18 November 2015
Hardly a day goes by at the moment without the financial and organisational turmoil within the NHS being in the headlines. In a time of pressing financial stringency, arguing the need to invest in cutting edge diagnostic technologies, treatments and other innovative methods of care may seem utterly inappropriate. How can we demand unaffordable luxuries when the system is struggling to meet its existing obligations? As others have already pointed out, this is an understandable but damagingly short-termist view. Indeed, the NHS Five Year Forward View rightly states that innovation will be key to the future success of the NHS in improving the health of our population. Why then, as noted by the Accelerated Access review, is the transformation of the NHS by innovative new science and technology progressing so slowly?
The key to this conundrum is, of course, risk. Investment in an innovation whose benefits are uncertain involves opportunity costs of time and money, and potentially even patient safety. While there are major potential upsides for patient outcomes and system efficiency if an innovative intervention has its intended effect, these often take longer to manifest themselves than the short term risks to in-year balance sheets and performance managed patient outcome measures – a significant disincentive.
The medical profession has developed systems to ‘de-risk’ innovative interventions and enable them to be implemented with confidence where the expected benefits do indeed outweigh the risks: a careful, incremental system of pilots and clinical trials plus supporting policy initiatives such as NHS Test Beds and Vanguards. We also practice evidence based medicine, using rigorous statistical methods to evaluate these trials and tell us whether or not investing in an innovative new approach is ‘worth it’.
So why are we failing to implement innovative interventions (and by extension replace outdated and less effective ones)? There are two key reasons:
The challenge posed by implementing innovations to deliver personalised medicine, such as genomics and electronic health records, can be summed up in two words: scale and maturity. Single purpose drugs or diagnostic devices can undergo thorough evaluation on a small scale and be developed to a mature and stable state prior to implementation. Since the benefit of the innovation experienced by each patient is independent of the number of patients using it and the length of time it has been in use, it is cost effective to trial such interventions in a small sample of the patient population. If these small-scale, low financial risk, evaluations are successful, large-scale implementation in the population should scale linearly and predictably.
By contrast, the multi-use, big data-dependence of genomics, electronic health records and other similar platform technologies means that their effectiveness may increase exponentially in relation to the scale at which they are implemented. They grow in effectiveness by ‘feeding’ on data from an ever greater number of patients, and may take many years to reach a stable or mature state where they could be evaluated using standard cost-effectiveness measures. It is impossible, therefore, to meaningfully pilot or evaluate a platform technology without first implementing it at a scale at which these benefits can be realised.
This ‘big bang’ approach is viewed as enormously risky by the health system because large scale implementation often (but not always) comes with a large bill to pay up front, in this case for unpredictable reward. Nevertheless there are a few notable examples of where it is being pursued, by the 100,000 Genomes Project (100KGP) and hospital-wide implementation of electronic records systems, as recently seen at Addenbrooke’s Hospital in Cambridge. These two very different projects have not been without problems, and have attracted criticism for them taking financial and political risks with scarce NHS resources -but they provide some important lessons for the NHS.
Clinicians and health service managers undoubtedly want the best for their patients, and are aware of the need to innovate to improve their services. So how can they be helped to overcome the aversion to the perceived risks of doing this? There is no simple answer, but here is my personal prescription for the NHS:
Clinicians and managers need dedicated resources and time to undertake the difficult work of implementing innovations in their practice. Hard pressed frontline staff are too often expected to develop and implement new services in their ‘spare time’ alongside existing commitments and with little additional funding. If the NHS really wants to become an ‘innovative’ organisation, it has to face up to the fact that it will take explicit, up-front investment to give its workforce the time, space and confidence to innovate effectively. It must tackle the fear of failure, by rewarding attempts to innovate and accepting that not all will be successful. Innovation must be recognised as a core part of professional practice, and a core ‘business value’ for the organisation, not a spare time hobby or optional extra that can be dropped as soon as things get busy or finances are squeezed.
In the financially stringent NHS environment, it cannot be acceptable for individual hospital and community health services to invest in capital-intensive innovations such as genomics - which require system level co-ordination for their effectiveness and affordability - in isolation. Instead the NHS should pool risk and protect its precious resources through central control of the development of expensive new technologies, as Genomics England is attempting to do. This ensures rapid, affordable delivery of population-wide access without wasteful duplication.
Similarly, it is essential that where NHS investments in ‘risky’ innovations are made, they are rigorously evaluated, and the lessons learned applied across the entire health system. Where multiple approaches are trialled, comparative evaluation and the ruthless ‘culling’ of less effective approaches must be undertaken, along with disinvestment in outdated and ineffective interventions. Finally, dismantling the damaging culture of competition between individual hospitals is essential to ensure that the health system can maximise the return on investment of its scarce ‘innovation capital’ by enabling the communication and collaboration essential to any system-wide approach to technology implementation.
Together, we must ensure that our health system capitalises on the investments made, and risks taken by projects such as the 100KGP to realise their tremendous potential benefits for the health of our nation.