Countering the Tragedy of the Health Care Commons by Exnovation: Bringing Unexpected Problems and Solutions into View

Willemine Willems

doi:10.3390/su132313082

Abstract

In the health sciences and policy, it is common to view rising health care costs as a tragedy of the commons, i.e., a situation in which the unhampered use of a resource by rational individuals leads to its depletion. By monitoring a set of outcomes, not only the costs but also patient experience and population health, simultaneously, it is claimed that the “triple aim” approach changes what is rational for health care stakeholders and, thus, can counter the rapidly rising health care costs. This approach has an important limitation: it reduces the monitored innovations to merely their outcomes; yet, how health care professionals and patients give shape to care delivery remains invisible. To get a more in-depth understanding of the consequences of adopting such an approach, in this article I use the method of exnovation instead. Exnovation foregrounds the everyday accomplishments of health care practices to enable reflection and learning. I draw on an ethnographic study into an innovation in care delivery aimed at rendering it more sustainable: Primary Care Plus. I reflected with both professionals and patients on what happened during 40 Primary Care Plus consultations. By presenting and analyzing three of these consultations, I foreground what is rendered invisible with the triple aim: improvisations, surprises and habits unfolding in practice. With exnovation, health care innovations can provide fertile soil for creating new forms of sustainable care that can help prevent the impending exhaustion of health care systems.

Highlights

Rising health care expenditures in European countries and in the US have raised grave concerns about the future of their health care systems [1,2,3,4]
Health care innovations can provide fertile soil for creating new forms of sustainable care that can help prevent the impending exhaustion of health care systems
In the Dutch health care system, primary care is provided by medical professionals, such as general practitioners and physiotherapists, whose consultations are directly accessible for patients and are paid for by obligatory health care insurance

Summary

Introduction

Rising health care expenditures in European countries and in the US have raised grave concerns about the future of their health care systems [1,2,3,4]. It is not rational to abstain from using the commons as much as they can, because they get the full benefit of its use, while the damage is limited because it is shared with the collective populace. In such a context, whether it is the use of fossil fuels, fishing, or receiving health care, there is one designated solution: “As in all tragedies of the commons, the great task in policy is not to claim that stakeholders are acting irrationally, but rather to change what is rational for them” [8] Whether it is the use of fossil fuels, fishing, or receiving health care, there is one designated solution: “As in all tragedies of the commons, the great task in policy is not to claim that stakeholders are acting irrationally, but rather to change what is rational for them” [8] (p. 761)

Methods

Findings

Discussion

Conclusion