Watch the Global Innovation Jigsaw lecture.

Douglas Travis

Good morning, everyone, and thank you for coming.  My name is Douglas Travis, for those of you who don’t know.  I’m the Chair of Better Care Victoria.  May I begin by acknowledging the first peoples and traditional owners of this land, the people of the Kulin nations, and I pay my respects to their elders, past and present, and to all elders who have joined us here today.  Welcome.

I’d like to welcome you here today to the State Library of Victoria, and this is a magnificent venue, and we’ll be joined here by David Albury in just a moment who will be delivering a lecture entitled The Global Innovation Jigsaw:  From Innovation to New Models of Care.

Welcome to those of us up in the corner there on the live webcast, and thank you for coming.  It’s terrific to be here with all of you today to talk about innovation and the opportunities it can bring to our health system and how we can tackle the challenge of spreading and scaling up innovation in the sector.

Better Care Victoria was established by the Victorian government in response to my review undertaken, or undertaken by myself, obviously, which recommends ways to improve the capacity of Victoria’s health system.  Better Care Victoria started on the 1st of July with its funding and we aim to do this by supporting the health sector and identifying and scaling and embedding innovation effectively.  Current investment in health care innovation has seen successful innovation projects achieve improvements locally.

However, the impacts are typically local and not replicated or scaled across the state, and that’s a waste of learning.  To help drive the kind of change that we need at a system level, Better Care Victoria will provide a central innovation support to the sector by providing funding for hands-on support for sector-led innovation projects, supporting the development of improvement and change capability across the sector and sharing in disseminating good practice across the sector, which is what today is all about.

Last month we were excited and still are, to launch the first 15 sector-led innovation projects which have been funded a part of the Better Care Victoria state-wide innovation fund, a further seven are in the process of being approved by the minister, and no doubt there will be a launch.  These projects provide an exciting opportunity to support sector-led healthcare innovation and drive change at system level, which is why we are here today.

Just some housekeeping things:  please switch off your mobile devices or switch them to silent.  Bathrooms are at the opposite end of the conference centre foyer and there are further bathrooms on level 2A outside of the seminar rooms.  In the highly likely event of an emergency, please remain calm.  Do not run around screaming “fire”.  An emergency warning will sound and further instructions will be given over the PA for evacuation points, which I presume is out the back door.

David Albury, thank you for coming.  Today we are very privileged to be joined by Mr David Albury, director of the innovation unit based in the UK and consultant to the Global Education Leaders Programme.  David is also an associate of the Institute of Government and a fellow of the Royal Society of Arts.  David has consulted and advised on forming and implementing strategies and policies for transformation and innovation in healthcare, education and in other public services internationally.  

He has worked with and coached senior politicians and policy-makers, leading managers and professionals in local, national and international organisations.  He works and speaks internationally in the UK, Canada, US, Brazil, Australia and New Zealand on creating the conditions for whole system transformation and radical innovation, especially in recent years on effective approaches to scaling and diffusion.  From 2002 to 2005 he was principal advisor in the UK Prime Minister’s strategy unit where he coordinated advice on health service strategy that led to a major review of education policy and also led a major review of education policy and co-authored the seminal report Innovation in the Public Sector.

David’s presentation will go for about 40 minutes, following which we will have a 20-minute Q&A session where we’ll take questions from the audience.  Please join me in welcoming David to the podium.

David Albury
Thank you, Doug.  Thank you very much indeed.  Well, it’s great to be here back in Victoria, and since I was last here you’ve launched the innovation fund which is really promoting, stimulating innovation across the sector, and I’ll say a little bit more about that as we go.

What I’d really like to do today is to sort of try and place that a bit in the international context as Doug was kind enough to say I have the privilege of working in a number of countries around the world with health systems as well as with other public service systems, so it’s some of that experience I want to draw on.  Hopefully it will be relevant to you, but if it isn’t at least in the questions and answers you can drag me back to the problems that you face in Victoria.

I just want to spend a few minutes in the beginning explaining why the issue that we’re here to talk about today, an issue that you’re addressing in your innovation fund, is not a local – it is a local issue, but it’s also a big global issue.  There are a set of pressures on health services, challenges to health services across the world which has meant that there has been increasing attention to the question of the innovation fund.  Doug was kind enough to mention the report that I co-authored a number of years ago called Innovation in the Public Sector.  When Geoff Mulgan and I were writing that report, there were very few, if any, innovation funds in health services.  It’s not to say there wasn’t innovation going on, there were very few innovation policies or programmes or initiatives, but over the last ten years we’ve seen a growth, not just in Australia and the UK, but across the world in these sorts of initiatives.

