Norman Krietman’s paper on the coal gas story describes the astonishing drop in suicide rates as the UK switched supply from 1960 to 1971. Before the switch over, many psychologists were pessimistic about strategies to prevent suicide, say protective barriers on bridges. If people really wanted to take their own lives , they would always find a way. Afterwards, it was obvious that this was untrue.
As we speak, Covid-19 is conducting its own natural experiment. Before the pandemic, there was an established narrative on the barriers to innovation in the NHS. Reports repeated similar lists of obstacles: lack of financial incentives, resistance by clinicians and a top–down system, among others. Research on social systems is a social activity. We all talk to each other. We read each other’s papers. There is safety in numbers. So there is a tendency to repeat the same things.
During the pandemic, we are seeing NHS services adopting digital technology at astonishing pace. In December 2019, NHS Digital reported that just 15 per cent of 23 million primary care appointments during the month had taken place by phone or online. By April 2020, 49 per cent of appointments during the month were by phone or online (NHS Digital 2020). By May, many GP practices were reporting delivering 90 per cent or more of appointments virtually. The transformation has been equally dramatic in some hospital and community services.
After the pandemic, we will need to review how much of our established thinking on barriers to innovation still seems credible. Can we still insist on the importance of financial incentives, if such rapid change could happen without them? Can we still claim, with the same degree of certainty, that conservative clinicians are a major obstacle to innovation, if those same clinicians could react so quickly during the crisis?
If the old stories no longer work, we will need to look for new explanations. The peak of the Covid-19 pandemic provided a rare moment when people across complex local systems had a clear, sense of their defining purpose, something that emphasises for me the role of vision and consensus-building to maintain this sense of purpose in future. Rather than incentives, the national NHS, Academic Health Science Networks (AHSNs) and others gave local systems substantial practical support, in particular access to digital platforms they would otherwise have to procure individually. My hunch is that changes in decision-making practices in organisations are also part of the story. Before Covid-19, you needed multiple approvals to introduce a change. In the heat of the pandemic, the number of people who could say ‘no’ went down, and the bar for doing so went up.
As well as teasing out these lessons on decision-making, health services will need to take a careful look at recent innovations after Covid, to decide what they should retain, modify or discard. You can’t ‘eyeball ’ a frail patient on the telephone. You may not spot the signs of domestic abuse if video calls replace home visits. Our recent paper on technology and innovation for long-term conditions, commissioned by the AHSNs, highlights some of the questions services may need to ask. For example, what do we know about people’s practical experience of accessing services online? And what is the impact for particular groups such as older people or people living in poverty?
Our paper also argues that technology has often been introduced conservatively in healthcare, making small improvements to existing ways of working rather than transforming the nature of health and care services. It asks whether there is scope to go further in the design of new digital services, for example using technology to develop stronger relationships between care givers and service users, to shift the balance of power between professionals and service users and to develop better-integrated, team-based services and to deliver holistic, whole-person rather than narrowly bio-medical care. Without a careful appraisal of the changes adopted during the Covid 19 pandemic, there is a risk that digital innovation in the NHS repeats past mistakes.