A healthy future demands an health ecosystem view of value and design

Note the perspectives and arguments in this article have been superceded in my later work. This can be found in my 2021 book Interactional Creation of Health: Experience Ecosystem Ontology, Task and Method.

Today’s complex health and care systems are buckling under the pressures of chronic problems and ever-tightening resources. Whilst there is always optimism that some new technologies will come to the rescue, many are not adopted, do not scale and fail to realise their ambitions. They do not create enough of the right value to make a big enough difference.

To me, it seems that many of our best efforts merely just slice, dice and recombine underperforming parts of the clinical failure-repair and recovery health system. They are designed within a narrow frame of logic, understanding and action … and value.

I say this need not be the case. I believe it is time to think differently, more widely and even more radically in order to discover and realise more valid possibilities for improving, transforming and redesigning value in health and care systems.

You may be working with a new technology and strategy already, navigating and maybe stuck on your own complex path towards adoption. Or are looking afresh, seeking new ideas, growth or service opportunities.

Whichever the case and whether in industry, a provider or in government, in this article I will explain how you can better succeed by following some important ecological principles.

Indeed, ecology — the study of interactions between and within species and the environment — can guide us to think and act differently. It provides many important and valid foundations for designing and transforming value in health, care and related social systems.

To discover and realise transformative possibilities in health, as in anything, I believe it is essential to find novel, smarter ways to undertake and connect two fundamental activities These are first, obtaining deeper INSIGHT into the current situation — what is going wrong and why, and second, widening our IMAGINATION of what is realistically possible.

And we mustn’t just undertake and combine these activities just once. We must embark on a never-ending repeat journey from one to the other, and back again.

Due to the sheer complexity of the systemic health problems we face, there is not really any defined map to help us on this journey. But I will show you that there are certain rules and principles we can adhere to. And certain mental equipment that we can acquire, carry and deploy along the way.

Indeed, along this journey are four staging-posts — four important steps that allow us to connect insight with imagination, and to better discover and realise valid or realistic opportunities for value creation in health systems — or ecosystems as I will call them.

And these steps form the four components of my framework for designing and transforming value in health, care and social ecosystems. Or Health Ecosystem Value Design as I call it.

So, let’s head to our first stage-post — FRAMING.

FRAMING

When faced with a complex system, the first thing we need to find do is a way to break down the challenge into smaller parts. We need to reduce complex health and care systems into practically useful frames to capture insight, discover opportunities and take valid, useful action.

Fortunately, we can learn from ecologists who do exactly this. They break down the complex earth ecosystem into smaller discrete systems using common units or contexts to distinguish one from another. Typically, these contexts are;

• A type of primary producer species that sits at the bottom of the ecosystem food chain. They are called primary producer because they perform the vital role of converting energy resources (such as light, water, soil) into food resources for all other species in an ecosystem. The presence, capabilities and health of primary producers provides the basis for an ecosystem’s existence and functioning.
• The nature of the environment itself (e.g., desert, coastal, forest) which determines the type, quantity and quality of resources available to the primary producer, and therefore overall ecosystem health and functioning.

What do these contexts tell us about how to frame health ecosystems? Well, we can identify and frame individual health ecosystems using similar contexts. These are:

• A particular patient group (with single or multiple disease or condition states) such as persons with diabetes or heart disease (or both even) or a population group such as the elderly frail or newborn babies.
• The characteristics of health and care resources available to the ecosystem. These may be human, economic, technological, cultural or knowledge resources. I call this context the health resource environment.

Of course, health ecosystems in advanced western economies have access to different resources than those in lower income countries … In this sense, like natural ecosystems, the SITUATION or the place of location of health ecosystems can be used as an important context to distinguish them too.

Using these contexts, we can frame individual health ecosystems that exist in multiple locations — in different countries, and across multiple regions or communities.

Just as in natural ecosystems, individual health ecosystems are adjacent to one another. Adjacent social ecosystems such as housing, education, energy, and food production and consumption contain many of the social determinants of ill-health and so we can add these alongside our framing too. Doing so means we look can much broader for health value-creation opportunities. We have a wider canvas to search and understand what is happening.

In fact, there is one more context we can use to frame a health ecosystem. For that we need to head the second staging-post … health ecosystem functioning.

FUNCTIONING

The second component of the framework reveals how health ecosystems function and the actors and other elements that constitute them. Again, we can learn from ecology here.

To survive and reproduce, species in individual natural ecosystems not only compete with one another but often interact in more mutually beneficial relationships by sharing resources with one other. In all ecosystems, certain species work together to perform a number of complimentary tasks that are vital to maintain or recover the health of the primary producer species and therefore the health of the ecosystem overall.

Ecologists call these teams of species — functional service groups — and they can be identified according to their nature of their interaction with the ecosystem, or their PURPOSE.

Increasingly ecologists recognise that the presence and capabilities of certain species in these functional service groups is more critical than diversity alone in maintaining and recovering the health of a natural ecosystem.

Whether in functional service groups or at the level of all species interactions, natural ecosystems can be conceived as resource-sharing and integrating service systems. The same is true of health ecosystems — or more correctly health service ecosystems.

Influenced by values, meanings and their role, actors (people, patients, clinicians, industry, providers, government) develop, share and integrate resources to access, perform, obtain or use health services. These services can be defined according to their purpose, such as to prevent illness, or improve, maintain or recover the health of a beneficiary actor — the patient or population group that benefits from the services.

