John Day is a physicist at the University of Bristol in the United Kingdom. He has an innovation that he believes will not only improve patient care but also save the National Health Service (NHS) time and money. Day and his colleagues have developed an endoscope that can be used not only to look at tissue in the esophagus but also diagnose cancer in situ. This eliminates the need to take a sample and wait for the results, which benefits both the patient and the clinician by allowing for earlier diagnosis.
However, like so many health-care innovators across the United Kingdom, he has found the process of commercializing his technology slow and frustrating. “I spend my time writing grant proposals and trying to find funds to continue the development of our miniature confocal Raman probe,” says Day. “The number of support organizations is bewildering, and the regulatory issues are a minefield!” The project has currently stalled while the team looks for funding to take the probe through clinical trials. “We have been working on this technology for more than ten years,” says Day. “The slow progress is frustrating because this product really can improve patient care.”
Day is pleased to have help and support from NHS Innovations South West (NISW), one of several innovation hubs set up by the previous U.K. government to help promote innovation from within the NHS. Angus Donald, NISW’s business development manager, told IEEE Pulse: “This endoscope not only has clinical benefits and patient benefits but also offers cost savings and has global reach. Patients will only benefit if we get it to market quickly. The problem is that to do this, we need investment. Investors want to invest in products that have been thoroughly tested, have a clear regulatory pathway and good clinical evidence. In many cases, to achieve this, the NHS needs to invest in innovation.”
Despite keen interest in finding new innovative health-care solutions that offer multiple benefits, such as Day’s endoscope, the move to invest in innovation is coming slowly and painfully in the United Kingdom, partly because the NHS system is not just one system but a compilation of several independent organizations. Even so, as concerns over the economic climate grow, efforts to implement change within the NHS have begun.
Navigating the NHS: Making Room for Innovation
From the outside, the United Kingdom appears to have an NHS. It is known around the world for providing a comprehensive range of health services, the vast majority of which are free at the point of use for residents. It appears to be one huge national organization, with national standards of care, a national procurement system, and a national management structure—one enormous single market. So theoretically, companies and individuals with innovations that could improve the efficiency and standard of care of that single market should find it quite straightforward to access this market and see their innovations used across the whole of the United Kingdom. But, unfortunately, things are not that straightforward.
For one thing, the NHS is not really national at all. It is divided into four NHSs—NHS England, NHS Wales, NHS Scotland, and Health and Social Care in Northern Ireland. These individual health services are quite independent and operate under different management, rules, and political authority. Each one of these organizations is then divided into smaller organizations, and it is these smaller entities that make decisions about how money is spent. NHS England is by far the largest of the four NHSs and has recently undergone some major structural changes. Until April 2013, it was divided into ten strategic health authorities and, below this, locally accountable trusts and other bodies. Now, it is divided into 160 acute trusts, which ensure that hospitals provide high-quality health care and that they spend their money efficiently, and more than 200 clinical commissioning groups (CCGs), which are responsible for commissioning services for their local communities.
Each trust and CCG is encouraged to act independently and serve its local population. So if a company has an innovation that has been adopted by an acute trust in Manchester, this does not mean that it will automatically be adopted by an acute trust in London. “It’s a bit of a mess,” says Tony Davis, chair of Medilink U.K., a national health technology business support organization. “The impression is that the U.K.’s NHS is one large single market. But in fact it’s not—it does not behave like a large single market. We have as many hospital groups as the United States, resulting in multiple access points where innovative companies have to influence decision makers in order to get their innovation commercialized.”
These multiple access points make it a real challenge to get an innovation adopted nationwide. “In reality, if you manage to sell your innovation to one trust, even if you use the same evidence to make your case, it doesn’t mean another trust will adopt your innovation,” says Davis. “When it comes to innovating, in the United Kingdom, we are great at inventing, but we can’t seem to get the adoption and commercialization bit right. The NHS often exhibits poor procurement practice and is lacking a harmonized way of adopting new technology and ideas across the whole system.”
