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 norms and societal behaviours will occur. Another is the ongoing introduction of digital technologies. All 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 are positive. In the face of relentless pressure 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 of the future 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 practices been developed. 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 informed through an analysis of the nature of the most contentious issues facing future health. It starts with an appreciation of the slow burn of evolution. This can be found in operational areas where the depiction of health management 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. While technology supporting this form of doctor/patient interaction has been available for a long time, its application to practice had been slow. That all changed with the arrival of Covid - 19.

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. 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 the 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 behaviour. 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, but controlled release 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, disruptive technologies; but there is a warning to those who act too rashly. Although not a health system, the experiences of Mark Wild, CEO of the UK’s new Elizabeth commuter train line running from the regional commercial centre of Reading in England's West to historical Abbey Wood in Southeast London, 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) (1), 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, the challenge is huge. 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 and are equally capable. Nor should they be at risk of becoming 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. This will bring an encrypted, trust-based transaction processing system along with 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 centric 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, bio technology in general and biomaterials in particular; 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. Even so, the problems were many. The worst problem cited by Mark Wild was insufficient flexibility in managing changes to track side 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. Scope for such changes had not 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 the evolution of 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 Strategic Management Institute (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 each 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. Strategic analysis is enhanced through a process of reframing. It demands leaders think differently about the future, by looking at the world through a new lens.

Questions asked are characterised by perspectives of ‘why not’ as well as ‘why’? The outcome will be an indicative description of what ‘might be’ rather than a definitive description of what ‘will be’. The former is more manageable, it is based on an expectation of change. The latter carries an inevitably of delay and failure as the unexpected occurs, and it will occur, and ruins everyone's day. The purpose therefore is not to predict the future per se but rather, to 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, and a basis upon which ‘nudging’ of new ideas can be based,

• a foundation upon which an expression of preferred features of a Future Health system can be based,

• an identification of assumptions that must be continually challenged as the transformation evolves from concept to reality are developed, and

• a platform upon which the transformation journey can be planned and established.

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 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, one 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 negotiation which are 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.

Ambidextrous Transformation at Ford Motor Company

Ford (2) recently announced its adoption of an ambidextrous approach to organisational transformation. 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.

• Ford Blue: To protect cash flow, Ford Blue is responsible for continued adaptation of production capabilities associated with its traditional, fossil fuel powered cars.

• Ford Model e: This business division is required to accelerate innovation and further the development of smart, electric vehicles (EV’s) that represent the company's future as a mobility system as opposed to a car manufacturer.

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) (3), 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 corporation is completed.

The transformation mapping process illustrated in Figure 1 is completed with an exercise in back casting. this is a method of analysis 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 (4) back casting 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) (5), 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/outsourced 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 in this system would focus on 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 (6). 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 incorporate. 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: 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’ of the 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, the technology of 2020 was far superior to that of 2007, 2008, the time project planning would have commenced. 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 ignoring the harshness of the reality of today though is not really an option.

(1) 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. 2. 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 3. Chakravarthy, B. and Lorange, P., Profit or Growth? Why you don’t have to choose, Wharton School Publishing Pearson, 2007. 4. Orr, S., Hunter P., Corporation of the Future, Routledge, Singapore, 2022

5. Beer, S. Brain of the Firm; Allen Lane, The Penguin Press, London, Herder and Herder, USA 1972 6. 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.