We can define the purpose from the point of view of the beneficiary actor too — to improve personal quality of life, manage a chronic condition such as pain, or recover from a trauma — for example.

So, to complete our framing, I add one or more PURPOSE to further distinguish individual health ecosystems.

When we set Purpose, we also frame an INTENT or a direction of future value-creation or transformation. Knowing a purpose and what is preventing actors from achieving it with the resources available to them helps guide and inform a more robust search for future possibilities for improving, transforming or disrupting a health ecosystem.

Below are a few examples of fully framed health ecosystems showing the four contexts of Purpose, Situation, Health Resource Environment and a Beneficiary Actor — along with the Adjacent Ecosystems.

With framing and functioning defined, we can now study an individual health ecosystem to better understand problems, variations, resources used, gaps and paradoxes in the desire and ability of actors to achieve the defined purpose.

But before we do, we need to organise our enquiry to discover opportunities for improvement or transformation. Let’s explore this at our next staging post — STRUCTURE.

STRUCTURE

In all natural ecosystems, ecologists define a hierarchy consisting of different levels and types of interactions between and within species. Starting with a single organism at the lowest level, then a single species, each higher level defines a wider variety of interactions between increasingly more diverse populations and communities of species — up to the highest level of the ecosystem overall.

It just so happens that it is possible to identify a universal hierarchy of actors and interactions within any framed health service ecosystem too.

Consisting of eight levels, each level denotes a particular configuration of actors — or what I call a co-creation practice — interacting in different ways with their own and other actors’ resources to provide, perform or obtain services. Let’s look at these different practices briefly.

At Level 1.0 are practices of interaction in the body and mind of beneficiary actors.

Level 2.0 defines the personal interactions that beneficiary actors — patients — have when on their own with their and others’ resources such as devices, drugs and other technologies.

Level 3.0 denotes the social or peer interactions that beneficiaries have with their family, friends or other people with similar conditions.

Levels 4–8 progress then through increasingly more complex practices that take place between the beneficiary and specialist health actors, and within and between health service teams, organisations, and overseer bodies.

For any health service ecosystem, we can map the practices of actors using this hierarchy. We can also map pathways through them. Doing so provides a universal structure for choosing and organising enquiry and for capturing deep understanding of ecosystem-level problems, patterns, relationships, trends and opportunities.

What’s more, all this can be done before we even start thinking about or assuming what solutions might be best. As well as when we already have a technology, solution or plan. In either case, all this insight can be captured objectively and independent of any bias or assumptions about how to address them.

This means that we can reveal novel possibilities for intervention or change of any kind. Not just for new technology, drug and device innovation but also for innovative provider health services, community initiatives, new forms of collaboration, and new health policies and programmes. We can also learn how to design new health ecosystems altogether.

To know how to do all this more effectively, we need to move along to our final stage-post — ADAPTATION

ADAPTATION

All natural ecosystems are in various states of dynamic adaptation. Any given state depends on the balance of available environmental resources, the health of the primary producer species, and the presence and capabilities of certain key species and functional service groups.

Some ecosystems are in a sustaining state, some are emergent, others are rigid or collapsing, and may be losing or have lost their resilience to cope with the decline of energy resources or the primary producer. In most cases though, a natural ecosystem contains a mixture of all these states in different degrees.

The same is true of health ecosystems. They too are in various mixed states of evolution, adaptation, stability or decline. Using the structure I have just defined, we can now see if, where and how our individual health ecosystem is changing or evolving.

We can see within-practice level, top-down, bottom-up, adjacent and disruptive forces of change — and respond to the weak signals and realities of those forces — more appropriately.

We can understand the influence, nature, dynamics and consequences of lots of different factors on the nature and form of adaptation — or what is known as the adaptive capacity of the ecosystem. Factors such as:

• Gaps in beneficiary and professional actor capabilities, their knowledge and resources available
• Variation in actor values which can sometimes lead to conflict.
• Resource types, cost and use including technologies
• Care access and equality issues
• The nature and influence of the social determinants in adjacent-to-clinical social contexts and
• The root causes of problems

And most importantly, how they all affect beneficiary actor outcomes, and why and how these outcomes vary. Because when we know these factors more deeply, we can also better discover and assess more, — more valid and more novel opportunities to intervene or improve your health ecosystem — or even transform it.

So instead of thinking in limited terms of improving outcomes and reducing cost — or fixing repair–recovery health care systems through greater efficiency and productivity — we can now adopt a far different and more bolder ambition. One that seeks to understand and advance the adaptive capacity of individual levels or of an entire health ecosystem, the constraints acting on it and the key drivers for evolving it.

And wherever you intervene, each of the levels of the ecosystem tells us which combination of design approaches are most appropriate to deploy.

I stress here that when you embrace the ambition of adaptive capacity, you will also understand how to develop your own adaptive capacity. When you do, you will develop more novel ideas, designs, business models, technologies, services, strategies, teams and organisations for improving or transforming the wellbeing and health of health ecosystems and not forgetting… most importantly, people and patients’ healthy lives.

In short, you will acquire new or better imagination for seeing and designing novel possibilities for value creation that are desired by actors, and sought by decision-makers. As well as for shaping those ideas and technologies you are already working with.