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Failing to adopt innovation hurts
Imagine your elderly parent is admitted to the intensive care unit (ICU) following a respiratory insufficiency. She is intubated for more than 2 days. As the hours go by, there is an increasing risk that stomach fluids and bacteria from her mouth enter into her lungs as the inflatable cuff that holds her tracheal intubation tube in place leaks.1 As a consequence, she develops ventilator-associated pneumonia (VAP), which is associated with a significantly greater risk of dying in the days to come. The good news is that a technology exists—the Venner-PneuX system—that almost entirely prevents such leaking of fluids into the lungs.2 The bad news is that uptake appears low and slow. Worse, most ICU clinicians, nurses, managers and certainly patients are unlikely to be aware of this technology, despite it having been available since 2007.
The story of VAP is one of many that helps us understand why the adoption of innovation in the National Health Service (NHS) remains elusive, despite much policy attention. It illustrates that we should turn our attention to those individuals and organisations we wish to take up innovation—rather than solely the innovators themselves.
Our key thesis is that efforts to support and promote the creation of innovation itself will not solve this problem. This argument has not been set out sufficiently before. The real challenge is to create healthcare environments in which the benefits of innovations can readily be seen and understood by those who can use them to improve patient care, and in which healthcare organisations can readily support the procurement and integration of those innovations into their systems and processes of care. In order to do this, we need to create organisational cultures, capabilities, infrastructure, processes and resources that make the uptake of innovation more likely. We need to create this beyond each organisation if the health system is to adopt innovation that crosses boundaries of organisations which is even more challenging than single point solutions.
Defining innovation, adoption and diffusion
We use the term ‘innovation’ in this paper to mean evidence-based services and products, new or established, that, when applied in practice, improve the value of healthcare that is, the outcomes for patients over costs.
Invention is the ‘creation of a product or introduction of a process for the first time.’ Thomas Edison was an inventor. Innovation happens when someone ‘improves on or makes a significant contribution’ to something that has already been invented. Steve Jobs was an innovator.3
While in the current fiscal environment costs may appear to be the predominant driver for change, in our experience the adoption and diffusion will only be accelerated in a non-market based national healthcare system if they also lead to better patient outcomes.
We distinguish between the barriers to adoption of evidence-based services and products within one organisation, and those preventing the diffusion of innovation throughout a wider health economy. Diffusion can only happen through the adoption of innovation in individual settings in the first place, and while there are similarities in challenges and enablers, there are also differences.
Given the pivotal role that innovation is seen to play—and for the sake of the arguments developed in this paper we take the positivist view of innovation at face value—in simultaneously improving outcomes and reducing the costs of healthcare, there is no shortage of attempts to understand why the adoption—and more importantly the diffusion—of innovation is so challenging in the NHS.4 Imperial College Health Partners (ICHP), one of the 15 Academic Health Science Networks, commissioned a review of the most prominent studies of barriers5 and a review of the local and national policy implications.6
Three different categories of innovation can be usefully distinguished:7
Emergent (innovations developed to prototype but yet to be fully proven and tested);
Required (innovations supported by evidence and incorporated into evidence-based and statutory guidelines, such as NICE);
Optional (innovations fully developed and tested with isolated examples of successful adoption but no formal requirement to adopt).
Most research and development (R&D) would fall into the first category. In the second, NICE Technology Appraisals are examples of compulsory innovation that is required by statute from providers. Finally, at the other end of the mature market there are many proven and fully developed innovations which are not prescribed but could be widely adopted.
Barriers to the adoption and diffusion of innovation
Here we briefly review the most common barriers to adoption and diffusion that we have experience in practice and group them into four broad categories: regulatory, structural, cultural and operational. While not comprehensive, they combine to make healthcare a dysfunctional market which is difficult for innovators to penetrate, no matter how good the quality of the innovation.
Healthcare is a heavily regulated sector in order to ensure patient safety and quality as well as to control costs. Regulation has been developed for pharmaceuticals and, more recently, for medical devices. The regulatory pathway provides a clear route to market readiness for products, but not necessarily to their adoption and diffusion.
However, it is now widely acknowledged that regulatory clarity is also needed8 ,9 for the newer area of digital healthcare. There is currently no one agreed definition of what constitutes digital, which is part of the problem. Generally, digital healthcare covers a broad spectrum applicable to, for example, patient pathways (wellness, prevention, diagnosis, treatment and monitoring and entail direct touch points) as well as health systems improvements (emergency response, healthcare practitioner support, healthcare surveillance, aggregation and analysis of clinical, administrative or economic data) all enabled by digital technology.
