All skin and bone: fragility in a changing world

Of late we’ve all read about flattening the curve of the pandemic; spreading out the burden of patients on the NHS by delaying infections, so that its limited capacity is not overwhelmed by all the severe illness happening at once. The idea is to go from this:

To this:

              This is a salient example of something that matters a lot, which is the fragility of systems. Typically when we create something, whether a company, a machine, a committee etc., we think of it as having a steady capacity, like the flat dotted line in the first picture for NHS capacity. The NHS had a certain number of intensive care beds and ventilators, and that’s what it can manage. The same applies to a company: it has staff employed for 40 hours a week, and we assume that those 40 hours are steady and identical, so the company has some multiple of 40 person-hours a week to use.

              As has been explained in hundreds of articles over the last few months, disease does not follow this pattern. Some problems have a reasonably steady rate of incidence, but infectious disease ebbs and flows. We are accustomed to the flu season every winter, which increases demand for ventilators, as vulnerable people need help to overcome the virus before summer rolls round and people stop crowding together indoors.

              So what capacity should the NHS have: level 1, level 5 or somewhere in between? All capacity costs money, so we can’t just pick the most capacity without suffering elsewhere. After all, that money could be spent on something else: tax cuts for the lobbyists, maybe, or other NHS treatments. If we have enough capacity to cope with the highest peak seen, or to cope with a potential higher peak, then over half of our capacity will, on average, be unused.

              Empty operating theatres, empty hospital beds… these are prime fodder for angry tabloid stories bemoaning government waste and bad health management. Why have we wasted money on stuff we’re not using when we’re not funding expensive cancer treatments for this one person we dug up?

              That, like most tabloid arguments, is utterly stupid. It could easily be that those beds, despite being empty some of the time, still save more lives than the equivalent price of an overpriced and oversold cancer drug. Tabloids never even attempt to consider that; they are oblivious to the variability in demand. While I’m on a little aside, that’s one reason why government programmes are often so expensive: they are, by their nature, universal. They need to reach everyone, and serve everyone. If some people are hard to access, difficult to deal with, or all need help all at once, then the whole point of government intervention is to be there in those difficult times. The private sector can serve the easiest, most profitable people, and actually does best by excluding difficult cases, as they reduce the average profit. Homogeneity is profitable… a point we might come back to.

              Anyway, I think we can all guess that we don’t have capacity at levels 1 or 2. We’ve gone through so many cost-cutting drives to find efficiencies, and 10 years of underfunding, that I’d not be surprised if we were lower than level 4. We don’t even have enough capacity for lowest levels of peak demand. This is the world we live in: we are making hard decisions about allowing some people to die in order to save money. Covid-19 has not suddenly created a situation in which need outstrips capacity; it has merely created a worse one than normal. If I haven’t been clear enough, we have already been letting people die in the name of efficiency. This is normal and necessary.

              Another aside: yes, I do mean necessary. The nature of healthcare is that there is always more that we can do. I do think that we should be doing an awful lot more, but even I recognise that some things that could conceivably be justified as healthcare are too expensive or disruptive to be worth it. So there will always be a balance between saving some health and allowing people to truly live.

              The immediate point is that the NHS had had capacity cut until it was already overburdened, because that ensures the most efficient use of assets by one measure of efficiency. If operating theatres are always in use; beds never unoccupied; doctors’ time always filled (to the extent that many are working double hours), then it necessarily follows that sometimes there will be unmet need and people will die. They won’t always die from famous, newsworthy diseases like a new global pandemic. They will be elderly or infirm people who just got unlucky. They got the flu or had a fall at the wrong time. Or maybe, like my mother, had a stroke and couldn’t keep a bed on the stroke ward with proper rehabilitation and physiotherapy because there were too many strokes, and so after recovering then got dumped on sedatives instead and died without ever really waking up again. At 63 years old.

              God forbid that we have enough stroke beds, and sometimes have them empty, with nurses and physiotherapists having an extra half hour a day to rest or devote to fewer patients.

              One more general point we can see from this example: fragility. I think that there’s more to fragility than simply gradually going over capacity. Fragility is about a system breaking; there are set points beyond which things don’t just get that little bit worse, but a whole lot worse. If you bend a twig, it gradually flexes out of shape, but at some point it’s under so much strain that when you bend it more it snaps. It’s important to be aware of fragility, identify it, expect it and prevent it.

