Demystifying theory and its use in improvement

Often initiatives to improve quality and safety in healthcare are short lived or affect no real change. For those that are successful, it is usually the case that they are not capable of being replicated. One reason for this is the theory can mystify us, and this discourages its use in our work. Or we can think the theory is far removed from the realities of implementation.

In fact, we all use theory on a daily basis. Informal theory can create change as people base their reasoning on intuition derived from experience, however, when this is successful the lack of formal theory means that there is no strong evidence base to learn from and so it cannot be translated into a model for a wider audience. A further issue with an informal theory is that our intuition is often bias, distorted and limited in scope.

The formal theory, however, is often seen as a barrier to change. We can see it as intimidating, irrelevant and something which academics are concerned with. Formal theory is regarded as time-consuming, and we will often wish to move straight to the implementation stage.

Sometimes we need to make explicit the formal and informal theories we are using. From this, others can understand the rationale for change as well as the process. Failure to utilise formal theory can frustrate the efficacy and understanding of improvement interventions. Hypotheses can be tested and lessons learned, making it easier to adapt rather than having to start again from the beginning if improvement is not achieved. Without this explicit declaration of relevant theories, there is simply an attempt at change that is either successful or not. There can also be a lack of awareness which can lead to skewed data because the reasoning behind the change is missed and so data is not collated in an appropriate manner and contradictory results can emerge.

Developing a programme theory appears daunting to many; however, the process is usually one that people go through informally, and many of the tasks are straightforward. Theories are not used in isolation, and it is rare to proceed to action based solely on formal theory. Improvement teams are well-advised and able to sketch out interventions, then identify the components and the link between the application and the desired outcome.

It is important to understand the role that informal theory plays when developing an improvement plan. Personal experience is a powerful tool and a combination of informal and formal theory be more effective than either type of theory used by itself. The ability to blend these two types of theory at all stages of the improvement interventions is a skill that sets asides the expert from the novice in improvement.

It is necessary that we demystify theory when it comes to improvement and affecting change. We can then realise that the use of theory on a daily basis and by formalising the approach we allow ourselves to build a strong foundation on which to develop, learn and share best practice.

To read more
Davidoff F, Dixon-Woods M, Leviton L, et al Demystifying theory and its use in improvement BMJ Qual Saf 2015;24:228-238.

Automation and Society: The Triple Revolution

In understanding some social concepts and theories around automation I came across The Triple Revolution a notion that developed in the 1960s with an open memorandum to the US President. The authors of the memorandum site cybernation, weaponry and human rights as the three revolutions they identified as being underway.

In 1964 when the Ad Hoc Committee on the Triple Revolution composed their thoughts, these three areas were hot topics for social activists. Half a decade later and these are still issues that are discussed. The evolution of weapons and the debate about whether nuclear weapons should be recommissioned is a topic that greatly divides opinion, and human rights are never far from the headlines. Interestingly though, it is the cybernation revolution that arguably has the most significant impact on today’s society, and back in 1964, it was the cybernation revolution that took centre stage throughout The Triple Revolution memorandum.

What is meant by the ‘cybernation’ revolution?
‘Cybernation’ is not a term that we tend to use now but the ideas behind it are the same now as they were in the 60s. The idea that machinery can complete work more efficiently and consistently to humans means that there is a constant development of technology. ‘Cybernation’ refers merely to the process of using machinery instead of people.

Automation is therefore not a new concept. The Triple Revolution refers to ‘automated self-regulating machines’, and there is a constant drive to move technology forward. We don’t tend to regard the use of machinery instead of people as a revolution, we see it as progress or technological development. However, the Ad Hoc Committee argued that the cybernation revolution is having the same impact on production as the industrial revolution had on agriculture. In other words, the principles of an organisation have changed radically with the use of modern technology and this is impacting on society as a whole.

Martin Luther King spoke not long before his death about remaining awake during a revolution, and arguably his speech is as relevant, if not more so, in today’s society. Speaking to an audience of young people, he described how too many people are living amid a time of significant social change but fail to develop the new attitudes and mental responses that the new situation demands. He urged the audience to keep their eyes open and remain awake during a revolution because by ignoring the changes that are happening we run the risk of missing the impact that these changes are having on society. By sleeping through the revolution we can miss the opportunity to take advantage of the new technology, but we can also miss the chance to address any negative consequences.

Arguably the increase in technology is seen on the surface as being a positive development. The purpose of technological advances is to make processes more efficient and more consistent, and more economic in the long term. However, for many of the people involved the impact is not positive and this was accurately predicted in The Triple Revolution.

The dark side of automation
The most significant negative impact of the cybernation revolution relates to employment, or more specifically, unemployment. For instance, it was predicted that machines would use most of the resources and leave humans becoming increasingly more dependent on the welfare state. While automation is not the only contributing factor to unemployment, it has had a significant impact and led to millions of people being officially regarded as long-term jobless (seeking employment for 27 weeks or longer).

