Driving health system change is complex – and challenging the world over. Among the numerous obstacles, Ontario's core challenge is rooted in the tension between resilience and adaptability. Alasdair Roberts' 2024 book The Adaptable Country: How Canada Can Survive the Twenty-First Century describes adaptability as the capacity to anticipate and manage threats and as a critical quality for state survival in turbulent conditions. This quality is exceedingly challenging for political systems and there is a growing recognition that Canada has been falling short. The same can be said for Ontario.
Professor Roberts will be speaking about the adaptability challenge at the upcoming Health Care Leadership Summit. Ahead of his session, we asked him to share some thoughts and perspectives on what it means to be an adaptable system.
You've written about the need for adaptability in the public sector. Can you share more about what adaptability means, and why it matters? In particular, is there a difference between resilience and adaptability?
I define adaptability as the capacity of a system to reorganize itself so that it can meet new threats or challenges. In my book, I'm looking at big political systems -- that is, the combination of governments at different levels. But you can apply the same concept at a smaller scale, for example to Ontario's health system.
The basic premise of adaptability is that it is impossible to design a system so that it works the same way forever. Circumstances change, and so do our values and priorities. So any system has to be renovated periodically to meet these new realities.
Resilience and adaptability are both important, but they are different. I would define resilience as the capacity of a system to continue performing its main functions even when it is hit by strains or shocks. Adaptability is the capacity of a system to reconfigure itself so that it can perform new functions, or perform old functions in new ways.
What does an adaptable system look like? What functions would it need?
In my book, I suggest that an adaptable political system is one that can perform four functions. The first is anticipation, by which I mean taking a long-term view, to understand how conditions are likely to change and what new threats or challenges might arise.
The second function is invention, which means devising alternative strategies for dealing with anticipated challenges. This isn't just a question of how we deal with one problem or another. I am thinking of grand strategy: how a system will deal with several complicated problems at the same time.
The third function is legitimation, which means building support for one strategy or another. In a complex democracy like Canada, we can think of legitimation at two levels. First, political leaders in different governments have to be on roughly the same page. And second, ordinary citizens have to agree on the path forward.
The final function is execution, which means translating the preferred strategy into action. This is like house renovation. You tear down the bits you don't need anymore, and you build new bits to suit your new requirements. In government, this involves dismantling agencies and programs, or renovating them, or building new ones. And similarly, repealing old laws and adopting new ones.
What are the obstacles to achieving adaptability in the public sector? Would you say that achieving adaptability is easier or harder than it was in the past?
Canada is a liberal democracy, which means that we take individual rights and participation seriously. It is also a federal system, because we share power between governments, including the governments of Indigenous communities. And it is a market-oriented country, which means that we give a lot of freedom to private enterprise.
These are all different ways of spreading power around, which we do for good reasons. But a political system that spreads power around like this also has vulnerabilities. It can be hard to get everyone on the same page, in the sense that they agree about challenges and how to deal with them. And it can be hard to coordinate action, even when people agree in principle about what needs to be done. Let's call this the integration problem: reaching agreement on strategy, and coordinating responses.
The integration problem in Canada is bigger than it used to be. To some extent, this is the unintended consequence of national success. There are a lot more people in Canada than there were thirty or forty years ago. People are better educated and they are more aware of their rights. Provinces are stronger. The market economy is bigger and globally integrated. In sum, Canadian society is more complex. It has more moving parts.
Moreover, we shouldn't forget the ways in which technology has changed the way we talk with one another. Among other things, everyone is more distracted: attention is a scarce commodity.
So the dilemma is how to perform the four functions I described earlier, in this more complicated world. How do we find the time for a collective conversation about long-term challenges, and how to deal with them?
Thinking specifically about Ontario's health system: What do we need to move from being a sector that is focused on survival to one that is looking to thrive?
Full disclosure - I'm not an expert on healthcare. But I'm going to guess that reforming the Ontario health system is complicated by several factors, in addition to the general considerations I just mentioned: (1) A tendency toward increased centralization or integration within the system over the last thirty or forty years; (2) A heightened sense of the importance or criticality of the system, both for individual well-being and in terms of Canadian political identity; and (3) Reduced time to think and plan, because of the sheer strain of responding to short-term requirements.
Putting this all together, I would imagine that the tasks would be: (1) Carving out time for deliberation, within the system and with citizens; (2) Finding ways of describing plausible alternate futures, to reduce uncertainty about what might happen and allow room for choice; and (3) Creating space within the system for low-stakes experimentation with new modes of service delivery.
What can our hospital leaders do to build this capability and capacity among their teams?
The usual caveat - I'm not an expert in hospital administration. But my hunch would be that there would be three steps: (1) Making an effort to space in the schedule for longer-term thinking; (2) Creating some kind of staff support so that this thinking is robust and evidence-based; and (3) Building up communications capacity so that stakeholders know what the organization is doing and have the opportunity to contribute.
On the first two points: this is something that I would imagine might happen at every level in the organization, and not just the hospital as a whole. And on communications capacity: in this media environment, success probably requires sustained effort, just to break through the noise.
How should we balance short- and long-term planning if we want to think strategically about the future but be nimble and reactive as needed?
I am actually a little ambivalent about the word "planning." Of course, long-term plans are necessary sometimes to guide investment and capacity-building. Otherwise, though, "planning" has connotations of top-down, technocratic design, and I think we want to avoid that. We need to build a collective understanding about long-term aims, make long-term commitments where necessary, and preserve room for experimentation where possible. Europeans have a concept called "subsidarity," which means pushing authority downward when practicable. I think that is good advice.
If there was one good place to start this shift, where would it be? Where would you suggest our health care leaders focus, to start moving towards an adaptable health care system?
Suppose I walked into your hospital, went to the front desk, and said: "I live in this community. I would like to learn more about the challenges facing this hospital over the next ten or twenty years, and how you are thinking about managing those challenges." Would your hospital have a citizen-friendly product—print or digital, text or video—that you could give me?
This might seem like an facile question to start with. But producing a product that is thoughtful, and generally accepted by key stakeholders, is hard work. You have to build deliberative capacity within the system before you can generate the product. And if you have built that deliberative capacity, you are probably going to be in better shape when it comes to preparing for the future.