And I think there’s really five sets of reasons why this has been the case.  Firstly, in many, many countries, in many, many states and territories, we find that there, or we’ve seen a shift in the population.  They shift from a population with increasing numbers of elderly people and it has to be said as a result and part of the successes of previous health systems and health practices, the nature of demand for health services has significantly changed, so the growth of chronic long-term conditions has meant that a health service that was built in part and designed in part or in the main to deal with acute and infectious diseases is increasingly have to shift its attention to a very different set of demands around chronic long-term conditions.

Secondly, the pressures as the health services developed, even though we have got better and better in some ways at clinical practices, at medicine, at different sorts of procedures, the inequalities in health systems are still considerable.  That is that in many states, territories and countries we find big disparities, both in terms of life expectancy, in terms of morbidity and mortality, between different sections of the population.

So both of these together have increased the pressure on health services to innovate.  And then there’s a sort of pull factor on this as well, which is when I was young and the first time I engaged with health services there were no – I’m very old – there’s no computers, there was no world wide web, there were no mobile telephony, there was no Skype.  All these technological opportunities and many more to come in genomics and data analytics and so forth create possibilities for health services that were simply not there in the past.

So we have sort of both push factors and pull factors in relation to health systems which have created this pressure for innovation, and then two final ones, by no means minimising them.  One is, and it sort of relates to technology which is about changing expectations from consumers, from the public, and it changes in two ways.  One is about getting new people more and more able to do their banking or book their holiday or their hotel online 24 hours a day seven days a week, and so their expectations of services are gradually changing as well, why can’t they do the same in relation to the sorts of services that they receive from healthcare organisations?  

And there’s a decline in what’s often called the decline of deference – that is people are as likely to look at information from their peers, their friends, their neighbours, patients with similar conditions, as they are to consult an expert.  So wherever I go in the world, I hear stories from doctors – both hospital doctors and primary care doctors – about people arriving in surgeries or arriving in outpatient clinics or arriving in the consulting room already having looked at a lot of information that is online or on the web in order to think about how they should be treated.  And so we get a change in the relationship between doctors and patients, between clinicians and patients and so forth.

So all these are sort of mounting pressures, and then along comes in 2008 another giant pressure on health services around the world, to a greater or lesser extent, which is increasing financial constraints.  And all of these have built a sense of, one could call it challenge, in many places crisis.  The health services that were built over the last 100 to 150 years are in many ways through this set of pressures and challenges both financially and socially unsustainable, that if we were to continue on the same trajectory as we are now, it would eat more and more of taxation and meet less and less of consumer expectation.

So with this set of things has arisen to, has created enormous both day-to-day operational and financial pressures in many systems, but also created the demand, if you like, for innovation.  The example was given, the report that Doug and colleagues produced is a classic example of a response to that situation, and extremely important and extremely welcome.

Actually, there’s something that’s interesting.  If we say well, if we look at sectors, not just health sectors, but if we look at sectors in general, in the economy and in society, which are, if you like, in a pre-crisis or pre-transformation position, we see something very common across those sectors.  That is, we see lots and lots of radical, but discrete innovations.  It’s sort of, again as Doug mentioned in his introduction, we get innovations arising in particular places.  We get different sorts of innovations coming up in different parts of the sector.  Each of those can bring some quality improvements or some cost savings, but often they’re failing to realise their full benefits.  We sort of, we look at them, whether it be telehealth, or whether it be out-of-hospital care, and it sort of feels as though they’re really making an improvement, but somehow they’re not realising the full potential that’s there.

So when we look at the health services, it’s by no means a comprehensive list, we can see a whole variety of different sorts of innovations.  You’ve got some incredible innovations in Victoria, around hospital at home, seeing things around day surgery, around telehealth, around health coaching, around data analytics, around people powered health, around genomics, around websites like Patients Like Me, and so forth.  We get this uneven distribution of a whole number of innovations taking place in different parts of the state or the territory or the country or the world.  The phrase that I like that was given to me by somebody else – all my best lines are stolen from somebody else – was that these innovations often tend to stay locked on the location of origin.  We can go to some parts of a state or territory, find that innovation, but it often doesn’t spread.  It doesn’t scale across a whole system, a whole territory, a whole state.  It only benefits the lucky few rather than entire populations or communities.

So lots of the work that I and colleagues in the innovation units and beyond have been doing over the last few years is around scaling and diffusion.  Why is it, what is it about the health sector and other sectors that often mean that these innovations don’t really scale and spread?

