Making prudent healthcare happen

Innovation – the driving force for prudent healthcare

  • Chris Martin, Member of the Bevan Commission, Chair of the Prudent Prescribing Implementation Group, Former Chair, Hywel Dda Health Board
  • Ifan Evans, Deputy Director, Healthcare Innovation, Welsh Government - Department for Health & Social Services

Summary

There are great people working in NHS Wales with great ideas about how to improve services and offer better care. NHS Wales can also learn from the many people who use services, many of whom have insights into how care could be provided in a more effective and efficient way.

Through a focus on prudent innovation, NHS Wales can enable and encourage staff and service users to turn innovative ideas into reality. This will result in better care and outcomes. This article addresses some of the obstacles to innovation and identifies what needs to change to create an innovation culture focussed on improvement.

Ward 7

We have to innovate now

Healthcare services are struggling to keep up with the pace of change, which is driven by many external factors, including the needs of an ageing patient population, advances in knowledge and technology, and ever-increasing public expectations.  This is something we have to address, or our current model of healthcare will eventually become unsustainable. As one expert on change in business, Jack Welch, says:

“If the rate of change on the outside exceeds the rate of change on the inside, the end is near.

Change before you have to. An organisation’s ability to learn, and translate that learning into action rapidly, is the ultimate advantage.”

Now and for the foreseeable future, we must meet increasing healthcare demand and raise quality from within our current real terms funding. This means simply doing more of what we have always done is no longer an option. We need to radically transform the way we deliver services. Innovation must become the core business of the Welsh NHS as we find a more prudent way to deliver healthcare services.  We are not alone – this is a global challenge facing even the biggest and most well resourced healthcare systems:

“Innovation is not optional.  It is a national imperative.  To generate the innovation we need at a cost we can afford we need to re-tool our entire ecosystem for medical innovation to deliver new treatments and cures to patients faster and less expensively than ever before.  This will require unprecedented cooperation and collaboration between industry, academia, and regulators – and recognition by the federal government that a vibrant life-sciences industry will generate higher national productivity, lower total health care costs, and technological ‘spillovers’ that will benefit almost every other industrial sector, from agriculture to defense.”

(The Hill / Congress Blog)

We have to innovate to deliver prudent healthcare

Prudent healthcare sets out the principles which we will apply in Wales as we do this.  The basic value equation of better outcomes from less intervention is being used throughout the world to drive improvement.  We are not the only healthcare system motivated by the ambition to do no harm and to find the most efficient way to deliver effective services. What makes Wales different is the principle of equity which lies at the heart of prudent healthcare.

For patients and healthcare providers, improving health and wellbeing is extremely rewarding. However, changing behaviours and improving public health is one of the greatest challenges in healthcare. This is why it is a shared commitment in prudent healthcare, with equal responsibility and participation of both healthcare provider and patient. Health is a profoundly personal thing, so we must take account of public and patient preferences and perceptions of value as we pursue better outcomes from less intervention.

Innovation is the key to working out how we can transform our existing model into one which reflects these principles of prudent healthcare.  Nobody yet has the answer and as we have our own priorities and principles in Wales, we will have no choice but to work this out for ourselves. One thing we cannot do is continue as we are.  As Peter Drucker says:

“The greatest danger in times of turbulence is not the turbulence; it is to act with yesterday’s logic.”

Prudent healthcare is not the same as our existing model so we will need to challenge many of our existing assumptions about what we do and how we do it. Driving change in large systems demands boldness, determination and persistence. The opportunity we have in Wales is that our healthcare system is comparatively compact and integrated and it takes a planned approach to how it organises and delivers services. Even though this will certainly not be easy, it will be worth it.

Innovation to achieve prudent healthcare will transform patient outcomes, while simultaneously improving quality and efficiency, releasing savings through increased productivity. It will also contribute to our economic development. By innovating with direction and purpose, we will not only shift to a more efficient, effective and equitable healthcare system, but we will also create valuable new knowledge, products and services in Wales.

What is innovation?

The Welsh Government’s Innovation Wales strategy defines innovation as:

“The successful exploitation of new ideas. Sometimes it is the result of the application of brand new knowledge, but more often it is the result of experimental changes, or new combinations of existing ideas and experience. It can involve the development of new or improved products, of different or better processes for producing goods or services, or the introduction of entirely new services. And these do not have to be for sale; they might also be the way public services are offered or delivered.”

