Monthly Archives: March 2017

Just how bad is the NHS at innovation? The answer – we don’t know

BY James Barlow

“There is strong encouragement for the NHS to make better use of innovation, but we’ve not known how our system performs internationally. Now we are developing a potential measure.”

The Accelerated Access Review (AAR) – which aims to help speed the introduction of health innovations into the NHS – was published last October. Readers with long memories may recall a string of previous reports all tackling the need to improve the UK’s health innovation system: the House of Commons Health Committee’s inquiry into the use of new medical technologies (2005)1, Best Research for Best Health (2006)2, the Cooksey review (2006)3, Innovation for Health (2007)4, Our NHS Our Future (2012)5, Innovation Health and Wealth (2012)6.

The AAR calls for a broader remit for NICE, to include more medtech and digital health innovations. Other recommendations are for closer alignment between regulatory requirements and processes, and for once-only assessment by NHS England of innovations not referred to NICE. Simpler and swifter procurement processes are part of the future agenda. And in an implicit nod towards the work of Clayton Christensen, the AAR suggests there should be some funding to support the commercialisation of disruptive innovations that have the potential to significantly improve care pathways.

These are all sound recommendations, but they are only the beginning. Recommendations now need to be turned into specific actions with budgets, owners, milestones and deliverables.

The good news from the AAR is that consensus seems to have broken out, with a genuine belief by government and NHS leaders in the potential of innovative technologies to improve patient care. The consensus extends to a call for more flexible approaches to pricing and reimbursement which can support the adoption of innovations.

The bad news is that the NHS is in deep financial trouble. For all the Churchillian rhetoric of healthcare leaders – “we have run out of money, now we must think” – and exhortations that a crisis is a great opportunity for innovation, the distinct tendency in the NHS is to hunker down, deal with the immediate concerns and shuffle innovation into the “too difficult” pile.

Goals, targets or crisis can of course concentrate the mind and, when coupled with the right kind of support and incentives, generate useful new ideas – a good example was Scotland’s Unscheduled Care Collaborative Programme in the mid-2000s7. However, the magnitude of the challenge of modernising the NHS, whilst continuing to run services with shrinking budgets, seems overwhelming. We know we need innovation, we know what kinds of innovation we need and we have a pretty good idea what is the potential impact of many innovations on improving care – the problem is introducing and establishing them in the NHS.

The AAR, if its recommendations are implemented, might help to speed up the flow of some new technologies into everyday practice, but it will not tackle the other layers of innovation that are needed. These were nicely described by the Health Foundation in 20158 as five interlinked components of a framework for change, all of which require innovative thinking – population health management, ways of delivering care, process improvement, active cost management, and scientific discovery, technology and skills. The report argued that all these are capable of delivering improvement over different timescales. Interestingly, the last of these – science and technology – is felt to have the most limited potential impact.

But just how bad is the NHS at innovation? There is much anecdote and received wisdom – “the UK is great at generating innovations but poor at adopting them”, “the NHS is always a late adopter”, “developing countries health systems are where the really interesting new ideas are”, “the USA over-adopts healthcare technology”.

Much seems to depend on perception. The 2016 Global Diffusion of Healthcare Innovation study surveyed 1,356 frontline health workers and healthcare leaders in six countries and found that the USA and UK were ranked as the two most important sources of innovation, but there were variations partly according to location – India was perceived as by far the most important by interviewees in some countries.

The volume of research on healthcare innovation processes has grown over the last fifteen years or so. We know what constrains the adoption of innovation and we know what innovators need to support them from research to commercialisation.

What we lack, though, is any kind of assessment of where different countries stand in relation to each other in their healthcare innovation capacity – how good they are at adopting innovative solutions developed elsewhere and originating innovations themselves. None of the reports on the state of healthcare innovation in the UK described above provide any real insight into our performance compared to other countries. Apart from limited work by Deloitte9, PWC10 and Accenture11, there has been no attempt to create an international comparative healthcare innovation index (the Global Diffusion of Healthcare Innovation is not an index because it teases out perceptions of innovativeness).

There are many indices or composite indicators measuring aspects of national performance in innovation in general. Indicators include measures of entrepreneurship, technology development and scientific research, innovation in general, and innovation in public sector organisations. However, these remain underdeveloped in relation to health.

A carefully constructed global health innovation index would be valuable in two ways:

• It would focus attention on the relative performance of the UK’s (or any other country’s) health system, pinpointing its strengths and weaknesses, identifying bottlenecks and issues for attention. This would enable policy makers and the healthcare sector to identify and prioritise the levers that can have the greatest impact on innovation.

• It would help medical technology and life sciences companies by providing an understanding of the attractiveness of each country’s health system as a market for products, as a source of innovations, and as a location for R&D.

