Feature Into the new paradigm: writing the script for

Article
the future of health care
Tim Porter-O'Grady

ABSTRACT:- The world is changing dramatically, driven by changes in technology and global
shifts beyond the control of anyone. The requisite of the leader ivill be to focus on the changes
and translate them in ways that provide meaning and direction for the future. Critical to this
process is the ability to embrace the emerging reality and to apply its principles to the delivery
of health services. The rules that once applied to our thinking and acting in health-service
provision no longer apply. The job of leadership is to understand the meaning of the changes
and to build appropriate responses to them. Wiratevcr the response, it will fundamentally alter
the way in which we see health-care delivenj and how we provide services for the immediate
future. The notion of value and its application to the changing health system is central to the
change activities and provides the context for any and all changes in the way health service is
conceived and provided for in the foreseeable future.

CREATING A NEW W O R L D 'seer' is the person who is open and available to the
message and what it might tell us about the next stage.
"It's a new world." Those weirds inspire and wreak
havoc at the same time. Civilisation is on an inexorable Being available to the message means getting past the
path into an age it knows precious little about. Yet the clutter of previous scripts and templates for receiving
globe is moving headlong into it without much and thinking about what we sec. )t is not that our historic
consideration ol the implications, or a real desire to view has no value or has contributed little to our current
know too much about the ramifications oi the journey circumstances; rather, it is that our post does not equip us
(Devereaux & Johansen 1994). with the context for the vision to which we are now
hearing witness. The 'virtual' tools necessary to read the
The purpose of this paper is to introduce tlii' reader to the landscape of a world quickly defined by its technological
conditions and circumstances surrounding a paradigm connections and quantum realities are only very recent
shift into a new age for health care and nursing. The developments, the use of which our history could never
conditions and circumstances supporting the move to a have adequately prepared us for ( Negroponte 1995).
new age are reviewed, and the expectations lor health
services and the requisites lor changes in role and LEAVING THE INDUSTRIAL AGE
performance on the part ol health professionals are
outlined. Further, the notion of value, and its impli- We are at a juxtaposition on the global stage. Leaving the
cations for the proposed design of the future health Industrial Age and moving to a still undefined 'new' age
system, are addressed, hmphasised throughout this is the current work of civilisation. Building the global
Tim Porter- paper is the notion of change as 'journey' and flu1 need community has already begun and, through the vagaries
O'Grady EdD PhD
for the leader to embrace it and work to help in the ol the communication revolution, our cultures and
FAAN is Senior
Partner with Tim process of transforming the health system. peoples are being driven to connect in wavs no-one but
Porter-O 'Grady the most prophetic could have imagined (Barnct &
Associates, Inc.,
Senior Consultant The major problem with this journey is that we must Cavanagh 1994). We cannot yet conceive the full
ivith Affiliated construct the script as we travel. Unlike past scripts, in implications ol this emerging reality. At present, most of
Dynamics Inc. and which endpoints were clear or attainable, no-one knows us can only be awed and overwhelmed by it.
Assistant Professor, where this new journey will lead or, indeed, what the age
Emory University
in Atlanta, will become (Carlson 1994). I he most we can do is read What is lell unchallenged is our personal conflict in the
Georgia, USA. the signposts along the way and be open to what they emerging paradigm lor social living. Experience and
might tell us about the journey and its direction. The expectations, faith and values, culture and society, person

ROYAL COLLEGE O F NURSING. AUSTRALIA 5 COLLEGIAN VOLUME 3 (4) OCTOBER 1996


What is left unchallenged is our personal conflict
in the emerging paradigm for social living.
and relationship - all are subject to reconceptualising
(Covey 1995). What if 1, as an individual, like the world
as I created it; if 1 am attached to the values and insights
I currently have; if 1 am fond of the life I have constructed
for myself? When the emerging constructs challenge
these conceptions and comforts, how do I respond to
them? How will our children embrace their world il we
do not engage those changes that are constructing it as
we live? What tools will they have to address their work
in creating their future?
these and a host of other issues provide the contests that
circumscribe the events of the time and identify the work
ol putting structure to the changes that are fast upon us
all. In health care, some of the old constructs that have
brought us to today are insufficient to lead us into
tomorrow. In fact, many of the strategies that served us
so well in the Industrial Age are no longer viable in the
new age (Bridges 1994).