Innovation Wales, Welsh Government, 2014

Narrowing our focus to healthcare, the definition used in NHS England’s Innovation Health and Wealth strategy is also useful, although we would prefer to think of a whole system of healthcare in Wales, which includes other care providers, patients and the public.

“An idea, service or product, new to the NHS or applied in a way that is new to the NHS, which significantly improves the quality of health and care wherever it is applied.”

Innovation Health and Wealth, NHS England, 2011

Why do we need to define innovation?

Definitions are important because everyone benefits from working to the same shared understanding.  Terms like improvement, best practice, research translation, knowledge transfer, system change and commercialisation are all covered by innovation, and they all mean slightly different things to different audiences.

For our purposes, innovation is about introducing new things into our healthcare system in order to improve the quality, safety, effectiveness and efficiency of health and care services in Wales. This does not necessarily mean simply adding to existing processes or practice – we must also discard products and practices that are shown to have no added value or which have been replaced by something new or better.

How does innovation make a difference?

To make a noticeable difference in organisations as large as the NHS, or to have an effect on the overall health and wellbeing of the population, innovation needs to be applied, demonstrated, and adopted.  In Wales, we have over a hundred thousand people working in health and care wanting to do things better, so of course we already have great ideas and impressive innovation.

But the benefit of this collective creative energy has not yet been fully realised because we do not have a systematic approach to taking these ideas and innovations rapidly to national scale.  That is what we need if we want to move from where we are now to a sustainable prudent healthcare system.

What is prudent innovation?

When people talk about innovation they usually do so in an open-ended way, because nobody knows what will be invented, or what the next great idea might be. Linking innovation to prudent healthcare means exerting some direction and control over the process, and over the areas in which we want to innovate.  If we want to urgently change our healthcare system, with limited resources, then we need to focus our time and money on that task, addressing the things we know we need to change.

Creating this link between innovation and prudent healthcare will be both engaging and motivating because directed effort is easier to explain and easier to understand.  Innovation offers excitement and opportunity, positive things which will have a halo effect on the promotion of prudent healthcare.

Do no harm

Innovation is about doing things better, so we must be absolutely clear that there is no compromising quality, safety, security, ethics or any of the other embedded safeguards in our healthcare services. In the context of innovation, doing no harm also means that we need to give people absolute assurance and confidence that trying something new will not harm their career or their reputation. We must create a safe environment for taking risks, because sometimes trying to do things better does not work. In fact, we are probably not innovating hard enough unless some of the things we try out do not work. Failure is a very strong learning tool, so we need to allow it. If people fear to fail, they will not risk putting themselves in harm’s way by trying; and if they do not try they cannot succeed.

Minimum appropriate intervention

We must do more to encourage and support innovation than we do now. We should be bold enough to learn from venture capital, which is deeply engaged with innovation and always aims for the maximum return on investment, even as it tolerates a level of failure. The way it does this is to back strong teams, to give them really clear milestones, and just enough money to reach them. Projects only get further investment if they deliver against their plan, otherwise the project or the team are changed, or the investment is written off. Investors use resources sparingly and they take delivery very seriously, using a systematic approach.

We need to do the same in healthcare – skills, time and money are precious resources so we cannot afford to waste them. Whatever we are doing to innovate, we need to set out a pathway to system-wide adoption, marked by unambiguous milestones and make continued support conditional on meeting them. This should apply to developing, testing, evaluating and rolling out new processes and practice, no less than to products and services.

Equity and co-production

Nobody has a monopoly on good ideas – we are all in this together so every perspective must count. In the health and social care workforce, new ideas and innovation need to come from everywhere – from front-line clinicians as well as from researchers, academics, specialists, managers and support staff. We also need to pull in ideas from outside by working with other healthcare providers, public services, the third sector, patients and the public, and with industry.

Just as prudent healthcare proposes a more equitable relationship between patients and providers in clinical terms, we should welcome views from the public and patients on how services and experiences could be improved and we should involve them at an early stage in trying out new prototypes, developing digital services, and so on.

