Taking Control of Future Health Care: Collaboration, cooperation, and integration
Introduction
While it is unknown exactly what the future will bring, one certainty about the next few decades is that a significant change in social attitudes will occur, in company with the introduction of a myriad of increasingly disruptive digital technologies. Another certainty is that these changes will exert a major impact on Future Health. While that impact will be both good and bad, it is in the hands of senior health leaders today to ensure the outcomes in the future are more positive than negative. In the face of unprecedented demands on day-to-day operations however, it seems impossible to find time to prepare for the transformation journey that in reality, has already begun. Amidst an emerging scenario characterised by uncertainty and chaos, the task ahead for health care leaders is nothing short of overwhelming.
It needn’t be. Just as methods and techniques in health have evolved rapidly in recent years so too have strategy and management remedies been developed by the Strategic Management Institute (SMI). Their application to practice will make the transformation journey a lot less complex, a lot less stressful and a lot more manageable. Some of these remedies are new and some are reinvented. They include tools and techniques that enhance the treatment of strategy practice, the design of organisational structures and the management of organisational change. Through their application the burning question at the back of every health service leader’s mind is addressed. It is:
“How do we transform to a health system of the future while fighting the never-ending fires that are igniting around us – everyday”?
The evolving picture of Future Health
The answer can be best informed through an appreciation of the nature of the most contentious issues that Future Health must confront. It starts with an appreciation of the slow burn of evolution. This can be found in health system operational areas where the depiction of future health is fuzzy, but not obscure. Most of the anticipated technological advances that are found here are procedural in nature, they typically evolve through a smouldering form of adaptation, telehealth is a good example. Technology supporting this form of doctor/patient interaction has been available for a long time, but its application to practice has been minimal. That all changed with the arrival of the Covid - 19 pandemic which created a rapid increase in demand for health care services. This was followed by a dramatic uptake in the use of telehealth technology. Many adaptations followed including the use of video streamed technology (Zoom, Teams) and remote monitoring technologies to manage vital signs.
While adaptation is a positive method of transformation however, its pace is sporadic, its pathway uncertain, its outcomes not necessarily in sync with more desirable long-term strategic objectives and their nuances both fuzzy and obscure. While tele/video health is literally about smart screens, data transfer technologies and scheduling, other, more sophisticated technologies such as Artificial Intelligence, Augmented Reality, Robotics, and Internet of Everything carry significantly greater investments, coordination demands and consequential outcomes. The pressure on health isn’t only attributable to technological change either. Other external influences such as advances in biotechnology and social media are also creating significant attitudinal change seen primarily in the creation of an awakened social consciousness and more aggressive societal behaviours. Many of these issues have been left unresolved for a long time. Guarantees for the protection of patient privacy will seem trivial when compared to resolution of more contentious issues such as the ethics surrounding gene editing technology (CRISPR), human cloning, clarification around responsibilities associated with a right to life, a right to self-determined death, and the licensing of 3D printed limbs and organs. The need therefore in designing the transformation journey is to reign in adaptation and build, in significant quantities, a capacity for deep, deliberate disruption.
Insight into Possible Future Health Systems
As day-to-day health services creep closer to the edge, pressure is mounting for health leaders to intensify and speed up the roll out of platform based, systems enabled, deliberately disruptive technologies; but there is a warning to those who act too rashly. Although not a health system, the experiences of the CEO of the UK’s new Elizabeth commuter train line that runs from the regional commercial centre of Reading in the West to historical Abbey Wood in Southeast London, Mark Wild provides a reason to be cautious. In 2009 construction of the new Elizabeth line commenced with a budget £14.8 billion according to van Leeuwen (2022) [i], its completion date was sometime in 2018. By November 2018 there was still no sign of completion, Wild was subsequently appointed to the roll of CEO charged with the task of ‘finishing the job’. Wild succeeded, but it wouldn’t be until mid-2022 before he could declare victory. The delay and associated budget blow out was not a result of inadequacies in the conventional aspects of tunnelling and track laying Wild observed . Rather, it was the “huge complexity” of the cutting-edge, digital aspects of signalling technology that caused the delay. In the end, the budget blow out had grown to approximately £4.2 billion.
Although a complicated system, railway track signalling is clearly nowhere near as complex as Future Health. Wild did not have to deal with continually evolving, individualised, life threatening/saving technology, he just had to implement what was already in place. Nor did he have to deal with a myriad of other issues on a day-to-day, hour-by-hour basis. Health does, so the danger for Future Health is that decisions will be made too quickly. In the face of huge pressure from a heaving electorate, resource poor political leaders and sales hungry technology purveyors it won’t make much sense to introduce high speed, fully automated surgical robots into a cancer treatment system for example unless all elements of the system are in sync, are equally capable and will not become redundant well before their time. The latter could easily happen if the surgery ‘system’ is not compatible, or at least sympathetic to the introduction of emerging technologies such as augmented reality, 3D printing, remote surgeons and/or surgical robots and all that a digitalised Web 3.0 internet platform will bring. Web 3.0, also known as the metaverse is epitomised by augmented reality but will also incorporate block chain technology as a basis for encrypted, trust-based transaction processing and high value componentry/patient ID labelling. Although early models of these ‘digital’ technologies are in place, others are still in development, but they will arrive, in one format or another. Examples of other, non-health specific technology developments that add to those in the pipeline must also be considered. They are Quantum computing; an extremely rapid data processing capability, Nuclear Fusion; a safe energy source, Superconductivity; a secure energy transfer technology, and biomaterials; eco-friendly, natural fabrics. There are also of course the unknown surprises that may come with outer space exploration. Amidst the enormity of uncertainty outlined in the foregoing a further key question is evoked, it is:
“Amidst the complexity, uncertainty and confusion that surrounds prospects of a transformation to Future Health, how can we know exactly what it looks like”?