In health care, some of the old constructs that
have brought us to today are insufficient to lead
us into tomorrow.
Some newer elements of the age create a changed context
for appropriate response.
• Centralised and unilateral strategies for change act in
contradiction to the reality that all sustainable change
is culturally specific and unfolds locally.
• Top-down directives fail to engage the stakeholders
and create an incremental approach to change that
tends to favour addressing symptoms rather than
underlying causes.
• Preferential decisions favouring one segment of
society always put the rest of society at risk, and
cause these people to underwrite situations which
advance social risk.
• Vertical integration in organisations relates to the
essentials of control. Horizontal integration
COLLEGIAN VOLUME 3 (4) OCTOBER 1996 6 ROYAL COLLEGE OF NURSINO, AUSTRALIA
evidences the necessity for relatcdness. Systems
must have both if the efforts of their members are to
bear long-term results.
• In the private sector the interests of the stockholders
to an enterprise are at risk, to the extent that the
interests of the stakeholders (at the point of service or
place of product production) are diminished. In the
new age, knowledge capital is as essential to thriving
as is fiscal capital.
• The future of systems is not found in more bricks and
mortar. The new architecture for sustainable systems
is the information infrastructure. Institutional con-
structs for work no longer define roles; nor do they
provide the context for labour.
• The emergence of quantum thinking requires a
broader understanding of systems. In it, all design
reflects the integration of structure and strategy
around the purposes and points-of-service in an
effective health system (Porter-O'Crady & Krueger-
Wilson 1995).
NEW P U L E S
These emerging principles, which reflect the new age
configuration, create challenges to the current modus
operandi at every level of society. As Peter Drucker, for
example, has so articulately pointed out, our growing
dependence on government management of social issues
has presented the clearest example of whole systems
failure, evidenced in both totalitarian and democratic
forms (Drucker 1994). Governments simply have never
been able to keep their promises in a coherent and
sustainable manner. They have, in essence, in the broad
majority of nations, become welfare managers - huge
centres of entitlement management which have not in any
substantive way increased the independence and viability
of their citizens through such approaches. Indeed, the
vast majority of the public resources of most countries go
to pay for government's failure to generate independent
means of support within a stable economic Iramework.
Instead of improving economic and social independence,
citizen demand for and use of these entitlement resources
simply continues to grow each year.
While government presents the best evidence of the
failure of old models to create a sustainable level of social
health, each component of society can take its share of the
 blame for conditions existing in the social enterprise.
Equally, they are all affected by the paradigm shift and
are called to a more whole systems view of their
circumstances. From that position a radical shift in
response will be required, in order to produce true,
sustainable social health (Lamm 1(JC)0).
THE SHIFT IN AUSTRALIAN HEALTH
CARE
I leallh care in Australia is, or soon will he, in the middle
of its own drama in a shifting paradigm. The system in
every state is ripe lor a broader frame of reference and
fundamental retooling from the point-ol-service to the
place ol payment. Whether it is public or private, much
of what is offered will need substantial redesign, in
order to provide a more vital foundation for the health
of the nation.
Several factors are influencing the sustenance of the
health-care system in Australia. The emerging age is
creating circumstances that will require several shifts of
focus and effort in transforming Australian health care
for the foreseeable future.
• Funding will increasingly be capitated as resources
cease to expand and efforts to address the deficit pick
up steam. Fixed dollars create all kinds of demand
lor effectiveness, streamlining and appropriate
service delineation.