              All systems need spare capacity. In my kitchen, for example, I need work surface to do my chopping, mixing etc., and to put newly dirtied pots and bowls. If there isn’t enough work surface, I have to spend a fair amount of time shifting things around just to get, say, the chopping board next to the bowl I want to put the chopped stuff in. And if, as in one shared house I lived in, all the surfaces are used as storage, it suddenly becomes impossible to cook at all. The free space that my housemates regarded as fair game for dumping cereal packets on was actually better empty.

              In the NHS, empty beds or operating theatre slots are important. Emergencies can crop up, and a spare slot allows managers to rearrange everything. That’s why in those little sliding piece puzzles one slot is empty: you need to be able to move a piece somewhere empty in order to free up its space. If, in the name of efficiency, you fill that slot, but the pieces need to be rearranged, you’re stuck. You’ve broken the system. And if you need to get things in place fast, you might be best off with two free spaces; that makes the puzzles much easier, whether it’s a child’s game or organisational management.

              Systems aren’t often like the picture below:

              Fragility doesn’t just come from inflexibility. There are all sorts of negative feedbacks that might emerge. If, for example, patients start to clog hospital corridors, staff might be less able to get to where they need to be, losing time on the patients they actually had time to book in. Or those extra patients will transmit disease faster to everyone than they would if in a ward space. Without flexibility, a delay somewhere, which becomes very likely, will lead to complete cancellations elsewhere, because staff or equipment suddenly aren’t available…

              That means that systems behave more like this:

              So, having explained how we’ve been killing people for years, what more important things can we apply the same concept to? Fragility is a broad concept that doesn’t just apply to life-saving work in healthcare, but to everything. Before we get to the economy, let’s start with games

              When you play a game with your family, you’re typically faced with risky or less risky choices. Monopoly, for all its flaws as a game, is widely known, so let’s think about that. Should you buy another house on your set or keep a bigger cushion of money in case you land on someone else’s? If you keep a massive financial cushion you’ll never get enough income from your under-improved properties and you’re guaranteed to lose eventually, but if you aim for a high income as soon as possible, and you spend all your cash on houses, then you’ll need to be lucky not to lose quickly. Ideally, with just your family playing, you judge your risks based on everyone else’s success: if someone else gets lucky, you need to spend your cushion to try to keep up, and take your chances now when they're better. With, say, 4 players, that can still lead to a game that lasts a while, although it’s very likely that someone gets unlucky early on and has to find something else to do.

              The same applies in any game. If you play pontoon (also called blackjack, or 21, or vingt-et-un…) you want to beat just one person, the dealer. That’s why the dealer should play quite safe; if he goes bust then everyone else knows they can just stick with what they’ve got and still win. But imagine you’re playing against everyone else. It’s really likely that someone out there will have a 20, even if there’s no obvious 5-card trick or 21. Playing it safe will just lose you your stake. You have to take a big risk to win.

              This is our capitalist market. You are in competition with everyone. In theory, the number of competitors can be modelled as infinite. That’s ‘ideal’. If you play it safe and hold something back for a rainy day, someone else will start up, cut that cost and sell things more cheaply at the same quality (not that quality is much of a signal in modern markets). That person will get all the customers; or else that person will sell at the same price but make more profit, and therefore get all the investors. Either way, your investment in resilience is wasted.

              The key to our current economy is competition (call it capitalism, neoliberalism, just plain badly-run or badly-regulated, or whatever you please; let’s save the argument about terminology for someone else). It’s about competition right now, for profits right now. That means cutting as many corners as possible to grab whatever share of the market you can right now: the future is too expensive to worry about.

              There are all sorts of theoretical answers to this counterproductive set of incentives. You might hope that investors have perfect information and therefore know which companies are more resilient, and therefore also know that those companies offer better long-term prospects. But perfect information is one of the theoretical assumptions that we’re furthest from. Even in the information age, people are more snowed under a weight of misinformation (also called PR or marketing) than they are well-informed.

              You might hope that the barriers to entry and obvious market volatility lead all the cut-throat market entrants to be less risk-taking with their businesses. But there will always be risk-takers hoping to survive through luck rather than good planning, and therefore make a big profit.We have no shortage of desperate people trying to come good with yet another throw of the dice.