So I thought I’d just share with you this moment and some of the reasons why, what have often been called the myths or the mistaken assumptions about the scaling and diffusion of innovation.  I’ve just – let me take one or two of those.  Firstly, we often think about the reasons, the ways in which we approach scaling and diffusion of innovation, often suggest that if we just give people enough information, enough evidence about that innovation, that it will of itself scale and spread, and yet research over five decades now in relation to scaling and diffusion – not just in the health sector, but beyond – shows that information is not enough.  Information and evidence is not enough for people to want to adopt innovations.  We have to deal with the fact that often in some of the most important innovations this requires sets of behavioural change, changes in power relationships, changes in the nature of organisations, changes in working practices for those innovations to take root.  And you’ll know from examples within your own lives that if it requires behavioural change, simply the additional of information and evidence isn’t sufficient.

Secondly, we often think that innovation takes place by, or the scaling and diffusion of innovation takes place by transferring from one locality to another.  That we think that that’s, if something happens in one hospital then we need to transfer it to another hospital.  If it happens in one location, then we need to transfer it to another.  If it happens in one community health setting, then we take it from that setting to another.  And our moderate scaling and diffusion suggests that.  But when we look at how radical innovations actually spread, often what we find it’s the innovative organisation itself scaling up and growing and taking over more of the sector or the provision.  It’s about an expansion of those providers, an expansion of the innovative providers and so forth.

And thirdly, we often think that we should get the innovation right and then think about scaling and diffusion.  Yet where we see radical innovation spread, it’s because the potential adopters and the end users are often involved at an early stage in the innovation.  We don’t try and get the innovation right and then scale and spread it.  We think about the ways in which we can involve users, involve potential adopters in it.

Two other mistaken assumptions about it, and then I want to say something else, is that the – we often, I think it’s a failure of some politicians particularly, often think if we do enough innovation, some of it is bound to scale and spread, if we just keep pumping out more and more innovations, somehow some of them will stick, some will scale and spread, or if we do more and more change programmes that some of them will eventually stick in that regard, but some – of course we find that’s not the case.  Instead we get lots and lots of change fatigue.  Indeed, the more innovations often that are put into the system, we find the less the scale and spread.  Innovation itself is a resource-intensive process, so we need to focus, to prioritise our efforts and we can see that in the Better Care Victoria innovation fund of singling out a small number of priorities to really focus on, or put more – for those economists in the audience – if we’ve spent a lot of time looking at the supply side of innovation and not enough time looking at the demand side.

And fifthly, in terms of that sort of mistaken assumptions about scaling and diffusion, is the notion that this happens through clinical or professional networks.  And your evidence around the world shows that where we get real scale and spread effects is because of the ways in which patients and users, patient and user networks, are involved in the innovation process and create demand for it.  So there’s a whole set of reasons why scaling and diffusion have not taken place at the pace or with the effectiveness that we would maybe expect or like.

But what I want to spend a little while on today is a slightly different challenge to that, a slightly different challenge to health systems and health sectors.  As I say, sectors that are in crisis or pre-transformation or faced with a number of challenges often have a large number of radical but discrete innovations, and whilst those are good in themselves, they don’t mount up to a real shift in the nature of the system as a whole, in the nature of the quality, the reduction of inequalities, the meeting of consumer expectations or patient expectations, meeting the financial constraints that are there.  The way that real transformation happens, and I’m just going to give one very simple example, is often through the combination of different sorts of innovations together.  So there was nothing revolutionary of itself in the iPod.  It was very elegantly designed and so forth, but there were many other of those sorts of music players in existence.  Equally, there was nothing fantastically innovative of itself in iTunes, having music libraries that one could access.  The great success of Apple, which transformed the music industry, was bringing these two pieces together, bringing the iPod and iTunes together.  So the music industry itself has been revolutionised or transformed by the combination of different, the integration of different innovations into a new system, a new way of working, a new way of thinking in that process.

I’m going to leave that aside.  So the question I want to ask today really is, who are the integrators in health services?  Where would this integration come about?  Instead of these radical and discrete innovations, how do we get from a place that is a bundle of this radical but discrete innovations, into new models of care?  Who would be the integrators in this environment?  And there are, there’s a professor at Harvard who, I don’t know whether, how many people have read anything by this guy Clay Christianson?  There’s a few hands going up.  So he wrote a book some time ago now, called The Innovator’s Dilemma, and in that book looking across different sectors in the economy and society, he presents an argument or developed a thesis or a body of evidence which said actually when you get potentially radical innovations, organisations or sectors tend to, as it were, be rather conservative and they sort of enfold that innovation into their current ways of working, their current systems.  They had big systems, big organisations, big bureaucracies – and he wasn’t just talking about public services.  Indeed he wasn’t talking about public services in his early work, he was talking about the ways in which large organisations in the private sector, large governmental organisations and so forth are very resistant to fundamentally changing the ways in which they operate.