• Incremcntalism is no longer a substantive enough
response to what doesn't work in the health system.
It should be clear to all participants that simply
tinkering with the parts does not effectively correct
what is wrong with the whole. Indeed, such efforts
actually cost more in the long term.
• Real health calls for a comprehensiveness of across-
service structures that will demand a kind of linkage
not yet available across the health system. Payment,
structuring and providing health services among the
various health constituencies (mental health,
community health, private and public hospitals,
rehabilitation etc.), which act as though they have no
... a radical shift in response
will be required, in order to produce true,
sustainable social health ...
ROYAL COLLEGE O F NURSING. AUSTRALIA 7 COLLEGIAN VOLUME 3 (4) OCTOBER 1996
interdependence, increases costs and reduces inte-
grity over the long term.
• Addressing demand for service is as critical as
having health services available as they are needed.
A public which demands services from the health
system too late in the health-illness cycle keeps
service generated at a high level of intensity and
assures an inevitable upward spiral ol cost.
• Because of the heavy emphasis on incremental
approaches to health services at the state level, a
huge costs and service impact is produced by a
change in governments. The new government's
subsequent policy alterations and contradictions
often destroy the confidence, commitment and
continuity of those who must implement them at the
point-of-service.
• A lack of understanding of how system theory and
process operate to influence sustainable social
relationships at both the federal and state levels
creates a mosaic of cross conflicts in both power and
accountability, impeding the consistent application
of policy and resources for health services.
• Engagement of the full range of stakeholders in
health policy and service decision-making prior to
major policy or service shifts is checkered at best.
This has resulted in the creation of professional silos,
non-investment of those necessary to imple-
mentation and the politicisalion and factionalisation
of provider groups necessary to successful, sus-
tainable health service.
While there are a number of factors in addition to the
above, these are sufficient drivers to question current
practices and call for a serious shift in the focus of the
health-care system in Australia.
THE CHANGING CONTEXT FOR
HEALTH
In capitated systems it becomes critical to know the
'subscribers' to health services as well as is possible.
Indeed, it is advisable to know about them far in advance
of their demand for health services. It is specifically
because providers do not know or act soon enough on
individual health-care issues that much of the cost for
service is generated loo late in the sickness cycle (Lynch,
Edington & Johnson 1996). Often hypertension isn't
 addressed until it is stroke, heart disease is left to develop
into a heart attack, poor eating habits become obesity and
uncompensated hereditary limitations become full-
blown disease. All serve to evidence the highly
incremental and interventive processes u c erroneously
call health care (Johnson 1994).
There is no suggestion that these issues haven't been
addressed at some level of the health-care system.
problem, however, is that they have been addressed in
the same w;iy all the other issues of health have been
dealt with - compartmentally and incrementally. Simply
devoting time and money to the issue docs not assure
that it will bo adequately addressed, or that the problems
associated with it will go away. Such efforts demand a
much more comprehensive view and call for entirely
different strategies, in order to obtain
able outcomes.
• Health is a community obligation. It must be
viewed in the context of systems thinking and be
driven from the place where a community delines
itself and lives its life.
Systems thinking demands consideration
of the whole and a look at the
components of the system from the
perspective of the whole.
• All services must be a part of a broader context for
health care. Resources must be distributed across the
service structures and both community
providers must articulate priorities and distribution
of fixed dollars across the range of health services.
• Decision-making for resource use and
priorities and their focus must be localised.
central control certainly attempts to be fair (which,
often, is simply sameness), it makes for poor
decision-making and population-specific service
design. A broader locus of control always lowers the
mean for service and raises the mean for cost.
• Horizontal connection across the service system
means treating all providers more equitably.
Physicians should not be at the top of the provider
'food chain', nor at the centre of the continuum.
Focus on health shifts the locus of control from
COLLEGIAN VOLUME 3 «> OCTOBER 1996 8 ROYAL COLLEGE OF NURSING. AUSTRALIA
treatment and intervention (medical model) to
education and self-direction, elevating the role and
the stock of other health-service providers who have
the attendant skills.
