Why we need innovation in the NHS
The North and East London Commissioning Support Unit, or NEL, sits within the NHS and provides a range of services to commissioners¹, providers², and NHS England, such as finance, IT, HR, medicines management, business intelligence, and data insight. NEL’s Healthcare Consulting team works on strategic health and care projects for clients across the whole NHS system, many of which are focused on transformational change.
I sat down with James Davis, Head of Innovation at NEL Healthcare Consulting, to talk about what innovation really means, the role it needs to play in the NHS, and whether or not we should fear the coming of robots.
James Davis has been working at NEL since 2013, implementing technology solutions in various roles in telecommunications and IT. He now finds himself a few months into a new role as Head of Innovation, juggling his time between looking after a portfolio of innovation-focused projects for healthcare providers and commissioners across the system, productising NEL’s services in efficient ways (for example, through continuous quality improvement and automation), and driving a culture of innovation internally at NEL. James also chairs NEL’s Innovation and Digital Board, building out an internal learning & development offering to give colleagues the tools and techniques they need to be innovative. He sits at the intersection between the public and private sector, maintaining relationships with technology leaders like Amazon and Google, with NHS trusts like Guy’s and St Thomas’ and the Royal Free, and in many cases bringing those two worlds together. That could look like anything from simply enabling WiFi in GP surgeries, to implementing an IoT (Internet of Things) video system to allow a mother to connect with her newborn in a paediatric intensive care unit, or introducing robotic process automation to help healthcare providers tackle backlogs of referrals and cancelled appointments. One thing he doesn’t see on the horizon anytime soon is boredom.
What is innovation? Is it synonymous with advanced technology?
“Innovation is executing an idea that addresses a specific challenge, and at the same time achieves value,” says Davis when asked for a definition. He is quick to emphasise execution beyond just ideation. “It’s fairly easy to get a bunch of people in a room and be creative and sit on beanbags; it’s another to then say, right, let’s put it through a rigorous gateway process; let’s pull it apart, put together a minimum viable product, and see if it actually stands up in the light of day.”
Inherent in successful execution is adoption and an appreciation of the case for change. What use is an awesome idea if no one else cares about it or understands why they need it? He cites the example of TiVo, first hailed as a revolutionary disruptor on its way to being used as a household verb, but ultimately falling short when consumers weren’t convinced that they really needed the product. To quote The Economist, “just because technology enables people to do something does not mean they will.”
In terms of what innovation looks like, Davis explains that it doesn’t always have to mean a flashy digital tool or piece of tech. He recounts a story about how the Americans spent millions during the space race designing a pen that could write in space, while the Russians just brought a pencil. Whilst he notes that this story is actually a myth, the concept still rings true. He brings up the well known issue of the scarcity of NHS hospital beds, and says that whilst on the one hand there are emerging data analytics platforms and tools to predict and plan bed demand better, the innovation needed in this case is more likely to lie in thoughtful, thorough process change. This would include, for example, examining the robustness of referral pathways to community services that actually allow patients to receive treatment at home where possible.
Indeed a 2018 review of recent innovation case studies published by the King’s Fund echoes this idea, noting that “while technology was often a key enabler, it was not necessarily the most important feature of the service innovations we studied… 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.”
Do we need innovation? Does the NHS?
The word innovation, which Davis bemoans as a now overused buzzword, can sound scary to some people. But, he says, “the NHS, whether people realise it or not, is constantly innovating,” even if gradual changes over time mean it’s hard to see. We’re happy and now even expect that our patient record will be held digitally, even if sharing it across health and social care still eludes us. Or that we have the ability to map not only the human body, but also our entire genome to better understand how we can live longer healthier lives. Yes, there’s more to do, but we would do well to remember how far we’ve come.
In Davis’ mind, this is partially a natural thing. “Humans naturally desire to see something, evaluate it, and improve it.” Plus, even when we’re talking about implementing a new piece of technology, the process can have quite a human element and reward. Davis recalls a project he was involved in to improve a complicated assurance process for high cost drugs that ensured patients weren’t under or overpaying, or being issued a drug that had been discontinued. Introducing robotic automation meant first bringing together many teams in different silos that had a hand in the process, into the same physical room for the first time to actually pick it apart. And the end result after isolating the pieces that really required human intelligence was that the teams actually felt more rewarded in using their resources more efficiently, and less stressed when they came into work.
While some believe innovation is a nice-to-have for when things are going well and we have extra time on our hands, Davis argues that “we actually need it most when things are not going well.” Several times over the course of the interview he cites the old adage that if you do what you’ve always done, you’ll get what you’ve always gotten. With particular regard to the NHS, he notes that the current state of affairs, especially with regard to financial constraints, means there’s no choice but to look at how to do things differently.
Barriers to innovation in the NHS
That said, there is no shortage of potential barriers to overcome in order to take advantage of innovative ideas in an organisation, not least in the NHS. For starters, there are familiar issues of money and time. Davis notes that some innovative ideas require significant spend in research and development before a minimum viable product can even be brought to market; he mentions the billions of pounds that Deep Mind have put into artificial intelligence so far without yet introducing a product, and how these amounts dwarf the funding the NHS will be able to access. “It’s also difficult to manage innovation, appetite for risk, and embracing failure, when you’re doing so with essentially somebody else’s money,” he adds.
Having responsibility for patient safety and health puts the NHS in a unique position, where the equation around risk-taking and reward is necessarily a bit different. Steering clear of negative newspaper headlines and any detrimental impact to end-users understandably plays a bigger role in decision-making when those end users are patients. For example, the multi-stage and careful process of clinical trials often means a long lag before new and innovative treatments can be released to the public.
