Foto: Claus Peuckert
Mission-Oriented Innovation in Prevention and Population-Based Healthcare
11. Apr 2024This article explores the role of mission-oriented innovation in prevention and population-based healthcare. You learn about three Danish cases and five characteristics of mission-oriented research and innovation
This article is a conversation between Peter Bentsen, Center Director, Center for Clinical Research and Prevention (CCRP), and Postdoc David Hilmer Rex on the role of mission-oriented innovation in prevention and population-based healthcare.
Introduction
David Hilmer Rex
Can you tell me about your background?
Peter Bentsen
Yes, of course, David. Thank you for inviting me. Initially, I am trained in exercise, sports science, and psychology. I hold a PhD in educational and health promotion research. I am director (together with Allan Linneberg) at the Center for Clinical Research and Prevention (CCRP), where we have strong expertise and extensive experience in population-based epidemiology, clinical epidemiology, health promotion and prevention, health services research, and biostatistics. We are based at Bispebjerg and Frederiksberg Hospital in the Capital Region. Additionally, I am also an Affiliated Professor at the University of Copenhagen.
David Hilmer Rex
How did you arrive at your current position? In a recent presentation, you noted that you were employed to open the hospital, health care, the CCRP, and your research to the outside world, practice, and policy.
Peter Bentsen
Yes, we wanted to make CCRP and our research more user-, applied- and impact-oriented (while maintaining our strong focus on excellence, fundamental research, and scientific understanding). I did my PhD at the University of Copenhagen. I have worked as a researcher and research leader and have been part of building centers at two different departments at the University of Copenhagen. Then, I was at Steno Diabetes Center Copenhagen as part of a health promotion and prevention R&D unit for eight years, where I also was a leader and helped build and grow that unit. I have also been a part of and helped with the initiation of the Center for Children and Nature. I have been at CCRP for four years. We are two center directors, and we are highly focused on our overall ambition of ‘a healthier and better-treated population’. Thus, my work is, among other things, concerned with population health, health promotion and prevention, partnerships, and, ultimately, making a difference in practice and policy.
David Hilmer Rex
CCRP’s overall ambition and approach are centered on what you could call ‘population health,’ where the focus often is on health in a defined population, e.g., a municipality, health cluster, region, or the like, and comprising a system of sectors and actors, e.g., primary, secondary, private, civic society. Can you elaborate on your approach?
Peter Bentsen
Yes, our overall ambition or vision, if you like, is ‘a healthier and better-treated population’. We work not only with treatment and health over the life course but also with the different sectors and actors of the healthcare system. With a population-based approach to health, you will often set goals to improve health outcomes for the whole (or a defined sub-) population, which typically also involves a goal of reducing health inequalities. You will monitor, explore, investigate, and try to understand health determinants from a broader perspective, including treatment, behavior, social factors, environment, etc. This approach will often also include the entire continuum of health promotion, prevention, treatment, rehabilitation, and palliative care.
We research, develop, evaluate, and monitor to improve these five areas. We collaborate across research areas, disciplines, professions, sectors, and industries, and we have specialized competencies within health research and focus on scientific excellence and societal impact. You could call it a translational approach, where we work across the value chain of basic research, exploratory and discovery research, intervention research, and finally, the implementation of results in practice and policy. We are based at a hospital close to the clinic and the patients –and in a region close to the municipalities and citizens. We have a strong background in biosciences, biobanks, and population-based surveys, both ‘wet,’ collecting data from the population, and ‘dry,’ where we conduct surveys with the population.
In addition to this, we do authority service, sector research, and health service research, where we help and assist politicians and policymakers in the region, at the hospital, and in the municipalities.
The future of healthcare and hospitals
David Hilmer Rex
In a recent presentation, you discussed three scenarios for the future of healthcare and a potential move from a so-called ‘fortress’ mentality of hospitals as islands to hospitals as part of integrated care systems or even hospitals as part of so-called population health systems. Can you elaborate on these scenarios and move from the ‘fortress’ to the more open, collaborative idea of population health systems and population health management?