Long-term joblessness in itself leads on to have an even more significant negative impact on society. Again, this was predicted. We have the capacity for every person in the country to have access to what they need, however, in the midst of this we have an increasing number of families and individuals who are living in poverty. The long-term jobless are becoming a class of their own, and there is little being done to reverse this trend.

It would be a massive oversimplification to suggest that automation is the sole cause of mass employment; however, the fact that machines can carry out the job of numerous people means that it is one of the leading reasons. Since 1964 there have been rises and falls in unemployment but the constant that has been seen over the past half a decade is that as automation has increased, so has unemployment. It makes sense that there are just fewer jobs available than there would have been before machines were brought in. It is not uncommon for a job advertisement to have hundreds of applicants for one position, or for job adverts to be ‘live’ for a short period before being taken down due to already having a significant amount of interest. Getting a job is therefore much harder than it has been previously. What the 1964 Ad Hoc Committee failed to predict was that women would start to enter the workforce in much larger numbers. Society still places the burden on women to be the primary caregivers in the family; however, it is no longer frowned upon for women to hold down a full-time job as well. This means that over the years as automation has decreased the demand for employees, the number of employees has been increasing. This is obviously not an ideal situation and has increased the impact that automation has had.

It is interesting that The Triple Revolution is still as prominent concerning the cybernation aspect as it was in 1964. After so many years it must be concluded that either the negative impact of automation is not as bad as it seems, or lessons that should have been learned and changes that should have been made are simply being ignored. Maybe we need to wake up to this revolution and make some changes before society is transformed irreversibly, for the worse.

The bystander effect

The bystander effect is an interesting psychological phenomenon which focuses on the behaviour of people when they are on their own or in a group of people. In an emergency situation the more people who are present, the less likely it is that anyone will intervene and help. The reasoning behind this is that people believe that someone else will help and so it takes the responsibility away from themselves. If a person is on their own in a situation, then they know that unless they do something, nothing will happen, and if nothing happens, it is their fault. By being with a group of other people, each can think that someone else will be more experienced than themselves and so they should leave someone else to take charge and help. The responsibility is diffused because when each person believes someone else should act, they are relieving themselves of any fault or blame and placing onto every other person. Therefore if there are other people around, the individually no longer need to feel guilty for not acting. Apparently, if everyone feels and works in this way, no-one intervenes or helps and so the more people that are around, the less likely it is that someone will act.

How does this relate to organisations?

While psychological research has focused on emergency situations and people helping out other people, it is easy to see that the same phenomenon occurs within organisations when it comes to implementing change.

If a group of people within an organisation have the same opinions and agree on what needs to be done or changed, the likelihood that it is moving quickly forward is reduced. By having more people who know what needs to be done, the same situation arises as to when there are multiple bystanders in an emergency; no-one takes the lead. Each person is able to rationalise why they should not be the person to make the changes, and so it can take longer for the changes required to be implemented.

On the other hand, if a person within an organisation is determined that their ideas for change are beneficial and should be implemented, they are more likely to drive their plans forward because they know they do not have the back-up of a group of people who will also be pushing the change ahead. This is where change activists are needed.

The role of the change activist

In many organisations, it is common to find that people know change is needed. Many people even have ideas about how things can and should be changed but usually stop short of putting these ideas into practice or bringing them to the attention of other people. A combination of the bystander effect and demoralisation of workers means that regular employees are not coming forward with ideas for change.

Change activists are the people with the passion and drive to put the wheels of change in motion. They are the people who do not fall into the bystander effect trap because they want to do the work of making change happen and do not want to leave it up to other people. Whether a change activist is working alone or within a group is irrelevant as they will ensure that any useful ideas for change are taken forward and are not left to others to implement.

Overcoming the bystander effect

Having a change activist within a team can increase the bystander effect. The members of the group who are susceptible to becoming bystanders are likely to justify their lack of action easily by believing the change activist should be the one who is acting. It is therefore essential to understand how to reduce the bystander effect and increase the number of people who work together to implement change.

As a team, it is necessary to decide who will take on specific aspects of implementing change. Giving workers specific roles decreases the bystander effect because people become accountable for their own tasks and so it takes the group away and leaves each person exposed. Whether a change activist is present in a group or not, if genuine ideas for change are presented it is important to allocate tasks as soon as possible. This gives the best chance of change being implemented because there will be no-one to hide behind and so each person should work effectively to complete their aspect of the change.

A network of people with a shared endeavour

“From an early age, we are taught to break apart problems, to fragment the world. This apparently makes complex tasks and subjects more manageable, but we pay a hidden, enormous price. We can no longer see the consequences of our actions: we lose our intrinsic sense of connection to a larger whole.”
— Peter Senge, 1990

A network of people.

Making change within healthcare is not about organisation or hierarchy or structure. It’s about a network of individuals in different places, at different levels, creating a shared endeavour.

