Getting serious about making changes in healthcare?

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Guest column by former director general of health Chai Chuah

Improved access, affordability and equity of health outcomes requires disruptive innovations, and that means different talent, capabilities and operating models than those needed to maintain the status quo.

Pressures in First World countries’ healthcare systems are relentless and increasingly feel insurmountable. Layers of initiatives and services criss-cross each other. It kind of works, but it’s difficult to make change, and God forbid that it should all collapse one day.

Solutions to date at best provide temporary relief and at worst actually make it worse. The mind-set of mainstream decision-makers in healthcare towards these intractable challenges is fundamentally to call for more resources (funding, staff, facilities and information) to improve the effectiveness and efficiency of current services, and when this does not work, to blame someone else.

There are those who realise this hiatus cannot continue and who are starting to do something different about this. Some are from the healthcare sector, but it is the non-health sector actors who are taking most of the lead, supported by like-minded health leaders.

While mainstream decision-makers in healthcare continue to discount and put up barriers to these new entrants, it has not slowed down the exponential growth of these new entrants. The announcement of the partnership of the UK-based Babylon with the China-based TenCent, together with the current discussion between Wal-Mart and Humana in the USA, are the latest data points providing a clear signal of the trajectory of change in healthcare.

These new entrants will not always get everything right and are likely to make some mistakes along the way. But they are more agile, open-minded and understanding of the power of exponential technology, as well as faster to give up what does not work and to figure out and try what might work.

Attempts by mainstream decision-makers in healthcare to date have not provided durable answers, yet more of the same is still being proposed in most First World countries. They have not and will not work for the following reasons:

• Linear and complicated solutions are proposed to solve complex problems.
• Solutions are often designed to improve each of the fundamentals, e.g., workforce, funding, facilities, but not the relationships between them. Such a silo approach is actually making the situation worse, not better, by reinforcing the importance of each fundamental but not the whole system.
• Solutions offered to date on improvements are designed to make the current system more effective, efficient and productive, when changes in context and environment require disruptive, not sustaining, innovations.
• Talents, capabilities and structures needed for disruptive change are fundamentally different from those that are managing the existing system.

Complex rather than complicated or linear

Linear and complicated solutions do not and will not work because complex challenges and problems have these characteristics:

• There are many and an increasing number of causes.
•  The relationships between these causes and their effects are not well understood, difficult to explain and constantly changing.
• The cause-effect relationships can only be seen after they have occurred, and they are difficult to predict.
• Even when the cause-effect relationships become apparent after they have happened, they do not necessarily repeat themselves.
• Data at best provides insights into correlations but does not explain causal relationships (why they occur).

Discovery approach

A discovery approach with a portfolio of safe-to-fail initiatives is the right response to find solutions for complex challenges. Some of these initiatives will not work, but learnings from them will provide insights for initiatives that follow. If there are no failures, then these portfolios of initiatives will not contribute to discovering the way forward.

There are no best or good practices to solve complex challenges. Yet how many times have we heard comments like “let’s not reinvent the wheel and adopt these best or good practices”. The value of the discovery approach is more in the learning and process rather than the milestone or results.

Optimising relationships between fundamentals

How many advisory groups for workforce, eHealth, capital planning, funding have come and gone, and the challenges not just remained but become more pressing? That is because each of these is designed to make recommendations to optimise each of these respective areas. Even when a whole system advisory group is set up, recommendations on these fundamentals are almost always cherry-picked by decision-makers when it comes to implementation.

Current interventions are designed to respond to events or trends that emerge from a series of these events, but not the underlying weakness of the relationship between the fundamentals of the whole system.

Complex social challenges need a system approach that optimises the relationships between all the fundamental parts rather than optimises each fundamental part.

Disruptive not sustaining innovations needed

Making improvements (effectiveness, efficiency and productivity) on something that works, but was designed for a different time, context and environment, is flawed. These sustaining innovation improvements still have to be pursued. But on their own, they are not nearly enough, and do not and will not improve access, affordability and equity of health outcomes that have emerged as a result of changes in context and environment.

The theory of disruptive innovation introduces new partners, new technologies, new networks, new operating and business models that are more relevant for today’s context and environment. These disruptive innovations properly executed will improve access and lower costs, which can contribute to improving equity of health outcomes for those who currently are missing out.

Different talents, capabilities and operating models

Asking current leaders whose talents and capabilities are designed to manage the current system to disrupt themselves is like asking the turkey to vote for Christmas. Incumbent leaders need to keep doing sustaining innovations to create the head room for disruptive innovations. But they are not the ones (through no fault of their own) who can deliver on disruptive innovation agendas.

Likewise, current organisation structures, incentives, rules and criteria of success, capabilities, skills and knowledge are all orientated towards managing the status quo.

Disruptive innovations require different talent, capabilities and operating models to execute a discovery approach on a portfolio of safe-to-fail initiatives that strengthen the relationships between all the fundamentals of the whole system. Therefore, a dual transformation approach that clearly separates the talents, capabilities and processes of sustaining from disruptive is needed.

Can this be done within a single organisation? There is some emerging literature that suggests it is possible, but current exemplars from what works in other sectors point to a need to set up separate organisations lead by leaders with different sets of talents and capabilities.

Linking the four concepts

These four concepts are interconnected. A complexity framework recognises that a discovery approach is the right response. The discovery approach is disruptive and requires a portfolio of safe-to-fail initiatives that strengthen the relationships between the multiple and varied fundamentals that make up the health eco-system. Different talent, capabilities and structures are needed to take a discovery approach to execute disruptive innovations.

Concluding remarks

As someone who could be serious about making changes to healthcare, take some time to mull over this article and begin the journey to find out whether you are a sustaining or disruptive leader –because you cannot be both.

To help you with your discovery journey, watch these talks that explain the above concepts and more in greater detail.

Systems thinking for social change

Social innovation in the real world – from silos to systems

The value of management theories in health care

The Cynefin Framework

This article was originally posted on Linked In on 7 April 2018.

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