Health October 25, 2019
Situational awareness: why integrated health systems won’t work without it

By Professor Terry Young and Professor Stephen Smith - Accountable Care Journal

Healthcare has borrowed ideas for decades. Once there was Lean and then innovation – especially technological – was going to save money and boost outcomes. Now we are focusing on integration. The idea is simple. With coordination, healthcare services respond faster and eliminate wasted activity. However, good coordination requires a capability that comes from the military, namely, ‘situational awareness’.

Most failures result from a lack of situational awareness: the driver went to the wrong store; the autopilot thought the plane was stalling; A&E could not discover what drugs the patient was discharged with yesterday. To improve responsiveness, healthcare systems must improve their situational awareness.

Healthcare systems around the world are seeking integrated solutions and the NHS is unique in what it has already achieved – a single service for all from cradle to grave. However, full integration represents a giant leap, even for an organisation such as the NHS.

Situational awareness is both an outcome of a well-integrated system and an essential component of it. Coordination is impossible without shared situational awareness, but it takes a smart system to fuse different types of information and generate situational awareness.

Imagine pouring coffee with one hand into a mug in the other. Muscles keep the mug centred on the stream of coffee and tense to take the extra weight while a complementary process manages the pot in the other hand. Unconsciously, you draw on sight, feel and memory. If your situational awareness is eroded through fatigue or impairment, you might have to place the mug on a stable surface to pour or hold the cup while someone else pours: either way, it takes longer and consumes more effort.


The integration juggling act

Up to now, the NHS’s forays into further integration have been largely structural around accounting and accountability. The NHS has, for instance, experience of merging budgets and different control regimes. However, knowing where you are against budget is an exceptionally limited form of situational awareness. Meanwhile, asymmetries in situational awareness persist, so that the right hand ends up pouring coffee over the left.

To make its flagship Integrated Care Systems (ICSs) work, it must reach a point where its collective intuition is good enough to sense the answer and quickly sense-check it for accuracy, in real-time, every time. So, what sort of systems are up to this type of response?

Since the second world war, armed services around the world have invested heavily in situational awareness: sensors and networks to gather information; processing power to fuse different types of knowledge; and displays that put meaningful information in the eye-line of decision-makers. Meanwhile, manufacturing and service industries have spent lavishly on networks and IT in order to make real-time distributed and joint decisions across corporations.

Situational awareness in healthcare is much more complicated than anything like it that humanity has attempted. It will require much better networks and systems that can fuse clinical, financial, lifestyle, logistical and management information. It will need best ways to present this to ambulance crews, carers, doctors, nurses, managers, OTs, patients, and physios, to name a few.

In different ways and at different levels, the NHS has always grasped the importance of integration. It now needs to integrate at a completely different level and to do that, it will need to provide everyone with a wholly new level of situational awareness.


Professor Terry Young worked in industrial R&D before becoming an academic and is now Director of Datchet Consulting. With over 30 years' experience in technology development and strategy, health systems, and methods to ensure value for money, his current focus lies in designing services using computer models and he set up the Cumberland Initiative to support healthcare organisations wishing to develop their services more systematically.

Three of his downloadable papers are:

Using industrial processes to improve patient care (2004, with Brailsford et al., British Medical Journal)

Performing or not performing: what’s in a target? (2017, with Eatock & Cooke, Future Hospital Journal)

Systems, design and value-for-money in the NHS: mission impossible? (2018, with Morton and Soorapanth, Future Hospital Journal)


Professor Stephen K Smith is a clinician/executive having held senior positions in Academic Medicine and the NHS at the University of Cambridge, Imperial College, London, NTU Singapore and most recently the University of Melbourne. He currently serves on various health and health technology Boards including Chair of East Kent Hospitals University NHS Foundation Trust, and Netscientific Plc. and previously the Boards of Imperial College, London, Imperial College Healthcare NHS Trust, the National Healthcare Group, Singapore, the Royal Melbourne Hospital, Melbourne, and the Victorian Comprehensive Cancer Centre, Australia.

Professor Smith led the formation of the UK's first Academic Health Science Centre at Imperial College Healthcare NHS Trust and was its first CEO. A gynaecologist by training, he has published over 230 papers on reproductive medicine and cancer. He was awarded his Doctor of Science in 2001 for his work in Cambridge on the complex gene pathways that regulate the growth of blood vessels in reproductive tissue. He was founder/director of the Sino-Japanese pharmaceutical company, GNI Group Plc, that is quoted on Tokyo SE and currently chairs a group of start-up digital health companies. He is a Trustee of Pancreatic Cancer UK and the Epilepsy Society.


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