THREE HORIZONS THINKING
The Fife Shine programme Margaret Hannah Director of Health Programmes, International Futures Forum
Health and social services in the UK are groaning with the strain of seemingly inexorable rises in pressure on hospitals, care homes and home care with growing numbers of older people and people with chronic health conditions needing support. Such deep systemic challenges suggest the current pattern of care in unsustainable. This paper describes how one small area of Scotland (Fife) has used fresh thinking to co-design bespoke solutions with patients and their families. While there is still further to go, there are signs that a more resilient and responsive pattern of care is emerging.
© Journal of holistic healthcare
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I have spent more than 20 years as a specialist in public health in NHS Fife, a Scottish health board which serves a population of 370,000 people. During this time, I realised the thinking which had led to huge gains in population health over 150 years was not proving powerful enough to tackle 21st century health challenges. Since the early 2000s, my links with International Futures Forum have enabled me to meet people with multiple perspectives, willing to share their thinking, which offered better possibilities. This led to work with public health colleagues called The Fifth Wave.
Introduction
Three horizons thinking
The White Paper Liberating the NHS in 2010 from Andrew Lansley, newly arrived as Secretary of State at the Department of Health, was a missed opportunity. With flatline budgets for the NHS for the foreseeable future, increases in an elderly population with chronic and complex conditions and declining morale in the workforce, something radical was needed. Instead, the White Paper set out plans to increase marketisation in the NHS and became enshrined in law in 2013 as the Health and Social Care Act. Today, the NHS in England endures the consequences of these decisions, struggling with waiting times, staff vacancies, deep financial deficits and a fragmented system with multiple providers and complex commissioning arrangements. Might there yet be hope that something different could emerge in Scotland, which abolished the purchase–provider split in 2003, yet is still facing many of the same challenges in terms of finance, workforce and changing patterns of disease? Might there be a way to sustain vital elements in the current system while growing a new one, better suited to the current and future operating environment? This paper sets out an example – the Fife SHINE Programme – from one health board area which aims to do just this.
To understand how a different system can emerge, it is necessary to think about how patterns of activity rise to dominance, subsequently decline, and new ones take their place. We also need to consider how to manage the transition from an old system to a new one in ways which sustain the viability of the whole over time. One way of exploring this territory is to use the three horizons framework (see Figure 1). The framework describes three different patterns of activity taking place simultaneously to create a complex adaptive system. The first horizon – H1 – is the dominant pattern at present. It represents ‘business as usual’. The third horizon – H3 – emerges as the long-term successor to business as usual and is much better fitted to the world that is emerging than the dominant H1 system. The second horizon – H2 – is a pattern of transition activities and innovations, people trying things out in response to the ways in which the landscape is changing. Without the ‘pull’ of H3 and a transition strategy to navigate the turbulence along the way, H2 innovation will inevitably be assimilated into the existing system. This might extend the life of H1 for a while, but increases the scale of the necessary
Volume 15 Issue 3 Autumn 2018
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