This is crucial.

Shared endeavour is when you stand collectively all wanting to achieve something, having an understanding of what you all mean and have a shared understanding of what that is. Creating an earnest and conscientious activity intended to do, or accomplish something.

Everywhere where systems leadership works well, people have trodden slowly, thinking through the process before acting. They’ve taken the time to work through what they understand to be the particular issue, planning how to take things forward to achieve the goal. Where projects have failed, those part of the project have dived in believing they know what is meant by integration or fragility or whatever it is. This has led to the project stalling, hitting insurmountable problems and often being abandoned.

More is needed for systems leadership to achieve change there has to be collaborative leadership, of a network, based on a shared endeavour.

Some may be anxious about change and show resistance to it. This is to keep the status quo. There can be many reasons for this, but to tackle it and move minds and hearts we need to frame it differently. Estine said ‘if you want a different result you have to try different approaches’. Often when we want to make changes we start by asking, ‘do we have the time to do this, how much money is this going to cost or how will we make staff change their way of working, but we could approach it a different way. We could ask, “what do we want services to be like for the people we care for?” You could also ask, “is this suitable for the local area/population or who else needs to be in the room to make this happen? It can be maternity services, cancer services or services for people with diabetes, this does matter, but that we use networks of people to achieve the endeavour.

For example looking at the Greater Manchester Devolution: Memorandum of Understanding it says very clearly, “There will be a principle that all decisions about Greater Manchester will be taken with the people of Greater Manchester,” So when we start to think in this way, we will seek to use the networks we have around us to make changes. Don’t start with structures or organisations or governments. But do start with relationships and influence and trust.

Systems move at the speed of trust.

When talking about systems we need to understand the importance of relationships in changing the culture. If we have good relationships, we can weather the most fierce of storms. If our relationships lack depth and trust, we can have all the charts and all the data, but this will not achieve real change.

Also we don’t have to do everything all at once. We can take the scenic route. It is much better to take a couple of steps, see where you are, and then decide what your next step should be, rather than rushing in pursuit of a strategy that you found has changed before you were halfway there.

Change is about collaborative leadership, it’s about networks, it’s about relationships, and it’s about where you are trying to change.

There are about four things, I believe, that help when you’re leading systems. First, know what you’re dealing with and how a system might work to support it. Remember that a system is not the same as an organisation. If you ask people to describe their organisation or their organisational chart, it’s likely to be quite linear and quite boxy. You will have your name and your job title. A system is seemingly much more chaotic and kinetic.

A good example of this is the internet. The early internet was quite simple and structured.

Can you imagine how much more complex it is now?  There will be about 75 billion devices that will be connected by 2020. We don’t need to panic, feel daunted or worry about this. We don’t need to be able to read the whole system, and anybody who tells you they can is lying. We only need to know the part of the system that we use.

The same with systems for change. The only part of the system we need to know is the part that we want to work on based on our shared endeavour. Systems are good because they are very, flexible, it gives us room to manoeuvre. We can ask, “Who might give me insight? Who can share some of the heavy workloads with me? What are the other connections I can make?” This can allow us a real set of freedoms, rather than us feeling change is daunting and overwhelming.

When thinking about a system some have the view it as benign, something unhelpful or at least neutral. Why? Because not all systems are nice. Some of them are ‘out to get you’ metaphorically. Possibly not dangerous literally, but certainly metaphorically. There are a couple of evolutionary biologists who have likened a system to an organism. Something like an amoeba. It might not have much of a brain, but it can feed, it can reproduce, it can get about, and it is absolutely adapted to its environment. It can take over and even destroy other things in its path.

So, we come along with an idea. We want to make some changes for really good reasons. Better patient care, better outcomes, lower costs. The response of the system is not to say, “That’s a fantastic idea. I would love to adapt to that.” No. The response of the system may be to see it is a threat and therefore try to stop it, to kill it. We may hear responses instead these like, “That’s really interesting, I’d love to discuss that with you, I’d love to meet up. But then what happens? How about never? Is never good for you?” sadly the idea never gets listened to and we can feel low and deflated.

My lightblub moment when attempting any change in healthcare came when listening to Debbie Sorkin.

Sorkin says: “People don’t necessarily fear change, but they do fear loss.”

Loss of status, loss of connection, loss of control, loss of job, loss of something. Loss can be terrifying. To support this is we need to be aware of what we are dealing with and think about how we might want to preempt some of this loss happening.

If an organism is given sufficient time, it adapts to the new condition. So too with time, we can all adapt to change.

If we come along with a new idea and we tell someone, they are unsupportive, do not lose hope. The thing to do is to keep going. It may take longer and it may take more out of us than we first thought. Also we cant do this on our own.  We need a coalition, our network. Have a group of people around us that support and encourage, that help us believe that it is possible to make a change.

So, first, know your system.

