Ensuring the adoption and spread of these latter innovations is a challenge in any health system. But anecdotal evidence suggests that the English NHS finds doing so particularly challenging, for example its slow progress in making use of basic communications technologies.
Policy-makers express their frustration by commissioning a new report every couple of years decrying the slow pace of change and highlighting the potential benefits of faster adoption of innovation. For advocates of directive leadership, the answer is for the national NHS bodies to play a more active role in mandating adoption of ‘proven’ good practice, with sanctions for those who fail to do so. For supporters of free markets, the solution is to break down monopolies, support entrants, allow inefficient providers to exit the market and unleash the creative destruction of competition, although doing so in the NHS has proved difficult in practice.
This article aims to make a pragmatic contribution to the discussion of how to speed up the adoption of service innovation in the NHS. It draws on eight examples of successful spread of innovation supported by academic health science networks (organisations set up by NHS England in 2013 to identify and spread health innovations, including through connecting the NHS with academic organisations, local authorities, the third sector and industry). We interviewed the originators of the innovations wherever possible and the AHSN staff responsible for supporting adoption and spread, to understand the approach they had taken and the challenges they had encountered.
The good news is that entrepreneurship is alive and well in the NHS, despite the different incentives for innovators than in more competitive markets and the significant obstacles that often lie in innovators’ paths. Kate Dale, a community psychiatric nurse in Yorkshire and the Humber, spent a decade developing physical health checks and running physical health clinics for people with severe mental illness, alongside a full-time day job and without any funding or support. Emma Redfern, an emergency medicine consultant at University Hospitals Bristol NHS Foundation Trust, found time alongside a hugely pressured day job to review performance and devise a strategy to prevent harm to patients in overcrowded emergency departments. We were struck by the enthusiasm and determination of the entrepreneurs themselves and of the AHSN staff supporting their projects.
The case studies also demonstrate the transformative power of simple, low-cost innovations in improving health and care services and the dramatic difference they can make to people’s lives. One patient struggling with longstanding mental illness received a routine thyroid test for the first time, revealing hyperthyroidism. Two years later, a person who had struggled to leave the house was free of depression and living a happy life. An isolated person with Asperger’s syndrome can sleep at night thanks to a text-messaging service. Thousands of patients are receiving treatment for arthritis, diabetes, cardiovascular disease and chronic liver disease who might otherwise be neglected.
While technology was often a key enabler, it was not necessarily the most important feature of the service innovations we studied. For many of the innovations in our case studies, success depended on much earlier diagnosis and intervention than delivered by previous approaches; fundamental changes to staff roles, in particular the roles of GPs, community services and hospital consultants in local systems; empowering patients to play a more active role in administering their own care. Patients take more accurate blood pressure readings, monitor glucose levels more effectively and may identify appropriate warfarin doses faster if supported to manage their conditions themselves.
Many of the innovations delivered dramatic improvements by improving access to services for the most vulnerable and neglected patient groups, for example people with severe mental illness, vulnerable older people and adolescents. It was also striking that many innovations in our case studies achieved improvements by addressing different underlying needs to traditional health and care services. Age UK’s care co-ordinators draw on voluntary sector services and community groups to reconnect older people with their communities, addressing loneliness and isolation rather than simply focusing on their health challenges.
The case studies therefore highlight the opportunities for improvement that come from overcoming siloed thinking as much as operational silos. Some of the big wins appear to come from organisations overcoming a ‘that’s not our job’ mentality, taking a broader perspective on their social purpose, and exploring a wider range of options for delivering the greatest impact for their communities. These include addressing needs that might technically be another health or care organisation’s responsibility, taking a more holistic approach to people’s physical and mental health, and addressing social challenges as a major cause of ill health rather than a second-order concern.
