The context of our innovation in Nottinghamshire is chronic liver disease, a condition that is largely asymptomatic meaning patients often present late with significant consequences for their health and life expectancy, and with economic cost to the health care system.
If liver disease is treated early enough, the liver can regenerate so early diagnosis is key – the heart of our innovation is to enable access to novel diagnostic tests from primary care and shift the focus to testing people with risk factors for liver disease.
Introducing novel pathways across primary and secondary care is challenging especially when asking individuals to work and think in a different way. However, our pilot projects were successful because liver specialists actively supported the innovation, and we had local GP champions and trained nurses to take on extended roles. Underpinning this we had a strong patient voice (via our patient and public involvement group) willing us to make radical changes.
But translating the success of the pilots in 2012 to the commissioned pathway in Nottinghamshire in 2016 was not a linear journey.
We were initially urged to describe the project as service improvement or research to secure funds. We did not believe our work fitted either category but applied for funds as both and were predictably unsuccessful.
The creation of the academic health science networks (AHSNs) catalysed our project and the East Midlands AHSN provided both financial support and specific expertise. It also helped us recognise that while we had the foundations of a strong case for commissioning, there were missing pieces, including the feasibility of the pathway in different socio-ethnic settings.
However, we didn’t let that stop us. I had heard the idea that you only need 40 to 70 per cent of information to make decisions – the 40:70 rule, attributed to former US Secretary of State Colin Powell. This approach is wonderfully apt for innovation, where waiting for 100 per cent of the necessary information before making a decision has opportunity costs and risks the innovation becoming obsolete.
So we approached our open-minded commissioners to find out what additional evidence was needed from their perspective but also reached an understanding on both sides that there were unknowns that would emerge only after careful evaluation.
This required both flexibility and acceptance of risk; qualities that are not always promoted in the NHS. A key question was who should provide the evaluation; the resources within clinical commissioning groups (CCGs) to do this were limited but without this evaluation innovation has limited value and legacy; in our case the East Midlands AHSN provided expertise for the ongoing evaluation programme.
Fostering innovation requires a supportive environment for the innovation and the innovators. The NHS Innovation Accelerator (NIA) fellowship provides this.
NIA fellows have wide-ranging backgrounds in industry, academia and the NHS. There is an opportunity to learn from other fellows, participate in leadership and innovation workshops and be mentored by experienced leaders in the NHS. As an NIA fellow myself (one of two represented in today’s report) I leave these meetings equally humbled and energised.
But despite this support, challenges remain.
One is how we reward innovation. Many innovators will have no direct financial gain from their innovation – so how does the NHS encourage and motivate them to continue?
Ring-fenced time, autonomy, contributing to career progression and active encouragement to take calculated risk (at an individual and organisational level) are strong levers but I am not sure these are employed in a coherent or consistent manner.
I believe three key issues are critical to the adoption and spread of innovation within the NHS.
- Innovation needs to address a tangible clinical need with buy-in from different parties including patients, providers and purchasers of health care.
- Clinical ambassadors must be actively supported to take innovation from pilot projects to mainstream adoption.
- Organisational structures focused on innovation, such as the AHSN network and NIA programme, should continue to provide valuable support until innovation is truly integrated within the NHS.
I hope that sharing the story of our journey in Nottinghamshire and the lessons we learned – along with the other case studies in the report – will help generate debate about what more the NHS could do to adopt effective approaches to supporting adoption and innovation.
Neil Guha is a clinical associate professor of hepatology at the NIHR Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham and Nottingham University Hospitals NHS Trust. He has received funding from the East Midlands Academic Health Science Network and has been awarded an NHS Innovation Accelerator fellowship (2015-2018). The views represented here are his personal views and not those of organisations that he is affiliated to.