What Are the Axioms for Continuing to Work

Many important human endeavours crystallise their wisdom into one or more, and usually several, axioms. Why are there no axioms for governing the health system? Axioms are the fundamental underpinnings of social movements, academic disciplines, or intellectual pursuits. They postulate self evident principles within a logic that everyone accepts.

Such propositions are typically used to remind members of obligatory values, to teach a lesson, or perhaps to prove a point. Although they have various commandments, the world's religions, for example, profess to the multitude something like, "Attend to matters spiritual, learn the sacred ways, and apply their principles in your life." Environmentalists hold to their own indispensable tenets about the stewardship of nature, the core of which approximates to "The earth is all we have, and its resources must be sustainably nurtured." Medicine's prime axiom is short, piercing, and famous: "First, do no harm."

The idea of the axiom originated in mathematics. Axioms in mathematicians' hands are very strictly expressed, typically as formulas encoding unimpeachable truths without the need for further proof. This type of Euclidean rigour is relaxed in other disciplines, but the force behind it—that specificity in axioms is vital—is retained.

Thomas Kuhn taught that axioms can change if the paradigm shifts. The revolution in physics, for instance, took us from the Newtonian view of a clock-work, knowable universe to quantum mechanics—a picture of the universe, below the atom, of weird unpredictability, uncertainty, and entangled particles. This is what Einstein called "spooky action at a distance." But in many fields axioms endure over time. Indeed, that is in part their purpose: to encourage consistency of application while other changes might be under way.

• Practise safely at all times; do unto patients as you would have done unto you

• Promote openness and fairness and treat patients as equal partners in all healthcare processes

• Engage clinicians in decision making in all parts of the system as a natural complement to "top down" governance tendencies

• Recognise and inculcate into practice that "we" approaches are much stronger than "us and them" approaches

• On this last axiom everything else rests: reinforce at all times that the essential elements of a high quality service are the sum of people's skills and ingenuity; adequate resources; sound support structures; access to appropriate technology; good information on which to base decisions; a focus on patients' needs, trajectories, and outcomes; effective leadership; continuous improvement; and positive interpersonal relations.

Some people think we are striving for a revolution in health care analogous to that in physics. Once upon a time each public health system around the world was a cottage industry based on individual expertise. Last century public sector health care was restructured in many countries, led by the British NHS in 1948. Although each system was arranged somewhat differently, many of the public health systems in the developed world became, in the name of efficiency, centrally organised, hierarchical, even monolithic. The new shift is in the form of a reconceptualisation of health sectors from highly structured, conventional services with clearly defined roles to more fluid, dynamic entities that are based on networks and teams with a mission to pursue ongoing systemic development. According to this reasoning the game is changing, and the metaphor for health systems is moving from that of a machine to that of a complex adaptive system.

Much has been written about the NHS and its international counterparts, the problems that beset them, and the possibilities and their capacities for this new agenda for reform. One reason reform is not as successful as desired is lack of clarity about what is intended. Health systems and provider organisations have not expressed their strategic intention. Clearly articulated axioms for the governance of health systems would help with this and allow the progress of reform to be tested against the basic rules of the game.

If we take governance to mean that sustained efforts to lead, manage, organise, and continuously improve health services can be made, and if we envisage that both corporate (from the top) and clinical (from the bottom) governance are encompassed in this definition, we can identify five candidate axioms (box).

What would a health system consciously governed with these axioms in mind be like? It would have a baseline acceptance that the patient is the starting point for all that happens and the reason for the system in the first place. It would also accept that health systems need to be organic and flexible rather than rigid and mechanistic and that we need to be running things with the right balance between the individual and the collective. These five axioms could be summarised into one golden rule (in part paraphrasing the Gettysburg address): "None of us is as intelligent as all of us, and this means that governance of health care needs to be of the stakeholders, by the stake-holders, for the stakeholders."

Figure 1

This heralds an inclusiveness and focus that is often missing in hierarchical, bureaucratic, and overly political health systems. Sadly, to many observers these adjectives have described most public health systems until recently, despite reform initiatives. We need to continue the momentum to alter this state of affairs. Agreeing the right set of axioms might signal a way forward to make deep changes for the better. It might help us work towards responsive health systems of which we can be proud. The paradox is that we need to change and reform many parts of health systems, but other things, encoded in axioms, must remain non-negotiable.

Is this too idealistic? Yes, but axioms are like that. They force you to think what it is that is fundamentally important and to bare your assumptions for scrutiny. And then, when absorbed, they demand that you live up to them. Every good mathematician knows that is the real job of axioms: once stated, they exist to be satisfied.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC557166/

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