NESTA on “people powered public services” and beyond the poverty of imagination

In my mind one of the most innovative organizations in the area of service design, cooperation and public services is NESTA.  They recently published a fascinating report,“The Human Factor”, that examines how co-creation with the public and patients within the context of the NHS can save both money and lives. The co-creation, cooperation, commons themes that run throughout the report are central to the work I’ve been highlighting on this blog around what I’m calling “open health”. The report is a must read for anyone interested in innovation in the healthcare or public health arenas. We’re going to have to become experts in this way of working in the future but getting organizations to think beyond traditional partnerships and anemic forms of ‘engagement’ will be challenging. Below I’ll provide some of the key insights from the report.

  • Beyond Efficiencies:  Just thinking in terms of saving money without changing the nature of service design will only get you so far.  What we need is radical redesign.  Think about how to design for desired outcomes rather than purely on existing, often dysfunctional and inappropriate infrastructures
  • A good case study of redesign is NeuroResponse, a social enterprise incubated by the Young Foundation’s Launchpad that addresses the unmet needs of patients with neurological disorders through the use of existing telecommunications infrastructures so that more patients can receive treatment at home. That is, moving from an acute care model to community care. The cost of a diagnosis of MS currently costs the system £17,000 per person or a total of £400 million of which the majority is for in-patient, hospital-based care. Telemedicine has the potential to save millions.
  • The Expert Patient Programme is another example of how self-care is being used to improve outcomes and patient satisfaction.  Hospital admissions have been reduced by 50% and visits to GPs reduced by between 40-69%.
  • Community-based initiatives tend to be better for behavioral change than top-down approaches. The Knowsley Primary Care Trust created a partnership for Wellbeing that focuses on cardio-vascular disease prevention at the community level and works through pubs, bingo halls and shopping centers. The result has been a 28% reduction in cancer morbidity rates and 32% decrease in smoking.
  • Well London is a consortium of health, environmental, education and arts organizations that invests in community projects for health behavioral change.  This includes projects like Healthy Spaces that transforms open spaces into greener, more attractive places.  Community mental health is one of the focus areas.
  • Transforming Innovation: perhaps the most difficult challenge is changing the way organizations think about innovation.  The US public health sector is in dire need of this change in mindset.  Getting funders AND organizations to take risks, experiment, move beyond dated ways of thinking about technologies and community is a challenge.  One of the platforms they’ve used in the UK is Patient Opinion, a platform that enables users of the NHS to provide feedback and develop networks of user-citizens to provide the essential feedback that innovators within the system can use to improve services.
  • Open Innovation for behavioral change: The Big Green Challengeis another initiative designed by NESTA focusing on climate change and how communities can reduce their carbon emissions. The program is essentially a platform that crowdsources ideas for innovative strategies and provides awards for the best proposals. The concept has been extended into the obesity/diabetes space through the Healthy Community Challenge Fund to test and evaluate ideas that make activity and healthier food choices easier.

In the month or so since I posted the draft white paper on open health and platforms for public health 2.0 below I’ve receive quite a bit of positive feedback from most quarters. One of the criticisms I receive from many within mainstream public health programs is that the content is bit ahead of where funders are in the present, too much in the future. I strongly disagree, these tools are here now. We’re at the BEGINNING of a prolonged financial crisis and the old ways of ‘doing’ health and public health are failing too frequently. This is the time to innovate and think about how to design more innovative approaches, innovative institutional cultures and experiment. I was listening to a conversation on stimulus funding in public health and how organizations are being asked to collaborate as they compete for funding from the federal government. We’re still thinking in terms of partnerships rather than networks. We rarely think of new business models that we could use in public health and couple these with user-led innovation and co-creation paradigms. We may not be able to fix the poverty of resources in the short-term but we can address the poverty of imagination in health if we open up to new paradigms.

Fragments of an open health economy…

Here’s a recent abstract from Health Affairs: During the projection period (2008-2018), average annual growth in national health spending is projected to be 6.2 percent–2.1 percentage points faster than average annual growth in gross domestic product (GDP). The health share of GDP is anticipated to rise rapidly from 16.2 percent in 2007 to 17.6 percent in 2009, largely as a result of the recession, and then climb to 20.3 percent by 2018. Public payers are expected to become the largest source of funding for health care in 2016 and are projected to pay for more than half of all national health spending in 2018 (Health Affairs 28, no. 2 (2009): w346-w357).

Everyone knows that the status quo is unsustainable given the worsening financial crisis and the fact that employers are growing less willing to pay more and get less in terms of health outcomes. In global health we’ve seen a great deal of innovation in terms of PPPs for neglected diseases but we’re coming up against similar problems with inefficiencies, fragmentation and a long way to go in terms of improving health outcomes. Health systems are performing poorly and the vertically driven approaches of the last decade are viewed as one of the problems.

