On Friday 7th December 2018, I was invited to join Professor Marshall Ganz and Dr Don Berwick in conversation at the Ash Center for Democratic Governance. 

The topic was how to make healthcare work. Rather than focus on the ‘programmatic’ challenges – designing better systems, spreading known improvements, streamlining flow… our conversation turned to what “leadership” might mean in our present moment. And, in particular, the external and inner complexity that those leading health and care now face. 

You can watch the recording here; and an edited audio recording is available here.

Here is the text of my opening remarks:

In 1948 the National Health Service was founded on a burning platform. The Service represented so much more than a narrowly conceived medicalised model of care. Its inception spoke to who we were as a country. What we had learned from the brutality of two world wars, and the great social evils that we then conceived to be intolerable.

Among the five “Giant Evils” famously described by the great Liberal economist William Beveridge, was “disease” (squalor, ignorance, want, idleness, and disease). There was an understanding that eradicating the evil of disease would prove a complicated problem. There was a determined desire to solve that problem – a desire borne out of a belief that defined processes, coupled with sufficient resources plus sustained political will, would see us home.

Many of the challenges faced were complicated.

Building hospitals.

Agreeing contracts.

Creating the infrastructure to standardise models of care that were known lead to rapid and discernible improvements to overall population health. These problems were therefore amenable to an approach which conceived of healthcare as a single system, through which sustained progress could be achieved and measured. I rehearse this history to draw a distinction between the complicated challenges that captured the imagination our post-war generations, and where we find ourselves now. On the cusp of 2019, the picture looks very different.

I would venture that there are few remaining challenges in health and care, at least in developed economies, which sit mainly in the realm of the complicated. And there is a dilemma, which ‘sits across’ any of the particulars we may discuss today in terms of the state of healthcare (whether equity, or long-term conditions or fiscal constraints). That dilemma is not the shift from complicated problems to complex challenges per se. Rather, it is whether we, as individuals and collectively, have the ability and the will to meet the complexity of the challenges we now face.

I’ll outline ‘complexity’ in two ways. First, there’s the complexity of the environment. This element is widely recognised, so let me dance lightly over some of the pressures which are creating an increasingly complex environment in healthcare:

  • How to optimise quality of life when faced increasing longevity.
  • The recognition that our biggest potential gains are to be had in prevention not cure.
  • The drive towards increasingly bespoke services (what, in the UK, we term ‘personalised care’. The difference, in other words, between caring for patients like you and caring for you. It’s a step-change which is increasingly demanded by the public, as well as sought by practitioners.
  • There’s the role of integration – that is, the bringing together of disparate public services into closer working – to address these demands.
  • There’s the negotiation of the relationship between human and artificial intelligence.  
  • Climate breakdown. How should a healthcare system adapt when data suggests that health accounts for around 5% of road traffic, and air pollution is so clearer linked to poorer health? This is now the case in the UK, and it’s a startling fact that surely transgresses healthcare’s most basic promise, to “do no harm”.

 All of these complex challenges require us to move beyond ‘solutions’ in healthcare which are linear and narrowly construed. That mental model no longer survives contact with reality. And we might, in our discussion which will follow, dive into any of these topics.

Yet before we do, I want to talk about a second type of complexity, distinct from the web of environmental factors we now face. I want to talk about ‘inner complexity’. The ways in which we think, as leaders, and as citizens. More than that, the ways in which we know and make sense of the world. The two questions I want us to hold are:

  • Do we have sufficient capacity of thought to gain insight into the complexity of challenges we now face, so as to act effectively?
  • And if not, what are we doing to develop that capacity in ourselves and others?

This is not simply what we know. It’s our ways of knowing, of making sense of the world and intervening accordingly. I draw a distinction between what most healthcare systems understand as “learning” (the acquisition of technical skills and competencies) and the shift we need towards more interdependent, subtle and complex forms of making sense of what’s happening. It’s what adult developmental psychologists such as Professor Bob Kegan might call “growing”.

The ability to hold contradictions,

To see patterns,

To discerns systems within systems which signal a bigger whole, and to adapt in response.

I’m sketching out nothing less than a shift in what we mean by education. A radical shift as to where we place our energies, away from a dominant focus on “information” towards enhancing the capacity and effectiveness of human judgement. And I recognise that it represents a direct challenge to our received understandings of what education means for clinicians, senior leaders and others in healthcare, where for so long (as in my own fields of Law, and as in academia) individual technical proficiency has been the coin of the realm.

I’m suggesting that the acquisition of technical competencies is vital, and that it is no longer enough. Not nearly enough. If we want healthcare to work better going forward, we need to recognise the scale of the “psychological” challenge we face as we reconfigure our healthcare systems at increasing scale and speed.

Inherent in this process is loss; letting go of one way of being to acquire a new, and perhaps unwelcome, identity.  This is one of the reasons why “integration” of public services remains sporadic at best. While integration must surely be the direction of travel, it is also a story of loss. Loss of professional distinctiveness for those whose understanding of discrete professional identity was formed in an earlier time.

It is this psychological element of change that is so poorly accounted for in our current stories of how we make healthcare work going forward. Let me draw these opening thoughts to a close by suggesting a bridge between Don and Marshall’s work. In both these worlds - healthcare leadership and organising for change - the Community Organiser’s starting question – “who are my people?” – has never been more urgent.

Alexis de Tocqueville, the great 18th century French philosopher, famously remarked that “knowledge of how to combine is the mother of all other forms of knowledge. On its progress depends that of all others.” Our progress in healthcare today depends on rediscovering, and then reimagining, that knowledge of how to combine; how we grow and adapt collective responses which are not simply programmatic but which also unleash our collective energies. It’s the difference between ‘change because we have to’ and ‘change because we want to’. And it’s all the difference in the world.