Walking backwards into the future, reviewing our first ten years.
The early years: 2013-2014
The foresight principle
Having worked in the policy field of quality improvement in health but with close links with other European business quality colleagues who were interested in transformational change in organisations, some of us were frustrated at the slow pace of change and decided to set a new NGO that used futures methodology to define key elements in the system that could accelerate the process.
We had a quick induction on scenario planning and on the Foresight method, which is a futures method much employed in the civil service for forward planning. Ten years on, we still think its an excellent framework, with the trio of horizon scanning (looking for emerging change), constructive conversations (creating change through exchanging ideas) and engaging in some change processes (getting your hands dirty, to learn by doing).
The four key levers for change we identified in the early days (for the healthcare system) were: patient empowerment (the citizen as active partner), eHealth (the potential power of effective digital transformation), innovation (new tools and structures that genuinely involve different ways of doing things, rather than re-packaging) and transforming health professional education.
Fundamental to our approach was the belief that the current healthcare system was not fit for purpose and ultimately not sustainable. During the two or more years we were preparing to launch the new organisation, prior to March 2013, we were heartened by a talk by the then head of research for WHO, Hans Kluge at the 2012 Gastein Forum, spelling out why this was so, and suggesting the areas that needed to be tackled including the shift from a heavy orientation to treatment towards prevention, more treatment in the community rather than in the hospital and a re-profiling of healthcare staffing.
Most striking for us was the EHMA annual conference in 2022 when, sharing a platform with experts from the WHO Observatory, they were making the same recommendations as Kluge had in 2012, confirming that the problems were unchanged, or worse; the expert approach, though rational, sadly had not had significant impact. The message was, that they were attempting to repair and improve a system which in fact needed transformation, a message that Don Berwick of the Boston-based Institute for healthcare improvement (IHI) had given as early as 2002 but which had not been acted upon.
The future of European healthcare – a possible scenario
Our early activities between 2013 and 2016 were taking ‘low hanging fruit’ i.e, using our previous network connections to establish a profile for EHFF and earn revenue while carrying out, as part of consortia, worthwhile policy projects in the area of patient empowerment, self-management etc. Other opportunities arose, linked to these interests, connected to the move to utilise the potential digital tools offered, to change clinical practices for the better.
From a theoretical perspective, incorporating knowledge of systems theory and complexity science, we were nevertheless quite conscious that the institutions, i.e., healthcare delivery systems that we worked with and the structures that supported them were still fundamentally based on a late nineteenth century rationalist format. More importantly, institutional structures such as these are systems which have the characteristic of powerfully resisting change, to maintain their original status. Hence we identified them as dinosaurs. They are no longer fit for purpose, because of their rigidity, but unlike the popular fantasy of a catastrophic meteor strike, it may be a very long time before they die out. A useful idea is that we must act like proto mammals running between the feet of the doomed dinosaurs.
Dinosaurs don’t become extinct overnight. Don’t wait. Work around them
The Shell scenario posits that for successful strategic planning an organisation needs to recognise that it operates within the contextual environment, which contains influencing forces it has no control over, and a transactional environment where it has ability to influence stakeholders. We toyed with the idea of turning that on its head and aspiring to ‘Dance with the Dinosaurs’. How we would do that, we weren’t sure but felt that counterintuitive thinking could be helpful, in keeping our minds open for opportunities.
Our activities during the period 2014 to 2020 could be the subject of as further review, perhaps to illustrate the range of projects undertaken in that period.
Although we genuinely believed in our label as a futures organisation, we had been criticised for not using other major futures tools. Luckily, however, in 2019, through links with a systems-thinking group, Metaphorum, ( https://metaphorum.org/) to have access to an expert, Ian Kendrick of H3Uni. Ian offered us his services free, to apply the Three Horizons scenario model to defining the three elements of the transformation of the health ecosystem: as it is now (H1), a model of health in society that it could transform to (H3) and the second horizon, H2, which defined what were the needed change processes to facilitate the transition from one to the other.
Using the Three Horizons to imagine transforming the health ecosystem
This project was subsequently funded for six months by a large charitable Foundation. We feel that this exercise has been of great value in defining (for the time being, as both context and subsequent events inevitably will modify our findings) key drivers for transformational change for health, namely, health literacy, reforming specialist education and boosting digital implementation (no surprise there) but unexpectedly, the importance of bottom-up, community based action, something we had spotted in our horizon scanning but not given as much weight to as the scenario exercise had implied we should.
The other major learning point was the concept of the transformational catalyst, developed by the US academics Steve Waddell and Sandra Waddock, whose input to the project helped us grasp the potential importance of these ideas in defining what the role of a relatively small organisation might be in helping bring about transformational change. Their thinking does map onto other work in the literature on defining the characteristics of movements that are successful in catalysing change and those that are not. It helped us more clearly recognise our purpose in the sense of what actions we needed to engage in, to fulfil our original mission. Something that along the way had been a bone of contention. We had been not infrequently asked ‘we understand your positioning, but what do you actually do, to bring about the change you say is so urgently needed?’
Currently then, we are pursuing the direction although without, for the time being, additional funding, but seeing the importance of the shift from central to local governance, the importance of collaborative action and the value in mobilising local community assets to bring about change and looking to support instances where we can see that this is starting to happen in different European states (so-called pockets of the future in the present).