Peter Bentsen
Yes, David, I can try. The healthcare system and hospitals have wildly succeeded during the last 100 years. We have treated and conquered many infectious diseases, work-related injuries, traumas, acute diseases, and illnesses, and much specialization has occurred. Public institutions have carried this success forward, and the success of the ‘general hospital’ has expanded the life expectancy considerably. However, it probably needs to change in the future because of a growing elderly population and an increase in non-communicable chronic diseases, among others (e.g., lack of staff, resources, and funding). We may have to push some of the healthcare system and activities into the primary sector, the municipalities, general practice, and even civic society – where people live, die, work, love, and go on Facebook. At the presentation you referred to, I discussed an exciting and highly relevant report by The Kings Fund in the UK,‘Acute Hospitals and Integrated Care: From Hospitals to Health Systems,’ where the future of care and hospitals is discussed. The report describes three scenarios for the future of acute hospitals: a worst-case, a current-case, and a best-case scenario.
The worst-case scenario would be a so-called ‘fortress mentality’ and hospitals as islands. You could say that some hospitals (or part of them) have a form of fortress mentality because of increasing service, lack of staff, and financial challenges, where a lot of patients are coming in, are sick, and the hospital will take care of them and send them back to the local community and everyday life. In previous centuries, this fortress mentality was probably good if you worked with infectious diseases, isolated patients, and took them away from the local community.
The following scenario is probably closest to the current situation where hospitals are part of an integrated care system, where you work with local partners and coordinate services and patient groups. I believe we are pretty good at this in Denmark, with our healthcare clusters, coordination, data and high levels of trust and collaboration.
The third and so-called best-case scenario is the idea of hospitals as part of population health systems, where we focus on population health management and how different organizations could work together around the health and well-being of populations. In that case, it is not only about reactively waiting for people to get sick and come to the hospital but also about improving the broader health of the local population (in addition to the integration of care services) through health promotion, prevention, improving their rehabilitation, and so forth. Many people and stakeholders argue that hospitals, healthcare systems, and organizations must transform themselves towards this scenario while at the same time delivering services, results, and outcomes here and now.
CCRP and mission-oriented research and innovation
David Hilmer Rex
When did you and the CCRP start working with mission-oriented research and innovation? How has it changed how you develop and carry out projects and partnerships?
Peter Bentsen
In 2013, I led and was part of a research group where we changed our vision and purpose to more mission- and impact-based statements. We focused on a long-term vision, outcome, and societal impact instead of simply generating new knowledge and only concentrating on our group and organization. That changed something for our research group, the mindset, recruitment, and how we could collaborate with other partners. Suddenly, we had the same goal, purpose, and mission as many politicians, practitioners, and organizations – and could collaborate across sectors, professions, disciplines, and industries.
At CCRP, we have also focused on a broader and overall ambition or so-called grand challenge related to society (‘a healthier and better-treated population’). We have had conversations about the center’s role, the role of research, how we can contribute to society, and our long-term vision. As I said earlier, we are experimenting and still learning. I believe we could do even more around missions and impact than we currently do; for example, we are organized in a rather traditional way as a university, organized in disciplines and research groups, not around missions in our organization. We have done some work in the region, e.g., through a master class and courses for research leaders, encouraging units, leaders, and people to develop missions in the region and beyond, as well as at the hospital and with other stakeholders. Missions can change your mindset and way of working; you must collaborate and work more outside your organization, e.g., with professionals, citizens, politicians, policymakers, and funders.
The article is part of our updated Mission Playbook.
Explore the other articles here.
From Stomach to Kindergarten. Partnership between Center for Clinical Research and Prevention (CCRP), Næstved, Slagelse and Ringsted Hospitals
Three case studies
David Hilmer Rex
I wanted to briefly discuss a few projects, partnerships, and missions that the CCRP is involved in or has been involved in. The first is Business Lighthouse Life Science.
Peter Bentsen
This was launched in 2022. It aims to make Denmark a place the rest of the world looks towards regarding life science and new, technological health solutions. The lighthouse and the partners are working with two ‘horizontal’ missions: Healthy Weight and Mental Health; however, it is also a more classical ‘vertical’ regional (Capital Region/Copenhagen), industry (Life Science), and sector (private) platform with a relatively strong product and technology (AI, health tech, drugs, etc.) focus. The backbone organization is the Danish Life Science Cluster. The long-term vision is to make a more sustainable and equitable healthcare system. The partnership is new and has been challenging and thought-provoking for us because many of our employees have mainly worked with research and development in the public sector and not that much with innovation, business promotion, commercialization, and companies (and also because of how the missions and related activities were funded). We have been part of the steering committee, some of the mission projects and pilots, and part of the monitoring, evaluation, and shared learning initiatives.
David Hilmer Rex
Another project is called ‘From Stomach to Kindergarten: Together to Create Value for Vulnerable Families.’
