Our edited book has three interlinked aims. First, its prime aim is to support the development of a healthcare system that can sustain in the face of increasing demands and limited resource. Second, to provide cutting-edge thought leadership regarding theoretical issues derived from a broad array of research carried out by Warwick Business School and associated researchers, relevant to sustaining healthcare delivery in the face of increasing demands and limited resource. The case for evidence-based management is well made; we need to accompany this with more evidence-based approaches to management and research carried out at Warwick Business School that is presented here hopefully aids such an endeavour. Third, we seek to ensure our theoretical analysis informs practical lessons for those seeking to sustain healthcare delivery in the face of increasing demands and limited resource. To this end, the question that drives our contributions towards thought leadership and practice around sustaining high quality, affordable and equitable healthcare in this edited book is:

What does our research tell us about how policymakers, managers, professionals, and service users, can sustain high quality, affordable and equitable healthcare through meaningful innovation and system transformation?

Readers might take note of our use of ‘meaningful’ in the question above. This reflects our intention to move from ‘what we (as academics) know’ in terms of evidence about organizing and managing healthcare delivery to ‘what we (as practitioners) do’ in organizing and managing healthcare delivery. In essence, our edited book is directed towards managing a translation gap, not in that of clinical evidence into practice (Cooksey, 2006), but organization and management evidence into practice that a Chief Executive would regard as useful on the ground.

Our inclusion of the Chief Executive of our local university hospital, University Hospitals Coventry and Warwickshire, Andy Hardy, in the co-authorship of this introductory chapter, reflects such an aim. Similarly, we include a chapter from Helen Bevan, one of the most experienced practitioners of change and improvement in health and care globally, who reflects on every chapter and pulls out a selection of actionable themes for practitioners everywhere.

Shaping High Quality, Affordable and Equitable Healthcare

As a starting point, let us define what we mean by shaping high quality, affordable and equitable healthcare. We recognize financial sustainability is crucial, given the increasing proportion of their Gross Domestic Product that nations contribute towards maintaining and developing their healthcare system, but seek to extend our concern beyond this towards a moral, as well as financial, imperative. Ensuring we can sustain, if not enhance current delivery of healthcare embodies a grand challenge for society: how to deliver the highest possible quality healthcare in the face of increasing demand and decreasing resources, and with the possibility that healthcare inequalities are getting worse, not better. Following which, we assert sustaining healthcare delivery is not merely about its efficiency and affordability, but that it is timely, accessible, equitable and high quality to enable all people to live well, age well, and die well.

Rather than engaging in policy debates about the desirability of insurance or tax-based systems for example, the thrust of our edited book to delivering healthcare that can sustain its quality and its scale in the face of increasing demand and limited resource is one framed by our expertise located in and around the interests of business school research, that about the organization and management of healthcare delivery. In doing so, we address a wide range of matters, considering institutional level, organizational level and service user level interventions. In particular, we recognize healthcare systems and organizations are peopled, encompassing professionals, managers and service users, so sustainable healthcare delivery relies upon all their efforts. The content of this edited book reflects this, emphasizing that values and culture are important, highlighting the importance of shaping behaviours of not just those delivering care, but those in receipt of care. And, even though our contributors are mainly drawn from a business school, as a set of authors that engage in critical scholarship, we hold management up to the light. Our contention is that healthcare is under-managed, albeit this does not necessarily entail we need more general managers. Rather clinicians need to be drawn more into managing healthcare delivery at an organizational and system level. Finally, we recognize most of our chapters are derived from the UK NHS experience, but suggest our parochial focus nevertheless represents an exemplar for other national systems that remain largely tax-funded. In summary, we hope our edited book is of interest to all stakeholders with a stake in sustaining high quality and affordable healthcare delivery for all, since only by coming together can we successfully pursue our aim. Let us now provide more detail about how we might go about sustaining high quality and affordable healthcare and then set out the shape of our edited book.