The traditional ways of assessing drugs for regulatory purposes (eg, through randomised control trials), are not appropriate for digital innovations. Instead new approaches are required that are based on systematic review and real-time observation of their effect on patients and populations in practice. This approach requires the use of aggregated patient data taken from clinical records and linked across different healthcare settings. Concerns about privacy and security of such information must be addressed before these methods can be adopted. Legislation and enforcement of data protection and privacy rules are required to build the trust of the general public before their data can be used in this way.
Part of the challenge is that NICE technology appraisals do not currently assess digital or device-based innovations such as the VAP, and so there is no mechanism to regularly raise the quality standards of specific interventions as innovations are approved.
There are a number of important structural issues:
The highly fragmented UK healthcare system;
The disconnect within organisations between clinical and procurement departments;
The lack of market forces that drive innovation in the private sector;
Budgeting structures that divorce future savings from current investment costs.
UK healthcare has become a highly fragmented system with more than 200 payers (a mix of Clinical Commissioning Groups and central commissioning), nearly 200 trusts with turnovers ranging from more than £1billion to a few hundred million, more than 8000 primary care practices and a structural separation between the NHS and social care of which 90% is provided by private organisations. This creates a confusing myriad of entry points for entrepreneurs and industry as almost all of the above organisations make autonomous purchasing decisions. Such a complex system cannot provide an efficient market for those who wish to sell new products or services into it.
To complicate matters, this fragmentation across the system is often mirrored within organisations, such as in the apparent disconnect between clinical and procurement departments. A related issue is that savings from the adoption of innovation do not always occur to those making the investment, or they appear to take too long to materialise to be meaningfully accounted for in annual budgeting. As a consequence, invest to save schemes are increasingly challenging.
The use of public procurement to stimulate the demand for innovation has previously been debated.10 A review was commissioned to understand how barriers related to processes, competences, procedures and relationships in public procurement influence suppliers' ability to innovate and to reap the benefits of innovation. This review found that the main barriers reported by suppliers are the lack of productive interaction with procuring organisations, the use of overspecified tenders as opposed to outcome-based specifications, low competences of procurers and a poor management of risk during the procurement process.11
The market forces that drive innovation in the private sector do not exist in the healthcare market in spite of the popular narrative of widespread privatisation of the NHS. The majority of services remain largely uncontested. This, combined with ‘soft-budget’ constraints and only a rudimentary ability for patients to ‘pull’ innovation or best practice due to a lack of systematic empowerment with information, do not provide a genuine incentive to innovate.
Cultural and operational barriers
The ability to truly innovate can be as elusive in the private sector12 as it is in the public sector—despite stronger market forces. While the consequences of not adopting and spreading innovation in the private sector may be more immediate because of their impact on commercial success in a competitive market, not all private sector organisations succeed. There are classic examples of companies that have failed to innovate and lost significant markets to newer competitors (IBM, Kodak to name but two). In the commercial sector, the right culture and operational capability distinguish those who are successful from those who are not—and this is equally applicable to the NHS.
One particular cultural challenge for the NHS is the over-emphasis on academic achievement at the expense of operational impact. This is not surprising given the significant amount of R&D funding available through National Institute for Health Research (NIHR) which, by its very definition, is focused on discovery rather than the adoption of existing best practice. Some progress has been made in requiring grant recipients to not only focus on academic publications but also real world impact. But in our experience these incentives are still far too small to accelerate the diffusion of innovation beyond academic organisations at any meaningful scale.
All the indications are that unless there is direct accountability for innovation among the executive team of organisations, innovation cultures remain aspirational. Systematically rewarding, enabling and realising innovation, whether internal or adopted from elsewhere, is a key characteristic of successful organisations. Addressing the inherent risk of introducing new ideas, products and ways of working by providing funding, skills, time and space are key enablers. Moreover, operational innovation which requires major changes in how departments conduct their work and relate to one another is a truly deep change, affecting the very essence of an organisation. Even successes in the private sector, such as Walmart, Dell and Toyota, have had to fundamentally rethink how they work in their industry. This cannot be achieved without the direct accountability of executive teams. There are a number of models to choose from, and ensuring they fit with the prevailing organisational culture and values is paramount.13
Importantly, while it is well understood that R&D does not just happen but needs substantial resource and capability, the same applies to the ability to identify and describe need, scout for external innovation that has been proven elsewhere and adopt it. But diffusion requires diffusible innovation. Unfortunately, the R&D space is incompletely resourced and lacks the capability of codifying service solutions sufficiently in order to be diffused more widely within or across organisations. All too often, innovation is written up for academic audiences or as case studies. Concepts are developed and demonstrated to academic satisfaction and then abandoned for the next academic challenge. Rarely are best practices actually codified into service manuals that can easily be shared and operationalised. This requires skills currently not available to the NHS.
Finally, deliberate and systematic demand will also help to inform entrepreneurs and researchers to focus earlier on the implementability of their innovations to ease adoption. For example, often academic or regulatory taxonomies of evidence dominate the development when those purchasing innovation may require a different set of evidence (eg, not just cost effectiveness but also the costs of switching and decommission existing ways of working). In other cases, the interoperability with existing systems is not easily achieved, hampering the uptake of otherwise helpful innovations.
