When I arrived in Boston as one of the 2012-13 Harkness Fellows I had no idea what learning I would want to bring back from the US health system to the UK. The Fellowship provides a wonderful opportunity to stand outside the UK as well as the US system and look at the strengths and weaknesses of both.
The greatest strength that I have so far seen in the US system is a genuine commitment to innovation.
This came into focus, for me, at the 24th annual National Forum of the Institute for Healthcare Improvement, which was held in Orlando, Florida last December. 6000 delegates converged on the marble acres of the Marriott World Centre, and 600 health care organisations from across the US were there to show off their newest ideas.
I have had the sense that innovation is not just a buzzword – it is somewhere between an expectation and a sacred trust
The program ranged through re-organisation of a whole hospital to deliver high performance health care at Bellin Health, via new approaches to medication adherence at Kaiser Permanente; from innovations in electronic medical records (a lot of these) to the wholesale restructuring of local health systems to build accountable care organisations (ACOs) and patient centred medical homes (PCMH).
What I really noticed, though, was that although the systems featured at the National Forum may have been among the best, they were not unique.
Some of the health care organisations I have encountered in the US have been – understandably – more focused on survival than innovation. But in many I have had the sense that innovation is not just a buzzword; it is somewhere between an expectation and a sacred trust.
These organisations – providers, insurers, Government offices – are constantly searching for new solutions to the problems of the US health system. The attitude seems to be summed up in Thomas Edison’s famous line – “There’s a way to do it better: find it”.
As the UK health system goes through massive structural change, and providers need to find innovative solutions in the face of funding constraints, it seems to me that there is something that the UK can learn from the US’s long tradition of innovation in health care.
So why does the US seem to care about innovation so much; and what if anything could we learn from it in the UK?
The most obvious spurs for innovation in the US are external: the recent passing of President Obama’s health care reforms which are sparking enormous changes, and the sense of urgency from the scale of the financial problem (health care costs account for 18 per cent of US GDP and rising).
But more interestingly, my sense in talking to people in the US health system has been that the main driver for innovation is an over-riding sense of personal responsibility. The US has no single central organisation overseeing the health system, and the powers of Government are sharply curtailed.
While this undermines many of the efforts to deliver a coherent (or universal) system of health care, it does at least mean that health care organisations have a sharp sense of their own role and agency. Sometimes to the point of excess - as one Chief Executive put it to me over coffee, “if we don’t save the country, who will?”
So what are the lessons that I shall be aiming to bring back with me to the UK?
-
Data, data, data. One of the most important features of the organisations featured at the Forum in Orlando was a willingness to invest in data and analysis. Leaving aside big systems like Geisinger and the Veterans’ Health Administration, with their world-leading data collection systems, even the much smaller systems were developing their own approaches.
Schneck Medical Centre, for example, with one community hospital and a handful of health centres, has carved out the funding to prioritise data analysis and take an intelligent approach to what information the organisation actually needs. With this starting point, innovation in the organisation has the potential to be genuinely evidence-based. -
Leadership. I have been fortunate to meet senior leaders from a wide range of provider organisations from across the US, and most of them have told me that strategic thinking and innovation are fundamental parts of their role, even in the face of severe financial constraints. Strategy and innovation are not the preserve of individual specialists - Bellin Health, for example, restructured the workload of its whole senior executive team around its high performance health care reform.
-
Culture. While the ‘permission’ to innovate needs to come from the top, an expectation is set at every level of the organisation that new thinking will be actively encouraged. In the best organisations managers are encouraged to listen to junior staff, in the belief that new ideas may not come from the people who have been heading up an organisation for the last 20 years. As Dan Heath, author of Switch and one of the keynote speakers in Orlando said, “Somewhere in your organisation there is someone who is already doing the solution to any problem you have.”
- Autonomy vs standardisation. US health care organisations arguably have more freedom to innovate than their UK counterparts; indeed sometimes this seems self-defeating, with so many good (and bad) ideas competing that it is hard to see how any single idea can be heard. If the UK system leans towards standardisation, the US system sometimes seems to lean towards anarchy. The best health care organisations in the US are finding a balance between the two, at least within their own smaller networks.
The US health care system has many fundamental problems, and not all of them are going to be solved by organisations working alone, however good the ideas. But the sense of energy here, and the belief that any problem that has been created by humans can be fixed by them, is palpable – and it is seductive.
The Commonwealth Fund’s Harkness Fellowships allow health services researchers and practitioners to conduct original research in the US.
This blog is also available on the Health Service Journal website.