• A required change in the direction of payment away
from hospitals, physicians and intervention forces
the system to change its focus and energies and
The creates the conditions for a real shift from sickness
models to less intensive health-service approaches.
• A shift of this breadth is not painless. At all levels of
the social enterprise there will be reasons aplenty to
withdraw from it. 'I he losses to current enterprise
are significant, regardless of the social gains
embedded deeply within the health-based config-
sustain- uration of the system.
• The fundamental 'noise' in a shift in the locus of control
and the design oi the health system relates specifically
to issues of the distribution of power. The change
agent should not be deluded into thinking otherwise.
In a conflict between structuring lor the public good
and holding onto the locus of personal power and
public control, the public good generally pays the
heavier price (1'orter-O'C.rady 1995).
SEEKING PEAL VALUE
The wonderful thing about systems -md sustainability is
the fact that if integrity (integration and outcome) is not
obtained in the system, this simply impedes the purposes
of the system until integrity is ultimately addressed.
and Systems thinking demands consideration of the whole
and a look at the components of the system from the
perspective of the whole. The systems leader is always
aware that each component must ultimately reflect the
health seamless linkage of the parts or pieces of the system in a
While way that assures the effectiveness and sustainability of
the system as a whole.
This is both the drama and the trauma associated with
constructing a more functional healfh-care system.
Currently the system is made up of a patchwork of
unsown and partially linked services which may or may
not achieve the ends for which they were designed. In
order to turn the patches into a mosaic or quilt, the whole
must first be 'seen' and designed. Only then can it be
constructed by the stakeholders, who will weave the
fabric together in a way that represents the conception of

The same incrementalism that has haunted both
cost and quality is noiv on the trail of the
clinical provider.
the whole they have 'visioned' through their dialogue
and discernment. The energy driving their efforts and
providing the format for their work is called value
(Sullivan 1996).
I he value identified here is not that which refers to a
standard upon which one bases moral and principled
action. Instead, it is a standard of measure related to how
well the expectation of the performance of a system has
articulated the elements which comprise it (Rayport &
Sviokla 1995). The constituents of value in a service
context are cost, quality and work, in that order.
COST AS A DRIVER
in almost all free economies the entre into the value
equation is via the route of cost (Cairncross 1992). It is
the distribution and use of resources, in conceit with
their availability, that create the originating interest in the
character and the viability of providing a service. While
cost concerns are an originating interest in the
foundations for service provision, they cannot be used as
a basis for sustaining service. If the focus on cost drives
the service activity or, more accurately, controls the
activity, it ultimately affects the attainment of sustainable
value. The need for management I oi the fiscal resource
and its increasingly careful allocation in a cost capitated
context always has a negative impact on value when
considered alone.
Consideration of cost factors out ol context of the other
elements of the value equation creates the attendant
condition for viewing services incrementally and drives a
system into compartmentalism, causing it to lose touch
with the linkage between elements necessary to obtain real
value. In short, a cost focus by itself keeps the system away
from real considerations of value (Daigh 1991).
QUALITY AS A MEASURE OF VALUE
The same holds true for quality It is becoming clearer
just how much the effort to obtain quality requires a
context which can help define it. Quality has been so
loosely addressed in health care that there is still a
limited notion of what it is and how it fits in the value
ROYAL COLLEGE O F NURSING, AUSTRALIA 9 COLLEGIAN VOLUME 3 (4) OCTOBER 1996
equation. Defining quality outside the context of cost
and action neutralises it and keeps it in the realm of myth
and notion. Many complex laclors comprise quality
determinations in health care. Whatever the factors,
there must be a link between them and the contributions
to their sustainabilily that both cost and clinical work
make. Sacrificing financial viability and cost manage-
ment on the alter of quality is certainly not the way to
assure sustainabilitv in any system (Bowers, Swan &
Koehler 1995).