Table 1 illustrates how the barriers and enablers to adoption and diffusion compare across the different types of innovation.
The balance is wrong—making innovation part of everyday culture
The policy response to the lack of adoption and diffusion has mainly focused on how to support entrepreneurs and industry to enter the UK market more effectively. This has taken the form of accelerator programmes such as the Small Business Research Initiative (SBRI) and more recently a whole range of central innovation programmes. There is certainly value in many of these though systemic evidence is still lacking for accelerator programmes more widely.14 However, adoption of services and products through these routes is the exception rather than the norm. Neither have top down initiatives such as innovation technology adoption programme (ITAPs), which compels providers to adopt certain innovations and which has been particularly successful.
In contrast, we argue that a main reason for the limited success is the almost complete lack of appreciation of the ‘demand’ side of the market for innovation in healthcare that is, healthcare providers and commissioners. Unless equal attention is paid to creating fertile innovation ecosystems within healthcare organisations, support on the supply side will have minimal sustainable impact because of the sparsity of buyers or deals for even the best products and services.
To date, innovation in NHS organisations is driven by dedicated clinicians, nurses, and managers often on top of their day jobs and mostly unsupported by and disconnected from the wider organisation. It is no one's day job to systematically define problems in NHS organisations and then scout for proven solutions or support those doing it already. It is a nice to have, not business as usual. It does happen mainly by accident for example, in transformation teams but the particular skill and resource required is unsystematic and not professionalised.
Our work shows that this is quite different in successful organisations in other sectors, many of which have dedicated innovation teams, deep routed innovation systems and, most visibly, Chief Innovation Officers. Most importantly, these cultures are driven and led by Chief Executives and their senior teams appreciating that transformation is the only route to sustainable success.
What are the elements successful organisations have in common? Comparative studies by Alessandro Di Fiore who has worked with a number of multinational organisations suggests that it is a combination of elements that matter rather than single characteristics, and that they are of equal importance.15 These are supporting (external and internal) best practices; developing skills; supporting units in new product and service initiatives; identifying new market spaces; helping people generate ideas; directing seed funding and designing shelter for promising projects. However, the exact design of organisational ecosystems is very much dependent on the existing organisational culture and may vary from centralised (eg, Janssen's Healthcare Innovation Centre) to highly developed (eg, P&G). In addition, building these systems takes time, often decades, and is an ongoing process which needs to adopt itself to changing environments.
There is currently little systematic support to build such ecosystems in the NHS. This is not to be confused with transformation teams of which there are many, although our impression is they often lack professional re-engineering skills other industries would deploy or that have been deployed in other healthcare systems such as the US as we recently saw during a visit to Duke University. It is also not to say that improvement teams cannot provide value. Our argument is that the existing improvement infrastructure needs to be part of larger, systematic innovation ecosystems within NHS organisations. Such systems would need to demonstrate the core elements as outlined above, including of high-quality identification and definition of problems and the systematic scouting for solutions.
However, the high staff turnover at the top of trusts (eg, at some point in 2015 33 out of the around 200 trusts had no permanent CEO), as well as in commissioning organisations more generally, makes this an even more difficult task given the long-term nature of such investments.
Creating an innovation ecosystem in North West London
Recognising this need, ICHP have launched an Intrapreneur Programme aimed at supporting provider organisations to create a more functional demand side for innovative products and services.
The nine-month programme, which is aimed at both executives and frontline staff, aims to help organisations develop the necessary skills, cultures, structures and processes to define needs more precisely and systematically scout for solutions. The programme requires participation of executives to address systemic organisational barriers, as their frontline staff develop the skills and capability to introduce best practice and innovations to address needs and transform performance. A strong emphasis of the programme is the scouting for proven external solutions.
Our aim is for the programme to provide a cultural and operational solution to help the adoption and diffusion of innovation in North West London, but it will also provide opportunities to address some of the regulatory and structural barriers highlighted above. For example, statutory innovations that raise the standards and quality of care will require mandatory operationalisation, audit and performance management, while voluntary innovations will likely follow the diffusion model popularised by Everett Rogers and Geoffrey Moore.16 The challenge for our programme participants will be to co-opt early adopters more rapidly through creating a culture of trust that embraces both intrinsic as well as extrinsic motivations to innovate, allows easy access to innovations that have been scouted for, and fosters the skills and capability within individuals to bring this about We hope that as organisations throughout North West London build this capability, networks of innovation diffusers with similar challenges will form.