Transformation to the Future Health System
The primary benefit in understanding the future of health today is that it enables the optimisation of the health system of the future. The blow out in cost and time budgets experienced by the UK’s rail system was excruciating, expensive and unnecessary. There was however much more certainty associated with that project than uncertainty. The problems were many, perhaps the worst could have been the fact that insufficient flexibility was allowed to compensate for changes in signal and scheduling technology, from the time the contract was written as opposed to the time of its installation. No doubt many significant improvements to technology had been made in electronic signalling capabilities in the intervening period, but scope for such changes may not have been considered at the time of the project’s approval.
In addressing the question of protecting core operations while transforming to Future Health therefore an acceptance and acknowledgement of significant change in technology and societal expectations is critical. Any long term strategically focused program written today, must be systems based, agile, flexible, and open. This represents a major break from the past when five-year static plans were the norm and SWOT analysis used to extrapolate unreliable and not well-founded predictions of the future. The SMI has developed an approach to transformation that accommodates the extent of uncertainty referred to in this paper – and to all transformations underway or in the pipeline for tomorrow.
Designing the Transformation Journey
In the design of a large-scale transformation journey the SMI adopts an ambidextrous approach to change as illustrated in Figure 1. This format is referred to as ambidextrous leadership.
Figure 1: An ambidextrous approach to the leadership of organisational transformation
The concept of ambidextrous leadership is based on an organisational learning format that encompasses two different business types: core business and emerging business. Each must be managed separately but led as a single entity. Core business is the legacy component that is typically in decline. The operations of this business must be ‘managed down’ while service levels, service quality, and financial stability are maintained. The alternative, emerging business is then built up, based on new structures, new cultures, and new horizons, all of which are articulated in the context of opportunity and growth.
As illustrated in Figure 1, ambidextrous leadership is a key component of transformational change. It starts with resolution of the second question asked previously; What will Future Health look like? In the search for an answer, a program of strategic analysis and reframing takes place. To reframe is to think differently and to look at the world through a new lens. Questions asked are characterised by perspectives of ‘why not’ rather ‘why’? The outcome will be an indicative description of what ‘might be’ rather than a definitive description of what ‘will be’. Its purpose therefore is not to predict the future but rather, provide:
a stage for debate amongst leaders as to plausible and possible narratives describing what Future Health might look like
the opportunity for leadership teams to develop, and commit to, a shared vision of the future
a format enabling dialogue, open discussion, and a basis upon which ‘nudging’ of new ideas can be based
a foundation for an expression of preferred features of a Future Health system
an identification of assumptions that must be continually challenged as the transformation evolves from concept to reality
a platform providing the foundation upon which the transformation journey can be planned.
The ambidextrous nature of the program requires broad-based skills in strategy, at a greater depth than is typically found in corporations and government today. It also requires a depth of understanding of organisational transformation techniques of relevance to a continually evolving, as opposed to fixed health services environment. Starting with an appreciation of the strength of the current health system, its strategic management capabilities, and expressions of a preparedness for change the protection of ‘what is’ is a critical component of survival before commencing a transformation towards what ‘could be’. A definition of what ‘could be‘ in turn is based on an envisaged future that is developed through a process of exploration, collaborative dialogue, negotiation, nudging and broad-based engagement. Stories of the future are developed to promote dialogue and stir imagination. Outcomes are realised through a negotiation exercise illustrated in Figure 1 as sliders; this is a nudging process that provokes conclusions via an iterative circumnavigation of alternative plausible and possible states of being.
Ford Motor Company [ii] recently announced its adoption of such a program. Having spent some five years in the design and trialling a preferred future the company announced in March 2022 it would split its business into two: Ford Blue and Ford Model e. To protect cash flow, Ford Blue is responsible for continued adaptation of production capabilities associated with its traditional, fossil fuel powered cars. At the same time, Ford Model e is required to accelerate innovation and further development of smart, electric vehicles (EV’s) that represent its future as a mobility company as opposed to a car company. Both will share specialist knowledge in software and vehicle technologies and services. Consistent with the design of an ambidextrous organisation prescribed by Chakravarthy & Lorange (2007) [iii], both businesses will be overseen by the most senior leadership team. CEO of Ford Inc., Doug Field will play a dual role as corporate CEO and leader of Ford Model e’s product creation, in the role of chief EV and digital systems officer. He will also lead the development of software and embedded systems for all of Ford. Completion of the transformation journey at Ford will likely see it return to a single stream company once the transformation to a smart car, mobility company is completed.