              And so we are likely to have repeated new entrants starting up, making profits in the good times, and going broke in the bad times. And if new entrants are providing that competition, big, established companies must follow the same strategy or lose out. And that’s how we get big banks, ‘too big to fail’ taking massive risks and in the financial crisis easily becoming insolvent. The market system we have set up pushes all companies to as close to breaking as they can go in a desperate attempt to keep up.

              In a racing analogy, with only one race, that makes sense. If you’re thinking of a predator and prey, a nice macho analogy, the prey must run faster, no matter what the potential cost. But as soon as you think longer than one event, it doesn’t make sense. If you push your car, or horse, or yourself, far too hard in the first of many races, you’ll likely have an injury or breakdown and do far worse. That’s fragility. Horses are actually a great example. They have evolved to be running machines; creatures that big shouldn't be as fast. But that has come at a cost. They easily break their legs, which have no excess weight, and therefore strength. In the wild, that's just collateral damage of their evolved survival strategy. But the same fragility in society equates to human suffering.

              We choose to set up a system which forces this desperation and makes it difficult to invest for the future. That’s how our markets work, with instant stock trading, and a focus on share price by senior executives, whose reputations are determined by stock performance now, even if their stock options mature in the future.

              Yet, just as with infectious disease, markets are volatile. Demand varies, by season and economic cycle as well as consumer whim. We must therefore expect, as part of our economic system, an endless cycle of bankruptcies, failures and job losses, with only the lucky surviving for any length of time until they become famous enough and respected, or have enough reach and digital information, that they have a massive advantage over new entrants. They can then afford a little safety; in fact, once established, their advantage can be so great that we get a whole load of other market failures, from disinformation (‘marketing’) through to lobbying and regulatory capture.   

              The essential point is that everyone sensible must take those chances, and therefore be lucky. And those few who are successful owe it more to luck than taking the best chances. If I give myself a 2% chance of winning and 196 others are incompetent enough to share the remaining 98% at 0.5% each, I still owe a lot more to luck than to skill if I win. That's true even though I'm four times better than any other rival. In the same example, whichever 196 of us lose, all will still owe their situation more to the system that forced us into taking those chances than their own incompetence.

              In short, capitalism builds fragile systems: it is intrinsic to the way we run it. And when big companies fail, we have seen what happens: public bail-outs. So in the end, we all pay for this disaster of a system, while those who have been lucky enough to have enough to invest, and crucially, enough to pay for lobbyists, end up winning in the good times and not losing in the bad. There are even ways to make money from the bad times, if you have enough to invest in the first place, and enough to spread your risk widely.

              That’s what has happened to privatised services. I don’t know much about our railways, but I have seen enough of the arguments train drivers have had with management to cast that argument as one about fragility: guardless trains, staffed only by the driver, are a safety risk. It’s not that a train can’t be operated only by the driver, if everything works well. But people do get stuck in doors, disabled people need help with wheelchairs, and so on. Much of the time, perhaps, a conductor is not required, but without one the train can be delayed, and then it might miss its slot on a packed trainline which has no spare capacity itself… The problem is obvious.

              There are other criticisms of privatisation, but this is not the place.

We do have an industry which has dealt with fragility, and that is electricity production. A functional National Grid is really a wonder of the modern world. The electricity is on all the time, even though daily demand varies enormously (although reasonably predictably, which does make things a bit easier). How do generators balance supply with demand? Through a whole company (National Grid has been privatised) and over 16,000 pages of dense legal obligations on top of normal laws and regulations.

              If you’re tempted to take it for granted, look at some other countries to see the results. I have a friend in Zambia who is plagued by what they know as ‘load-shedding’; rolling, unpredictable blackouts that can happen as much as every day for hours, because electricity supply and demand are not matched (and oversupply is dangerous too, as it can blow fuses or equipment).

              Just a little change can short-circuit the whole system. We ensure that suppliers always supply through definitive legal obligations and considerable amounts of government subsidy, planning and intervention. One could argue that some of this is unnecessary, but without some form of payment for availability as well as for electricity, we would not be able to match demand to supply. Availability is a commodity that has value.

              Except, of course, when it doesn’t. And that’s when it’s individuals’ availability. Low wage workers are not typically paid to enter zero-hours contracts.

