Creative disruption: the key to healthcare transformation
Charles LeadbeaterAuthor and advisor
Creative disruption: the key to healthcare transformation20 August 2019
In response to the growing complexity and rising costs of healthcare, healthcare systems will be subjected to repeated and often controversial reform programs in pursuit of fairer care for all
As innovation strategies to improve the current system yield diminishing returns, we will be forced to explore more radical, imaginative strategies that lead to genuinely transformative change
There are 5 key design principles of these transformative strategies and current healthcare leaders can use these as a guide to assess where they currently stand and where improvement is needed to contribute to a sustainable future system
Our modern healthcare systems are arguably one of civilization’s greatest achievements: the organization of knowledge, science, technology, and people to help their fellow citizens live longer, healthier lives. It is a system designed to provide care, expertise and empathy on a vast scale. To someone born 150 years ago, the services a modern hospital offers would seem little short of miraculous.
Yet partly because of its own achievements the healthcare industry finds itself facing huge challenges. People are living longer, healthier lives, with more treatments for more diseases. On current trends, with the population of most countries ageing, the health and care industries are only set to consume a growing share of public and private spending for the next several decades. Growing cost pressures are just one reason healthcare will need radical, transformative innovation in the years to come.
The modern hospital-focused healthcare system was designed as a response to the toll of infectious diseases, which were the biggest killers at the turn of the 20th century. Now our biggest challenges come from multiple, often overlapping chronic conditions – diabetes, heart and lung conditions, arthritis, dementia –which people can live with for 20 years and more.
Thanks to advances in medical science, doctors can offer a much wider array of potential treatments to patients who expect the best care possible. Greater specialization, however, leads to growing complexity and rising costs.
In pursuit of fairer care for all, healthcare systems will be subjected to repeated and often controversial reform programs. Providers will be pushed to search for organizational models that can yield higher quality care, which is more effective, personalized and efficient. This will require completely different models – both mental and organizational – for what care is, and how and where it is provided. We will need leaps of imagination as well as advances in science.
Healthcare innovation strategies
The different kinds of innovation that we will need is suggested by the simple grid below which is intended as a tool for self-diagnosis for organizational leaders.
The grid divides innovation into two main types along the vertical axis: sustaining innovation supports an existing business model while radical or disruptive innovation seeks entirely new solutions.
Innovation takes place in two main settings mapped along the horizontal axis: the formal institutional settings of the healthcare system as we know it – hospitals, clinics, doctors surgeries, laboratories – and more informal settings namely homes, communities, workplaces, public places, social networks.
The grid yields four different innovation trajectories: improve, combine, reinvent and transform.
As innovation strategies to improve the current system yield diminishing returns, we will be forced to explore more radical, imaginative strategies which will take us into the other quadrants and eventually down into the bottom right-hand corner of genuinely transformative change.
Let’s look at what each of these strategies involves. All have a role to play and something to add.
The most familiar is the top left-hand corner: sustaining innovation in formal institutional settings. This is the focus for most governments in the developed world, to drive higher quality and productivity from existing systems. The scope for improvement rests on the idea that there should be a best possible way to treat a condition which doctors should share.
This strategy might sound incremental. Yet the most significant improvement innovations in the last decade have come from super-lean hospitals in India which point the way forward.
The most famous are the 11 hospitals which make up the Aravind Eye Care System. Aravind started with just eleven beds in 1976. Now with less than 1% of India’s ophthalmic specialists, Aravind accounts for 5% of the country’s ophthalmic surgeries performed each year. In the year to March 2017 the hospitals provided 4,067,265 out-patient visits and 463,124 surgeries and laser procedures. Two-thirds of the outpatient visits and 75% of surgeries were provided to poorer patients either free or at very low cost thanks to a cross subsidy from the full fees paid by wealthier patients.
Models such as this require a radical rethink of the processes used in hospitals. Aravind’s operating theaters are modeled on Toyota production lines with surgeons operating on a continuous flow of patients in theaters equipped with multiple beds. That only works however, if there is a complete system to bring the patients in, prepare them for treatment and then to care for them afterwards. That end to end approach is why Aravind describes itself not as a hospital but as a system.
However effective these strategies are, even they will not suffice.
The big challenge facing healthcare systems is not to improve treatment of relatively discrete ailments: an eye cataract or a heart by-pass. The big challenges involve drawn out, multiple, chronic conditions, linked to people’s lifestyles, where people need support over perhaps two decades or more. The limits of the improvement strategy will push us to look elsewhere for solutions.
Reinvention will create very different versions of the hospital and the clinic challenging conventional wisdom and design principles. The key will be to break down the demarcation lines which characterize the current system.
Many of the most difficult health challenges, including long-term conditions, involve mental factors as well as physical. Many people with long-term conditions suffer from depression. People who are lonely are more prone to depression and more likely to become ill. The holistic hospital would combine the mental and the physical, just as the best hospices and cancer care centers do now, such as the Maggie’s Centres for women with cancer.
Mounting evidence shows that health outcomes improve the more that doctors and patients work in partnership. The Picker Institute in the US which promotes patient voice in health care has long argued that “patient centered care” should be a design principle for health systems, including providing personal budgets to patients with long term conditions to promote better self-management. These ideas once considered fringe have recently started to move into the mainstream: they play a central role in the most recent long term plan for the NHS in England.
The logic of this approach is that hospital of the future should be more like a creative community of doctors and patients joined in the common cause of creating better outcomes. One place where that happens is the Minnesota Cystic Fibrosis Center at Fairview-University Children’s Hospital in Minneapolis, where patients benefit from some of the best results in the world. This is in part because clinicians have developed a deep partnership with patients to aggressively attack the condition.