Peter Bentsen
Yes, it is a rather new and developing partnership around families, pregnant women, and young children from age 0 to the end of kindergarten/start of schooling. That is why it is called ‘From Stomach to Kindergarten.’ The shared vision is that all families visiting obstetrical, gynecological, and pediatric departments at Slagelse, Ringsted, and Næstved Hospital will reach their full potential. That inequality in health and well-being will be reduced. The mission is to develop, test, and implement interventions and programs (understood and defined very broadly) based on evidence and collaborations across sectors, professions, disciplines, organizations, and local communities. Research shows that a small proportion of the families having problems at birth drive a lot of the health care cost over their life course. If we can help families and children at an early stage, we can significantly impact life, health, and well-being – now and later (and the healthcare systems).
David Hilmer Rex
The last partnership is ‘Together about the health and well-being of children and young people’ in Vordingborg Municipality.
Peter Bentsen
Yes, and it has been expanded to concern health and well-being in children and youth. It is a long term partnership between Steno Diabetes Center Zealand, Vordingborg Municipality, and other stakeholders, e.g., from general practice, the region, and the pediatric and obstetric clinic at Nykøbing Falster Hospital. We have initiated a baseline and follow-up survey on pregnant women and children to monitor the partnership’s progress and the project portfolio. The partnership is five years, and we are in year three now. We have initiated different mission projects. For example, a bottom-up call have been made where citizens, professionals, and civic society can apply for funding for initiatives aligned with the overall mission and some more strategic and top-down initiatives.
Prevention of Obesity in Children and Youth in Vordingborg Municipality. Partnership between Center for Clinical Research and Prevention (CCRP), Steno Diabetes Center Sealand, Vordingborg Municipality the pediatric and obstetric clinic at Nykøbing Falster Hospital
Behavioral change, social innovation, and new services
David Hilmer Rex
The portfolio projects of the last two case studies strongly focus on population health, behavioral change, social innovation, structural approaches, new services, and systems. In contrast, Business Lighthouse Life Science has a stronger focus on technological solutions and products (but also on health behavior and systems). Researcher Phillipe Larrue noted in a review of mission-oriented innovation policies that “Most mission-oriented innovation policies follow an open and non-prescriptive approach whereby they ‘pick problems, not solutions’. However, as the organizations promoting and leading this approach are mainly from the science and technology policy fields, few of them consider social innovation” (Larrue, 2021, p. 9). Could you elaborate on why you think these partnerships succeed in maintaining a focus on the need for population and behavioral change and social innovation?
Peter Bentsen
I can try. I think it is because they are more about health promotion and prevention as well as policy and policy-making. They are not initiated by medical, technical, and life science professionals – and the aim is not commercialization or business promotion but value creation for the citizens, professionals, and the public sector. At the same time, you could critique them because digital solutions could offer interesting scaling and growth possibilities. Suppose you have a technological solution or intervention that works. In that case, it is probably easier to scale, but it can also be more expensive and include concerns around equity and who has ownership and rights over data.
Technical or digital solutions can furthermore prove to be a challenge because research shows that if you want to change population health, it takes a long time. Structural prevention, such as population-based incentives like policies, laws, and structures, is often more effective. I wish that we could work more with structural prevention at different levels. While it is mainly encouraged and practiced nationally, you could also experiment with structural prevention at the regional, municipal, or even organizational level, for example, by having smoke-free workplaces or screen-free kindergartens. I believe we must work with a combination of structural prevention, political incentives, social innovation, service design, and behavioral change. The problem with behavioral change is that it is challenging at an individual level.
You must take the initiative and change your behavior many times during the day if you want to improve your health and well-being now and over the life course. Every time you, e.g. eat, sit, smoke, drink, sleep, get stressed. That is why a population-based approach and structural prevention are so important.
Five characteristics of mission-oriented research and innovation
David Hilmer Rex
In a recent book chapter, you outlined five characteristics when working with mission-oriented research and innovation. They are:
- Involve users, citizens, and professionals
- The importance of a portfolio and investment approach
- Develop and build impact pathways
- The need for a backbone organization that drives development
- Involvement at the political and strategic level to solve societal challenges.
Can you elaborate on those?
Peter Bentsen
They are from a chapter I wrote (with Søren Barlebo Rasmussen). We looked into the practices and literature on missions as a structured framework for change and development to identify what characterizes mission approaches. At the same time, we have also experimented and gained some understanding and shared learnings from our own initiatives and mission-driven partnerships (cf. the above cases). I believe it is crucial to have all five present; you cannot just pick one of them.