The programme has been developed jointly with ?WhatIf!, who bring their experience from other sectors. A large part of the programme addresses behaviours required for innovation including greenhousing, playfulness, signalling, freshness, curiosity, realness, momentum and bravery. Developing a corporate culture that enables and supports innovation is a journey, which needs to be sustained through embedding the cultural structures that make innovation repeatable: process, tools, incentives, communication and metrics. These will be developed jointly with executives for their specific organisation.
Specific tools and methodologies enable participants to navigate through the innovation process of identifying the problems, gaining insight, generating and scouting for ideas, incubating and finally making an impact.
Considerable time is spent problem hunting and identifying the challenges and needs, with clear criteria on how to select those to work on. Insight gathering is a crucial part of this process. Participants are provided with tools to hunt for clues and to immerse themselves, armed with insight questions. An example where ‘need’ has been clearly identified is demonstrated by Embrace, who instead of developing more economic incubators, developed the Embrace Warmer in response to the need for infants born prematurely in areas of the world to be placed in an incubator until they were able to make it on their own. The success criteria for this innovation was that it is durable, can be reused up to 50 times, portable, can be used while the baby is held in the mother's arms or during transport, hygienic, easily cleaned using soap and water, safe, simple and intuitive to use, validated through routine safety testing and extensive clinical trials, effective, incorporates an innovative phase change material to rapidly stabilise the temperature of an infant suffering from hypothermia.17
Idea scouting uses an exploratory and iterative approach. Starting points for scouting may be close to the challenge, through personal and organisational networks, through the global world of health and beyond the health sector in related worlds. Rather than a set process or formula, it is the participants' determination and nous and how they connect, that will yield success.
Incubation of ideas involve rapid experimentation. In a highly regulated setting, rapid prototyping and experimentation may be counterintuitive. However, testing critical questions in a designed environment with minimal risks ensures that ideas are not stultified by too many unknowns. Well known examples of rapid prototyping have been provided by IDEO. They worked with one cancer centre to provide a better experience for chemotherapy patients. Starting with one team's initial idea to create a binder for patients to collect useful information over time, the solution evolved to build an ‘interactive device’ that would help them discover what information patients would find most valuable. Based on this early response to their initial prototype, the design team decided to abandon the idea of a binder altogether and instead morphed their idea into a series of ‘conversation cards’ with which to initiate conversation with patients and family members. These conversation cards are now in widespread use. Their introduction as a prototype spawned the creation of a new protocol at the clinic: Each floor manager now spends two h/week in the waiting area with the cards, moving from patient to patient to have conversations.18
Once ideas have been formed, participants will embark on a process of understanding the rational case and value, the emotional engagement and barriers, and the political environment to enable solutions to make an impact.
Returning to our VAP example at the beginning, if a product such as Venner-PneuX were to be introduced to such an innovation ecosystem, the ICU team would have identified the root cause of VAP, a scout (who had been looking for innovations in this area of need to prevent VAPs and is empowered to look outside their organisation), would have been in contact with the innovator, and flagged it to the ICU team, before working with them to understand the mechanics of adopting this, and then with innovation procurement to provide the case for change. Systemic scouting and trialling of innovation is supported from Chief Executive level down, and so the case for change is highly likely to be supported. In this way, innovation becomes everyone's business and is part of the everyday culture of an organisation.
We know that there are a number of barriers to the adoption and diffusion of innovation—cultural, operational, structural and regulatory. These barriers need to be tackled simultaneously, at national and local level, and by a range of organisations. The current Accelerated Access Review run by the Office for Life Sciences provides a substantial opportunity to address many of them. However, we will make little progress in our desire to adopt and spread evidence-based products and services faster and more systematically in the NHS (or any healthcare system) unless we prioritise the cultural and operational needs—the organisational cultures, capabilities, infrastructure, processes and resources that make the uptake of innovation more likely. In the past, too much focus has been on supporting the supply of innovation in the hope that pushing innovation at providers and commissioners will eventually yield results. It has not—or at least not sufficiently.
What is needed to make this happen? At the local level, provider and commissioning organisations need to realise that shifting the balance between the urgent and the important is crucial to allow space for the systematic transformation of healthcare. Second, those organisations need support in building the necessary capabilities in their staff. Academic Health Science Networks, Health Education England, the Royal Colleges and industry all have a role to play and it is paramount to protect this space in current fiscal climate to enable disruptive transformation. For example, we are already integrating an innovation module into one of London's biggest nursing education providers.
However, while local buy-in is essential, we should aim to scale local models as quickly as possible in the interest of time and efficiencies. It has been proposed that part of the additional funding for the NHS should be ring-fenced for innovation, and will be important to recognise the need to allocate sufficient recourse to the capability and capacity building outlined above. NHS organisations are only going to be able to deliver the best possible outcomes for their patients if they have a culture that celebrates innovation at all levels, supported by staff that are empowered to identify and adopt it. Innovation needs to be everyone's everyday business.
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