The Challenge of Shaping High Quality, Affordable Healthcare for All

Extraordinary advances in medicine have meant that people all over the world are living longer. According to United Nations, the world’s population is expected to increase by one billion people by 2025 and by 2050, 1 in 6 people in the world will be over the age of 65 (up from 1 in 11 in 2019). Further, increases in life expectancy are no longer the preserve of high-income countries, middle- and low-income countries are also experiencing a sudden and rapid rise in their ageing population. By 2050, for example, 80% of older people (aged over 60 years) will be living in low- and middle-income countries (World Health Organization, 2018).

If living longer is one side of the equation, living well is the other. An increasingly older population is associated with an increasing number of individuals with one or more long-term (chronic) conditions (LTCs), representing what many refer to as ‘a changing burden of disease’. As many as one in three adults globally suffers from multiple LTCs (Marengoni et al., 2011); the greatest prevalence of patients needing long-term care is in high-income countries where three out of four older adults suffer from multiple long-term conditions (Kingston et al., 2018). The prevalence of long-term conditions in middle- to low-income nations is also expected to rise dramatically in the coming years (World Health Organization, 2018). Our edited book relies upon studies located in high-income nations; nevertheless, we hope there are lessons to be gleaned for those in low- and medium-income nations as well.

Our more general readers, beyond those directly managing or delivering healthcare, may well have family members with such conditions through whom they can relate our aim for sustaining healthcare delivery that is inclusive of the need for older people to live well. It is a matter that affects us all. In our introduction, we present the scale and urgency of shaping sustainable healthcare as a moral and financial imperative.

A Moral Imperative

The impact of LTCs upon the individual is significant. LTCs can lead to premature mortality, a low quality of life, decreased workforce participation, productivity and financial stress. Individuals living with LTCs often have complex needs that require more holistic interventions than most health systems are designed to cater for. Subsequently, complex needs associated with multiple LTCs result in fragmented, inefficient and poor care quality for patients and their families. In a world where modern advances in medicine and medical knowledge can alleviate suffering, health systems that deny, restrict or delay access to appropriate care are widely considered unacceptable (McKee, 2018).

Therefore, health systems globally must respond to a ‘changing burden of disease’ and transition from a care system designed to treat episodic and acute disease, to one that coordinates and connects with a network of providers including hospital and community-based care delivery organizations, voluntary partners and charities. Providing a more holistic, coordinated approach to care delivery can potentially mitigate some of the negative impacts of LTCs, helping the world’s population not just to live longer, but to live well, age well and when the time comes, to die well (Eaton et al., 2015). In some nations, this means building a system from almost nothing. In others, it means rethinking long-term care: from a basic safety net for the most vulnerable, towards a broader system that maximizes older people’s functional ability and upholds their autonomy and dignity (World Health Organization, 2017).

In sum, the co-ordination of patient-centred care interventions from multiple specialist teams and providers must become the over-arching guiding principle of sustaining global health systems around the world in the face of increasing demand and limited resources.

A Financial Imperative

The proportion of a country’s Gross Domestic Product (GDP) spent on healthcare varies greatly. The United States spends by far the most on healthcare, equivalent to 16.9% of its GDP; the second highest spender is Switzerland, spending 12.2%. Germany, France and Italy spend around 11% of GDP while other high-income countries, including the UK, Australia, New Zealand, Chile and Korea, spend between 8 and 10% (OECD, 2019).

Overall, healthcare spending is highest in developed countries, with increased spending generally associated with better outcomes. The United States, however, is a notable exception to this rule having some of the poorest outcomes for life expectancy and early mortality. McKee (2018) cites ‘massive transaction costs’ associated with the US system arising from complex administrative and regulatory processes alongside a failure to treat people at an early stage of disease, leading to higher costs of care overall.

While demand for healthcare services has consistently risen year on year, the changing burden of disease outlined above correlates to an increasing proportion of healthcare spending associated with managing LTCs. As an illustration, the high cost of treating individuals with LTCs is set out in England’s NHS Five Year Forward View (2014). This strategy document identifies approximately 15 million people in England living with at least one LTC, accounting for 50% of primary care appointments, 70% of all acute care bed days and 70% of the healthcare budget.