And so when we look at other sectors, what we see is the way in which they change is how it was, was not by the big organisations developing really, really new ways of working, new models of care in our language, but by the, as it were, smaller start-ups coming into play, nurturing very different ways of thinking and practising, and then growing themselves and eventually displacing the incumbent organisations in the sector.  That the, if you like, the transformation of sectors doesn’t come about by the incumbents in that sector changing or innovating, but by new players coming into that sector and being able to develop those totally new models of, in our case, care and grow and displace existing providers.

So in this case he’d argue, well, in this book, if you took that book literally in The Innovator’s Dilemma, he’d say, ‘You know, the big hospitals, they will continue to innovate, but they will continue to innovate sort of within their own paradigm, within their own mindset, in terms of their own ways of working.  They won’t really be able to turn around and shift the health system, if you like, into new models of care.  They will be, for all sorts of understandable reasons, they’ve got emotional investment in the ways in which to operate, they’ve got financial investment in these big institutions called hospitals, they’ve got big physical investment in all these things.’  So they’re very, his argument in the book, The Innovator’s Dilemma, was very resistant to this.  Indeed one could argue there even more resistant to it because they’ve been fantastically successful.

As I said in the beginning of this talk, one of the reasons why you’ve got a changing demand in health services, because of the very success of the health services themselves.  Now I want to take you back to that story at the beginning and say why do we have hospitals in that form?  Why?  How do these come to be created?  Because they were a very logical thing to do.  When people had to choose infectious diseases, one of the best things to do was to bring people into hospital, separate them from their community, apply the best possible medical and clinical expertise to bring together the sorts of capital equipment that we’d need to sort it.  And that’s in a sense why over hundreds of years, five, six, seven hundred years, hospitals were created to do this.  It’s the best way of treating, or one of the best ways of treating people with acute and infectious diseases, with accidents and acute interventions and so forth.

It’s, though, perhaps not just not the best, it might in fact be almost the worst way of treating people with long-term conditions, long-term chronic conditions, where we know from evidence and surveys around the world that one of the most important things is to be able to find the ways of enabling these people to live as healthy lives as possible in their own homes, to receive care as close as possible to their own homes.  And so often what we get in health services at the moment is a sort of tension, all these radical innovations developing, but developing in a sense within the current models of care that we have, and even when we have out-of-hospital care and so forth, even where we have telehealth, they somehow continue to be rather hospital-centric situations.

So he would argue in this book that if we’re really going to develop transformative new models of care that deal with the sorts of demands that health services have now, it’s more likely to come from organisations outside of the current health system than within.  Actually, truthfully, so that I don’t do him an injustice, in his book on the health services in particular, he says well, he says it might be a bit of a special case, and he argues predominantly it may be a special case, because he says clinicians have a sort of moral purpose that’s different from the sorts of aims and objectives of private sector organisations and in a sense he’s arguing that they want to do the very best by their patients, so maybe in fact it’s possible to do it from within the health system itself.  That maybe actually hospitals, community care, by reconfiguring themselves can create the health system and the models of care that’s necessary to deal with the different sorts of demands and financial constraints that we have now.

So there’s, even within his own body of work, there’s a question.  So my question is open about who are the integrators?  Who are the people who can take all these different pieces, whether it be the fit bit and data analytics, whether it be telehealth and out-of-hospital care.  Who are the people that are able?  Who are the organisations?  Where is the space at which these can be brought together?

And interestingly, in pursuing this sort of question takes us to – and I don’t know how many regulators there are in the audience, so just be – how many people would regard themselves as regulators of the health systems?  People who help shape the health system?  Are there any of those sorts of people here?  There’s one or two brave hands, brave hands going up.  And I just want to say a little bit about the nature of sectors that are capable of being both high-performing consistently innovative and transforming themselves, and then we are going, and then I will pause and we can have some questions.  And this is a very schematic diagram, so I just want to try and explain a little bit.

I talked earlier on about the challenge of scaling and diffusion.  In fact one of the most critical factors in whether innovation scale in a health system or indeed in other systems is not about the density of clinical networks, not about how many innovations there are, not about the availability of information and evidence, but it is to do with the way in which those sectors are regulated.  So when we look at those sorts of sectors around the world, what we find is that they have a sort of fairly common shape about them, and you might recognise this, because it’s not, in some aspects of it it’s not dissimilar from the health system, but I want to argue there’s particular ways in which health systems are different from this, that may give us a clue as to both why radical innovations don’t scale and spread and a clue as to how new models of care might be embedded.

