Richard Smith: How can we encourage innovation in the NHS?

Richard SmithHow can we encourage innovation in the NHS? Niti Pall, a GP and entrepreneur from Birmingham, asked herself this question and hit upon the idea of asking all the people she knows who might have some thoughts on the question to a meeting, putting them in a room together, letting them generate their own agenda, and devising a follow up process. I met her at a conference/dance at a schloss in Salzburg and so got myself invited.

Niti is the chair and clinical lead of Pathfinder Healthcare Developments, a community interest company that provides high quality primary care to deprived communities. The company works mostly in Birmingham but is also looking to develop in India.

The description of Niti on the Pathfinder website says that she “is highly skilled at building inclusive and sustainable networks for improving patient care across traditional boundaries, particularly with secondary care and the voluntary sector through an open and inclusive leadership style.” That’s all true, although jargonistic, but many people lovingly describe her simply as “a bit of a nutcase.” Irrepressible is another word for her. She’s a woman in a hurry to improve health care and intolerant of bureaucracies, traditions, and jobsworths who stand in her way.

The starting point of the meeting was that it is hard to innovate in the NHS, and it’s true of all health systems. But the idea may be worth unpicking. Some technologies—like some new drugs or procedures—may spread rapidly, but anything that depends on people doing things in a very different way tends to spread slowly or not at all. Many at the meeting felt that there is a paradox at the heart of the NHS in that “everything is supposedly changing all the time but nothing changes.” It could be that the NHS has the worst of all worlds, the pain of change but not many of the benefits. Alan Maynard, the health economist, famously says that “the NHS does eight out of 10 for bright new ideas but three out of 10 for implementation.” And without implementation bright new ideas are just fairy dust.

 Many of those at the meeting were GPs, and most of them seemed to welcome the opportunities offered by current health reforms. They were not uncritical of the reforms, but they see an opportunity to innovate.

Appropriately the meeting was an open space meeting, which means that there was no preplanned agenda. People proposed topics for conversations, and everybody chose which conversations to attend. The “law of two feet” applied, and you might chose to be a butterfly, fluttering from one conversation to another, perhaps not saying much, or a bumble bee, pollinating one conversation with ideas from another. When you got fed up you simply walked away.

Around 50 conversations took place, and each leader of a conversation had to produce notes that were handed to “scribes,” who typed all the material. We are promised the results within days. I attended only a few of the conversations, but I can give you a sense of the feel of the meeting by listing some of the topics of conversation,

  • Is professional “puffupedness” the main block to innovation?
  • How can we get little bits of money to support new ideas and enterprises?
  • How can we form networks of innovators?
  • Innovation is an old fashioned idea
  • We don’t need a tweak we need a Cairo
  • Let’s get rid of intellectual property
  • How can we develop robust outcome data that people believe
  • We need to learn to put ourselves in other people’s shoes
  • Clinical innovation is strangled by managers
  • Money needs to follow ideas
  • Change is talked about all the time but never really happens
  • Who owns the NHS?
  • How can we use art, music, sculpture, architecture, comedy, technology, and Skype to promote innovation in the NHS?
  • Why if China can simultaneously be the largest communist country in the world and capitalist can’t the NHS be socialist but use market mechanisms?
  • We want people led commissioning
  • You don’t need RCT evidence to appreciate music: why is evidence overdone?
  • Why do people keep expecting linear outcomes from complex systems?
  • How can innovation reduce inequalities?
  • How do we create an implementation culture?
  • Turning general practice from a corner shop enterprise into Waitrose
  • Moving change from local to global
  • Innovation and failure go together: how can we make failure acceptable in the NHS?
  • Turning high risk teams into high reliability teams (from an ex-pilot)
  • Why are some doctors “invulnerable to human error?” (This one attracted ironic laughter, as intended)
  • Is disruption impossible in the NHS?
  • How can clinicians connect with alternative providers?
  • Myths about innovation: you need money, it’s risky, you need lots of ideas
  • What would an innovative NHS taste and smell like?

All of this emerged within about an hour of the meeting beginning, so you can get some sense of the energy generated. The next step after circulating the document summarising the conversations is to decide on three topics for the focus of the next meeting. That meeting, Niti promised, might include investors.

Competing interest: Competing interest: RS is employed by the UnitedHealth Group, a for profit group whose subsidiary UnitedHealth UK is working in the NHS in England. He does not, however, work with UHUK but rather on a philanthropic programme to create centres in low and middle income countries to counter chronic disease. He has shares and stock options.