We clearly need to rethink what innovation in health and public health look like. We can no longer just view new technologies as the answer. Just being new is not innovation. Furthermore, the mindset of the health professions must change; we need new tools, new ways of thinking about systems and then implementing an entire assemblage of new/old norms, technologies, social technologies. Health reform, well, if you aren’t tired of the same old set of health wonks boring you to tears with why nothing works, why universal or consumer-driven healthcare is the way of the future, then, I don’t know what to tell you. Several years ago while working on a Pioneer Grant for the Robert Wood Johnson Foundation that was to help RWJF think about how they could leverage the tools and technologies of cooperation to become a better catalyst for health system transformation, we interviewed a number of other Pioneer grantees. The most interesting thing they had to say was that the first step was to NOT do another blue ribbon panel with the same voices that have benefited from a dysfunctional health system. If only….

For the past year I’ve been thinking about what a paradigm for health system transformation, not “health reform” (those words make me somewhat ill), might look like. My last gig at IFTF in 2007 was to run a conference on what we called “Open Health”. I now think their are enough pieces of the puzzle in place that we can see some hope for a nascent “Open Health Economy” if we start putting the pieces of the puzzle together and work to disrupt the current system and not allow “health reform”, the rather anemic and euphemistic “consumer-driven” healthcare and its various guises to become the only available discourses for how we think about health and healthcare.

We live in a networked world whether you’re a fan of Manuel Castels or not. And no, to my friends in public health who at times flinch at the mere mention of technology and like to speak for “the community”, that is “technology-less”, the poor are not too stupid to use technologies, appropriate them and cannibalize (and here) them for their own ends.  We can certainly raise issues of access and the processes of technology development (see Melissa Leach and Ian Scoones on this topic here).  In fact, ‘innovation’ should include new innovation systems that bring end-users of technologies and systems into the equation earlier. As our knowledge of health grows we know that there are complex interactions between the environment, genetics, social networks, etc.  However, our institutions are still in an analog form and poorly equipped to deal with chronic health issues, food safety (eg. the current peanut butter/salmonella crisis is showing how our food system is in tatters when it comes to food safety), ecological health, and the myriad connections of factors that influence health outcomes. etc. We’re hit the limits to single slice solutions and prevailing economic conditions place limits on how we approach complex problems. 

The paradigm of “Open Health” that leverages the insights from open innovation (eg. InnoCentive, Nokia’s open platforms, Henry Chesbrough, Global Brain, Index Award), peer-to-peer production (eg. Yochai Benkler, the Foundation for P2P Alternatives), calls for open data (eg. Free Our Data, Open Data Commons), co-created health services (eg. RED Project’s Open Health initiative), new commons (eg. Social Venture Commons, Science Commons, Knowledge Commons, Health Commons, Entrepreneur Commons), social media in health or health 2.0 (PatientOpinion.org.uk,Patients Like Me, etc.), social business models and social entrepreneurship (Narayana Hrudayalaya, Aravind Eye Hospitals, Health Launchpad, Participle, ), open access publishing, medicine 2.0, the mobile web, geoweb, government 2.0, collaboratories, cooperation (eg. smart mobs, Peter Kollock) and citizen science (here, here, here).  From the world of design there are organizations such as Think Public  ( and more hereherehere, and here) and new urbanism and learn from Varnelis how to think about cities, health and networks:

 “networked ecologies,” plural “infrastructures” that are “hypercomplex” and as likely to consist of legal mechanisms and barely visible cell-phone networks as the heavy stuff of tunnels and bridges. Inherently less apparent than the infrastructure that came before, they’re also as likely to be owned by corporations as by governments—meaning these networks can’t really be controlled, only “appropriated” according to their own logic. With traditional planning made impotent by capitalism and NIMBYism, rebuilding the city now requires a “new type of urbanist,”

 What we have here is a vast and growing network of projects, experiments, technologies and new ways of framing problems that can be brought together to RETHINK HEALTH and drive towards health system transformations in the US and abroad.  What is lacking is a synthesis or, for lack of another term, a health innovation portal for bringing these various strands of thought together, think through the politics of open health and develop new strategies, business models and approaches.  For example, the public health community has generally been in an antagonistic relationship with the food industry and its role in marketing junk food to children, use of HFCS, etc. However, the market drivers are pushing food companies toward more sustainable and nutritious food systems and we can only change these systems by engaging with the food industry for new “healthy” partnerships that get better food into communities and bodies.  Food companies have had to deal with the call for healthy foods but often these fail in the marketplace.  Can we work together to create better food eco-systems without the finger pointed at us as sell-outs?  I believe so and feel that we must.  There are lost opportunities here if we don’t.  The list above is by no means the sum total of what can be done. But there are important political insights if one thinks critically about the tendency towards techno-libertarianism and the “market solves everything” mentality that runs through much of the social entrepreneurship and technology innovation fields.  We’re in a period of restructuring of markets and thought.   A strong dose of policy entrepreneurship is needed as well. The next generation of social entrepreneurship will have to address the issues of the politics of social businesses and political life in general and how to cooperate with government for win-wins. Critical thought here would aim to unpack the taken-for-grantedness of some of the concepts and approaches and look for ways that disruptive innovation through novel forms of cooperation and network organizations, rather than analog institutions, could make us healthier and avoid the immense degree of unnecessary suffering that health systems worldwide continue to tolerate.