Furthermore, the more helpful information and data we are able to collect, store, and process about patients, the more important safeguarding and governance become, with the potential for information to get into the wrong hands; these concerns justifiably can slow down the pace of change.
Davis also highlights resourcing challenges facing the NHS around recruitment and retention, especially for innovators who might be more tempted to work for the likes of Google or Amazon. “Working directly for the NHS is more than just a day job; the hard working and dedicated people across the system do so out of desire. The NHS needs to continue to make itself a great place to work, knowing when you leave for the day you’ve made a change to the system, not only your bank balance.”
Finally, a key challenge not unique to the NHS is that of adoption, and the need for key players in the system to actually want innovation and see its value. For example, in the growing push towards digital primary care, GPs will need to see value in taking advantage of new digital tools to open up bookable online appointment slots before they embrace them; those tools won’t take flight if GPs perceive that they will hamper their ability to treat the right patients. Equally, a patient that hasn’t grown up accustomed to managing his or her health online might not love the idea of speaking to a clinician over a video call on a mobile device.
…Yet reasons to be hopeful
Despite challenges, Davis sees reasons for hope when we discuss the conditions necessary for successful innovation in the NHS.
Opportunities for breaking down barriers in adoption come with the growing prevalence of technology in our lives, and in starting to become accustomed to using digital tools to carry out other essential life functions. Davis sees the financial sector as a leader here; as we get more used to doing our banking on our smartphones, the idea of looking after our healthcare needs online starts to become more palatable too. He reminds me that it wasn’t long ago that selfies were not a thing and that people were uncomfortable seeing themselves on screen, whereas today the practice of using this kind of technology has gone far beyond the early adopters and into the mainstream.
This is only more true for the next generation of patients. “There are children today who will have never known a time when they haven’t spoken to a machine that gives them an answer, which is ridiculous if you think about it,” he says. (Anyone else’s mind immediately jump to the scarily prescient recent BBC1 series Years and Years?)
He adds an example from his own experience working with community health providers that offered anti-obesity and sexual health clinics. These providers found that patients were sometimes uncomfortable walking into a building that had “sexual health clinic” plastered onto the front of it, and that patients struggling with obesity and potentially accompanying mental health issues didn’t always enjoy leaving their homes. Introducing a platform to allow video consultations with clinicians helped address these patient stresses and allowed clinicians to keep in touch with them regularly.
He also sees a growing appetite and openness from NHS trusts to have conversations with cutting-edge technology providers early and often, especially around the use of automation technology and artificial intelligence. He cites the example of an intelligent automation platform provided by Thoughtonomy and procured by the East Suffolk and North Essex Foundation Trust that has, by way of employing “virtual workers”, cut down the initial stage of GP referrals down to five minutes from 15, saving staff time and ultimately driving a better patient experience by prompting faster actioning of referrals.
Davis finds this growing recognition of the importance of innovation reflected in the increasing number of roles like his that he sees being established across the public sector, by leaders that are ready to instill a culture of innovation in their organisations. He adds that these leaders have to genuinely walk the talk themselves, too. “As children will see through their parents, staff will see through their leaders,” he adds; leaders wanting to truly encourage innovation must live and breathe it themselves.
What the future looks like
I asked Davis what he’s most looking forward to in the years ahead. He’s excited about the potential of artificial intelligence and machine learning, and pointed out that many of the opportunities for innovation to improve patient outcomes are in early detection and intervention. He referred to the recent headlines about an artificial intelligence model developed by Google Health that diagnosed breast cancer better than human consultants, opening up the possibility of AI to function in future as one of two reviewers in a speedier diagnosis process (the other, still a human). He visualised what a suite of cognitive analysis services, with machine learning at its core, could look like in a doctor’s waiting room: cameras that identify how many people are waiting, take a read of each person’s body temperature, categorise their demeanor based on facial expression, and then tie that data back to what we know will indicate which patients are likely to be severely unwell, to then help get them the intervention they need sooner.
Imagine a clinician consultation with a patient where a computer is “monitoring the consultation, transcribing the conversation, analysing its content against medical dictionaries and data repositories, and building up a series of possible diagnoses or thoughts that would then help or support the clinician in their triaging process and treatment of the patient, whilst at the same time putting everything onto the patient record.”
So basically, put into Terminator terms: “the future is about how Skynet won’t kill us, but help us.”
Bringing it back to purpose
In Davis’s mind, purpose-driven thinking is needed for patients, providers, commissioners, and others across the healthcare system to embrace the innovation and change that will enable progress towards improved patient outcomes. He cites Simon Sinek’s Golden Circle concept and the importance of going back to the ‘why’. “If you can help people to understand their why — why it is that they do what they do, not just what it is that they do, then they’re on the journey with you, and they’ll natively want to live that in their everyday life.”
In the context of healthcare then, it’s important to keep in mind that ultimately, the patient should be at the centre of innovation activity. For Davis, that’s what brings him in to work. “I think in general, we need innovation, to feel sustained and feel like we’re contributing to the greater good as it were. It’s good to walk away from a day at work feeling like you’ve done something that brings benefit to the end-user; in this case, the patient.”
When asked if it’s everyone’s responsibility to innovate, he would reframe the question. “It’s everyone’s opportunity to.”
This interview was transcribed in a matter of minutes with pretty impressive accuracy by otter.ai, which also then facilitated easy corrections with its smart in-line audio playback. I thought this was a pretty apt time to try it out.
[1]: Organisations that contract with providers to provide health and healthcare services
[2]: GPs, hospitals and other NHS trusts