The implication of these approaches is that the distinction between primary and secondary care needs to be obliterated to create seamless care pathways. The city of Valencia in southern Spain has a system of payment for health outcomes which incentivizes providers to find the most effective, low-cost method of healthcare provision. This often means helping people at home rather than in hospital. The Presbyterian Health Service in New Mexico runs on similar lines: it provides hospital care but as the final port of call. Most care is dispensed door-to-door by local healthcare providers.
These efforts of reinvention all head in the same direction: towards breaking down barriers between the physical and the mental, doctor and patient, hospital and community. That leads us to the third strategy, to complement what happens in the formal health care system with initiatives in the community.
Good health is created in communities and through relationships, by how people work, live, eat, exercise and play. Lonely people have poorer health. People who live in supportive social and family networks often have better health outcomes. So the big focus on the combine strategy is to create much more capable communities of care in society to complement the services provided by health care systems.
One of the most impressive examples of this combination of community + system is the revolutionary Neighbourhood Network for Palliative Care in Kerala. This network is a 10,000 strong volunteer-based community of care workers who provide frontline palliative care for anyone bedridden and likely to die within the year. The network calls in the limited specialist medical expertise available only as and when needed. Instead of people going to hospital, the doctors come to them. The community is the focus for care, rather than the hospital.
To pursue this strategy we will need more programs that embed health expertise in the community such as the Nurse Family Partnership program in the US and its cousin, the Family Nurse Partnership in the UK. The Care Transitions program in Ohio works with families of people with long-term conditions to ensure they can remain at home as long as possible.
Community-based patient groups can also provide and support health services. In Africa, one of the prime examples is the Mothers-2-Mothers network of mothers positive for the human immunodeficiency virus (HIV+) who support and advise other HIV+ mothers.
Another outstanding example is BRAC’s Manoshi maternal health program in Bangladesh. The Hogewey community outside Amsterdam, specially designed for people with dementia to live with their partners, is an example of how housing and health need to be designed to work together. Pharmacies, gyms, mobile service providers and health insurers are all interested in these health and social business models.
When the efforts of improvers, reinventors and combiners come together then we may have the ingredients for really transformational change; not merely better versions of what we have but something completely different, an alternative kind of healthcare system.
This is the territory of the uncharted bottom right-hand corner. This will require a new kind of organization, perhaps something like the Les Mills exercise program,– Body Pump,–which now runs classes through gyms and has spread to 14,000 clubs in more than 80 countries. Mass fitness campaigns, such as the Park Run movement, which engages hundreds of thousands of runners each weekend in hundreds of cities around the world.
Combining the critical ingredients in healthcare transformation
The healthcare systems of the future look as if they will be both more social and more technological. They will operate in communities to help people prevent the onset of conditions and manage them more effectively in situ; that means they will be highly social, mobilizing the power of social norms, peer support and motivation. Yet future systems will be highly technological, using mobile platforms and artificial intelligence, genetics and personalized care plans. This combination will be critical to their achieving low-cost solutions: mass self-help enabled by technologies which operate in homes and workplaces rather than hospitals.
THE DESIGN PRINCIPLES OF THESE TRANSFORMATIVE SOLUTIONS WILL BE THE 5 Ps
|1.||Their PURPOSE will be to promote well-being rather than to cure disease.|
|2.||The PLACE where they work will be in communities rather than hospitals.|
|3.||The PEOPLE doing the work will not see themselves as patients so much as participants aided by professionals.|
|4.||The PROCESSES they use will be super streamlined, intelligent and adaptive to allow scope for personalization and co-creation. They will allow people to create well-being for themselves rather than delivering health care to them.|
|5.||The way that they are PAID for will be more like a membership subscription or a community contribution rather than a tax, an insurance claim or a transaction. We will sign up to be part of well-being federations which we contribute to, pay into and draw from.|
What does this mean for you as a healthcare leader?
3 points to consider when determining your organization’s role in transforming healthcare.
- Take the two-by-two grid of innovation strategies and map out where you see yourself and your organization on that grid. Are you in all four quadrants or only one? Where are you putting your resources to explore different possible futures?
- You cannot go it alone. You do not have the skills nor the resources to do so. Who else do you need to work with to explore the different options in the grid? Who will be your key partners in the future?
- Take the five Ps which are the key ingredients in the transformative models of the future. What is your answer for each of these for your service in 2030? If you look back from 2030 what would you say should be what your service stands for in each of these areas?
When Christopher Columbus set off on his voyage of discovery it was to find a new route to the Far East. When he returned to Spain triumphant that is what he thought he had found. That was because he was working with the wrong map, one which did not include the vast Continent of possibility of America both north and south. It was a second explorer Amerigo Vespucci who realized a new map of the world was needed.
Transformative innovation often starts with a map of possibility which is severely limited. Yet only by setting forth do we realize not only that we need a new map but that we have a much wider, richer set of possibilities to play with. That is where we are now in healthcare, just setting forth on a long journey to find the future.
Charles Leadbeater is a Life Fellow of the Royal Society of the Arts and a visiting Professor at the Institute for Innovation and Public Purpose at University College London. As a leading authority on innovation and creativity, he has advised companies, cities and governments around the world on innovation strategy and drew on that experience in writing his latest acclaimed book We-think: the power of mass creativity. In 2005 Charles was ranked by Accenture, the management consultancy, as one of the top management thinkers in the world. A past winner of the prestigious David Watt prize for journalism, Charles was profiled by the New York Times in 2004 for generating one of the best ideas of the year, the rise of the activist amateur, outlined in his report The Pro-Am Revolution.