Second, actually practice good systems leadership. We don’t need to be the charismatic leader speaking from the stage. When talking about systems leadership, many people think that leadership isn’t for introverts. But we can practise systems leadership as a thoughtful and calm personality, who supports and enables other people. It is not about saying, “Taa-Daa. Here we are.” It is about having people that follow you because they believe in your shared endeavour.

There are about six key dimensions in systems leadership that we know from the research works.

  1. Ways of feeling – about strong personal values
  2. Ways of perceiving – about listening observing and understanding
  3. Ways of thinking – about intellectual rigour in analysis and synthesis
  4. Ways of relating – the conditions that enable and support others
  5. Ways of doing – behaving in ways that lead to change
  6. Ways of being – personal qualities that support distributed leadership


First of all, it’s okay to live in our values. We are not doing this because we have a particular role or because we have letters after our name. We are doing this because we think it’s the right thing to do for those who we care for. We can step back and ask how do I feel about what I am trying to achieve. Does it fit in with my personal values?

Most of all, think about telling emotionally resonant stories. It’s about what this means for patients and service users based on evidence, based on data. It sounds woolly. It is not. Stories are some of the most influential tools in our armoury to assist change. We need to know our story, it’s worth practising sharing it to let our narrative be heard and getting people in your teams to do the same. When we are trying to move people from other sectors or from political environments to change what they do, don’t underestimate stories and the way we frame things can move people to action.

The third thing is to learn from what other people have achieved and failed at. Often when change is successful, relationships are the core. By which incidentally I don’t mean super friendly relationships, perhaps if we viscerally hate each other it may be more challenging, but we certainly don’t need to be best of friends. All we need is enough respect that we can keep talking when to push us forward get stuff done or to keep us on track when we disagree. Perfectly fine to start small as well. Start anywhere. Follow it everywhere. Keep going even if it takes longer than you think.

While management support can be helpful, don’t leave it just at the senior level. Change is something that has to percolate all the way through. It is about working with the willing. It is about hearing all voices, all ideas. It is also about using prototypes and keeping on tweaking until we get improvements. Also, we can seed leadership, rather than just trade it. Sometimes it’s better for a CCG or a trust or a local authority to lead, and can move change on.  Don’t be scared to seed leadership, instead nurture it and watch it grow.

This is not to say that it works every time. Sometimes stuff just gets in the way. It may be the history or culture. If you’ve got a history of toxic relationships, it’s going to be difficult. So too an ingrained culture can be hard to break. Sometimes geography gets in the way. Better to start it in a small geographic area than a larger one. If you’ve got political imperatives, sometimes it’s just the wrong time and the wrong place and the wrong people. The key thing is to hold fast in that shared endeavour and to keep going and think about what the scenic route might be. There are lots and lots of examples around in the country where we have done things differently, from better dementia services, better mental health services. Where referrals that used to take a week, now take a day. It’s interesting how this is starting to be used to join up the workforce and around data sharing as well.

The other thing we can do is just learn by doing. This is not something you read about. This only makes sense by actual practical application. Do something that’s real. Which means incidentally being real about performance as well and who’s accountable for performance. This isn’t about just saying, “I sent you an email,” this is not the same as actually sorting an issue together. It is about creating just enough clarity, for now, to get going. Don’t worry if we can’t see every little step of the way, start, use our narratives and frames to change perspectives. It is also about taking things down to the front line and getting people to try new things and giving them permission to do so, so they don’t feel scared to fail. There is a saying that we shouldn’t be afraid to fail we should be a not to try.

So be brave and try something different because the process we use to get to the future determines the future we get. If we keep doing things in the same old way, we shall miss the prize because we will only achieve the same outcomes.

Too summarise, I believe that current systems leadership approaches can help us. The key is to start by seeing ourselves as systems leaders. We are not on our own. We are not just our organisation. Start with behaviours and value and shared ambition, build a shared endeavour. Make the connections. Build the relationships. Listen to the voices of all. Most of all keep our patients at the centre. Understand it’s going to take time. It’s going to feel messy. There are going to be setbacks. If we keep going, if we take that scenic route, if you look for progress rather than solutions, it is possible to see a change in that will benefit all.

AddventureBrum Open Society

AddventureBrum is a fun filled weekend that uses design principles to get diverse people together from the commaunity to work on ideas that can be implemented in the city of Birmingham, England. People from all walks of life to come together, share ideas, and co-design the next big community venture in Birmingham.

“Our mission is to work collectively with communities to help bring ideas to life for accelerating social innovation.”

This is the 2nd year I have taken part.

Organised by the excitable guys at Future Leaders Club.

The start of the first day is always great you get to meet new and interesting people. Encouraged to create badges for someone else, I had my badge created Joanna Axinte, and I create Jo’s.

After a long week of work, I was ready to get the coffee into me to get started on collaboration. However, the team had other plans to get us and moving.