To do this, I need you to just for a moment stop thinking about the health system and think about, you might want to think about banks or supermarkets or software companies or whatever, because these are sectors that do manage to be both high performing and consistently innovative.  And they have a very particular shape about them.  They have a core which are a small number of large organisations, keep thinking about, keep in your head either banking or software or supermarkets, any of these big sectors that you might be familiar with.  They have a small number of large providers, giving a lot of the provision in that particular sector, and what’s called in economic terms highly oligopolised sectors.  There’s often four or five major providers, a small number of large providers providing quite a lot of the provision.  And they’re surrounded by a wide periphery of start-ups, organisations of niche providers, of specialist suppliers and so forth.  Yes?

And they have boundaries, fluid boundaries between these two.  So in these organisations, in these sectors, forgive me, in these sectors, they have a fluid boundary in the middle which allows for lots of merger and acquisition activity and lots of spin-off and demerger activity.  That is that they allow large organisations to acquire innovative organisations out here and take those innovations to scale and simultaneously for large organisations, they enable people to spin-off new ventures, new companies, new organisations to do radical things.

Round this outer boundary is also fluid in the sense that it enables new organisations to come into that sector or that market or that system, relatively low barriers to entry as it’s called in economic terms, and for those that survive they’re able to, or who are doing good things, they’re able to grow and displace other organisations, but for those that are unsuccessful they’re able to be exited.  There’s low barriers to exit.

So, what example should I take?  So Microsoft, big software company, lots of its innovations come about and lots of the innovations go to scale because there might be someone working away in their backyard with a great innovation, along comes nice Microsoft and says that’s fantastic, we’ll give you lots of money, you’ll be very rich, we’ll take your innovation and we’ll put it across millions of window platforms.  And these large organisations are, if you like, the engines of scaling, or in supermarket terms the – as I’m sure you have them here – the loyalty cards were invented by a small organisation.  It wasn’t the supermarkets themselves conventionally, the supermarket then acquires that innovation and takes it to scale across.

When we look at the health system itself, what we find is, although we’ve got this here, you’ve often got a small number of relatively large providers, we call them hospitals, arguably we might have quite a range of this, but the boundaries between the two are rather fixed.  It’s quite difficult for a new entrant to come into the health services space, though more and more people are buying health packages out, or health technologies or health diagnostics outside of health systems, but the boundaries here to spin-off and to demerger are not as, to spin-off and to acquire are relatively low.

So the question I want to go back to, but I’m happy to talk about any of the things that are here, is who, when we talk – so we’ve got a great fund, and I don’t want to speak here, I think the work that it’s doing is great and we’ve got sessions later on today to talk about some of the features of the innovation fund.  It’s a great fund, it’s a great motive for innovation.  The question is, how do we enable both those innovations that are produced to scale and spread, but critically how do we integrate those radical, those discrete innovations into new models of care that can really meet the needs of people in the 21st century?  So I’ll finish there, Doug. Thank you. 

Douglas Travis

Thank you, David, for that thought-provoking introduction to your long day of labour today, and thank you very much for subjecting yourself to that.  It did bring me to mind to think about one organisation that I’ve come across in my travels at working in the interspace between hospitals and the community, and it was interesting, their philosophy and way they’ve set up, because they’re relatively new in the space, was that to actually have access to hospital beds is a barrier, because they said if their organisation doesn’t have hospital beds, so it works much, much, much harder to stop people.   But when hospitals run those services, there’s the default mechanism – oh well, if it all just gets too hard we’ll just put him in hospital.  So I think it’s very interesting and apropos of some of your talks.  Because of the system we’re in, I think who are the integrators?  A part of that has to come and be a push from organised government to push and do it.

David Albury

Douglas Travis

Because the capital free market mechanisms you’re talking about are far less adaptable in the public healthcare system and also partly because the customer, the patient, doesn’t control the funds particularly well and the politics controls funds in different mechanisms to true capital markets.

David Albury

Yes, I think it’s interesting, Doug, what you said about those sort of organisations that’s sitting between the two.  So we see, for example, in the UK, the growth of what I call GP federation or multi-community providers, and often these organisations are capable to bringing about these new models of care.  So it’s not, my argument wasn’t necessarily about a free market system at all.  It’s about the ability of organisations who in a sense aren’t part of the hospital-centric model, if I can call it that for now, to be able to really develop new models and to expand that provision.  So I agree with you that it’s definitely not just a case of a sort of free market system that can do this.

Douglas Travis

Okay, so we have a couple of microphones, and if people could wait until they get a microphone, because those on the web connection can’t hear you unless you have a microphone.  Are there any questions?  Thank you for putting the lights up.  There’s one down here, front right and one, yes?  Depends which way you do left and right, I suppose.  Start on that side.