1) Involve Users, Citizens, and Professionals
The success of a mission is dependent on the involvement of relevant users, citizens, and professionals, as they are central to understanding a given societal problem and mission area (as well as possible solutions and implementation) – a so-called ‘pull’ vs. a ‘push’ approach to innovation. It is essential to ensure bottom-up involvement when deciding on the mission, portfolio, and desired value creation at the early stage. Missions can, therefore, be powerful in gathering citizens and specific groups of people, e.g., a group of patients or patients’ association around a purpose and a desire to do things differently. This is especially important around grand societal challenges, given that they require profound behavioral changes at the population level, not only technological innovation and new products. Health is not only developing new medicines, drugs and treatments but also e.g. communities, diet, artificial intelligence, physical activity, sleep, and digitization. The involvement of users, citizens, and professionals will lead to engagement and legitimacy from the citizenry, user groups, and population. It will create the conditions for anchoring and implementation of the mission projects.
2) Portfolio and Investment Approach
Missions often have three overarching phases. Design of a shared mission, mutual development and innovation, and lastly, implementation and continuous value-creation. The second phase will often benefit from a portfolio approach, where you must identify and execute the proper mission projects and portfolio. This is inspired by risk management and strategic investment logic, where risk and resources are spread across a portfolio through a collection of synergistic and reinforcing projects, prototypes, and experiments across sectors and actors (e.g., instead of one big project or a more classical ‘linear’ approach). Innovation is risky, non-linear, and uncertain. Some projects will fail, while others will succeed.
In the portfolio approach, you have a set of projects associated with varying degrees of risk. For example, in Business Lighthouse Life Science, there were three projects about children and young people, three about the workplace, and three on treatment (almost like an investment portfolio).
3) Develop Impact Pathways
Developing impact pathways sounds a lot fancier than it is. The idea is that you go from R&D into daily practice, daily operations, implementation, and value creation. As I see it, innovation must be new, beneficial, and valuable, and it must be implemented, exploited, and become part of daily practice. The ‘new’ is not a solution or an innovation before it is implemented into daily practice. When working with missions and a portfolio of projects, you e.g. have to assist and prepare the clinic, so they can implement a new service or product into daily practice. This is also related to the economy and the education and preparation of the professionals who must implement and use it (and change their daily practice). Otherwise, we have seen a lot of ‘stuff’ (product, services etc.) being developed, yet it will never be implemented into practice because it is too expensive or infeasible for other reasons. Implementation, diffusion, and coordination can become severe bottlenecks if not addressed in the innovation process.
Ongoing monitoring and evaluation are central here to ensure learning and adjustment of the portfolio as it develops. Hospitals and clinics working with missions must consider how time and resources are used more actively and what adjacent sectors, organizations, and actors they can collaborate with. Lastly, they must consider how existing systems can be altered through collective actions instead of reactively waiting for the traditional ‘push’ system of innovation to develop technologies and solutions.
4) The need for a backbone organization to drive development
The fourth is the need for an organization that drives the development of the mission. This has been called a backbone organization, a mission secretary, or an ARPA unit. It is simply a unit that can drive development and make it easy and efficient for the partners to collaborate and participate. The unit should provide transparent and straightforward management and governance, and it requires permission to make ongoing decisions and govern resources in an agile and flexible way. Ideally, it should be located between the partners and not at one of the partners.
5) Involvement at the political level
The fifth characteristic is related to involvement at the political level. While developing solutions, services, and systems change, you need to involve a political level that can change regulation, incentives and laws (in a more top-down way) – often coined ‘leveling the playing field.’ This, of course, depends on what kind of mission you are thinking about. Whether it is top-down missions initiated by the government at the national level or bottom-up missions initiated by local stakeholders. You also have more accelerator missions focused on, e.g., implementing and scaling new technology or more transformative missions, where you have a more open approach and want diverse stakeholders to collaborate to develop solutions and approaches – often focusing on radical innovation and changing systems.
Mikael Seppälä's and SITRA’s work in Finland
Maturity of innovation ecosystems
David Hilmer Rex
You and others have been inspired by Mikael Seppälä’s and SITRA’s work in Finland. He described the development from labs to hubs and networks, to collective impact, and finally, to innovation ecosystems as the most mature stage. Can you briefly introduce the model and then maybe discuss it in relation to some of the work you have been doing?
