The NHS is a complex network of organisations, each with their own duties and priorities, micro cultures and regulatory requirements, and each managing exceptional financial pressures. Significant efforts have been made to support the adoption of innovations across the NHS, but against this backdrop, it still struggles to overcome a number of obstacles.
Following the Nuffield Trust review of innovation in the NHS, this blog explores some of the system barriers that hamper attempts to spread innovation. While the Nuffield Trust explored MedTech in particular, the barriers are pertinent to innovation and improvement initiatives more broadly.
In their review, the Nuffield Trust found that those seeking to encourage the spread of innovation continue to lament silo working, the inability to introduce change in to pathways of care that span services, and an unwillingness to invest in innovations that produce savings elsewhere. These experiences are not just limited to the area of innovation and, to a large degree, reflect the way the system has evolved. While the current legal and system architecture certainly does not prevent collaboration across institutional boundaries, it is predicated on the autonomy of individual organisations.
The tension between competition and collaboration is once again in the spotlight.
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The tension between competition and collaboration is once again in the spotlight. We have the move towards services providing joined-up and integrated care around the needs of patients, as set out in NHS England’s Five year forward view, alongside the imperative to meet individual obligations to local communities, commissioners and the regulators.
This makes a challenging environment for NHS trusts, and their partners, to navigate. The tensions manifest themselves in the ways in which care is organised, paid for and regulated. Under the current system, payments are made within organisational boundaries. Activity based reimbursement, such as payment by results can discourage joint working or investments in initiatives to prevent future ill health, both of which are national policy objectives.
While trusts are committed to transforming services in line with these objectives - for example through sustainability and transformation partnerships - they are being asked to deliver annual savings in excess of 5%. This is an impossible task which risks the quality of patient care and places an intolerable burden on staff. Given this, it is easy to see how attempts to spread innovations across organisations which are not set up to collaborate and facing enormous pressures can be frustrated.
A key element in the effective adoption of innovation across as system as complex as the NHS is striking the balance right between national approaches and local flexibility.
The temptation is often for the national bodies to adopt a 'command and control' approach with the introduction of incentives schemes, targets and programmes. The danger is that this reinforces the short-term and siloed focus that, as the Nuffield Trust identified, continues to undermine attempts to adopt innovations across the system.
The message that we are hearing is that there is a need for national consistency with local flexibility, enabling local implementation with national support. The recent evidence suggests this is possible: as part of the national new care models programme, NHS England admitted that "many of the local issues that the vanguards have faced stem from the adverse and often unintended consequences of the national rules, systems and behaviours". The vanguard sites have had explicit backing from the national bodies to try new ways of working; as a result they have experimented with pooling budgets across services, developing outcomes-based contracting models and risk-sharing agreements, and introducing innovative technologies.
The national bodies have an essential role to play in setting the frameworks in which they expect organisations to operate, sharing best practice across the system and ensuring that local areas are appropriately funded and resourced to deliver.
A key element in the effective adoption of innovation across as system as complex as the NHS is striking the balance right between national approaches and local flexibility. This is difficult but not impossible. There are two factors that have been especially important for enabling the new care model vanguards to innovate: firstly the national bodies have provided sites with funding to ensure that local teams have the capacity, resources and support they need.
Secondly, they have sought to work with local areas to develop approaches, rather than mandating them. The national bodies have an essential role to play in setting the frameworks in which they expect organisations to operate, sharing best practice across the system and ensuring that local areas are appropriately funded and resourced to deliver. However they must remember that local teams, who have the understanding and experience of their local processes, challenges and histories, are best placed to ensure that innovations are adopted effectively and sustainably.
This article was originally published on the Association of British Healthcare Industries.