play down how difficult it will be to reach the goal.  Most goals worth achieving require time, planning, effort, and persistence.  Studies show that thinking things will come easily and effortlessly leaves you and your employees ill-prepared for the journey ahead, and significantly increases the odds of failure.
#5  Successful Leaders Focus Their Team on Getting Better, Rather than Being Good Believing you have the ability to reach your goals is important, but even more important is believing you can get the ability.   Many people believe that their intelligence and other aptitudes (e.g., social skill, creativity) are fixed – that no matter what they do, they won’t really ever improve.  As a result, they focus too much on proving themselves, rather than developing and acquiring new skills.
Fortunately, decades of research suggest that the belief in fixed ability is completely wrong – abilities of all kinds are profoundlymalleable. Encourage your employees to see that they can change, and that it takes effort and experience to reach your fullest potential.  (This means allowing them to make mistakes when trying something new or particularly difficult. Improvement takes time.) People whose goals are about getting better, rather thanbeing good, take difficulty in stride, enjoy their work more, and turn in the most impressive performances.
#6 Successful Leaders Have Built Their Willpower Muscle
As you’ve probably already noticed, successful leaders need a lotof self-control.  (Incidentally, research shows that employees are also more likely to trust a leader who seems to have a lot of self-control.)  Your self-control “muscle” is just like the other muscles in your body – when you give it regular workouts by putting it to good use, it will grow stronger and stronger.
To build willpower, take on a challenge that requires you to do something you’d honestly rather not do.  Give up high-fat snacks, or stand up straight when you catch yourself slouching.  As your strength grows, you can take on more challenges and step-up your self-control workout.
#7 Successful Leaders Don’t Tempt Fate
No matter how strong your willpower muscle becomes, it’s important to always respect the fact that it is limited, and if you over-tax it you will temporarily run out of steam.  So don’t put yourself in harm’s way if you can help it.  If, for instance, you are already exhausted from a long day of putting out fires, don’trespond to the irritating email from your most difficult employee – you will probably say things you will wish you hadn’t. Many people are overly-confident in their ability to resist temptation – like the temptation to call your employee an incompetent doofus – and as a result they put themselves in situations where temptations abound.
#8  Successful Leaders Focus on What They Will Do, Not What They Won’t Do
Do you want to improve your team’s communication, increase productivity, or put a lid on your bad temper? Then plan how you will replace bad habits with good ones, rather than focusing only on the bad habits themselves.  If you want change the way you or your team does something, ask yourself, What will I (we) do instead?
For example, if you are trying to gain control of your temper, you might make a plan like “If I am starting to feel angry, then I will take three deep breaths to calm down.”  Or if you want to improve communication, don’t just say “We can’t continue to keep key information to ourselves” – figure out exactly how you will all get the information where it needs to go.  By coming up with replacement behaviors, bad habits get worn away over time until they disappear completely.
#9 Successful Leaders Have Grit
Grit is a passion for, and commitment to, long-term goals – something leaders certainly in abundance.  Studies show that gritty people obtain more education in their lifetime, and earn higher college GPAs.  Grit predicts which cadets will stick out their first grueling year at West Point.  In fact, grit even predicts which round contestants will make it to at the Scripps National Spelling Bee.
The good news is, if you aren’t particularly gritty now, there is something you can do about it.  People who lack grit, more often than not, believe that they just don’t have the innate abilities successful people have.  If that describes your own thinking …. well, there’s no way to put this nicely: you are wrong.   As I mentioned earlier, effort, planning, persistence, and good strategies are what it really takes to succeed.  Embracing this knowledge will not only help you see yourself and your goals more accurately, but also do wonders for your grit.
This article appeared in the May edition of Leadership Excellence, and was adapted from The Nine Things Successful People Do Differently, HBR’s most-read blog post of all time.

Health Act makes NICE stronger than ever before

NICE will be stronger than ever before under the new Health Act producing quality standards that will be the backbone of commissioning and playing a vital role in value based pricing, the Health Secretary has said.

Addressing delegates at the NICE Annual Conference in Birmingham yesterday, Andrew Lansley said that NICE will be central to developing a NHS based on evidence and will be placed on a firmer footing to do so.

“NICE is currently established in secondary legislation, as a Special Health Authority. If a future Health Secretary so wished, they could abolish it at the stroke of a pen.