Miles Ayling, head of innovation for NHS England, agrees. He told IEEE Pulse: “The NHS has long been accused of being slow in adopting new ideas, but then any large disaggregated organization such as the NHS struggles with this. The government has recognized this and, with publishing of the Innovation Health and Wealth (IHW) report, has come up with a plan to improve the situation.”
Creating an Innovation Model
Coming up with a model to improve technology adoption and innovation in the NHS is no mean feat. It is no good looking around at other countries to see what they do because the NHS is so different from any other health-care system in the world. The new model was not going to be driven by free-market forces alone, but it was also not going to be driven by the state alone. “Changing the way the NHS works, breaking old business models, will take pressure from all directions,” says Ayling. “We are determined to change the ‘not invented here’ attitude that prevents innovations being copied and adopted by other trusts and NHS organizations.”
Ayling goes on to describe the model that will be used to bring about this change—top-down, horizontal, and bottom-up pressures. Top-down pressures involve changing central requirements, regulations, and incentives, as well as support, such as guidance and skills development. Horizontal pressures are factors such as peer influence, transparent reporting, collaboration, competition, and effective marketing from external suppliers. Bottom-up pressure comes from patient and public demand for best practices, professional and managerial enthusiasm, entrepreneurialism, and choice.
“This model will be used to break down the six key barriers to innovation that were identified in the IHW report,” says Ayling. “Some will take longer than others. For example, changing the leadership culture will take time, whereas some, such as the need to recognize and reward innovators, are already in place. And with the recent setting up of the 15 academic health science networks (AHSNs), we hope to address the lack of innovation architecture.”
The 15 AHSNs will fundamentally change the way health-care innovation is handled in England. They have been created to drive innovation in the NHS—and create wealth for the U.K. economy. Their core functions include informatics, service improvement, procurement, and engaging the NHS with research. The idea is that everyone who is involved in health-care innovation should be part of an AHSN. This includes industry, hospital trusts, commissioning groups, universities, NHS organizations, patients, and clinicians. “An AHSN will now be the first local point of contact for anyone, whether they work within the NHS or outside it, who has an innovation that will improve patient care,” says Ayling.
Angus Donald welcomes the setting up of the AHSNs as he believes it is important to drive innovation at a local level. “The creation of the AHSNs is a good step forward,” says Donald. “But driving innovation in health care in the United Kingdom is still fundamentally a challenge. Each organization within each AHSN faces its own financial challenges, and, at the end of the day, the primary aim of the NHS is patient care, so even the most forward-thinking acute trusts struggle to invest in innovation.”
Medilink’s Tony Davis also welcomes the establishment of the AHSNs. “We are wholly supportive of the IHW report, particularly because of what the ‘W’ stands for (wealth),” says Davis. “Until now, the department of health (DH) has seen itself solely as a consumer of wealth. But now it has realized that it can also generate wealth by improving the way it innovates and by working closer with industry.”
Davis hopes that the AHSNs will go part of the way toward achieving this goal by reducing the points of contact for companies and individuals who want to bring an innovation into the NHS, thus speeding up the adoption of new technologies (see “Decluttering the Landscape”). “The NHS has been protected from reality for many years,” says Davis. “While it continues to invest in increasing its workforce numbers, every other industry sector has had to find ways of working smarter and leaner by investing in automation and digital technologies.”
[accordion title=”Decluttering the Landscape”]
In the IHW report, Sir lan Carruthers, chief executive of NHS, South of England, admitted that NHS England needs to “declutter the landscape.” He wrote: “Over the last decade many new organizations charged with improving innovation in the NHS have emerged. The landscape is now fragmented, cluttered, and confusing.”
Miles Ayling, head of innovation for NHS England, agrees. “We did an audit, before IHW was published, of all the organizations that offer advice and support on innovation,” he says. “There were so many that we had to stop counting. And they were all paid for by the public purse.”
Many of the old organizations are now shutting down or have already shut down. The establishment of the 15 AHSNs will bring together the remaining organizations and give innovators and industry clearer points of contact for access to the NHS. “The AHSNs will be funded by NHS England with an element of local match funding to begin with but will eventually need to become self-funding,” says Ayling. “The AHSNs will have to become good at spotting new ideas and adding value.”