The quest for value in healthcare is a global one, and it serves a huge market, so we should also collaborate more effectively with life-sciences industries, in order to benefit from their knowledge and endeavour. We have things which partners find it very hard to come by – hands-on know-how, clinical experience and instinct, access to patients, national scale, comprehensive coverage, trust and confidence – when we work with others we need to understand that embedded system value. This will help to ensure that we are really co-producing, sharing effort and reward, with every partner making an equitable contribution and getting a fair return.

Only do what only you can do

No one person can take an innovation from an original idea to widespread adoption. Developing a prototype, protecting intellectual property, raising finance, building a business, training people, sales and marketing – all of these aspects of innovation need different skills, many of which do not currently exist within our healthcare system. We need to address this gap in two ways.

Firstly, we need the right skills and experience available.  Sometimes this will mean releasing people from their current role, but more often it will mean using dedicated and experienced teams to accelerate the development of ideas and projects. Their competence, effectiveness and expertise will develop through being tightly focused on this activity, in the same way as for clinical practice.

Secondly, we need to build trust and confidence in this approach. Many people hold on so tightly to an idea it never has a chance of being developed and applied. This is often because they believe they could be exploited or denied a fair share of the value of their idea. This is challenging territory but one way to address it is to set out a systematic innovation pathway which offers reassurance on confidentiality, competing interests and commercial exploitation. Success breeds success.

None of this means that innovation can be delegated away. Delivering services is likely to be the origin of most ideas and the front line of healthcare will always be the place where innovation is developed, refined, tested, evaluated and adopted. Almost all of the people who will be delivering prudent healthcare in 2020 are already working in Wales now and they are the people who will deliver the rapid transformation we need. We need to develop capability and capacity with urgency and purpose – spreading innovation skills throughout our workforce, and creating an environment in which they will be used.

How to make innovation happen

Innovation is ultimately about people. The answer given to the question of how to make it happen, is most often suggested to be leadership to support the development of an innovation culture.  These two things are important but in isolation this approach underestimates the challenges of organisational change, fails to take account of structural barriers to innovation, and in some cases assumes that culture is the same as competence.

Perhaps it also overstates the cultural opposition to innovation, because people are very willing to innovate and to adopt new things, if it is easy and attractive to them.  So as well as leadership and culture, we should try to make innovation and adoption easier and more rewarding for everyone. Part of that will be about steering innovation towards the areas where it is most needed because that is where it is likely to make a bigger difference, and to deliver greater improvement.

Use information

Information drives improvement at every stage. Looking at compliance and variation helps focus attention on things which are out of the ordinary. Understanding the resources and outcomes involved in a clinical pathway will highlight areas for improvement, or indicate potential value from prevention or early intervention. This kind of information generates new knowledge and understanding, which in turn stimulates innovation. Information also helps to measure impact and to provide feedback on experimental and incremental changes during the development of a new process, product or service, so it is a key part of the innovation pathway.

Evidence-based appraisal and evaluation is a critical part of the adoption process. A health system needs to provide a solid foundation for innovation, and a large part of that is having information which is routinely collected, comprehensive, accurate, consistent and timely. Patients and the public need the same information if true co-production is to become a reality.

Have a system

People take comfort from clarity and certainty. Methodologies and pathways speak to clinicians. They will have more confidence to innovate if there is a clearly set out approach to innovation, which is delivered in a systematic way. If people know what will happen to their idea when they share or disclose it, they will be more willing to do so, even where there is a likelihood that it will be rejected. This is important because only a few ideas will make it all the way to widespread adoption and most will fail at the first hurdle, so people need to be prepared for disappointment. A well-presented innovation pathway is therefore a wonderful tool for promoting awareness and engagement with innovation, as well as a tool for managing expectations, and for managing the performance of innovation teams and functions.

Provide a structure

People also take confidence from things being real. That does not mean investing in bricks and mortar but it does mean having identifiable services, dedicated teams, a published calendar of events and other similarly tangible things that people can engage with. These structures reinforce organisational and leadership commitment to innovation and they are also recognisable ways for people to access the basic resources they need to support innovation, like expert advice, hands-on support, networks and partners, information, explanation and reassurance. This should be embedded into training and education for managers and clinicians.

Invest resources

For every idea with genuine potential there comes a point where additional resources are needed. Every innovation needs people and money to translate quickly from an idea to widespread practice. This is not limited to commercialisable ideas: even pure practice improvement needs help to be widely adopted, because evidence is rarely enough unless it is made easily replicable, backed by promotion, communication, training, products, systems, software.