“I feel strongly that NICE deserved more than that. That an organisation as important as NICE should be established in primary legislation and it should have its independence guaranteed.

“For the first time, NICE will be placed on a solid statutory footing, your remit will stretch beyond the NHS to cover social care, both for adults and for children.”

“Your reputation for excellence, your experience in engaging with and listening to the people who will ultimately benefit from your guidance means you are well equipped to carry out this new and essential role.

“I want the new health and social care system to deliver better quality care, more personalised care, longer, healthier lives and reduced inequalities between the richest and the poorest in our society. In short, I want better outcomes.”

“The NICE quality standards will bring common ambition to all parts of the NHS. Not setting out the minimum that we should expect, but the excellence we should strive for.

“I published the first quality standards nearly two years ago. There are now 17 Quality Standards and in the coming years there will be as many as 170. Quality Standards should become the backbone of the commissioning system. I know that the NHS Commissioning Board.”

Moving on to the topic of value based pricing, Mr Lansley said that the current Pharmaceutical Price Regulation Scheme (PPRS), which expires in January 2014, had worked well and provided stability but had failed effectively to promote the use of new, innovative treatments or increased access to these new treatments.

“There will be a successor to the PPRS for existing medicines, for new branded medicines there will be a new system- Value Based Pricing – for agreeing prices. And NICE will be vital to this too.

“As enshrined within the NHS Constitution, the NHS in England will continue to fund existing drugs that have been recommended by NICE. And that right will continue and will apply to new medicines to which VBP applies.

“NICE will examine the evidence on the potential clinical and cost effectiveness of new drugs as they become available; drawing on its world-leading expertise in the field.

“And, importantly, under the new system of VBP, NICE will no longer be obliged to make yes/no decisions on access, based on its own cost per QALY thresholds.

“Instead, you’ll be free to focus on the rigorous appraisal of evidence to show the relative benefits of a new medicine.

“There will be price ranges under VBP, reflecting the contributory aspects of value, including the additional therapeutic benefits, the quality of innovation, the response to unmet need, and societal benefits.

The resulting pricing thresholds will be set as part of the VBP pricing mechanism, by Government, rather than by NICE.

“No longer restrained in this way, your appraisals will be even more applicable across the world, cementing further your international reputation.

“Clinicians will always need advice they can trust and depend upon, to make the best decisions for their patients. But through this new system of Value Based Pricing, I hope that those options available to clinicians will include more new and innovative treatments that may not have been available so readily under PPRS.”

Paying tribute to the work of NICE, Mr Lansley said that time and again, NICE had proved that it has the people, the skills, the sensitivity and the objectivity to lead the way within the NHS and in public health.

“The decisions you have taken have helped ensure that millions of people get the benefit of the best drugs and technologies, and that their doctors know exactly what the best and latest treatments are,” he said.

17 May 2012

http://www.nice.org.uk/newsroom/news/HealthActMakesNICEStrongerThanEverBefore.jsp

Il Governo inglese chiama Wikipedia: “Diffondiamo gratis le ricerche accademiche”

Il Ministro inglese per l’Università ha chiesto a Jimmy Wales, fondatore dell’enciclopedia online, di sviluppare un sistema di condivisione gratuita e libera della ricerca accademica. Per il Ministro «è l’inizio di una nuova era». Sul piede di guerra i colossi dell’editoria, sotto accusa per gli alti costi delle pubblicazioni.

Basta costose riviste accademiche, basta pubblicazioni quadrimestrali dai prezzi inaccessibili. Il governo inglese ha chiesto al fondatore di Wikipedia, Jimmy Wales, di sviluppare un meccanismo di condivisione online delle ricerche universitarie che sia gratuito e facilmente accessibile a tutti.

L’annuncio è arrivato direttamente dal Ministro inglese per l’Università e le Scienze, David Willets, che ha fissato il varo del progetto in due anni. Riguarderà tutta la ricerca finanziata pubblicamente dai cittadini e farà parte di quella che in Gran Bretagna si definisce “primavera accademica”, ovvero quella campagna, portata avanti da accademici e finanziatori di diversi atenei, che mira a rendere la conoscenza sempre più libera e open.