Obviously, we were better than the Gorilla in the Italians song for the Eurovision song contest that night.

Everyone else can see the Gorilla, right? Right? *looks at Baileys, throws away Baileys *

— BBC Eurovision (@bbceurovision) May 13, 2017

The weekend got even better when we had to work in our groups to create a life still photo of what the world will look like in 20 years.

#AddVentureBrum caption this!!! What is @DomCushnan up to? #socialinnovation

— Future Leaders (@_Future_Leaders) May 13, 2017

Before I get into the serious work we did and our idea here is my understanding of what a Birmingham Bull should look like.

The Addventure organisers got us to work through our ideas using various design thinking toolkits. The team I was part of kept evolving our idea. We wanted Birmingham to be the best city in the UK, if not Europe and the World. We discussed multiple themes, two stood out, Mental Health and Artificial Intelligence. Since Mental Health was going to have its own event for AddventureBrum later on in the year we decided to focus on the AI theme. How can Birmingham as having one of the youngest populations in all of Europe become what we described as a prototype city and have it so that people would flock from all over to live and work here? What if AI was used in the running of public services.

As we found ourselves going around in circles, Jazz brought us all back as a group and discussed and helped us all shape our ideas into actionable plans.

Open Society was born

Open Society

Our ideas evolved to the point where we knew that if wanted any change to have a “utopian” view of public services we needed a couple of first steps.

We worked through the problem of asking how engaged people are in the local decision-making process of public services. We built a survey shared it online and went to the streets to ask the general public.

The results from our survey.

Our presentation.

“We knew that it was no longer enough for us to merely inform or provide information. Parisians wanted to actually help projects evolve… We wanted to construct a stronger relationship with citizens”.

Pauline Véron, Deputy Mayor of Paris

People I met.

I met some wonderful people too many to mention. Algar who has shown real leadership in our NHS. Kumbi who consistently lit up the room and came on her birthday, Joanna who’s curious mind is going to change the world. Matt who I loved talking too about how we technically change the world together. Jazz who is full of inspirational quotes and if it wasn’t for his taking a step a few years ago all of this was not possible if he had not brought his idea to life as Future Leaders Club, respect. Callie who is one of the kindest people you will meet and who works with Jazz in FLC, I am looking forward to addventureMind with her. Sarah who despite starting a new job on Monday came and supported the event, you can see the fire in her eyes as she wants to get behind some local projects. Lynda who travelled all the way from Liverpool, I had such a delightful conversations with her about how do we together tackle the issues around all forms of mental health, and who consistently got us all to remember to think about how our ideas/products/services would support the disabled. Of course my teammates, Michaela and Marion both who worked with me as we kept going from one great idea to another and were a delight to work with and look forward to working with further.

Letter to my future self

Hey Dom

How are you doing? It’s hard to believe you have made it this far.

Did you get healthy or are you still saying it will be tomorrow?

Life is complicated. Did you challenge and choose the right battles?

Did you travel to countries and meet people from all walks of life to expand your understanding of the how the world works.

How have you been creative? Did you build software and tools for the benefit of society and collaborate based on impact.

I would love financial independence so to focus on the outcomes rather than the income.

Are you seen as a leader as the potential of the use of technology in healthcare, did you author a book on the future of technology in health? Where has Artificial Intelligence got have we found a utopian possibility for the world?

My frustrations with the status quo will erode my energy for changing and disrupting the thinking so we can build a health system on the basis of caring. Did you find a way to manage this?

Focus less energy on the mini-celebrities and celebrating those that choose the harder professions of looking after the sick and dying.

Future Dom from the year 2027

Video on some of my thoughts


Hammersmith & Fulham Healthy & Fit Hackathon

Having worked on the Hammersmith & Fulham hackathon planning for a while. I took a few days after the event to reflect on what was achieved and how important the event was.

Obesity is on the rise and childhood obesity is a national conversation we need more of. As part of NHS Englands commitments for this year obesity is on the top of their list.

I am going to look at what the hackathon movement in healthcare is doing for how services are thought out and how they are empowering the people. Democracy + Hope.


Hackathon events allow democracy for everyone that comes to get their ideas heard and presented which traditionally have people in office blocks coming up with the “aha” we should build this/ commission this etc. By bringing a diverse group of people together from all walks of life we will allow disruptive thinking to enter into environments.

With my role in NHS England, under the Horizons team, I had the privilege of work with Public Health England and Hammersmith & Fulham Council in their first every hackathon.

It is refreshing to see organisations embrace new ways of engaging with their community.


Hammersmith & Fulham with PHE really embraced the opportunity of people power, by giving the winning team the most amazing opportunity of £4000 and are working to deliver within 100 days.

The winning pitch involved expanding physical activities in parks, with accessible events with personal trainers and outdoor fitness equipment.