Demos Cruscos

Thank you.  Thanks, David.  Demos Cruscos, North Richmond Community Health.  I want to go back to your comment, or comment from Clayton Christenson around the healthcare system might be a little bit different because it has a moral purpose.  Would you expand on that a little bit and just tell us a little bit more about why that is a significant element which might distinguish, if you like, the healthcare sector from other industry sectors?

David Albury

So, very briefly, the drivers for incumbents in private sector organisations is very related to the, as it were, return on investment, and they have a massive investment in existing ways of doing things, and therefore being able to invest in new ways, both financially and emotionally, is very low in Clay Christenson’s argument, whereas his argument is that clinicians have different sets of impulses.  They’re not driven by a bottom line return on investment.  They’re driven by what’s best for patients.  And therefore that they are more likely with others to develop those new sort of new models of care.  So it’s that sort of argument about investment.

I mean, for me, it’s interesting.  I don’t think it’s a, it’s not a, it’s by no means a closed question.  It’s not going to have an answer sitting here about who are the integrators, because I see health systems around the world struggling to develop these new models of care and it’s not clear yet, it seems to me, whether that is possible by some of the existing incumbents, by the hospitals themselves, or whether it requires a sort of different configuration of organisations in that sector and so forth.  I think we live in that particular time.  What I’m trying to introduce into the debate on this is the question, the issue that’s been posed, and Doug, you referred to it, and it’s a very real challenge, it’s a challenge about the people have seen, it’s about scaling and diffusing innovation, and the remains a challenge, taking it from locality to locality.

But the other big question that I think is facing us at this point in the journey is how do we integrate these different pieces?  As I say whether the fit bit on one hand or self-care on the other, whether it be out-of-hospital care and data analytics, how do we begin to put those together into what will be the genuinely new models of care that will provide better care for populations, and at a price, if you like, or at a cost that can be afforded within taxation systems?  So that’s what I’m trying to put on the agenda as well.

Douglas Travis

Can you please identify yourself as well?

Chris McLaughlin

My name is Chris McLaughlin.  I’m from the Alfred, one of those big hospitals.  And I really liked this idea of having beds as a barrier and we are, the success is also our barrier to innovation.  And wondered in terms of the sort of who are the integrators?  Of course, big health services are full of all these brilliant people, and yet they’re not often brilliant in areas outside of their speciality, and thus the sort of, the idea of marrying very different sorts of thinking like marrying supermarkets and healthcare, or whatever it might be.  And the chronic disease issue, I’d love to hear what you, where you think there’s been radical innovation there in terms of rethinking models of care in health.  So an example for me is when someone comes back to the EED we pretty much say welcome back, as for an example in Sweden, where they say what are you doing here?  What failed?  And so there’s a whole mindset.  I’m interested in about where have you seen radical innovation that’s stuck?

David Albury

So I think there are pockets of these innovations in many places around the world, of places where people have started to incubate, started to put in place models of care around people with long-term conditions, that are much more reliant on care in the home, on some forms of telehealth, on remote diagnostics and so forth.  I think there’s examples listed around the world.  In fact some of the best examples, not surprisingly, are in places which don’t have very well established hospital systems because they didn’t have them there to fall back on, so you think how the hell do we manage in this, so we see in India and some part of sub-Saharan Africa some really interesting new models developing of how you help people, because they’re starting to have that sort of, if you like, the disease to the 21st century there that would really support people in or close to their own homes.

But you said something.  It just makes me want to add in one caveat, I guess, or caution I want to say.  I’m not arguing that hospitals or healthcare systems should be like supermarkets.  I know that’s not what you advocate.  It’s often that we can learn something from these different sectors and industries and organisations about ways that they think about.  If you think about banking.  Banking used to be somewhere a bit like the health system, where you had to go into a bank and do all your business in the bank with a bank clerk in order to sort of get money out or post a cheque, or whatever it might be.  And we can learn something from how banking started to rethink itself in order that most of the banking activity now takes place in people’s homes or anywhere that you’re on the move.  What was it about those sorts of circumstances?  And one of the great things that I know you’re doing in Victoria is for example to bring in much more service design and use a centred design into your processes, which help.  That means it’s not about just clinicians or clinicians or managers thinking about what these models might be like, but as so often in radical innovations, it’s about bringing the patients, the clinicians, the carers, the managers and the policy-makers together in processes to really redesign those services to create the models of care that meets the needs of patients within the constraints available.

Douglas Travis
There’s one here.

Robyn White

Hi, Robyn White.  I’m CEO for the Eastern Melbourne Primary Health Network, and I guess I wanted to reflect on what you’ve just commented on, which is getting the right people in the room to have those conversations.  I think the Primary Health Networks are actually an extremely good vehicle for looking at some of these opportunities for better integration.  I have within our PHN, we have structured a lot of collaborative, so exactly, we can have these conversations, and particularly getting the clinicians and consumers to address some of the issues around how to better keep people well and in the community rather than in a hospital setting.