«Diamo alle persone il diritto di consultare gratuitamente la ricerca finanziata pubblicamente. Questo ci condurrà verso una nuova era di scoperte e di cooperazione tra studiosi e docenti», ha detto il ministro inglese al Guardian. Secondo Willets, il valore delle pubblicazioni cartacee in ambito di ricerca è indubbio. «Ma, mentre il mondo attorno cambia, si evolvono anche cultura e tecnologia e i relativi modelli di business. Voglio lavorare con l’Associazione Editori mentre sviluppiamo il nuovo modello».

La decisione arriva in un momento cruciale della storia accademica britannica: poche settimane fa, quasi undicimila ricercatori hanno firmato un appello per chiedere il boicottaggio delle pubblicazioni di Elsevier, uno dei colossi dell’editoria universitaria. Sotto accusa i costi elevati dei giornali di ricerca, definiti «una piaga nelle casse sempre più povere delle biblioteche degli atenei». Le sottoscrizioni ai periodici possono arrivare a costare, ad una struttura di grandi dimensioni, anche milioni di sterline all’anno.

Il governo britannico ha quindi deciso di solcare l’onda, chiedendo aiuto ad uno dei guru della libera condivisione della conoscenza, Wales appunto. «Wikipedia è diventata un punto di riferimento cruciale nel nostro orizzonte culturale, e poter beneficiare dei consigli dell’uomo che l’ha creata ci sarà di grande aiuto», ha detto il Ministro inglese. Secondo una fonte interna al governo guidato da David Cameron, riporta il Guardian, a Wales sarà data carta bianca: «Il fondatore di Wikipedia si occuperà di sviluppare interamente la piattaforma in cui le ricerche saranno condivise», ha rivelato la fonte anonima. «Suggerirà il formato più adatto per la pubblicazione dei documenti e setterà gli standard dei dati». Proprio qui si gioca la partita fondamentale, «visto che oggi gli articoli possono essere ripubblicati, mentre i dati no. Dobbiamo creare un sistema in cui i dati possono essere pubblicati interamente insieme all’articolo, attraverso un format aperto, accessibile a tutti e gratuito», riporta il giornale londinese.

La piattaforma, che sarà sviluppata nei prossimi ventiquattro mesi, verrà dotata anche di uno spazio di discussione dedicato ai ricercatori, affinché possano agevolmente confrontarsi e mettersi in contatto tra di loro. Ma come si comporteranno i grandi editori di letteratura scientifica? La maggior parte della produzione accademica britannica, circa un milione e mezzo di articoli all’anno, è diffusa oggi da tre publishers principali: Elsevier, Springer e Wiley. Per queste compagnie, i prezzi elevati assicurano una revisione dei contenuti di alto livello. Ci si aspetta battaglia, sia da parte loro, sia da parte dell’Associazione Editori britannica. Ormai, però, il governo ha lanciato il dado: resta solo da vedere chi farà la prossima mossa.

thinkpurpose

Think of a canal lock

  • Water is queued on one side of the lock waiting to move to the other side of the lock.
  • It is moved in a batch up or down to the other side of the lock.
  • The water itself does not move either in the lock or on either side of the lock. It is stationary, the only time it moves is when the batch of water, together with the barge, moves from downstream to upstream.
  • The barge and most of the water spend a good deal of time stationary inside the lock without moving.

A person working in a command and control environment will see work in this way. Work is cut up into discrete chunks, queued and sorted into batches. For example, Housing Benefit offices will split work into queues held on databases, staff will be assigned to a queue to process cases in…

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L’accademia sopprime la creatività? Un punto di vista accademico dalla Florida @muirgray

L’accademia sopprime la creatività, scoraggiando il cambiamento, l’innovazione dell’università e della ricerca, lo sviluppo della leadership, e la crescita?

The Scientist pubblica un contributo di Fred Southwick , Professor of Medicine at the University of Florida. He is the Project Manager of New Quality and Safety Initiatives for UF & Shands Health System and is the author of the upcoming book Critically Ill: A 5 Point Plan to Cure Healthcare Delivery.

Creativity enhances life. It enables the great thinkers, artists, and leaders of our world to continually push forward new concepts, new forms of expression and new ways to improve every facet of our existence. The creative impulse is of particular importance to scientific research. Without it, the same obstacles, ailments, and solutions would occur repeatedly because no one stepped back and reflected to gain a new perspective.

Unfortunately, in the academic world—where much of today’s scientific innovation takes place—researchers are encouraged to maintain the status quo and not “rock the boat.” This mentality is pervasive, affecting all aspects of scientific research from idea generation to funding to the training of the next generation of scientists.