To summarize, the moral imperative for sustaining high quality and equitable healthcare is correspondingly supported by a strong financial imperative as governments come under pressure to focus on efficiency and contain rising costs in the face of rising demand and depleting resources.

Rethinking Healthcare Service Delivery

For many countries, shaping and sustaining high quality, affordable and equitable healthcare requires a radical rethink about how we deliver health services that enable our ageing population to live well, and it is to this endeavour that we must urgently attend. We see the ‘answer’ as located at three analytical levels. First, we need to consider the institutional and environmental level within which we can shape and sustain high quality, affordable and equitable healthcare. This encompasses consideration of policy imperatives and their effect, and also the effect of professional organization and associated professional socialization that shape frontline clinicians’ practices. Second, even if policy is orientated towards sustaining high quality, affordable and equitable healthcare, then we need to ensure that any gap in policy implementation is bridged through appropriate organizational level interventions. A classic intervention to ensure policy aspirations is realized for evidence-based intervention towards sustaining high quality, affordable and equitable healthcare is that of leadership distributed throughout the organization. More of this later.

Across the edited book, the importance of strategic or managerial practices to realize change is emphasized, reflecting the practice-based approach to organizational and institutional change as a strong feature of healthcare research at Warwick Business School. The better use of evidence and data is articulated in the final part of our edited book, including judicious use of patient experience of healthcare delivery. The common refrain that ‘we are all in this together’ heard throughout the COVID-19 pandemic reflects the need for service users to co-produce sustainable healthcare delivery. Our edited book examines the challenges and solutions to sustaining high quality, affordable and equitable healthcare delivery aligned to three dimensions of analysis: institutional level analysis, organizational level analysis and evidence-informed frontline service delivery analysis.

At the institutional level, those that study public policy highlight, first, that its constituent components can sit inconsistently alongside each other; for example, inter-organizational collaboration for healthcare delivery is encouraged (the ‘network’ imperative popular in contemporary policy solutions), but at the same time it may be stymied by simultaneous policy emphasis upon competition (the ‘market’ policy imperative) and performance (the ‘hierarchical top-down’ imperative to ensure accountability for resourcing) (Currie & Suhomlinova, 2006).

Second, the dynamics of professional organization represents a significant influence upon prospects for innovation. Much innovation to sustain high quality, affordable and equitable healthcare is service or process innovation, which encompasses workforce reconfiguration and new ways of working for frontline clinicians (Currie & Spyridonidis, 2019). To ensure clinicians at the frontline are agents of change and innovation, we need to understand how they are organized and socialized. For example, their jurisdictional expertise and associated demand for autonomy in serving patient needs, requires those seeking to encourage innovation to tread carefully in aligning prospective change with professional practice (Waring & Currie, 2009).

At the organizational level, we suggest healthcare providers and commissioners are ‘under-managed’ with respect to the change required to sustain high quality, affordable and equitable healthcare. While politicians in the UK have attacked ‘managers’ in the NHS as ‘men [sic] in grey suits’ that don’t add value to care delivery, our limited resource needs to be more effectively managed, and the NHS has a low proportion of general managers (around 3% of staffing in any hospital) compared to other national healthcare systems, and indeed compared to private sector enterprises in the knowledge-intensive industries (Nuffield Trust, 2015). This argument extends to under-management beyond healthcare, since integrated interventions, notably across health and social care, help sustain high quality, affordable and equitable healthcare delivery; critics might argue against increase in the number of (general) managers, nevertheless health and social care systems need more effective management to ensure we can sustain high quality, affordable and equitable delivery.

‘Leadership’ commonly presents itself as a glib panacea, but the attributes of effective leadership require delineation; it is a process as much as a person (Currie & Spyridonidis, 2019). Panaceas for organizational change almost always highlight the requirement for leadership commitment from the top of the organization. It is clear that top-level managers face competing priorities in developing their strategy for a healthcare system that sustains high quality, affordable and equitable delivery, as the policy imperatives highlighted above shift. At the same time, we need to consider how leadership from the middle and at the frontline of the organization is crucial to realizing high quality, affordable and equitable healthcare delivery (Currie & Procter, 2005). We also need to recognize that at the same time leadership is distributed across the organization vertically, it is also rendered more effective where it is diverse and inclusive (Mousa et al., 2021). In such a way, we have a critical mass, an ‘army’ of leadership actors engaged and championing necessary innovation (Currie & Spyridonidis, 2019).