My question to you is, we absolutely need to get consumers and clinicians together.  One of the challenges that we’re looking at is how do we wrap technology innovations into those conversations?  I’m starting to think that a lot of the use of, and different uses of technologies, is driven mainly by consumers, but can you comment about how we bring that aspect into our new ways of thinking?

David Albury

So, there’s lots to work that our colleagues in innovation units and other organisations do.  In a sense is the way in which we often do that is to play in at the points in that sort of co-design process or that re-design process, not in the beginning, but sort of, as it were, half-way through, where some of those technological possibilities may be.  So people start to think about well, I’d like care closer to home.  If you bring it, what are the technologies that would enable and support that?  What are the ways in which, what sorts of different technologies can enable people to monitor their own health effectively?  What sorts of technologies might enable them to support changes in their lifestyle and so forth?

But I say it’s a process in general we bring in, sorry, a sort of intervention we bring in half-way through or in the middle of such processes because our experience, and I think the experience of many programmes around the world – and I’ll give an instance of this – is that technology-driven change, technology-driven change seldom really works in terms of fulfilling its full potential.  So there’ve been many health systems around the world, including probably my own home-based one there, has spent extraordinarily large sums of money trying to create, for example, electronic-shared health and care records that are accessible to clinicians and patients and all the rest of it.  We all know this problem.  And many health systems have spent millions and often billions of dollars on these sorts of enterprises, often slow in terms of implementation, often resisted, and often not giving the benefits that people expected, whereas you take, for example, one of the projects which I had nothing to do with, but I think it’s one of the great innovation projects of the world, in Canterbury District Health Board in New Zealand, what they focused on was how do we get the sort, how do we get changes in relationships and mindsets first, how do we create the relationships of trust and collaboration, and their implementation, development and implementation cost a few thousand, or a few tens of thousand dollars to do that, because the relationships and the mindsets and the practices were in place before the technology, if you like.  The technology enabled it to embed and deepen, but it’s about bringing those into play.

So I think there are various tools and techniques in the middle of design and redesign processes that enable us to do that.  My experience is, with both clinicians and patient groups, that putting the technology upfront and saying look how wonderful this is, wouldn’t it be great if – it doesn’t in general work.  There’s something about getting the relationships and the models right before we try and do the technology.

Harim Yefsky

Hi, David.  Harim Yefsky, Access Health and Community.  I notice your slide there, I see that word “integrator” all the time, but do you think there can be true disruption in healthcare?  Because integration suggests a very soft sort of thing, but in lots of other industries there’s actually real disruption and you don’t know where it’s coming from.  You take Uber and what it’s doing to the taxi industry and so on, and do you think that we’re actually, by what we’re doing at the moment we’re thinking that we are maybe in a very comfortable position, but something’s going to come from left field and actually turn everything on its head.

David Albury

Yes, I mean, do I think there could be?  Absolutely.  And do we often not see it coming?  Absolutely.  So if you go back to the sort of early 1980s, let’s go, since we’ve introduced technology, there was IBM, the big computer firm, very successful, etcetera.  And people started telling it about there were these funny people in Southern California developing devices that just sat on a desktop and people could do all sorts of things with them, the sort of senior people in IBM said oh, it’s just a bit of nonsense over there, we’ll carry on making big mainframe computers and the world will carry on just as it was.  And, of course, that wasn’t the case, as we know.  That industry was revolutionised by those funny people in garages in Southern California.  And one of the interesting pieces that, I think where it’s sitting at the moment, is when we’re talking with patients, and members of the public more generally, of course, they are accessing health information, some forms of diagnostics, some forms of care and treatment independently of the health sector, and at the moment my feeling is in the health sector we’re generally going a bit like the board of IBM, as it were, saying yes, no, I understand all those bits and pieces over there that they’re sort of playing with online and patients like me and Fitbit and blah-blah-blah-blah-blah, but I think those might well be the germs of exactly the disruption that you’re talking about, and that we haven’t quite seen how that comes together yet.  But I think it’s quite conceivable that it will.