Academic leadership

Many who succeed in advancing to leadership positions in academia have been cautious, making few enemies and stirring little controversy. But such a strategy fails to generate the insights that drive scientific fields of research forward. The history of science is filled with mavericks who refused to accept the prevailing theories and challenged the status quo. In the field of infectious diseases, those scientific mavericks included Louis Pasteur, whose germ theory was ridiculed; Joseph Lister, who promoted the concept of sterilization; and Ignaz Semmelweis, who determined the cause of puerperal fever and emphasized the importance of hand washing as a preventative measure. In recent years, Barry Marshall and Robin Warren challenged the dogma that peptic ulcer disease was the result of stress when they proposed and proved that this disease was actually caused primarily by the bacterium Helicobacter pylori.

In today’s environment, out-of-the-box thinking is ever more important, as change is now the rule. The internet combined with the availability of powerful personal computers and smart phones has greatly enhanced the worldwide sharing of ideas, and as a consequence, the rate of change is progressively accelerating. All institutions including our academic centers need to adapt and reevaluate policies concerning how progress and success are defined.

Effective responses to environmental challenges require adaptive leaders. These leaders can convince others to change their viewpoints, challenging prevailing scientific dogma as well as more logistical issues such as the methodologies used in the lab. This type of influence is critical to easing the sense of loss and anxiety that comes with change. Common responses to these emotions include procrastination, denial, and discontentment, which can perpetuate an environment that resists change—and progress. Ironically, the tenure system designed to allow academic professors to speak freely without risk of losing their position also allows them to resist change and discredit leaders who encourage it.

Research funding

In the realm of research, funding governs projects and possibilities. The maladaptive insistence that research scientists obtain their financial support by continually writing federal, state, and private grants often prevents scientists from stepping outside the boundaries established by this grant process. Because the success rate is now down to 10 percent, academic scientists are forced to spend much of their time writing proposals, rather than performing creative research. Universities need innovative leaders who are willing to change the way research enterprises are supported, or they will continue to stifle their creative and energetic faculty.

In this respect, universities can take a clue from the business world, which has realized that investment in human resources and employee development—not brick-and-mortar structures—creates successful, competitive enterprises. Just as successful businesses work toward profits, successful universities need to work toward their primary mission of creating new knowledge. Too often, university administrators spend the majority of their time on fundraising and budgets rather than creating a fertile environment for true innovation.

Effects on teaching and students

The results of this suppression of creativity are not limited to the world of grant-funded research. The same leadership that fosters the status quo in research also affects the classroom. A university education is supposed to teach students how to think critically. However, that goal has been set aside in many of our classrooms, being traded for the less ambitious goal of memorizing facts. Curiously, when the rote memorization is emphasized, creative students are often penalized. Multiple-choice exams are the standard for testing a student’s ability to memorize facts, and creative students are usually not adept at guessing what a test writer is thinking. They are much better at solving problems, generating hypotheses, designing protocols, and developing a deep understanding of their discipline—all key aspects of good critical thinkers and professionals in science. By rewarding those students who accept the current facts as gospel, rather than skills that are likely to lead to the creation of knew knowledge, universities are stifling the next generation of scientists.

The removal of creativity as a priority can also affect life in the lab, turning a promising dialogue of new ideas and challenges into a monologue. Lead investigators too often quell discussions, rather than encourage junior investigators to share their ideas. They prevent innovation in their laboratories by imposing an autocratic and hierarchal structure. Science has become ever more specific and specialized, making it impossible for one individual to grasp the full complexity of the field. In the current era, effective and truly innovative science requires teamwork and very active discussion to overcome these barriers to creativity.

Keys of creativity and communication

Thankfully, some scientific institutes recognize the need for collaboration and, following the lead of the business world, are utilizing teams of experts in different specialties to work together to generate the hypotheses and design the appropriate experiments to advance knowledge, promote growth, and foster creativity in their fields. The university system would benefit from embracing this same approach. University governing bodies need to assemble leadership teams comprised of people who actually work in their laboratories and understand the challenges of today’s research environment. Ambitious and creative minds have revolutionized our world, and our perceptions of our universe, in a very short period of time. If our universities fail in their primary mission to create new knowledge, our progress toward creating a better world for everyone will be seriously compromised.