Leadership obviously requires contextualizing, and for those readers researching or working in healthcare systems in low- and middle-income countries for example, we note the influence of cultural and socio-economic influences upon the import of models of organization and management from OECD nations (Vaitheswaran et al., 2021). Rather than copy and paste prescription, those implementing innovation in healthcare need to allow adaptions where necessary (Greenhalgh & Papoutsi, 2019). As leadership is distributed across the healthcare system, strategic and managerial actors need to reflect upon their strategies and tactics (practices) for sustaining high quality, affordable and equitable healthcare (Vaara & Whittington, 2012). Realizing strategic change needs to go beyond top-down planning; it needs to extend towards inclusion of the middle and frontline of the organization, within whose ranks change actors need to tread carefully as they potentially intrude upon powerful clinicians’ jurisdiction.

At the final level of analysis, evidence-informed frontline service delivery, we need to attend to user-centeredness so that healthcare sustains quality, affordability and equity. This is a consideration at population, as well as individual service user, levels. With respect to the former, given limited resource, we need to target public expenditure to ensure priorities are met and that particularly vulnerable or costly segments of the population are targeted. ‘Business intelligence’ is crucial, with a need for sophisticated data analysis to ensure resource is targeted with best effect; hence a need for data science capability. At the same time, we suggest ‘data’ is multi-faceted, not just cost or clinical evidence, but ‘data’ that captures clinicians’ tacit knowledge about service delivery and their patient population (Dopson & Fitzgerald, 2005), and crucially ‘data’ about user experience of care delivery.

Cost can also be reduced, and alongside this, patient experience enhanced, where we encourage self-management of conditions when appropriate. How do we shape patient and carer behaviours towards such self-management? Digital innovation is increasingly prevalent, even more during the COVID-19 pandemic (Budd et al., 2020), and usefully contributes towards self-management from patient and carers of long-term conditions. To engage service users in change that aims to sustain quality and equity in the face of resource constraint, it needs to chime with their values, more so with marginalized populations that may be slow to access care (Goodman et al., 2017). Behavioural science expertise at Warwick Business School has made a strong contribution towards understanding and shaping consumer behaviour across many domains, including healthcare delivery, through, for example, nudge-type intervention (Vlaev et al., 2016).

The organization of our edited book follows from the above, with each of our contributing chapters orientated towards the issues raised above.

An Examination at the Institutional and Environmental Level

In the first part of our edited book, we begin with an institutional or environmental level of analysis to provide insight into how we might sustain high quality, affordable and equitable healthcare systems. We begin the first part with discussion and analysis of integrated care systems. This global trend has accelerated in recent years as publicly funded health systems are being forced to deliver more with less, without compromising quality or safety. Calls for integrating care are gaining global traction since millions of service users experience poor standards of care when input is required from diverse health professionals, working within diverse settings, across multiple locations. From the perspective of service users, carers and their families, poor synchronization between these settings contributes to lengthy delays to access, a poor patient experience, poor patient outcomes and a service that is more expensive to deliver than it needs to be. In England, the transition to integrated care systems could also reduce the volume of patients attending hospital emergency departments for illnesses that are best treated by specialists operating outside a hospital context (Johnson et al., 2020).

Since most healthcare systems are not currently set up to deliver care in an integrated way, Chapter 2 offers valuable insight into Canada’s decades of experience integrating care across diverse geographical and political systems. Reay’s chapter describes four approaches to integration and discusses the pros and cons of each approach. Drawing upon organizational theory, Reay highlights four factors that shape the efficacy of integrated service provision, from relational factors such as leadership and authority, professional identity and inter-professional dynamics, through to pragmatic issues of inter-organizational communication processes and geographical issues of organizational place and space.