“The room was buzzing with really practical and interesting ideas,” said Cllr Vivienne Lukey, Cabinet Member for Health and Adult Social Care, one of the judges at Saturday’s H&F Healthy and Fit Hackathon.

Young people, parents, healthcare and policy professionals, developers, designers, coders, social entrepreneurs, food bloggers, chefs, teachers and students were among those putting their brain power to the test at the event itself, with people from across the borough and beyond having the chance to follow the event and participate via social media.

I would like to thank the all those who came on the day and those who supported the event. We have created the start of something that really allows people power and the ability to take community ideas to prototype testing in such a short period of time.

You can view the video pitches here the links below will take you to the team videos on YouTube:

Idea A – Better at it

Idea C – Fitness & Phood (peoples choice winner)

Idea D – My lifestyle

Idea E – Free, Fun, Fitness (judges winner)

Idea F – Cook Local (3rd in people choice)

Idea H – Shake it, make it

Idea I – Breast Friends

Idea J – Real Beauty

I was playing around with Adobe After Effects and produced this ident that will go at the start and the end of the videos created at the hackathon.

Uberisation of health services

“The abundance of ever-cheaper, more powerful technology allows small teams with the right approach to accomplish feats previously only achieved within the province of governments and major companies — and to do so faster and more effectively than their bigger competitors.” Nabyl Charania (@nabylc)

There are times in every industry when processes become stagnant even oppressive and if this is not addressed then current attempts at change no longer have the desired effect.

Uber is a prime example of disrupting an industry. By leveraging the abundance of available drivers and the power of algorithmic pricing software, the low-cost vehicle service is replacing traditional taxi fleets, with their endless costs and liabilities. And Uber CEO Travis Kalanick is doubling down on the “urban logistics fabric” that Uber is spinning across the globe, hinting at disrupting logistics across all industries, and launching food delivery pilot programs in Chicago and New York City

But exponential companies aren’t simply more competitive. They’re also, in many cases, the only types of organisations set up for long-term survival.

In today’s world, as products and services are becoming more and commoditised and software is eating the world, entire industries are being disrupted by organisations that are growing at exponential rates. Software algorithms are controlling the on-demand needs of its users.

A complete overhaul, or in this case I like to call it an “uberisation,” of the systems, processes and the healthcare industry in general is needed in order to make it efficient again. This Uberisation is taking place in many industries, and the health sector is not immune, and nor should it be. It is becoming increasingly difficult to ignore the argument that this is where the healthcare service industry is heading, or to some people it has already arrived.
Take the room rental industry as another example at $25.2 billion, Airbnb’s valuation has already surpassed the market cap of major hotel chains like Marriott ($20.6 billion), Starwood ($14.1 billion), and Wyndham ($10 billion), and it’s close to eclipsing that of Hilton ($27.4 billion) as well.

Why is “uberisation” needed in healthcare?

Before delving into how health services can change it is important to look at why they need to. We currently live in a world where we can have what we want and when we want to some large extent. If you want to go shopping in the middle of the night, you can find a supermarket that it open. If you prefer internet shopping, you can place an order and have it delivered to your door within an hour, or two hours if you are outside of one hour area, but two hours is not a long time to wait using services like Amazon Prime Now.

Generations are growing up in an era where they are not expected to wait. Even viewing habits demonstrate this trend as people no longer have to hold on a week to watch their favourite shows, or set a recorder to make sure they don’t miss it. Streaming via Netflix, BBC iPlayer, Amazon Prime and various other services ensure that there is something to watch 24/7 and there is no need to wait.

When it comes to the healthcare services however, the situation is different. In a world where we can order a taxi, it arrive within minutes and you do not have to worry about having the right amount of change because you can use your phone to pay, it seems incomprehensible that it is okay to have to wait at least two weeks to be able to see a GP.

The staff who work in healthcare are usually the first to acknowledge that the service currently being offered is not to the level we all want and try and find ways to influence change. Many services are understaffed and under resourced. This does not mean that staff are not working hard or are unwilling to provide the service that patients need and expect, it just means that they are unable in the current situation/systems to do anything about it. There are change activists who try to push forward new ideas but on the whole, people don’t want to rock the boat because everyone has bills to pay, do their job and go home. A situation has developed where everyone knows something needs to change but it is not happening quick enough or on a large enough scale.

The answer: the technological shift

The rate of technological advancements over the past ten years has left a lot of the healthcare sector unable to keep up. Whether this is a lack of resources, a lack of desire to incorporate technology, or a combination of both is largely irrelevant. Comparing healthcare services to other industries it is clear that technology has a love/hate relationship and has led to a situation where there is a divide between healthcare services in regions through the country and other industries. Organisations are increasingly taking advantage of this gap and developing healthcare services that use up-to-date technology.