Peter Bentsen
The model is relevant and exciting because it shows a way to develop and improve our collaboration around societal problems and missions. It is also an indirect critique of some previous and current methods, partnerships and labs; it is probably not enough just to co-create and work together. SITRA argues for innovation ecosystems, where an entire ecosystem works in concert; you have funding, portfolios you create together, and a platform to support the collaboration and the stakeholders. You work with research, development, innovation, and the system’s capabilities and actors. They argue that it is the most mature, productive and impactful form of collaboration.
The model is also an indirect critique (or areas of improvement) of the work we have been doing with partnerships, missions and some of the cases I have discussed here. I think that this is natural – that we must try, learn and improve. For example, the case from Vordingborg is a partnership that you could categorize as collective impact. We have a common agenda. We have some form of measurement. And we have some form of a backbone organization. However, we have not started with or solved the partnership and mission funding issue, lacking in our work and across many mission-oriented works currently being developed. If we keep the old funding scheme and try to make new partnerships, it will probably not work.
I think it is expected that you must learn and advance from just being one organization working with your mission or working with your key performance indicators to begin working with other organizations where you have a lab together or co-create something with your users, patients, or other organizations. You can also see this play out at various universities, where they announce or identify several missions or challenges. Then, they make an internal mission and ask the different departments or faculties to work together. That is probably not mission-oriented innovation if you want to be strict. Because you need other sectors collaborating and, as we discussed earlier, citizens, users, and professionals as well as impact pathways and implementation in practice and policy. Maybe it could be a way forward to become better at joining each other’s missions. Many people would like to orchestrate missions, but we may have to be better at joining different organizations, partnerships, and actors’ missions or be orchestrated. Nobody wants to be orchestrated; they want to orchestrate themselves. If everybody makes their own missions, it will probably not amount to ecosystem management or innovation ecosystems. It will just be a lot of people innovating, communicating, and doing activities, but we will miss out on true impact at the scale of the problems we are facing.
David Hilmer Rex
From my point of view, the life science ecosystem in Denmark is one of the most mature ecosystems of that specialization. But would you say the life science ecosystem can cater to your work around prevention and population health? Or is it more geared towards the development of new drugs, new technologies, and products?
Peter Bentsen
I think the life science ecosystem is more geared towards drugs, products and profit and where the business is currently, but of course, we can be inspired by the work taking place. They are doing great things with AI, open innovation, scaling, and exploitation. The public innovation system is probably the worst? We can learn from this system, how we can collaborate between hospitals and municipalities. But, as we talked about earlier, it is probably okay to be a lab, hub, or network for a start. We have to grow and learn as leaders and as organizations how we can open up and collaborate with others. Also, the life science sector.
David Hilmer Rex
One thing we have discussed on a different occasion is the question of mechanisms of change. How do different things scale? Products and technologies have the affordance that they are often engineered to scale rapidly and efficiently, whereas behavioral changes present some difficulties in terms of being spread to a population. Can you say something about the mechanisms of change and some of the challenges regarding your work in prevention and population health?
Peter Bentsen
Yes, we discussed that earlier, as well as the problems with scaling when it is not a product, app, or drug. It is much harder to scale service design, service innovation, or even systems innovation. However, I genuinely believe it is possible. For example, you can change the behavior within a population with regulation, incentives or structural changes. Improving the bicycle lanes, for example, could increase citizens’ physical activity in a city. We must also measure on a population level in addition to the individual level. But it takes time and it is challenging. I mean, it is more complex than just selling a product or digital services, which often is more sticky and more scalable.
The model could also inspire funders (or even public leaders, politicians, and policy-makers), who could go in and fund an entire mission. Set up a platform, find stakeholders, create a coalition of the willing, assist in developing the portfolio projects, and assist in innovation across the whole value chain. Or even better, a group of stakeholders crowdfunding a mission themselves? We have to be better at funding, business models and investments (exploration as well as exploitation).
Another inspiration from the model could be the question of how we govern. How do we orchestrate and lead these missions? Where do we situate the backbone organization? We probably need more knowledge about backbone organizations, mission secretaries, or ARPA units. How are we going to lead them? And fund these? Who will lead them, and what capabilities are needed in such a unit? And if it is going to be situated between the partners, how are we going to fund it, and how are we going to give it the accountability and agility to make decisions, for example, about the portfolio or activities, although all the stakeholders own it and are a part of it? There will definitely be some exciting and relevant knowledge and learnings about this, which we need to learn as a system and as stakeholders.
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