The idea of being accepted to do a Harkness Fellowship was almost inconceivable. I submitted my application with bated breath, not wanting to let myself really think that there was any chance it could become a reality.

‘The American healthcare system is not what I expected. In fact it is wrong to refer to it as “a system”’

The email inviting me to interview was a week later than scheduled and in this time I convinced myself it wasn’t going to happen for me. Then there was the elation on making it onto the short list, followed by the dread of being grilled by such an incredible panel of healthcare experts. For the next month, everything was focused on getting me through the interview and successfully to the other side.

I got a taste of what it would be like to be a Harkness Fellow through my intensive preparation. The generosity of support from fellows past and the enjoyment I got from taking time out to read about the actions we can take to improve our complex healthcare systems on both sides of the Atlantic gave me a flavour of what the year ahead might hold, and made it an even bigger must-have…

Now, looking back six months into the fellowship programme, was it worth it? It has changed my life in unexpected ways. Honestly; some good, some bad. Would I trade? Not a chance. It has challenged me in ways beyond my expectations: a new city, country, time zone; an alien healthcare environment; subtle but important cultural differences; and an academic challenge greater than any that I have previously undertaken. It has not been easy.

Pieces of different jigsaws

Now, truly, I don’t want the year to end. As everyone said I would, I have fallen in love with San Francisco. I am gripped by my policy question, constantly challenged, stretched and overwhelmed by the unwavering support from my mentors, and learning more and faster than I ever have.

‘With the US’ lack of standardisation and centralisation comes huge scope and opportunity for innovation’

The American healthcare system is not what I expected. Despite vicariously reading about it while in the UK, I was not prepared for the level of fragmentation and disconnect. In fact it is wrong to refer to it as “a system”.

It reminds me of healthcare IT in the UK. Lots of separate systems built independently for different purposes. Pieces of different jigsaws that we are now trying to make fit together into one systematic whole.

The lack of standardisation has surprised me most − how we take that for granted in the UK. Moving from Scotland to England I still knew how to get a primary care doctor, that it would be in the local neighborhood to where I live, when it is appropriate to go the see the GP and when that doctor will more than likely send me on for specialist advice. It might not be perfect, but the system works for us.

Against-the-odds integration

In the US, there just isn’t consistency. The points of access depend on the health insurance you have, if you have insurance, if you have access, where and when you access care and the criteria that micro-system has for how you navigate their care.

Self-advocacy is crucial. You can’t ask friends or colleagues for advice or guidance, as their experience will be individual to them and not necessarily relevant to you. But with this lack of standardisation and centralisation comes huge scope and opportunity for innovation.

My only hope now is I can say something useful in the next six months that others in both the UK and US can learn from. My desire to distill something simple and tangible from the complex pockets of change and innovation happening in public hospital systems that have against-the-odds integrated care and payment drives me on.

Sounds easy? I think not. But, if there is one thing this year has taught me, it is that if you put your mind to it, then anything is possible.

The 2012-13 Harkness Fellows write exclusively for HSJ and the Nuffield Trust blog.

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