Resources are scarce, so there needs to be a system which robustly and transparently allocates them to the right projects, and continually drives delivery against challenging milestones. This includes assigning people to projects alongside money, reflecting the prudent principle of only do what you can do as well as minimum appropriate intervention.

Provide space to innovate

It is hard to innovate in your spare time and it is hard to innovate in a very large organisation. We need to provide the space for innovation: if they are the right person for the task, we should release people from their daily roles; if things need to be protected from other demands and pressures, to be agile, or to work with partners, then they may sit better at arm’s length from service delivery. Providing space and the right environment also means creating room for failure, so that we do no harm to people willing to push innovation.

Culture

Finally, innovation needs clear leadership, constant encouragement, incentives and recognition. It needs skills development throughout the workforce and demonstrable engagement at every level. It must not only permeate our organisations, but also invite contribution and collaboration from external partners, including patients and the public.   Working our way to a better system of prudent healthcare is in all our interests, so we all have an equal part to play.

Next steps:
  • Create a national structure for innovation, adopting the general principles set out here, drawing on recommendations made by the Health and Wellbeing Best Practice and Innovation Board, and informed by models of good practice in other parts of the NHS and internationally
  • Set out and deliver a systematic approach to innovation, which helps to promote understanding, to allocate resources, to manage expectations, and to drive performance
  • Each health board must make a real commitment to innovation, by designating a board champion, an executive director lead, and an innovation team or function with dedicated and protected resources. Innovation should feature prominently in integrated medium-term plans
  • Deliver an Invest to Change fund, which will serve to: incentivise innovation addressing known challenges, aligned to prudent healthcare; and provide resources to drive accelerated innovation, using expert teams and delivery milestones.
  • Implement a sharply focused innovation and improvement skills strategy, which will develop workforce capability, and should also include measures to create a better environment for the use of innovation skills.

Our ambition must be for the NHS in Wales to be defined by its commitment to innovation, demonstrated both in its support for research and its success in the rapid adoption and diffusion of the best, transformative, most innovative ideas, products, services and clinical practice.

There are great people in the NHS in Wales with great ideas. Through a focus on prudent innovation, we are going to enable and encourage them to turn those innovative ideas into reality. This will result in better care and outcomes for our patients.

 


Further Reading

Christensen C, Grossman J, Hwang J. The Innovator’s Prescription: A Disruptive Solution to Healthcare. McGraw-Hill; 2009.

Health and Wellbeing Best Practice and Innovation Board. Reports and Recommendations. 2013; Available at http://www.wales.nhs.uk/sitesplus/888/page/67458

NHS England. Innovation Health and Wealth: Accelerating Adoption and Diffusion in the NHS. 2011; Available at http://www.england.nhs.uk/wp-content/uploads/2014/02/adopt-diff.pdf

Topol E. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Basic Books; 2012.

Welsh Government. Innovation Wales. 2013; Available at http://wales.gov.uk/topics/businessandeconomy/innovation/innovation-strategy-wales/?lang=en


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Watch Chris Martin talk more about this article, click the video to view.

Example of good practice: Welsh Wound Innovation centre

The Welsh Wound Innovation Centre is an all-Wales centre for research, teaching and innovation in the field of wound healing and prevention.  It received start-up funding from the Welsh Government and all health boards, and operates as an arms-length collaboration between the NHS, universities and industry.  This multi-partner approach systematically links the delivery of clinical services to research, innovation and improvement.  The centre also has international links and has already contributed to attracting two new companies to invest into Wales.

Making it happen

  1. We have to innovate now – the way we have delivered healthcare services over the past 65 years leaves us struggling to keep up with the pace of change. This is something we have to address.
  2. We have to innovate to deliver prudent healthcare – innovation will be the key to working out how we can transform our existing healthcare model into one reflecting the principles of prudent healthcare.
  3. We need prudent innovation - we need an approach which responds to Welsh needs and we should apply the principles of doing no harm, minimum appropriate intervention, equity and co-production t the way we innovate.
  4. We need to commit resources to make innovation happen – we should use information to drive improvement, have a systematic approach, establish support structures, create and protect space for innovation, and develop innovation culture and capability.

We should be developing prudent housing alongside prudent healthcare @HousingandCare #TAI17 @rmollart pic.twitter.com/yIXkjyKaJk