Some of the findings on how to support adoption and spread are embarrassingly simple. Innovators and adopters need to be able to access appropriate funding quickly to ensure rapid adoption of innovation. Professor Mike Hurley found it relatively easy to secure the initial funding to design his ESCAPE-pain programme for people with chronic hip and knee pain. However, he hit a ‘brick wall’ at the point when he needed to secure funding for adoption and spread of the programme. Suddenly the resources disappeared, and trusts began to discontinue successful pilots. By the early 2010s, Mike was seriously considering making a career change. In his own words, ‘what was the point in dedicating a decade to research if it was just going to sit on a shelf?’ Emma Redfern explained that some trusts were unable to find £15,000 to £18,000 to implement her checklist for crowded emergency departments, despite its dramatic impact in reducing serious incidents.
Things appear to have got a little better. Mike Hurley described being thrown a lifeline when the newly created Health Innovation Network, the AHSN for south London, decided to support his programme in 2013. Nevertheless, the lack of adequate funding, and the startling mismatch between resources for innovation and resources for adoption and spread, remain a substantial barrier. As long as the NHS sets aside less than 0.1 per cent of available resources for the adoption and spread of innovation, a small fraction of the funds available for innovation itself, the NHS’s operating units will struggle to adopt large numbers of innovations and rapidly improve productivity (see Figure 1 below). These choices are in stark comparison with some private multi-nationals that set aside up to 25 per cent of turnover to promote their innovations, in many cases significantly more than they dedicate to research and development.
None of this would matter if the adoption of service innovation was a simple, technical process such as replacing a branded drug with a generic. But our cases studies consistently highlighted the complexities of transferring even simple, well-designed innovations from one site to another. When Neil Guha and Guru Aithal, two hepatologists, started to carry out proactive fibroscanning in GP practices, they immediately doubled the number of people diagnosed with chronic liver disease. Unable to cope with increased patient numbers, they needed to make fundamental changes to the roles of GPs, nurses and consultants in treating the condition. Meanwhile, proactive diagnosis highlighted the need for better services to support people with earlier stage liver disease.
Figure 1: Comparison of spend on innovation and on adoption and spread of innovation in the NHS (see end note)
Sources: Department of Health 2016; NHS England 2017
In this and other examples, the decision to introduce one innovation had a domino effect, triggering a series of changes to diagnosis, treatment and the roles of staff and patients and revealing new patient needs – in short, a lengthy period of iterative testing and refinement. This goes a long way towards explaining why the spread of service innovation in the NHS, as in other industries, is a difficult and costly process even if the innovations appear simple. Adoption of most service innovation needs to be seen as part of service improvement rather than the process of ‘rolling out’ a ‘proven’ approach.
Given these complexities, the types of service innovation covered in our case studies are unlikely to spread rapidly across through traditional NHS approaches such as presenting information on them at conferences or developing toolkits. Instead, almost all the case studies highlighted the importance of putting ‘boots on the ground’: senior clinicians able to spend substantial time convincing colleagues of the benefits of innovations, experienced project teams to help providers implement innovations, and continued support for providers in evaluating the impact of changes and sharing learning. While individuals often played key roles in developing and spreading innovations, success depended on effective teams with a range of skills including investment appraisal, marketing, change management, service improvement and evaluation. Otherwise, as Dr Julia Reynolds, the head of programmes responsible for the Innovation Agency’s atrial fibrillation programme explained, ‘there is a risk that only the most “sticky” innovations get adopted or only the most enthusiastic individuals are able to introduce them sustainably.’
Despite this, many of our interviewees explained that they were preparing to revert to more passive strategies, for example developing toolkits and websites, for when funding for active dissemination programmes was withdrawn. Given funding pressures, most of our innovators had only received funding to support active spread of their innovations for a couple of years. Many described encountering unrealistic expectations about the speed with which they could ensure widespread adoption and impact. The risk in reverting so quickly to passive dissemination is that programmes lose momentum well before they have been adopted across large parts of the NHS.
Frustrated with the slow pace of change, there have always been voices in the NHS advocating national direction, or the use of highly directive incentive schemes, to speed up adoption of innovation. We see limited advantages in central bodies mandating adoption for the types of service innovations considered in these case studies. Local health services are complex, interconnected systems with different starting points, different challenges and finite skills and resources for innovation and improvement. External bodies are ill placed to determine which service innovations would deliver greatest value within a local system or how they should be adapted to deliver greatest impact. In any case, the evidence for service innovations is constantly shifting, with new innovations emerging. If so, calls for national directives show outdated thinking on the nature of service innovation that needs to be challenged.