Staying on the topic of collaboration, Burgess argues for a more relational approach to regulation. Chapter 3 presents a novel analysis of a partnership between a system regulator and five hospital chief executives. The partnership was designed to foster knowledge exchange between the five chief executives and members of their regulator concerning the enablers and challenges of leading improvement in the English NHS. The goal was to derive a set of lessons for NHS system leaders about how to foster a culture of improvement across the wider healthcare system. Underpinning the partnership was a compact which makes explicit the relational behaviours the new ‘partners’ agreed to adhere to. Adopting an ethnographic and processual approach to data collection and analysis, Burgess highlights the importance of embedding the compact within organizational routines that formally trigger conscious appraisal of the agreed goals and promises on a regular basis. Routine reflection ensures goal alignment and attainment over the long term and enables trust to emerge among partners. Notably, when things go wrong (as they do), the formal compact became a mechanism to surface that error, discuss what went wrong and why, and subsequently reaffirm the partnership’s commitment to the shared purpose. Noting the limitation of this study as a unique and small-scale partnership, Burgess draws optimism that a more relational ‘partnership’ approach to regulation for improvement is both possible and desirable.

From policymakers learning from hospital leaders in Chapter 3, Chapter 4 looks at the barriers of adopting evidence-based practice (EBP) guidelines into practice. Presenting findings from a micro-level analysis of evidence use by orthopaedic surgeons, Grove reveals practice is shaped by a hierarchy of evidence, with professional norms situated at the top of the hierarchy. Delving deeper into the impact of such cultural dynamics upon implementing EBP, Grove concludes the evidence-to-practice gap persists because it fails to align with contextually dependant micro-clinical cultures. Grove argues closing the evidence-to-practice gap requires mechanisms that permit an internalization of EBP into micro-clinical cultures so that they become useful in the context of practice, for sustainable healthcare delivery. Encouragement to move away from formal evidence is also a central argument in a later chapter within our edited book by Nicolini and colleagues, who emphasize the processual and negotiated nature of evidence construction that will prove acceptable to the wide range of stakeholders necessary to sustain high quality, affordable and equitable healthcare.

In the concluding chapter of Part I, consistent with our pluralist view of evidence, we examine knowledge gleaned through patient and public involvement and engagement (PPIE). In Chapter 5, Croft and colleagues identify PPIE as an important (but under-utilized) knowledge generating mechanism that has potential to disrupt normative forms of decision-making described in other chapters. Highlighting the value of contextual knowledge that patients and their carers bring to inform decision-making about health service delivery, alongside the unique overview of the patient experience and efficacy of the ‘joins’ in healthcare systems, Croft et al. propose a ‘democratic imperative’ for more strategic involvement of patients and carers in decisions about service provision. Research has shown PPIE knowledge acquired through formalized systems often fails to be integrated into service development; instead, PPIE forums tend to be seen as an opportunity for knowledge dissemination, rather than knowledge acquisition. However, drawing on the concept of absorptive capacity, Croft et al. illuminate the role of socialization factors that create organizational conditions for incorporating PPIE into strategic decision-making. Acknowledging some limiting factors of PPIE, the authors emphasize the importance of diversity and representativeness across all those engaged in decision-making processes, meaning that socialization processes need to promote and actively seek out involvement from representatives across society.

In the second part of our edited book, we more specifically focus upon an organizational level of analysis to provide insight into how we might sustain high quality, affordable and equitable healthcare systems. Chapters in this part cover core organizational issues, such as distribution of leadership across the workforce, strategic management (particularly practices enacted by middle managers), financial management, multi-disciplinary teamworking to ensure co-ordination of care, and how healthcare organizations might be proactive in addressing the many crises with which they are faced.

