Why healthcare needs aligned ‘Horizon Three’ thinking as we rebuild after Covid-19

If you’re working in healthcare management, policy or strategy and haven’t come across Bill Sharpe’s Three Horizons model, you’d be well advised to take a look. It’s one of those models that looks at first sight a statement of the obvious, but turns out to be hugely powerful as a tool of enquiry.

Put far too simply, the model suggests that executives need to think in terms of three horizons when making plans.

Horizon One is what we need to do to keep the show on the road — responding to today’s problems with today’s tools.

Horizon Two is the disruptive stuff coming down the line — the new tools and innovations that can help us to change the way we do things. The kinds of things that entrepreneurs tend to excel at — often solving today’s issues in a new way; sometimes with more far reaching consequences.

Horizon Three is more visionary — it envisages how a system might look from a future-back perspective. Often involving some kind of paradigm shift.

Looking at the UK healthcare system, it’s easy to see how Horizon One thinking has tended to dominate.

Most managers are tasked and incentivised with delivering in Horizon One; and so their decisions are driven by optimising for that. Horizon Two innovations can help improve the way things are done, but there is a danger that they are ‘captured’ by Horizon One thinking — swallowed by today’s system and stifling Horizon Three. Sharpe calls this ‘Horizon Two Minus’; and its converse, where Horizon Three thinking pulls through the potential in disruptive innovation to drive progress, ‘Horizon Two Plus’.

Sharpe argues that executives need to maintain all three perspectives — a different kind of listening that manages the conversation between the voices of the three horizons. It’s something that’s hard to do in a massive complex system and a world of constant accelerating change — let alone when a shock like Covid-19 hits.

Looking at the UK healthcare system, it’s easy to see how Horizon One thinking has tended to dominate. For example: the incredible speed with which digital tools have been adopted in the NHS in recent weeks and months despite many of them being around (and sometimes used in parts of the system) for decades; and the rapid acceleration of cross-silo collaboration and new practices — both as a result of Covid-19 — indicate how progress has happened when what were Horizon Two ideas became Horizon One necessities.

But there is a danger that the new practices rapidly adopted to enhance the existing system may not lead to the kind of paradigm shift needed and potentially achievable in healthcare because they are grounded in the thinking of Horizon One.

In a system constrained by the political business cycle, concrete Horizon Three thinking is all but impossible — the budget mandate doesn’t last beyond the next election. And there is a danger in the coming months that the language of ‘recovery’ in the healthcare system will lead to a backward looking context for a return to repair and improve the old system; and a missed opportunity to look forwards to build a system fit for the healthcare challenges of the 21st century.

It’s very hard to see through the fog of Horizon Two, but if we can shine a light on what happens beyond the fog we are more likely to make aligned decisions that move everyone in the same direction.

The Three Horizons model gives insight into why the framework described in Beyond the Fog — effectively a framework for Horizon Three thinking in healthcare — is potentially so valuable. Here are some reasons:

• Horizon Three thinking is very difficult because it involves long time horizons and complex systems where there is a great deal of uncertainty. It requires a coherent and thought-through system-level model across a huge range of organisational and sectoral silos; and a common language for discussing how it will impact the organisation (which may lead to existential questions for existing silos in an evolving system). Few organisations can afford to do this. And few, if any, as far as we have found, see it as their job — almost all future-focused healthcare thinking is understandably closer to Horizon Two where the funding is. In healthcare we haven’t found another framework which does this in the way that Beyond the Fog does.
• Second, even if you do make an attempt to describe Horizon Three, other organisations will come up with their own views of what it looks like. Diverse views are a good thing; but when highly interconnected organisations work towards system transformation with a different set of assumptions and incentives (and a lack of understanding of the scale of change required), progress will be very slow and misunderstanding will occur.
  
  At the least a shared framework and language for understanding the future can help to mitigate one of the biggest problems with driving change in complex adaptive systems — that of co-ordination. A shared long-term direction of travel (even if that is only an understanding of the profundity of the implications of the advances that will drive oncoming change) will naturally lead to some semblance of self-co-ordination when making local decisions.
• And finally, Horizons One and Two are, right now, pretty depressing places to be. When you look beyond the fog to the potential for Horizon Three, there is the possibility of positivity, optimism and ambition to be part of creating something that can provide a better quality of health and care for everyone by realising the potential of the scientific, medical and technological advances that are coming our way.

Horizons One and Two are, right now, pretty depressing places to be. When you look beyond the fog to the potential for Horizon Three, there is the possibility of positivity, optimism and ambition

We’re hosting a webinar, (Rethinking healthcare for the 21st Century — what better future awaits us if we have the ambition?) on 26th June, which will explore through the lens of Beyond the Fog — still the only truly system-level framework for looking beyond the fog of the coming years — why a shared longer term vision of healthcare is so vital, shining a light on what this future could look like and the collective system-wide ambition it calls for .

Please do join us. Details and registration here.