Entirely to the contrary, these case studies highlight opportunities to accelerate spread by transferring decision-making to local systems and frontline services. They illustrate how the current performance management regime and financial incentives restrict innovation by focusing attention on narrow measures of performance, short-term rather than longer term improvements, and improvements within organisations rather than across systems. Interviewees described commissioning as a remote tier of decision-making that slowed the adoption of even small-scale changes in how services were delivered. Innovators could make faster progress when commissioners delegated responsibility for improving services to providers. Rather than mandating innovations, the AHSNs were connecting innovators with NHS organisations, helping providers to identify solutions to their challenges that would work in the local context.
As the case studies make clear, the attitudes of local leaders and the working environment within provider organisations have a significant impact on the speed of innovation and spread. Some interviewees described local leaders who actively championed innovation: helping to articulate clear and ambitious goals for their organisations; encouraging staff in the search for new ideas; encouraging staff to connect with colleagues within and across organisations; supporting staff in accessing the funds, tools and expertise to execute their plans. Other interviewees described pursuing innovation despite the discouragement of leaders who would prefer them to focus on their day job. This suggests that there is still a need to convince at least some leaders that innovation is a solution to the NHS’s challenges, rather than an unaffordable luxury, and that they should play a role in supporting it.
Finally, our interviewees highlighted the challenges of ensuring rapid adoption of innovation given the current fragmentation of health and care services. Unlike some other health systems, health and social care services in England are compartmentalised in both service silos and geographic silos, meaning that there are few formal mechanisms for transmitting learning across sites. The AHSNs were playing an important role in connecting sites through learning collaboratives and developing actionable data to support improvement. Nevertheless, Phil O’Connell, the developer of the Florence telehealth application, noted the differences between working with the NHS and working with large integrated health systems and hospital chains in Australasia and the United States. In those systems, organisations could deploy innovations across multiple sites and draw on established systems and accumulated experience to support implementation.
Looking to the future, the development of more integrated local health and care systems in England presents an opportunity to address many of the barriers to adoption and spread identified in this report. At least in theory, emerging accountable care systems may be able to establish more appropriate objectives, financing mechanisms and performance management to support innovation. Within more integrated local systems, it may be possible to establish stronger relationships between professional groups and deeper connections between services, more effective mechanisms for sharing of ideas and learning, a common language and shared methodologies for innovation and improvement.
This article is part of an independent report commissioned by the six AHSNs responsible for spreading health innovation in the East Midlands; Kent, Surrey and Sussex; the North West Coast (the Innovation Agency); South London (Health Innovation Network); the West of England; Yorkshire & Humber. The views and conclusions in the report are the author’s own.
I have much sympathy with the author, about a topic that cannot be the most exciting in the realms of the NHS at present. At least this is how I feel about it. The reason for this is that I have been working successfully transforming services in local authorities for 13 years, and trying to do the same in the NHS. I am happy to do more in LAs, but I found the experience in the NHS as being almost impossible. And this is why...
In any organisation, the key to innovation is not in getting a group to come up with innovative approaches - thats easy. When those approaches are implemented, there are very good reasons in the system that act as barriers against that initiative. The key is that those reasons can be changed in LAs, but in the NHS they cannot. Why?
1. The current poor practice is a result of how leaders and managers have set up the current system. The first thing to do it to identify, recognise and accept this.
2. The basis for innovative approaches must be the transformation of that which exists. Therefore taking point 1, those root causes of why the system works as it does have to be replaced. An example here is KPIs and the RAG report. They are one of the most divisive and damaging parts of the system and its behaviour. And they cant be replaced unless leaders go through point 1.