Leadership is commonly seen as a panacea for any ills of healthcare delivery; correspondingly, we include a chapter by Croft and Dawson on distributed leadership with a particular eye on ensuring more diversity. Of course, this has a normative, more moral rationale, but only in part. There are good business reasons for ensuring diverse leadership. First, we might better reflect the make-up of our population and the patients we serve. Second, in the face of workforce shortages at all levels, we should be concerned about missing out on a potential source of leadership from women or under-represented groups in the workforce, whom help sustain high quality, affordable and equitable healthcare delivery. Commonly, this is viewed as a ‘glass ceiling’ challenge. Croft and Dawson reverse this metaphor and characterize the challenge as one of ‘sticky floor’. Rather than ‘fixing the person’ through enhancing their ability to enact leadership, Croft and Dawson argue we must fix the organization and system, so that motivation and opportunity for under-represented groups in leadership position are enhanced.

Continuing our pre-occupation with leadership, we also see contemporary discourse that emphasizes the importance of strategy and leadership to support its enactment. Traditionally, this is viewed as planning activity undertaken by the upper echelons of organizations. More recently, process and practice-based views of strategy have been ascendant (Vaara & Whittington, 2012), within which the role of middle managers in supporting strategic change has been highlighted, including within healthcare organizations (Currie & Procter, 2005). Woolley and Currie draw upon the practice-based view of strategy to illuminate ‘how’ top managers need to share leadership and elicit a middle manager contribution to strategic change in a hospital. Given the challenges of the professional context within which change is realized, then hybrid managers (those that combine clinical and managerial perspectives) are highlighted as an important resource. Woolley and Currie advocate for strategic practices focused upon ‘context setting’ and ‘boundary work’ to realize a contribution from hybrid middle managers towards change. They draw upon two detailed illustrations to make their argument, focused upon clinical efficiency and cost control. Their call is one that views strategy as emergent and co-produced across the ranks of top managers and middle managers if strategic change towards a sustainable healthcare system is to be realized. Implicit within which, they provide a warning about the limits of traditional top-down approaches to strategy, within which strategy planning and its implementation are seen as a linear progression.

Radaelli continues with a focus upon strategic practices, but focused upon managers nearer the frontline of care delivery, with particular concern for their role in improving care delivery across multiple professional teams and departments within a hospital. Indeed, he highlights the important role that ‘general’ (without a clinical background) managers play in constituting multi-disciplinary care. Focusing upon empirical cases within which managers are mandated to engage clinicians in a drive for service improvement, Radaelli reveals how they do this. First managers appropriate the work regarded as low level by clinicians to ease the contribution of the latter towards change (Huising, 2015). Second, they share their specialist functional knowledge (e.g. operations management or human resource management) with clinicians in co-producing service improvement. Third, they tactically use their peripheral and technical status in the organization to mediate micro-conflicts between clinical groups. His research study provides a useful contribution towards relational understanding of how to realize change (Kellogg, 2019) that is likely to prove useful to practitioners.

Kerridge and colleagues also argue that, for innovation to deliver sustainable transformation of healthcare systems, leadership is a critical ingredient. Yet how individual and collective leadership blends with national policy and front-line practice to produce innovation is not well understood. They highlight that, while a ‘thousand flowers bloom’ at a local level, few innovations scale up nationally. They pose the question ‘how might leadership for (scaled up) innovation be strengthened?’ and accordingly, make recommendations in pursuit of such an aim. They emphasize collective leadership needs to flourish beyond individual organizations across networks and larger systems. They argue, to support such collective leadership, resources require distribution away from national agencies where competition is fierce and limiting, to regional and local agencies, across whom collaboration is more likely to flourish (Fairman, 2013).

And of course, within our organizational level of analysis, while emphasizing quality and equity considerations, we cannot ignore the fact that financial considerations dominate policy discourse regarding investment in healthcare systems. Following which, healthcare managers and professionals need to justify any resource investment and put performance management systems in place to monitor financial, as well as quality of care, outcomes. Such a point is forcefully made in the chapter presented by Crump, but within which the challenge of developing effective measures of financial performance is revealed. Crump sets out how such a challenge might be addressed, indeed if it can be. Crump may not set out a ‘full’ answer, but does offer an exemplar for financial measurement provided to evaluate the outcomes of large-scale transformation within an NHS hospital that others may learn from in pursuit of high quality and equitable healthcare.

