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Strategy and Organisation

Strategy generally involves setting goals and priorities, determining actions to achieve these goals, and mobilising resources to execute the actions [135]. It is often thought of as a deliberate, explicitly stated plan, but can also be viewed as a “pattern in a stream of decisions” [136]. While much strategy literature addresses competition in business or war, it is not always obvious how this applies to healthcare, particularly in public systems [137] or to a Learning Health System. Ultimately, strategy is a set of inter-related choices on how a team or organisation will deliver value [138].

The Learning Health System can be a vague concept and there are almost limitless ways in which it could be organised. A given organisation must choose what sort of Learning Health System will best meet the needs of its stakeholders. A strategy can help to make this explicit. Like every other element of a Learning Health System, strategy must be co-designed by the stakeholders. There are many guides and tools that can assist with this process [139-142]. For larger programmes, strategy consultancies can take an organisation through the process, though it is also essential to develop strategic thinking capabilities within the Learning Health System.

Once a strategy has been developed, people and resources must be organised to deliver it effectively. This is sometimes known as the Target Operating Model (TOM) or an Organisational Architecture. An organisation wishing to become a Learning Health System can create a TOM that describes how its people, processes and technology should be deployed [143]. Such an approach can be helpful in a complicated environment. It can orientate stakeholders to their role in delivering the strategy and can aid in planning long-term investments like infrastructure and training. It has been employed by NHS Digital, the recent NHS London Nightingale hospital, and other healthcare organisations [28]. It necessarily makes assumptions about the future. Because this is often not possible within a complex system, the operating model must itself be subject to learning and change.

If misapplied, this mechanistic systems approach can have drawbacks. Longwinded multi-year strategies can be out of date by the time they are published and cannot respond to emerging threats and opportunities. This was highlighted by the Covid-19 pandemic.

McCrone and Snape consider strategy within the different domains of Snowden’s Cynefin Framework [144] (see Figure F). In a complex Learning Health System, strategy might be better thought of as a verb than a noun: a continual process, rather than a masterplan. It is a series of safe-to-fail experiments (see Figure F – Probe, Sense, Respond). Learning comes from those that fail, as well as those that succeed. Successes can be amplified by attracting more resources. As evidence from experiments accumulates, an environment can move from complex to merely complicated, because cause and effect becomes better understood and more stable.

A Learning Health System can have a shared purpose or mission, while individuals and groups can have autonomy to develop complementary microstrategies and safe-to-fail experiments [144]. The infrastructure of a Learning Health System can enable such an approach (see NYU Langone Health exemplar box). Over time, a Learning Health System that is complex at the enterprise level can have lower-level functions that are simple or complicated, lending themselves to more traditional strategic planning and TOM approaches.

A Learning Health System may well exist within a wider organisation, such as the NHS or another funding network. These organisations might have requirements for traditional long-term plans, which can limit strategic innovation. This can, however, be helpful in planning long-term investments, like infrastructure or training.

An alternative approach is the actor-oriented learning network organisational form, proposed by Britto et al., which aims to facilitate co-production and cooperation at scale to improve healthcare (See Learning Network Box). This has three components [145]:

  • Aligning participants around a common goal: Mission, vision and values are visible and shared. There is transparency and learning between teams. Stakeholders understand how they can get involved, while leadership and co-design are distributed.
  • Standards, processes, policies and infrastructure to enable multi-actor collaboration: These can be shared across centres to reduce costs and customised as required. Leaders have dedicated time to ensure that these elements are continuously improved using standardised Quality Improvement methods.
  • A commons where information, knowledge, resources and knowhow to achieve the goal are created and shared: As well as data registries, other platforms can be used to share different resources within and between networks. This leads to the development of a shared knowledge base.

Learning Network

The Learning Network approach has been pioneered by ImproveCareNow [25] , one of the oldest and most successful Learning Health Systems in operation. Unlike many others, ImproveCareNow has scaled up and spread by sharing its common framework, methods and processes. It started as a Learning Health System for Inflammatory Bowel Disease at Cincinnati Children’s Hospital in 2007. By 2017, it had been followed by nine other Learning Networks covering a range of paediatric conditions [145]. The Cincinnati team have produced training materials to help others join and form new Learning Networks [196]. They have also formed a spin-off company to help scale and spread the necessary infrastructure. Along with the Institute of Healthcare Improvement [197] [198], they are seeking to develop 100 active Learning works by 2023