Another unexpected development, through EHFF’s engagement with a Brussels based policy lobbying consortium, AP4HE ( https://healthyeurope.eu/ ) was becoming engaged in policy work on the wellbeing economy. This led us, as it did our Irish sister organisation, FEASTA ( https://www.feasta.org/ ) an NGO focused on environmental sustainability, to join the Wellbeing Economy Alliance ( https://weall.org/. )
The diagram below is a perhaps over-detailed representation of the wellbeing economy because Scotland, like New Zealand, Finland and Iceland is one of the few governments so far to implement the concept in their national economic planning (the so-called WEGo group). The essence of the wellbeing economy is to replace Gross Domestic Product (GDP) as the key measure of a country’s prosperity. Growth and increasing financial wealth it is still argued by some, benefits all in society, with the rich getting richer, encouraging investment and more growth: a virtuous spiral. Lower down in society others benefit from a trickle-down effect, so that wellbeing is enjoyed by all. Unfortunately the facts do not bear this out. GDP based economies are essentially extractive, they deplete natural resources, tend to undermine citizen’s rights in the pursuit of profit and the gap between the rich and the poor steadily widens.
The wellbeing economy (Scottish style)
What makes this alternative model attractive to us, is that it is a holistic approach, arguing that the economy should serve the needs of society as a whole, with economic planning predicated on improving opportunity for citizens, caring for the environment, the health of citizens and for greater fairness (reducing inequality). It may be idealistic, but the pioneers of WEGo are busy measuring outcomes, with different sets of indicators. The jury is out.
The holistic notion of a healthy society in a healthy planet seemed to us another system transformation project which mirrored what we had been exploring for the health ecosystem itself. Both recognise the intrinsic inter-connection between different systems in a society: if health is poor, it affects economic output, if business isn’t regulated, it impacts on the environment, significant social deprivation impacts on educational attainment, and so forth. The Wellbeing Economy Alliance is a growing network which one could see as an example of a potential transformational catalyst. National or local WEAll hubs aim to facilitate the change process (where there are the seeds of interest in the wellbeing economy within Government) by mobilising community resources, the wishes of the people, to persuade Government to embrace change. Essential to this is organising agreements between active groups in a society who have perhaps different goals but common aspirations. No mean task, which is why community action doesn’t happen as often as it might.
Since 2021 FEASTA, EHFF and several other players formed the steering group for an all-Ireland WEAll hub ( https://weall.org/hub/ireland ) dedicated to such a task. After a couple of public on-line meetings and support from the WEAll central group, we obtained funding last year from the Carnegie Trust ( https://www.carnegieuktrust.org.uk/ ) and are developing a community of practice for ‘cultural creatives’ as an innovative way of harnessing the public imagination through use of the arts (something we felt was especially suited to the Irish culture). Our observation is that those interested in the wellbeing economy have a significant focus on the effects of the dominant economic model on the environment. EHFF aspires to get better recognition within WEAll for the role of health as a significant area for concern, an interesting cross-over with the ‘health in all policies’ agenda we are also engaged in, elsewhere.
Finally, since the completion in 2022 of the setting up of the European Centre for Patient and Community Empowerment ( https://cempac.org/ ) funded over four years by another large Foundation, as one of the trustees of the not-for -profit company they set up, EHFF has continued to nurture a long-standing international network of friends and colleagues in the patient empowerment field, meeting maybe four times a year as the CEmPaC Exert group. One output of this during 2022 was a back-to-back on-line conference, show-casing the latest international developments in this field (which covers health literacy, shared decision making and self-management) and the next day an invited Roundtable of 20 different stakeholders, to debate the future of the concept.
A small group of us are now looking at which elements merit being promoted, such as the idea of an integrated framework (the elephant) to help understand the complexity of the concept, reduce confusion and to see how different aspects can be reconciled. We think this can represent a valuable contribution to thinking about this concept and in addition there are specific issues about the teaching of health literacy and of shared decision making. A third element that can be promoted is the importance of community engagement and a shift of governance from central to local. We feel that we have achieved something here, but need to harvest it properly. The real challenge is to make recommendations that can actually be implemented in a pragmatic way. To that extent the second two elements share with our other current preoccupations, an aspect of the need to change the way the health ecosystem operates. A challenge for us might be to think of the problem (finding a sensible means to implement change) as something we would need to apply complexity thinking to, rather than the old-style ‘fix-it’ mentality.
How has our mission changed?
Apologies if the explanations above are rather drawn out , but some readers may find some of the concepts unfamiliar. Overall, our mission and its rationale hasn’t changed essentially . We think that the four levers for change we identified during 2013/4 remain valid but perhaps with the additional theme of community: bottom-up action as a valuable lever for system shift.
This leads naturally to our last reflection which we feel is quite profound. While it could be argued that our thinking over the years is of interest, but with the danger of ‘yes, but so what, as we happen to live in the real, not in an ideal world,’ what we feel has happened over the last ten years to our thinking is that:
- a) we have expanded our thinking of what ‘holistic’ means recognising that even reforming the way better health is achieved in a society requires engagement in other systems within that society if genuine progress is to be made (breaching silos). As an adjunct to that, by being in touch with attempts to transform the economic model, for example, provides useful lessons about effective ways of bringing about analogous change in the health ecosystem.
- b) that an expanded vision of what the task is, by not focusing on health alone, opens up our thinking to system change in a different way, with learnings from what makes movements for other changes in society more or less successful.
Our view is that such methodologies, applied within the health ecosystem, which we now feel obliged to get involved with, represent something that we had an idea about, but no clear sense of how to apply in practice. That is, applying a complexity science/ systems theory based methodology to helping bring about systems change. We feel sure that such ideas will bear fruit in practice, and we have a vision and motivation to continue the long journey.
The next steps?
The recent projects we reported on form the primary basis of our focus going forward but as far as the transformation of health goes, the big challenge remains: how to best promote collaboration between like-minded groups.