Idealized Design For The Future Of Healthcare

By Gerrit Van Wyk.

We no longer have telephones.

Russell Ackoff told a story of a visit to Bell Laboratories in 1951. He was invited to attend a meeting during which the vice-president of the company challenged people to imagine the telephone system no longer existed, and based on that to design a different one from the ground up. His argument was most important contributions to telephone communication were made more than 50 years before, and all the laboratory did since then was to tinker with the parts of the system.

What he wanted was a complete redesign of what a telephone system of the future could look like, and then finding the parts to make it work, rather than the other way around. There would be two constraints; the design had to be technologically possible, and operationally viable. Different groups would work on different design components, but if their design affected other groups, they had to negotiate with them until an agreement was reached on how to proceed, and he wanted to see a completely integrated redesigned system within 12 months.

Ackoff’s group worked on handset design and came up with the first design for touch tone dialing, call forwarding and waiting, voice mail, caller ID, conference calls, speaker phones, speed dialing from numbers in memory, and mobile phones, all of which only became available years later as technology caught up with the ideas. What we take for granted today didn’t exist then and had they not gone through the exercise and conceptualized a different future, we may still be speaking with telephones of yesteryear. What they couldn’t have anticipated was internet connectivity and a phone camera, which only became feasible much later.

Based on this experience, Ackoff came up with Idealized Design; plans acting as a future guidepost we may not reach for a long time, but can adapt and make progress towards as things change along the way. That is different from goals planning where we specify what we wish to achieve and a detailed plan to get there, which only works if nothing changes. It does, because our world is complex, yet goals planning remains the default. No wonder most strategic plans fail. As Von Moltke the Elder said, no planned strategy survives the first contact in battle, hence the value of moving away from goals towards an ideal.

Like the telephone system, current health care practice emerged more than 100 years ago for a time when it suited the conditions. Since then, we tinkered around its edges, renovated the bathrooms, replaced the shingles, and slapped on a new coat of paint, but the basic structure remains the same and it no longer works for us. It is time to knock it down and design a new dwelling better suited to our needs.

Messes are interconnected problems, and wicked problems socially complex. Wicked messes, or social messes, are both interconnected and socially complex. The Godzilla of social messes is health care.

For such problems it means your perspective determines how you try to solve the problem, the problem doesn’t end, and solutions can make the problem better or worse. No-one has the right solution, there is a lack of information, people have conflicting values, and there are political, economic, ideological, and cultural constraints to what you can and can’t do. There is a lot of uncertainty and ambiguity, people resist change., and problem solvers are disconnected from the problem and its possible solution. Given the biological, social, and technological complexity of health care, this describes its problem situation to a T.

Unlike current practice which tries to hammer the square peg of complex health care into a simplistic round hole, a better health care system cannot be designed by planners, academics, or consultants who think they can see every aspect of a very complex situation. Instead we need to design bottom up through contributions from patients, physicians, nurses, managers, ministries, etc. Their differing perspectives matter for finding innovative ideas about what health care could be like in the future and getting buy in to implement it.

Unlike tame, or clockwork problems, you cannot plan for a social mess ahead of time, and you don’t know what methods to use, the answers to both, like all things complex, emerge from interacting with the problem. You therefore need to approach it with a toolbox, not just one tool. Clockwork solutions are communicated, but solutions to social messes emerge from conversation and dialogue.

To the extent there is a planner, it is someone steering and mentoring conversation and dialogue. The only such approach known to me is Strümpfer’s designed conversation which, over a 40-year time frame, succeeded about 85% of the time over more than 400 interventions. Contrast that to the 5-15% success rates of all other change approaches. It uses conversation and dialogue to construct a picture of the problem situation from which different perspectives emerge, one of which may be promising enough to trial, and, since the approach assumes a complex human system, it adapts to feedback about the intervention. In short, it shows some similarity to the approach by which Bell reinvented telephone communication.

It has four consequences; adapting to our actions in response to feedback creates a never ending collective learning system, people learn individually and collectively how their actions influence outcomes no matter how small their contribution, it changes how people see and experience the world and hence how they act and interact with it both physically and socially, and, once the approach is embedded, it becomes self-sustaining. That matters because social messes are ongoing, not stable.

When Bell abandoned an obsolete telephone system, they had no idea what the outcome would be, but made it work. In the same way it’s time to abandon obsolete health care processes, even though that requires the insecurity of not knowing ahead of time what new ones may look like. It’s possible to create a new picture of what it could be from many perspectives, if we can get a representative group to sit down and talk about it together.

What keeps us inactive is the inbuilt political, economic, ideological, and cultural constraints in health care. Politics can sell hope, but not uncertainty, and the will to act rather than political platforms based on wishful mechanistic fantasies. We won’t fix health care with more money, we must use what we have more wisely. The ideologies of mechanistic science and Neo-liberal economics guard against competing narratives, such as this one. And existing health processes is embedded in the images of professional health care cultures which makes it resistant to change. We must find a way around that.

The vice-president of Bell Laboratories had a vision for breaking the mold and creating a different future, and the courage to start the journey without a plan or knowing the outcome. What we are waiting for is someone with the same vision and authority to start the ball rolling in health care. Hopefully it will not be a long wait.