Finally, given the onset of COVID-19 pandemic, it would seem odd if we didn’t encompass discussion of how healthcare systems might sustain high quality, affordable and equitable care delivery in the face of challenges that emerged, e.g. dealing with associated bed and workforce pressures, improvising care and innovating on the front-line, ensuring return to mainstream care as pressures subsided. The chapter by Dawson and colleagues highlights how routines and practices derived from a systematic value-based quality improvement intervention (in this case, ‘lean’) implemented pre-pandemic, facilitated an effective, real-time response towards innovation for care delivery in hospitals in England. Given pressures upon the healthcare system from crises are likely to increase over time, extending beyond ‘winter flu’ hospital admissions, hospitals in particular (but also encompassing other parts of the health and social care system) might want to attend to how they implement and scale up lean and other continuous improvement interventions in preparation.

In Part III of our edited book, we return to the complex, situated and context-laden issue of evidence use for decision-making discussed in part one. Nicolini and colleagues share insights from a processual study of decision-making processes within Clinical Commissioning Groups (CCGs), the entities, until July 2022 (when they were replaced by Integrated Care Boards), that were responsible for making decisions about planning and resourcing healthcare provision. Like Grove in the first part of our edited book, Nicolini and colleagues lament the fallacy of treating evidence as an entity in itself; instead, they argue evidence is constituted via an observable negotiated process of ‘evidencing’, where evidential value is assigned in ways that encompass practical, moral and political judgements (not just scientific evidence) to inform the decision-making process. As argued in earlier chapters of our edited book, such a pluralist conception and use of evidence inform the realization of high quality, affordable and equitable healthcare delivery.

From decisions about funding allocation by CCGs for sustaining high quality, affordable and equitable healthcare, we turn our attention to the role of the consumer and specifically the decisions people make that ultimately shapes consumption of health-related services. Adopting insights from behavioural science, Ding, Makki and Vlaev assert human behaviours and decisions are often sub-optimal, placing immense cost pressure upon health systems that could potentially be avoided. Using case studies of the application of behavioural insights to the treatment of diabetes, cardiovascular diseases, and cancer in each of the three stages of the ‘behaviour change pathway’, Ding and colleagues show how advances in behavioural science can support patient and carer self-management in ways that foster better health outcomes while reducing the cost of service delivery.

With respect to diffusing innovation into practice, Bharatan and colleagues argue we should pay attention to processes of value alignment and the mechanisms that underpin it. This seems more significant given recent policy moves in the English NHS and other nations such as Canada (as noted by Reay in Chapter 2), towards more integrated care across health and social care. And even more significant with client populations that are hard to engage with any service offering, such as the homeless population that Bharatan and colleagues focus upon. They highlight several studies that have shown healthcare innovations are more readily adopted when they are compatible with an adopter’s values, norms and desired outcomes. Since values and norms are inherently socially and politically invested, any shift would take considerable time and effort. In line with other chapters’ focus upon managerial practices, Bharatan et al. shed light on the mechanisms through which values alignment can be accomplished to sustain innovation processes and from which high quality, affordable and equitable healthcare derives.

Concluding Part III, Han and colleagues examine the role of big data science in delivering important insights for sustaining high quality, affordable and equitable healthcare. Han, Yaraghi and Gopal demonstrate the role big data science can play in unveiling a vast range of hidden problems and solutions, from revealing unnecessary variation in the cost of medical treatment, to predicting outbreaks of epidemics, and more generally to improving the overall quality of care delivery. In this chapter, to empirically evidence their argument, Han and colleagues use big data to examine the impact of star ratings upon financial success (i.e. profit) of care homes in the United States and how this correlation induces ‘rating inflation’ among care homes. Using big data scientific methods, Han and colleagues reveal between 6 and 8% of care homes engage in ‘dishonest’ reporting. They thus provide a timely warning about the challenge posed through performance management systems and a reminder of the dangers posed by the ‘gaming’ of such systems (a topic also reflected upon by Burgess in Chapter 3).