Much of the efforts abroad - reflecting total quality
management, or continuous service improvement and
the like - have fallen into a gross functionalism that has
more to do with producing reports and generating
paperwork than with any genuine improvement in
value. Upon further study in most health facilities, there
is little relationship between the need to obtain value and
the activities of the organisation's quality functions. Seen
within the context of value, quality is a constituent that
needs tight interlace with its co-constituents of cost and
work (Custafson, 1 lelslad & Hung 1995).
WORK AS AN INTEGRATOR O F
VALUE
The same incremental ism that has haunted both cost and
quality is now on the trail of the clinical provider. It is
assumed by the incrementalists that they can obtain
immediate cost benefit if they reduce the numbers of
providers at the point-ol-service as a part of 'getting the
fat out" of health care. Many efforts to downside
institutions and downgrade work are underway, in
response to the demand for a more cost-eflective and
'lean' organisation. While their intent is to be lauded,
their approach is not (Doerge & I lagenow 1995).
Bereft of its attachment to the other components of the
value equation, work cutting a n d / o r retooling will result
in the same conflict and contradiction as does a solitary
focus on each ol the other elements of the value equation:
shortsightedness with regard to appropriate service
provision and symptom management with regard to
the current problems confronting health care (I litt, Heats
etal!995).
At no time in any of these current efforts is there a
comprehensive systems approach to addressing the
issues of reformatting health care. And that's the rub
here. II sustainability is the real goal of effective social
and service systems (including health care), its driving
 force will be the effective confluence of the v.iluc
elements which evidence it (Lisler 1995). The
integration of the forces of the cost (mid price) of service,
the quality of that service (desired health outcomes),
and the effort required to obtain health (the work of
providers) is necessary to create the Inundation for
establishing an acceptable level of personal and
community health.
... the future of health care is a commitment to a
nezv way of conceiving, planning and applying
essential ivhole system changes.
FOCUS ON THE JOURNEY AHEAD
The real work of the political and community leadership
is, first, to recognise the failure ol compartmentalised and
incremental approaches to social issues. Lurcher, it is
necessary for this leadership to understand that whole
systems thinking, economic balance, technological
innovation and the emergence of knowledge as the central
capital of the new age are changing the construct for both
thinking about health care and conceiving approaches to
providing health services for the next generation.
What is seriously necessary to constructing the future of
health care is a commitment to a new way of conceiving,
planning and applying essential whole system changes.
Leadership in both government and service must know
that top-down, centrally conceived and authority-
driven change strategies have not worked and cannot
work to create sustainable and comprehensive changes
at either the social or personal level. Indeed, a new
contract must exist between the players on the social
stage, in order to assure that the right people are
configured around the issues, and that the processes at
work continue to engage the stakeholders in the
creation of effective and efficient service structures. At
the centre of the table must be the truth of promise and
failure in past approaches to social health, enumeration
of that which divides the essential players, and the use
of process and method (whole system strategy, future
search, values conferencing etc.) to reconnect stake-
holders in a substantive effort at designing a real,
health-based system.
Our children have the right to assume that we are doing
all we can to prepare for them a world better than that
which we obtained. The advancement of the social
COLLEGIAN VOLUME 3 (4) OCTOBER 1996 10
contract is the obligation of leadership in each
generation. Such advancement depends on how much
we have learned about the social journey, what course
corrections we arc willing to make ant] how committed
we are to applying what we have learned to creating a
preferred future.
I here is much which is good in what we have already
created. We must celebrate and bring that with us on the
journey into a desirable future. Such constructs should
serve as the foundation for our assessment of the system
and of our strategy to create an even more eflective one.
Creating a sustainable future requires the engagement of
many people, integration of the efforts of a wide
diversity of leaders, and the consistent focus of every
stakeholder around a core set of values that serves as the
groundwork for change. It is creating and living that
relationship which is the central work of the time.
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