3. The whole design of the NHS rests on functionalisation. it is how it is structured. Many innovations show that by working together, we can overcome. Well, if the NHS was not so functionalised, the innovation would be normal practice. So when they try and implement the innovation, the budget restraints, and the initiatives and the target reporting prevent the innovation from succeeding.
4. Based on the above, when an innovation is implemented, it has to sit in a current of behaviours and characteristics of managing, that is like sitting in a strong current battling against the flow. Then ultimately, those working with the innovation cannot sustain the push against the current anymore. An example of this is referrals. Referrals and departmental assessments are one of the most functional and greatest barriers to working together. Everything about them forces in delay, waste and a mindset that works against integrated working. Yet, I know of no initiative that succeeds in replacing referrals and functional assessments.
The answer is to allow the underlying system to change, looking at the system systemically, so that innovations can be implemented, and they go with the current - so to speak. This means releasing the shackles of functional design, units of work, and measures, and allow leaders to design workflows that mirror how the work flows. An example is the underfunding of GPs actually creates greater cost than they save in the wider NHS. That can be recognised by a nine year old who has no management training. I believe that by sorting out the structure first, the subsequent innovations will follow. And no its not rocket science, and its not complex to do.
An important factor is a failure to associate innovation with risk, and to realise that to avoid all risks requires one to avoid innovation.
Appreciation of the risk-benefit balance through patient-clinician dialogue is necessary, as is the need to understand that with innovation things can go wrong – but the aim is to improve outcome.
It is the early-adopter health care professionals that are the enablers of widespread adoption, as occurs in all domains, and with these individuals constrained by the risk aversion of their employer, the system finally grinds to a halt.
The Report, and the comments above, hit on every key point I have personally encountered during my work attempting to support innovation in the NHS, regardless of whether the source was from within the NHS itself or external to it. There is undoubtedly a head-start when the innovation source is from within the NHS, due to the pre-existing personal and professional networks already in place to help disseminate the concept of the innovation, but at some point, as the Report points out, the steam just 'runs out'.
In large part, this is because the NHS-person who is acting as the 'Innovation Champion' is not being paid to operate in this role and the demands on their time to keep the 'push' going increase as they get further away from 'home' and as their own personal connections become weaker. In many ways, this weakening effect is aggrevated by the well-known functional and funding silo-effects that exist due to the way the NHS is structured.
With regard to this silo-effect, I would recommend that prior to attempting to launch or introduce an innovation into the NHS, there is a full and through examination of the 'unexpected consequences' that it may (will) introduce above and beyond the clearly anticipated benefits presented in the Business Case. After all, if the Police had known that the widespread introduction of public telephone boxes was going to result in a massive increase in reported crime, they might have wanted to influence the rate of the Post Office's roll-out programme .... if they had known who to talk to.
We are unlikely to see the broad-brush reform of the NHS structures and funding that will change these behaviours. In their absence I have no better alternative than to suggest the creation of a new (well, currently absent anyway) network within the NHS, but one which requires the creation and funding of a brand new dedciated role - that of full-time and NHS-funded Innovation Champion, on at least a one-per-Trust basis and at a Trust Board-report level of seniority. These Champions would be required to network together to evaluate and to jointly co-ordinate agreed innovations across the well-known internal barriers that will continue to exist, and to collectively argue the cost-benefit-risk case to the Boards and importantly gain their support to implement the changes.
One would hope that by this means the Trust Board would feel empowered by trusted (sic) internal advice, and the new network would be able to create a cohesive implementation programme that would gain the engagement of their fellow NHS professionals.
As an adjunct to my comment above, it should clearly be a given that those appointed as Innovation Champions all receive the same appropriate training and use a common innovation management toolkit/system/processes such that they can speak to each other at a common level of process understanding, jointly work through a commonly understood methodology and openly (not competitively) work on agreed innovation projects. That is, they should be innovation professionals who form a networked team and not just be people who are 'pet favorites' of the Trust Board who just happen to be available! They should also be funded for long enough for them to demonstrate their value (eg: 5 years) and not be worried about where next years funding is coming from, which otherwise simply results in their evaporation to more secure pastures.