The transformation mapping process is completed with an exercise in backcasting, a method of analyses that starts with perceptions of the future and the steps to get there, but in reverse. Again, a topic of past discussions by the SMI [iv] backcasting is a technique best understood as the reverse of forecasting. When addressing a period of extensive longevity, as a transformation to Future Health would be, sufficient and significant flexibility and agility must be afforded those in charge of the transformation mapping process.
Insight into what could be: A Viable (Health) Systems Model (V(H)SM).
There are many formats that could define Future Health. An underlying format proposed by the SMI is evolved from an adaptation of the concept of a Viable Systems Model (VSM). Developed as an outcome from research conducted by Stafford Beer (1972) [v], the model is based on the concept of cybernetics; a science that explores the structure of the human brain and associated mechanisms that control physical thought patterns, bodily movement, and communication/control mechanisms. Beer was the first to apply the notion of cybernetics to management science. He uses the same structure of the human brain to depict a VSM which he describes as “a model of the organisational structure of an autonomous system capable of producing itself.” As an adaptation, the Viable (Health) Systems Model (VHSM) depicted in Figure 2 appears to depict a single entity, but it could also be representative of any number of different entities. The most immediate difference between a singular, macro entity such as a regional health system would be that of a specialist private/company operated micro health system. Many alternative formats can be found in a V(H)SM. As a dynamic, integrated system different entities are able to take a financial stake in any of its independent, but synthesised components. An example is the business operating system depicted in Figure 2. The most likely target of an investment would specialist components of a Health Treatment system such as imaging, pharmacy or on a grander scale, the physical management of a hospitals or network of hospitals. An example of the latter could be children’s hospitals, located everywhere in Australia. A network on this scale would constitute a system-based collaboration that was described in a separate White Paper prepared by the SMI [vi]. It is a system described as a Corporate Collaborative System. The concept of a Corporate Collaborative System is defined in that paper as “a collaboration of transaction processing entities that deploy platform-based services capable of hosting many and large commercial networks”. It is a construct that is based on the notion of a corporation as a complex, dynamic, living, organic system.
Figure 2: A health care system illustrated within the context of a Viable Systems Model
Conclusion and getting started
This paper provided insight into the nature of the transformation of Future Health and a depiction of what it could look like. It sought to address the latter component as a critical question being asked by most health professionals today. Its resolution provided a backdrop against which an ambidextrous approach to leadership could be based. This in turn provided a solution to the equally pressing question can be addressed: How do we transform to a health system of the future? Of course, there is no laid out recipe to follow. There are however several strategically focused, transformation techniques that can be applied to work out the ‘big picture’ transformation journey. Those discussed include the concept of ambidextrous leadership and Beer’s concept of a Viable (Health) Systems Model (VHM). The discussion also alluded to the application and relevance of the notion of a Corporate Collaborative System, a concept discussed in detail in separate SMI White Paper, but directly associated with a VHM. A number of important messages for those seeking to lead a transformation to Future Health were proposed. One is to ensure decisions to invest in high technology aren’t made too quickly, or at least out of context with other, existing, and emerging technologies. It was also observed that care should be taken to build flexibility into the transformation journey. As we saw with the UK’s Elizabeth rail line, technology of 2020 was far superior to that of 2008. Most important is the first step in the ambidextrous, transformation road map (Figure 1). It is a capacity to reframe. To think differently and to embrace what ‘could be’ over what ‘will be’. In an absence of the critical first step, what ‘could be’ is in danger of being underimagined and under stated. Similarly, a statement of what ‘will be’ is in danger of being not much more than an extended, linear extrapolation of ‘what was’. The idea of continuing the harshness of the reality of today though is not really an option.
[i] van Leeuwen, H., Boss of London’s newest train line has a warning for Australia, The Australian Financial Review, 22 May, 2022 https://www.afr.com/companies/infrastructure/london-s-newest-train-line-bears-warning-for-sydney-melbourne-metros-20220521-p5an95. Accessed 1 Jun, 200. [ii] Ford Media Centre (website), Ford Accelerating Transformation: Forming Distinct Auto Units To Scale EVs’, Strengthen Operations, Unlock Value, 2 Mar, 2022 https://media.ford.com/content/fordmedia/fna/us/en/news/2022/03/02/ford-accelerating-transformation.html. Accessed 2 Jun, 2022 [iii] Chakravarthy, B. and Lorange, P., Profit or Growth? Why you don’t have to choose, Wharton School Publishing Pearson, 2007. [iv] Orr, S., Hunter P., Corporation of the Future, Routledge, Singapore, 2022 [v] Beer, S. Brain of the Firm; Allen Lane, The Penguin Press, London, Herder and Herder, USA 1972 [vi] Strategic Management Institute (SMI), Inventing the 2040 corporation: Evolving the corporation as a Corporate Collaborative System, https://www.smiknowledge.com/post/inventing-the-2040-corporation-evolving-the-corporation-as-a-corporate-collaborative-system.