While this is nothing new, private healthcare always has an edge by using the latest technology; private health is becoming a standard option for many users, and it is becoming much more accessible. It is not merely that technological advancements are being used within healthcare procedures more frequently, but various organisations are also using technology as a way of allowing people to engage with health services. The Internet allows people to search and find whatever service they need but technologically minded organisations have taken the use of technology even further. An excellent example of this is Babylon App. The Babylon App connects patients to GPs, as well as a range of specialists via a smartphone. Many health related problems do not require the patient and doctor to be in the same room and applications such as the Babylon App employ this fact because it offers an efficient service for people who want to access healthcare on their timeframe. For £4.99 a month you can have access to a GP as many times as required and can usually see a doctor on the day they need to. For further services there are additional charges; however, the App does offer a full range of services that you would expect to be available including referrals and prescriptions. You can also submit a question to be answered for free, purchase test kits and all of your medical records are stored online in your account area. Not only do organisations such as Babylon allow patients to be in control of when they have their appointments, but they also ensure patients have full access to their records and can be part of monitoring their health. Currently a notion that is widespread throughout the healthcare sector.

What is happening to the health care sector?

Currently, numerous exponential organisations are forging a new way of offering healthcare services to the public. Accessing healthcare professionals online are becoming more common and more popular as it offers patients an efficient service that works to their deadlines. Other organisations are focusing on a different aspect of healthcare.

Apple now has the HealthKit, ResearchKit, and CareKit, which allow users of Apple products to be part of their health and care, as well as allowing medical researchers access to large amounts of data. By allowing third party App developers to tap into the health-related aspect of Apple products, consumers now have ways of recording almost everything about their health. From simply inputting information such as blood type, illnesses or medication was taken, to the device recording data like sleep cycles, steps walked, calories burned and pulsed rate. The capability of these devices to analyse the data and provide people with reports means that the general public has the ability to be in possession of much more information about themselves than any medical professional.

23andme also allows people to have access to information about their own health profile that they have never been able to access before. For a price of £125 people can find out more about their genetics, ancestry and how these can impact on health, including what types of medications may work best. In a similar way to the Babylon App, 23andme also allows patients access to their reports and profiles online anytime they want.

This quantified self approach to health and fitness has the potential to transform the health care service for the benefit of patients and professionals. Having access to more information could reduced waiting times as less information gathering may be required, and it also gives doctors a better idea of the patient and their lifestyle as a whole, leading to faster and more accurate diagnoses.

Lets not even get started on AI and big data approach to our health systems but that is another post.

Where is the health care sector heading?

At the moment, it can be seen as a disconnected way of accessing health services, and many people are unaware of what is on offer. Arguably this means that many people are not accessing health services on offer from organisations outside of the NHS because the benefits are not always clear. In the future, it is almost confident that the organisations that provide these different aspects of health services will become much more cohesive. The benefits of having access to healthcare records, tests, and continuous health-related data, as well as being able to see health professionals easily and quickly, will become the norm and will become what the public come to expect. If the current system can’t offer this, then it will become redundant. While many great things are happening and change activists trying to move forward as quickly as possible, it is simply not happening fast enough to keep the public happy, or to compete with the range of exponential organisations sitting on the edge of the healthcare sector just waiting to be called in and take centre stage.

A further change that could be just around the corner is the possibility of having healthcare appointments ‘out of hours’. Without needing to get drawn into the debate about what should or not constitute ‘out of hours’, it is clear that there are hours throughout the evening and night that are not employed for appointments. Machinery shuts down for the night that could be being used to reduce waiting lists and allow more patients to be seen promptly. The question to be answered is whether the public would welcome this type of change (resourcing is another problem to solve). There will, of course, be people who would much rather attend an appointment at 2 am than sitting on a waiting list for months. There are also people who find it difficult to take time off work during the day and would benefit from the option of night time appointments. Undoubtedly there will be opposition to this, however, with the people becoming more accustomed to being able to access what they want at the time they want it, it seems like it will be a natural progression.

What does this mean for patients?

Whilst this is not a discussion of the social impact that these types of changes will have, it would be remiss not to acknowledge that private healthcare will not work for everyone. With more people living below the poverty line, expecting them to pay for health services is largely unreasonable. It is these people who will not have the option to choose to use apps to have GP consultations or pay for health related tests. For these people, the reality will undoubtedly be a situation where the organisation who can save the most money while providing an essential service will take over the responsibility of providing healthcare on a widespread basis.

The most worrying aspect of this type of change is that it could quite easily go down the route of one organisation having a monopoly with no opportunity for competition. In situations where organisations have to bid for the work it is the competition that ensures quality and value for money. In a monopoly the lack of competition would lead to people having less say over their healthcare services because without the possibility of losing work there is less incentive to provide a service that the public want. Capitalism and making a profit should not be viewed in an entirely negative way. There is nothing wrong with capitalism as long as there is a fair competition which leads to a service that patients are happy to access.