Douglas Travis

I’ll just buy in on that.  I think the big disrupters in health will continue to be what they have been in the past, and that will be scientific discovery will be, and has been, the big disrupters.  All the TB sanatoriums have gone because someone invented a pill.  When someone invents a pill to fix cancer, half the hospitals will shut, and that’s going to be the really big disrupter.  In my area, in urology, stone surgery disappeared overnight.  What happened in stomach ulcers?  Stomach ulcer surgery has disappeared overnight, because someone discovered the scientific revelation – it was a bacterium that was causing the problem.  We already had the antibiotics.  And overnight that changed.
So yes, there will be big disruptors.  I think it’s going to be more in the discovery which will allow an entirely different new way of delivering that solution to the problem rather than someone finding an entirely new way of putting a hip joint replacement in for a broken hip.  It may be something Star Trek-y that fixes the bone, but it’s going to be that, I think, rather than just a process change.  But, yes, there will be big disruptions.  There have been and there will continue to be.

Angela Jacob

Hello.  Thanks for your talk, David.  Angela Jacob from Latrobe Regional Hospital.  I’m just thinking about this idea of disruption and also the focus, I suppose, on the end user and the consumer.  I think it was Henry Ford that said, if I’d asked people what they wanted they would have said faster horses, not cars, because it was so far from what they can conceive.  And I’ve also heard talk about innovation where they were talking about the fact that a lot of innovation happens at the interface between sectors and industries and an example of that was ICU changeover of patient from ventilators and looking at the practice of motor racing pit crews and the teamwork and the timing that goes around that.
So are you aware of sort of areas where that’s happening in healthcare, where it’s those interfaces where the really big innovations are happening?

David Albury

Yes, I mean, I think that’s a very, I mean I think for all sorts of reasons, I think the way in which Grand Prix racing, formula 1 cars were dealt with in sort of pit stops, gave a lot of food for thought and interaction between that and sort of some of the emergency or acute interventions that we carry out in healthcare systems.  And in a sense that’s a bit of an answer to the first issue that you raise, the sort of, so Henry Ford reputedly said, if you’d just asked me what they want, they would have said faster horses and carts, rather than cars, is to look at what sort of processes do shift patients and the public from thinking about just better ways of current working into new or different models.

I’d really say, I think there are two things that can be really important here.  One is, as you’ve said, it’s about the exposure to what’s going on in other sectors, other industries, other organisations, other countries, so there’s a sort of, well, I can call it, it’s called horizon scan, so all our big innovation projects often start with saying how have other sectors or other countries or other localities thought about a similar issue?  So that can help sometimes break people’s mindsets.

But the other is often on the very question that we ask, so doing work recently with one patient organisation, a large patient organisation, where actually people had similarly said a sort of Henry Ford point to me and colleagues, which was if you ask people what they want, they’ll always just say they want better outpatient clinics, more clinicians, more this, more that, more of what they know.  And that was definitely true when they asked them sort of what would you want?  Actually taking the very same organisation and asking them to describe their ideal life of living with their particular chronic condition was the complete reverse, and closer to what Doug was saying earlier on.  They say the less time I spend in the hospital, the more time I can spend in my own home, the more I can share the treatments and care with my neighbours, etcetera.

So it’s a question about, in a sense it’s often a very subtle process about what question we ask, and all too often in the consultation engagement processes we ask people that lead them to an answer that is always inevitably, they want more of what they have now, or better of what they have now, rather than being able to thing out, if you like, outside of the box.

So finding the questions, finding the format, finding the more openness that allows people to explore what their ideal lives would be like, and this is particularly true – I’m sure you’re familiar with it here, having looked at the data here – but if you ask people about end-of-life care, for example, particularly in that sort of sphere, they have very different responses, if you can get them to paint pictures, as it were, of what their ideal end-of-life care would be like, rather than asking them something specific about sort of what do you think of your nearest and dearest when they passed away, what was the service like, when they tend to give rather transactional answers.

So I think there’s something about the nature of the questions that we ask as well.

Doug Travis

Thank you very much.  We’ve just got to the end of our time, so David, thank you very much for your insights and your presentation.  I’d like to thank the guests for coming and also the people who have joined us on the webcast in the back corner of the room.  If any of the guests are attending the masterclass which starts at 10:15, it’s upstairs in seminar room 1, which is out the door.

I just want to have one minute of advertising time.  Two things to talk about.  Better Care Victoria next year will focus on outpatients and access to hospitals, so get your thinking caps on and that’s a very broad church and we would be very keen to be looking at not just outpatients inside the walls of a hospital.  So how you can deliver those sorts of services is really what it’s about, not necessarily in an outpatients clinic, and on a Friday or two ago, I think it’s eight days ago, there were the announcements around Safer Care Victoria, and for those who heard that and are wondering what’s happening, a lot’s happening, but what I can tell you is that Safer Care Victoria, and Better Care Victoria will work glove-in-hand and work very closely together in order to help you.  We will not be competing with each other and it’s about getting better outcomes.  So we’re not in competition and we’re here – well, I’m from the government.  We’re here to help.

So thank you very much, and we finished at 10:00.  Thank you very much, David.