It’s a default for workers to work between 9 and 5 (or in many jobs nowadays, 8.30 and 6 or longer….). It doesn’t matter if they’re a bit ill and would benefit from a lie-in or a shorter day; the world of work, including office work that isn’t shift-based (when the timing is important, for overseeing machinery or serving customers), demands that people work set hours. But individuals do not have a steady capacity for work. Illness, life events, home trouble, a neighbour’s party: a vast range of things can make the cost of 9-5 on one day feel like more than on another. Presenteeism encourages workers to turn up even if they feel less than 100%, instead of doing work when best able to. And if it’s a demanding job, then it requires that they do the additional work of managing the timing of their capacity. No late dinners with friends: work must start at 9, not 10 tomorrow. No social life. Got ill? Well, tough luck. Take some drugs and hope the stimulants mask the fact that you should be resting more than usual.

We treat workers as substitutable components; Lego bricks all the same size and purpose in any role. Workers aren’t automata who can perform at (the same) 100% for precise, unbending periods of time. They have more or less capacity at different times and ideally each individual life would have flexibility to do more at some times at less at others. If we require people to operate at peak capacity all the time, at the same times, we can expect the system (their life) to break down.

And by require, I include demands of career advancement and promotion. If we reward dedication then we will end up rewarding those with the free time to dedicate to work. Those who can spare most capacity for work will do best, and those burdened with care, housework, poverty and budgeting constraints, illness or just hobbies and creative interests will all lose out, and everyone will end up, as happens with companies, putting in as much time as they can in order to avoid falling behind and trusting to luck that life doesn’t unravel. There will be no free time for creativity; no spare capacity for events. Spare capacity is a source of social shame: what are you doing with your time? Why are you wasting it? And at the same time as our culture demands you give all your time, researchers are finding that having too much to deal with reduces your performance at everything. This is most obvious with the poor and unfortunate: even when they have time for something, the stress of the rest of their lives, and the intrusive worries about all their other problems, reduce their performance. They have gone past their capacity and negative feedback has begun to demonstrate fragility in their enforced lifestyle.

And then we discuss burnout and mid-life crises. By the time burnt-out people have hustled their way to depression they’ve already trodden others down. The people who knew that they wanted a good work-life balance all along have been elbowed out of the way by those who used their spare capacity and were fortunate enough not to need it for anything else… but now find it might have been nice to have it for something else. Everyone has lost, even those who had it right all along.

Spare capacity should be a point of pride and thankfulness.

The flip side of a set 40-hour week is that employers frequently expect office staff to work longer hours at peak times. As we can see in the electricity market, that sort of extra capacity is hugely valuable when we (the people) buy it, but it has become a hidden expectation that we (the people) don’t get paid for when giving it away.

There’s a reason that contractors and consultants charge a lot, and it’s not always just their over-inflated brand value. They allow flexibility: they are a whole segment of the economy that exists to provide flexibility in capacity for organisations. The downside is the overheads of contract management, performance monitoring and lack of trust; or lack contractual flexibility in outsourcing.

The drive for leanness in systems comes from a lack of trust. Managers don’t know when they’re being taken advantage of… and are driven to take as much as they can from employees. Cut things away and see if anything breaks would be a good idea if only effects were immediate and stresses constant. There is wisdom in the old design maxim that you achieve perfection not when there is nothing left to add, but nothing left to take away (yes, if I spent more time on writing, I could apply that here). But wisdom only. You need to know what actually could be taken away.

My father always used to like the solid, real-world example of a bridge. 97% on a test isn’t good enough: a 97% survival rate when crossing your bridge isn’t good enough. The same applies here. You can save some materials and still have a bridge stand up when you first build it, but if it collapses when the first storm wind blows, you haven’t been clever. And maybe it’s more expensive to put emergency supports up every time the wind blows…

What is leanness? It used to mean just being thin: the opposite of fat. And we get fat for a reason: to survive hard times. Weightlifters go through bulk and cut phases because they can’t grow quickly without also getting a bit fat: fat is an intrinsic part of growing strong, and is not just waste. Obesity is unhealthy, but a human with no fat is seriously ill. The same applies to organisations and systems. The clue is right there in the words that modern management jargon uses. We should learn from Mother Nature: in volatile times, spare capacity matters.