It is impossible to lay the blame for the failings of the health services at one thing or any one person’s door as many factors have led to the situation that is currently being experienced. Long waiting lists, understaffed and under-resourced services, health boards with huge deficits, demoralised staff, etc. do not happen over night. Small changes to try and repair the damage and get the health service back are track no longer sufficient. What is needed now is for it to be acknowledged that the current system does not work and “uberisation” is the next logical and necessary step. Technological advances need to be incorporated into health services because they offer the best form of care in many situations. The quantified self is not something that should be feared or mocked but embraced as a way of people taking control of their healthcare journey. It allows patients and professionals to be more informed and should be encouraged. Currently, the entire health sector is disconnected, with serious differences in the level and standard of service offered in differing locations. “uberisation” of the area of health needs to bring a cohesive approach that provides a high quality of service, with flexibility for patients but that does not exclude any section of society. To achieve this the time has come for a complete overhaul and anything less is destined to fail.

Ethos of Building a Collaborative Team Environment

While working on a project looking at online collaboration tools it became apparent that there are lots of ways of communicating with each other but they do not always work or are integrated poorly in our organisations. Until we have fostered a culture for building a collaborative team environment, these tools will always be full of tumbleweed.

Using the information online and from the book Tips for Teams: A Ready Reference for Solving Common Team Problems, by Kimball Fisher, Steven Rayner, and William Belgard, 1995I have attached a mind map of the core ethos to building a good and working collaborative team environment.

PDF Version of ETHOS of Building a Collaborative Team Environment

By Dominic Cushnan, Pollyanna Jones and Rob Parker.

The Agile Manifesto and how it could save Health and Care organisations

The Agile Software Development Manifesto became a formal proclamation made by the key players in the software field in 2001. Seventeen professionals met to discuss the issues they had with documentation driven, heavyweight software development processes. Each of the people who attended wanted things to change, but individually there was little that they could achieve. Together they discussed how to deliver the services that they felt their customers deserved, and it resulted in 12 principles that now act as a guide to creating and delivering a people-centric approach to software development. The Agile Manifesto.

What does the Agile Manifesto state?
As an alternative to the software development processes that were being used, such as the ‘waterfall method’, the Agile method is focused on keeping things simple. The 12 principles are also concerned with customer satisfaction, testing the development often so that changes can be made early in the process if necessary, and teams working effectively to create software that is sustainable. All in all, the Manifesto details how a business should run to be efficient and effective in delivering high-quality software that meets their clients’ requests.

Manifesto for Agile Software Development

How is the Agile Manifesto implemented?
There are various models that implement the Agile Manifesto with SCRUM and Kanban being two of the most popular. Both have similarities due to being client focused; however, they also have significant differences.

Scrum is based on multiple small teams working interdependently and requires well-trained, specialised teams who can work effectively as a unit while relying on other teams to ensure a project is successful. For further reading see my slides below.

Kanban requires a more generalised team as in this model only one team is required, and so the team members must be able to complete tasks throughout the entire project.

There are also differences in how the work is organised and distributed, however, what they have in common is that the customer is key. They both deliver work as and when it is finished, they keep the customer involved and up to date with the progress, they do not use unnecessary documentation that can lengthen the timeframe of the project and they test their output rigorously and regularly. These two models are fantastic examples of the Agile Manifesto in progress.

How is the Agile Manifesto used in business?
The Manifesto is used as a guide of how a business should operate. The 12 key principles effectively give a list of what should happen throughout the running of a project and the attitude that workers should have towards their work. The effect of incorporating the Agile Manifesto into business practice is that any organisation not already focused on their clients will have a shift in focus. If followed, the Manifesto forces businesses to be efficient in their practice, be flexible accept that changes will be required, and be critical of their work.

Can the Agile Manifesto be adapted for the Health and Care Sector?
While it was created specifically for the software development world, the Agile Manifesto can be adapted to almost any situation where a service or product is being offered. To use the Agile Manifesto, the principles simply need to be adapted to focus on patients and patient care rather than customers, and treatment services rather than software development processes. With these changes, the Manifesto could have been created for the Health and Care sector.

Is Health and Care ready for the Agile approach?
The Health and Care sector is a prime candidate for an Agile overhaul. The focus of many organisations has slipped from being centred on the patients and now rests on budgets, staff shortages and many other negative aspects. When changes are attempted there is usually this heavyweight, documentation led the process that the Agile Manifesto was created to combat. Things take too long, they are not designed for patients in mind and too often they are not adequately tested to ensure they are working throughout the process of implementation. An amended version of the Agile Manifesto that focuses on Health and Care is welcomed and long overdue. With guidance such as this in place, health organisations can get back to doing what they should be doing best – caring for patients and ensuring that the care they give is more than simply adequate.

Can we co-write a Health and Care Agile manifesto and principles?
Following from this I am organising a session where anyone who would like to contribute to a working draft of a manifesto that is patient rather than customer/client and software product focused. If you are interested please connect with me.