The Act@Scale program: why size matters when it comes to population health (and what to do about it)

CK: What are the challenges to scaling care?

Prof. Newman: Achieving organizational change, along with appropriate reimbursement for activity, and a robust business model. The Act@Scale programs are designed to hopefully reduce hospital admissions; but if the payment model rewards activity -- such as hospital admissions -- it will work against change. For each potential project you need to ask: whose savings are you trying to affect and if you save in one area, who benefits?

You also need to consider the timescales involved. To transform healthcare, as one of the most complex types of organization in the world, you need an understanding that it takes vision and commitment from many different people and services over multiple years.

CK: How do you go about making large scale change?

Prof. Newman: This is what we lay out in the handbook. We know that telehealth technology works. And we know that pilot projects can get great results. The danger is that we assume that a small research project carried out in one environment will translate easily to another. 

I think the key to scaling projects is organizational change. For me, that means changing peoples’ way of working, enabling integration across services, and new models of care. You need support from clinicians and management together with political support. I think the Scottish online self-management platform My Diabetes My Way, which reached 22,000 diabetes patients across the nation is an excellent example of widespread support for changing practice.

CK: How have patients reacted to these pilots?

Prof. Newman: Traditional healthcare is very paternalistic. Young people – and increasingly the elderly – no longer subscribe to that approach; they want to know what their risks are, what the likely health outcomes are, and what they can do about it. When you get patients involved in self-managing their condition – which we call “citizen empowerment” in the Act@Scale handbook -- then this is where the real gains can come from.

CK: Which pilots stood out for you and what can we learn from them?

Prof. Newman: I think the Spanish projects are worth highlighting because of the way they integrated political and financial support from regional government. The Basque Country multi-morbid integration program successfully scaled up to 16,000 patients with multiple conditions across the region by integrating a diverse set of programs that combined clinical monitoring with patient self-management. 

CK: What are the next steps for the Act@Scale program?

Prof. Newman: I think that this program has answered skeptics’ comments about whether it’s possible to make changes on a large scale. You certainly can and it’s vital that we do. From here, I want to prioritize funding for mutual visits to the best examples from other countries so that we can inspire each other. 

For more information on ACT@Scale, visit http://www.act-at-scale.eu and download the full ACT@Scale handbook for more detail on best practice analysis, examples and results here.

[1] This quote is variously attributed to Yogi Berra and the computer scientist Jan L.A. van de Snepscheut. The earliest known appearance of the quote in print is Walter J. Savitch, Pascal: An Introduction to the Art and Science of Programming (1984), in which it is attributed as a “remark overheard at a computer science conference”.