In addition to the AHSNs, there are still many other organizations that offer support and advice about innovating in health care in the United Kingdom. These organizations, and the services they offer, are listed in the table below.
Organizations That Offer Support and Advice About Innovating in Health Care in the United Kingdom
|Organization||Support Available For:|
|Association of Medical Research Charities
|The Medical Research Council
|NICE Implementation Collaborative||X||X|
|NHS England’s Innovation Hub||X||X||X|
|The National Institute for Health Research (NIHR)
|NHS Innovation Challenge Prizes
|NHS Regional Innovation Hubs||X||X|
|Engineering and Physical Sciences Research Council
|Technology Strategy Board (TSB)
|Wellcome Trust Translation Funds
|Association of the British Pharmaceutical Industry (ABPI)
|Association of British Healthcare Industries (ABHI)
|British Healthcare Trade Association
|The British In Vitro Diagnostics Association (BIVDA)
|National Institute for Health Research Devices 4 Dignity
|Small Business Research Initiative (SBRI)
|Rapid Review Panel (Department of Health)||X||X||X|
|NHS Supply Chain
Testing the Model with Telemedicine
It seems the NHS has finally woken up to the use of modern methods of working. This is evidenced by the NHS’s recent push to roll out telemedicine. After a big successful demonstrator project in 2011, which showed that telemedicine (also called telecare or telehealth) can substantially reduce mortality in patients with a range of conditions, NHS England has initiated what it claims is the “largest rollout of telehealth anywhere in the world.”
“Face-to-face contacts make up 90% of all health-care interactions in the NHS,” says Ayling. “Every 1% reduction saves up to £200 million for the NHS; yet, many opportunities to provide more innovative solutions are missed. We plan to change this by encouraging remote consultations and the use of e-mail and text messages to communicate with patients.”
Ayling cites the example of home dialysis for patients with kidney disease. “Many patients prefer to do dialysis at home if they can, and this also saves the NHS money,” he says. “We want to enable more patients to use home dialysis, but to do this, we have to come up with new ways of working with industry to make the equipment more affordable to the acute trusts. This may involve rental agreements instead of purchases, or other financial arrangements, for example.”
[accordion title=”SBIR vs SBRI”]
The United Kingdom’s Small Business Research Initiative (SBRI) is similar to the United States’ Small Business Innovation Research (SBIR) program. The SBRI is a simple process. Typically, competitions are split into two phases. All competitions are based around a market need, which is expressed as a desired outcome, rather than a required specification. Phase 1 proposals concentrate on proving the scientific, technical, and commercial feasibility of the proposed project, while prototyping is undertaken in phase 2. Projects that successfully complete phase 2 can then be commercialized and offered to government departments and others under a normal procurement process.
The amount of money available in SBRI grants has increased substantially over the last few years. “In 2009, £5 million was on offer for SBRI grants,” says Miles Ayling, director of innovation for NHS England. “This now stands at an annual budget of £10 million and is set to increase to £32 million in 2014, with an aim to get to £64 million in the years to come.” But according to Tony Davis, chair of Medilink U.K., the initiative has one flaw. “In the United Kingdom, if a company gets some SBRI money, the U.K. government says ‘if you are successful, there is no guarantee we will be able to purchase’.” This is because European Union (EU) legislation requires all tenders to be available to the whole of Europe, not just the United Kingdom, says Davis.
But Ayling does not believe that EU legislation is a barrier. He says: “It is only right that companies should have to tender for business. However, we recognize that the NHS does have an issue with innovations sitting on shelves and not being used, and that is why, in the future, the AHSNs will oversee the awarding of the SBRI funding. It is hoped that they will only award funding to those technologies that they themselves have a market for and thus there is a higher likelihood of the local NHS organizations adopting the innovation.”
Find out more at http://www.sbrihealthcare.co.uk/.
