Watch.UsNow is a great video about how the web lets people take things into their own hands and just get on organise stuff. There’s Clay Shirky, Charlie Leadbetter, William Heath, Lee Bryant plus mums from netmums and many others all talking very good sense. Well worth a quick watch (and thanks to Jonty  at Demos's Progressive Conservatism project for bringing it to attention).  

But looking at it I realised that Patient Opinion doesn’t quite fit. And the reason is that we don’t ‘do community’ in the same way that netmums or Facebook or Couch Surfers do it. For them the community is the whole point – they are about giving people a place where they can do what they want in ways that they are passionate about. This is what Web 2.0 has been all about up to now and it’s releasing a wave of mutual help and support that will, for sure, change the world in just the ways that the Watch.UsNow video explains. 

You can easily imagine similar communities building around Patient Opinion with people discussing services for endometriosis or hospitals  in Wolverhampton. And of course we’ve talked long and hard about whether Patient Opinion should do this. Our worry is that such groups would quickly turn into moaning arenas or gravitate to the ‘let’s go beat them up’ approach. But perhaps we’re doing everyone a disservice by such assumptions and we should trust people more and go test it out. 

But there is also another reason why we don’t quite fit into the standard web 2.0 model and that’s because we’re focused on changing services whereas most of the standard bearers for  ‘web 2.0 is a revolution’ are focused (rightly) on their members interests. So netmums is about mums not primarily about services for mums. And Couch Surfers is about finding congenial  people to stay with for free in new cities, not about improving travel services.  

Patient Opinion together with sites like MySociety are doing something different – we’re trying to engage the service, to get busy staff to act in new ways. This is very different from setting up a community of users ‘outside’ the system and who are all too easily perceived by staff as being critical. So it is possible that vibrant communities of users might indeed make our  core task – improving services – harder not easier. 

This isn’t an either/or of course – sites that focus on mutual support or benefit and sites that want to change the system are both really worthwhile. But Patient Opinion’s task of changing the system by engaging many thousands of staff as well as  tens of thousands of users, is distinct for two key reasons. Firstly it creates a different sort of public value to groups focused on mutual support. Second if we are successful, it opens up different revenue streams beyond the old stalwart of advertising that everyone and his dog is trying to make a living from on the net. After all if we could help patients and carers initiate 10,000 service improvements a year this will create significant value for the NHS. If we could find ways to extract this value and feed it back into more patient-initiated change - now that would be exciting. Then there really would be money in them there pills!

Sitting on a working party the talk was all of governance, protocols, making sure that ‘the lessons are learned’. Life was proceeding as it has in the NHS for several decades on the general assumption that if control is good, more control is better.

This might be called the One Last Heave model of service improvement: having implemented  the 137 recommendations made by Lord Laming following Victoria Climbie’s death, and being faced by the appalling case of Child P, the system homes in relentlessly on ‘further lessons that must be learnt’, another inquiry, yet more checks and controls. One Last Heave will get us to Nirvana where bad things can’t happen. 

Such is life in an environment where systems are tightly coupled. And sitting there not doing full justice to my working party, I realised that’s been the major characteristic of the last 20 years of my life as a clinician in the NHS. We’ve been busy using the power of newly digitised practice to build ever more tightly coupled systems. More and more is governed, linked, joined up, defined, evidence-based. Variation has been driven out, and following agreed practice is valued over the exercise of judgement and discretion. 

The dream behind building tightly coupled systems is that they will lead to control, equity and cost-effectiveness. Which may be so in the short run but in the longer term tight coupling leads to rigidity, risk aversion and declining innovation. Tightly coupled systems deliver decreasing returns – every additional goal, policy, organisation, partner or issue leads to less return.  There are two reasons for this. Firstly because variation is seen as the enemy: noise, randomness, error and failure are all things to be engineered out where as in fact they are often needed to make the system work. And are an important source of insight and innovation. Second the coordination costs of tightly coupled systems rise non-linearly as the number of things to be coupled increases.  So ‘joined up government’ quickly becomes toxic.   

And now we are faced with an economic situation that gets ever more uncertain. It is unlikely that the ‘one more heave’ philosophy of tightly coupled systems will work in a severe recession. Being risk averse, relying on protocols, KPI’s and micro-management will fail in the newly austere state because such approaches deliberately exclude the variation from which the new solutions will emerge.

The answer to all this? Look for systems that have increasing returns. Google, Wikipedia, e-Bay, the web itself – all deliver increasing returns. The more people use, edit and review Wikipedia the better it becomes. Such systems are almost always loosely coupled. No body is forced to use Google, no one accredits e-Bay buyers, and there was no government roll out plan to teach teenagers to use SMS text messaging. Is it possible to build increasing return systems that help improve health? Don’t know yet, but if it is I know they will look more like the net than NICE, more like Wikipedia than Whitehall.

Hits and clicks are the steroids of the web. Got ‘em and you’ve got growth, revenue and eyeballs. Without ‘em your dead in the water – or at least that’s the conventional wisdom. But whose interest do clicks and hits really serve? Well sometimes it’s useful to know that lots of other people liked an item – it’s a great way to get a sense of a field that you know nothing about. But thereafter hits and clicks mostly serve advertisers and shareholders. They are important because they reflect the ability of the site to raise revenue. But what if your site isn’t interested in selling things? What if you’re site is about changing the world?

Of course if your site is about campaigning or growing a political movement, then getting the message out is important and size still matters. But there is a new game in town, sites that are about generating hyper-local change. Patient Opinion for example is about making ward 15 in Solihull General less noisy at night, or about working with staff at Rotherham to improve how relatives are cared for. Here the motivation comes from the citizen - people are often strongly motivated to stop others going through some particular aspect of  care that has been poorly delivered at some specific site in the NHS.

No point in thinking that this posting will or should garner thousands of hits. What is much more important than size is that just the right 3 or 5 or 15 people who can do something practical about the problem see it and act on it. If we could find a currency and a business model that drove such micro changes, then we would be looking at a way to release the energies of citizens to improve the world in hundreds or thousands of small but significant ways. We might also be looking at the next YouTube. 

Four economic aspects of the web make such a system possible: cheap voice enables everyone to have a public say; RSS feeds increase the signal to noise ratio and enable your message to get to just the right people; the web makes it easy to find ‘people like me’ cheaply and quickly – people who are driven by the same passion or problems as your self; and finally the web makes it easy for people to coordinate action from email to PledgeBank to MeetUp new tools are helping people get organised.  All these tools are currently citizen-centric not organisation centric. For the first time in history it’s easier and cheaper for citizens to put together an effective response than it is for organisations. The problem is that such citizen campaigns can undermine collective solidarity. Such effects can be seen with both Al Quada and the ability of particular patient groups to (understandably) pursue their own with the effect of reducing benefits to others.

So what we need are tools and a web currency that rewards citizens for their efforts and passion about some hyper-local aspect of a service whilst incentivising busy staff so that they no longer see patient comments as blemishes but as the starting point for getting professional and organisational rewards.

Hyper-local tools are what Patient Opinion is now working on. How can we exploit the new economics of the web to enable citizens and front line staff to change thousands of micro-aspects of care?

Finding ways to combine these two aspects of great health care, the highly personal and the highly systematic, is the task of health professionals in the 21st century.

Click here if you want to see an example of a story brim full with acts fo work and courage - or here for one that fails on almost every count.