Innovation and the public sector are often seen to be in opposition, yet the caricature of a creaking bureaucracy is largely false. In the face of increasing demand, rising citizen expectations, decreasing budgets and accelerating technological change, the public sector continues to innovate. New, improved or reconfigured policy, products, ways of working and processes are always emerging as a response to these challenges.
With systems that are past their use-by-date the impact of these pressures is magnified. They are also designed to respond to needs that are both individual and context specific which means that what works for one person or in one locality will not automatically translate into a solution for everyone or everywhere.
Let me be clear about some definitions. By innovation, I draw on the definition established by the Organization for Economic Cooperation and Development (OECD) whereby innovation is the implementation of a new product, process, business model, method of communication, or opening up of new markets.1 This could mean something created for a specific purpose, or something that has been created elsewhere and adapted.
By spread I mean the horizontal dissemination of best practice. This means that it is a bottom-up process. The Institute for Healthcare Improvement define spread as the ‘actively disseminating best practice and knowledge … and implementing each intervention in every available care setting’.2
In contrast, by scale Is mean more vertical strategies that seek to implement innovation through incentive structures. Scale utilises formal authority such as the alteration of policies, regulation or funding to provide structural support that facilitates and encourages the adoption of best practice.3
To have impact, innovations must not remain at the margins; those that improve health and social care outcomes, for example, should have the tools to spread into new contexts and scale. There are two primary ways in which impact at scale may be achieved: changing the paradigm and harnessing the power of disruptive forces.
Changing the paradigm
The public sector in general, and the health and social care sectors in particular, still largely operate within a command and control paradigm that is increasingly shown to be no longer fit for purpose. Institutions were established to leverage economies of scale, such as the “hospital-focused health system” which emerged in the 19th Century in response to the contagious and acute diseases born by urbanisation and industrialisation.4 The NHS was born into a world that no longer exists yet its design philosophy largely endures to this day.
As we move to a new future, it is essential that our system of health and social care is redesigned to be more resilient than its predecessors and offer flexibility in the face of a changing context. A number of ideas are emerging and being tested in response to this scenario. In the ‘Relational State’ Hilary Cottam advocates public services that put the needs of individual people at their heart. Representing a shift away from ‘how much of what we offer do you need’ to one based on a process of getting to know the individual and their actual requirements and preferences. In many respects this is to see the individual or family as a ‘complex system’ in their own right.
Additionally, an agenda of localisation, communalisation and democratisation of services speaks to a community-centric approach. Heiman and Timms5 for example talk about a shift from old power to new power, in which the tools and structures of traditional hierarchies, specialisms and input-output processes are replaced with networks, open-source working and greater transparency.
We see that a new ‘operating system’ is required for our public services to more effectively experiment, adapt and scale. A model which harnesses the opportunities of today and is fit for purpose for tomorrow. To have a chance of building and maintaining momentum for transformation, public institutions need not only be renewing their legitimacy and their operating methods but also building the capability to continuously experiment and adapt and enable successes to spread across the system.
The need to innovate is also a response to the social, political, economic and environmental context in which we live and work today. Traditional businesses and business models are being usurped and the implications for the public sector are just as real. We see that old mechanisms of the design and delivery of services and of addressing challenges are no longer fit for purpose, whilst modern technologies and changing social norms provide new opportunities for health and social care to navigate. Innovation is in high demand.
A broad range of trends and disruptive forces are playing out across society – digital innovation, new relationships, changing ways of working, and wider global and environmental factors. How these themes change will impact the needs, aspirations and demands of individuals and families; the nature and resilience of our communities and our shared values; and our institutions and ways of allocating resources.
Additionally, an agenda of localisation, community and democratisation of services speaks to a community-centric approach. Heiman and Timms talk about a shift from old power to new power, in which the tools and structures of traditional hierarchies, specialisms and input-output processes are replaced with networks, open-source working and greater transparency.
Trends such as these serve to destabilise the existing paradigm; this serves to open-up the system and those within it to the possibility of change. While Lewin framed this process in rather linear terms as ‘unfreeze – change – refreeze’, the idea that disruptive forces can drive the unfreezing of a system is an important one. Only then can change at scale be realised. These drivers could, at one extreme, help us to navigate our way towards a desirable best-case scenario for individuals, communities and institutions, or force us towards a dystopian future.
How these challenges and trends in health and social care play out will go a long way to determining the opportunities for improvement and innovation in the future. But we can also look to the present. Where are we seeing innovations starting to happen and how can we accelerate these opportunities for change to scale and spread to new contexts?
1 OECD (2018) Oslo Manual 2018 Guidelines for Collecting, Reporting and Using Data on Innovation, 4th Edition. Available at: https://www.oecd-ilibrary.org/science-and-technology/oslo-manual-2018_9789264304604-en [Accessed 13 March 2020].
2 Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting Started Kit: Sustainability and Spread. Cambridge, MA: IHI. 2008. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideSustainabilitySpread.aspx.
3 Shaw J, Tepper J, Martin DFrom pilot project to system solution: innovation, spread and scale for health system leadersBMJ Leader 2018;2:87-90.
4 Charles Leadbeater “The DIY State”, Prospect Magazine, January 2007
5 Heiman and Timms ‘New Power’