A Chief Executive’s Perspective

The chapters in this book support the call for health and social care professionals to be enabled to work seamlessly together in partnership to address the challenges of a health and social care system in crisis. The phrase ‘clinically led, managerially enabled’ seems important. Too often I’ve seen clinical professionals (and healthcare leaders) become distracted and disabled by policies and infrastructure that do not befit a patient-centred healthcare system. Fragmented IT systems, inefficient processes, siloed working, punitive regulatory processes and conflicting political priorities all add up to a badly run, inefficient and costly system that fails the patient, fails the public and fails the people that work tirelessly to deliver the highest possible quality of care. With this in mind, there is much to learn from research presented in this book to help us transition towards a health and care system that is joined-up, integrated and patient-centred.

As one of the chief executives involved in the partnership described briefly in Chapter 2, I can’t emphasize enough the value of institutions working together towards a shared purpose and the role of managerial practices (in this case, a leadership compact) to guide and sustain new ways of working even through challenging times, holding us each to account in a manner that fostered deep and lasting inter-organizational learning for improvement (for more detailed information about the partnership see the evaluation report by Burgess et al. [2022]).

One striking and enduring theme of this edited book is the contested nature of evidence. Evidence takes many shapes and forms; failure to recognize the normative processes that privilege certain types of information above others can lead to decisions about resourcing and patient care that might not represent ‘best practice’ in context. Similarly, failing to capture tacit forms of knowledge such as that of diverse specialists alongside the unique knowledge resource service users can also lead to avoidable blunders of service design, resource allocation and a service that costs more yet delivers less than it should. Croft et al. make a powerful case for elevating the perceived status of patient and public involvement and engagement (PPIE) from one of ‘lay expertise’ to one that is representative of a unique and valuable resource that offers the potential to disrupt normative thinking and decision-making, and shape patient-centred service design and delivery in a meaningful way. In other words, a more strategic inclusion of PPIE into decision-making processes can help ensure constrained resources are used in ways that deliver the highest possible value to our patients.

When it comes to sustaining high quality, affordable and equitable healthcare, inclusivity represents a pervasive theme. At an organizational level, inclusive leadership means proactively engaging middle managers and frontline managers in strategic change. Moreover, inclusive leadership must embrace diversity, for which as Chapter 5 illustrates, there is much that remains to be done. The ‘sticky floor’ metaphor is powerful; all healthcare leaders and managers have a duty to support under-represented employees to reach their full potential. Nobody should ever be overlooked for issues of race, gender or disability, quite simply we as leaders must do more at an organizational and institutional level to enhance diversity and inclusion among our leadership teams.

In the English NHS, system leaders are being encouraged to adopt a systematic and embedded approach to improvement and innovation across their organizations, requiring investments and changes to leadership infrastructure and training. This challenge is made harder at a time when an under-resourced system is struggling to bounce back from the pandemic, its workforce suffering the long-term effects of burnout. Since 2015 my own organization has adopted a systematic approach to building improvement capability across the whole organization and to embed a culture of continuous improvement. During this time, I have come to believe quality improvement isn’t a luxury, or a ‘bolt-on’ to everything else we must deliver; instead, I have learned ‘improvement’ is everyones’ job, every day. As a leader this transition has required changes to my own leadership style, recognizing that the people who do the work are the ones who know best how to improve the work. This means healthcare leaders must seek to frame problems for others to solve and to encourage and enable employees to solve problems and lead improvement as part of their daily work. In my opinion, the real test of the power of an embedded quality improvement approach came during the global pandemic COVID-19. Our experience and that of others are captured in the chapter by Dawson and colleagues, providing a fresh and timely look at the role of quality improvement in times of extreme crisis.

Finally, we must also be able to measure change in a meaningful way, so that we can know where we are headed and how well we are doing. There appears some strong evidence gleaned through research carried out by faculty at Warwick Business School regarding the processes and structures that support delivery of high quality, affordable and equitable healthcare. As Crump highlights, we need to develop understanding of the outcome measures we apply to success in our endeavour. We must, therefore, continue the research agenda and address the myriad of issues raised in this edited book.