Financial incentives play a major part in the model that NHS England has adopted to encourage innovation: for example, it has increased the amount of money available in grants (see “SBRI versus SBIR”) and also the Commissioning for Quality and Innovation (CQUIN, pronounced “sequin”) framework. The CQUIN payment framework enables commissioners to reward excellence by linking a proportion of English health-care providers’ income to the achievement of local quality improvement goals. CQUIN payments will only be made to those providers who meet the minimum requirements of the high-impact innovations (see ”High-Impact Innovations”) as set out in the IHW report. In short, if an organization cannot prove that it encourages innovation, it loses about 2% of its income.
[accordion title=”High-Impact Innovations”]
NHS England has identified six high-impact innovations and every NHS organization is expected to address these or face losing part of its funding.
- Three Million Lives: Rapidly accelerate the use of assistive technologies in the NHS. The DH believes that at least three million people with long-term conditions and/or social care needs could benefit from the use of telehealth and telecare services. Implemented effectively as part of a whole system redesign of care, telehealth and telecare can alleviate pressure on long-term NHS costs and improve people’s quality of life through better self-care in the home setting.
- Esophageal Doppler Monitoring (ODM): ODM is a minimally invasive technology used by anesthesiologists to assess the fluid status of the patient and guide the safe administration of fluids and drugs. NHS England aims to launch a national drive to get full implementation of this or a similar fluid-monitoring technology into practice across the NHS.
- Child in a chair in a day: Improve the provision of wheelchairs for children, bringing the waiting time down from an average of 200 days to one day.
- International and commercial activity: NHS organizations are required to work with the NHS Improvement Body supported by U.K. Trade & Investment to explore opportunities to increase national and international healthcare activity.
- Digital by default: Decrease the number of unnecessary face-to-face interactions and increase the use of lower-cost alternative such as e-mail, remote consultations via telephone, or online technology.
- Caregivers for people with dementia: Improve the support for caregivers of people with dementia. Better support is needed in emotional support, assistance with day-to-day caring, respite and short breaks for caregivers, and access to a range of psychological therapies.
This represents a fundamental change in attitude toward innovation in the NHS and the U.K. government and was driven by a realization that the NHS could not continue on as it has for many years. “Now, and for the foreseeable future, we face a much tighter economic climate,” says Ayling. “This means that simply doing more of what we have always done is no longer an option. We need to do things differently. We need to radically transform how we deliver services. Innovation is the way, the only way, we can do this. Innovation must become core business for the NHS.”
As the way innovation in health care is encouraged, managed, and adopted in the NHS in England undergoes major changes, how will we know if these changes have been successful? How will we know if, in ten years’ time, the NHS is more innovative than it is today? “Measuring the success of the new strategy is a major challenge,” says Miles Ayling. “There are lots of innovation indices, but they are hugely complex and impenetrable. So we have developed a three-part plan to measure the success of the new strategy. It involves an academic approach, introducing basic measures such as the innovation score card, and measuring whether the culture of an organization has changes using the innovation compass.”
NHS England has commissioned a formal evaluation of the impact of the IHW report. Many of the major U.K. universities are expected to tender for this work, and it will result in a full academic study lasting up to three years. Scorecards will be used to measure levels of compliance with technology assessments (TAs) compiled by the National Institute for Clinical Excellence (NICE).
The innovation scorecard is not intended to be used for performance management or for benchmarking purposes. It is intended to identify where variation in the adoption of TAs may exist between health-care organizations and for these organizations to understand, be challenged, and explain any variation. This is based on the assumption that reduced variation will result in improved quality of care. The final measure, the innovation compass, is a self-assessment tool kit that organizations can use to assess whether or not they do enough to encourage innovation.
Together, these measures will help provide the means for the NHS to gauge how well these new innovation models have met the needs of U.K. innovators, industries, and most importantly, the patients who rely on them.
- Innovation Health and Wealth: Accelerating adoption and diffusion in the NHS
- Innovation Health and Wealth: One year on
- The structure of NHS England
- Explanation of AHSNs
- Miles Ayling discusses Innovation in the UK, Video