A project funded by PIRU has carried out the groundwork needed to develop a global health innovation index12. We reviewed existing global innovation indices and explored the conceptual, methodological and practical issues that must be addressed. We draw three conclusions from our review.

First, one should proceed with caution when deriving policy, research or other implications from composite indicators. Before we can be confident of their implications for the comparative performance of countries or regions and establish benchmarks to underpin policy or other decisions, it is essential to understand how innovation indicators impact on innovation processes. This in turn requires indices to be underpinned by a clear and strong theoretical framework.

Second, there are a number of data issues which have to be addressed. To explore the dynamics and evolution of health innovation across countries through an index requires panel data (collected over time). While the availability of cross-sectional data (between countries) is fraught with difficulties, the use of panel data is even more so. Another issue is variation at the regional or local level. Policy makers are interested not only in their national scores, but in whether different regions in their country perform differently.

Finally, policy makers should be careful not to draw conclusions about the relationship between composite innovation indicators and other indicators of policy interest such as health outcomes. While it may be of interest to correlate innovation index scores with those of an index of health outcomes, we must always remember that correlation does not mean causality – introducing a new drug or device may well lead to better health outcomes, but an index will not tell us this.

We are now hoping to create a prototype index for a few countries. This involves investigating data sources and more work on what the index is measuring, for whom and for what purpose.

Anyone interested in finding out more should contact James Barlow at Imperial College Business School, j.barlow@imperial.ac.uk

James Barlow is a Professor of Technology and Innovation Management (Healthcare) at Imperial College Business School and a member of PIRU. His latest book, Managing Innovation in Healthcare, was published by World Scientific in January 2017.

1House of Commons Health Committee (2005) The Use of New Medical Technologies Within the NHS: Fifth Report of Session 2004–2005.
2Department of Health (2006) Best Research for Best Health: A New National Health Research Strategy: The NHS Contribution to Health Research in England.
3HM Treasury (2006) A Review of UK Health Research Funding.
4Strategic Implementation Group & Healthcare Industries Task Force (2007) Innovation for Health: Making a Difference.
5Department of Health (2007) Our NHS Our Future: NHS Next Stage Review – Interim Report.
6Department of Health (2011) Innovation Health and Wealth, accelerating adoption and diffusion in the NHS.
7Dattée B, Barlow J (in press) Multilevel organizational adaptation: Scale invariance in the Scottish healthcare system. Organization Science; Dattée B, Barlow J (2010) Complexity and whole-system change programmes. Journal of Health Services Research & Policy 15, S2, 12-18.
8The Health Foundation (2015) Shaping the Future. A Strategic Framework for a Successful NHS.
9Deloitte (2012) Innovation Indicators for Healthcare in Emerging Countries. Understanding and Promoting Innovation in Emerging Markets.
10PWC (2011) Medical Technology Innovation Scorecard. The race for global leadership.
11Accenture (2013) Measuring the Unmeasurable. A New Framework for Assessing Healthcare Innovation.
12Cravo Oliveira T, Barrenho E, Vernet A, Autio E, Barlow J (2017) Developing a Global Healthcare Innovation Index. PIRU Reports 2017-20. http://www.piru.ac.uk/publications/piru-publications.html

Next step: develop Social Investment Partnerships

by Ben Jupp

The experience of Social Impact Bonds can inform a wider set of relationships to help address social needs, argues a key innovator in the field.

The health and social care system I work in has rarely been in greater need of transformative investment. As demographic and financial pressures threaten to pull it apart, better responses to people’s needs are urgently required.

In my experience, developing more community focused and preventative health and care services will rest on approaches which combine both innovation and rigour. It will rely on strengthening the capacity of services to understand needs, learn from others, adapt and implement change. It will take an approach that looks beyond the annual budgeting of the NHS.

Many Social Impact Bonds seek to change systems
To me, and my colleagues at Social Finance, Social Impact Bonds (SIBs) have always been one tool to support such transformative responses. Take, for example, the Reconnections Service in Worcestershire. It aims to address chronic loneliness, responding to a need that was highlighted by older people in the county themselves.

Establishing Reconnections has involved designing a new service, pioneering long-term cost-benefit analysis on the impact of chronic loneliness, and helping draw together a partnership with a network of half a dozen voluntary and community sector organisations. For the range of commissioners involved, an outcome-based contract was attractive: making payments only if and when the new approach is effective. For the service itself, an outcome-based contract has also enabled flexibility and innovation.

The first year of Reconnections has been hard. Service providers, volunteers and investors have all had to work in ways they had not expected. We have had to learn and adapt. But, slowly, the six charities and community organisations are developing better responses to needs that have often been neglected for far too long, to the detriment of individuals and the health and care system as a whole.

The value of Social Investment Partnerships
Our experience of developing the Reconnections Social Impact Bond and other transformative programmes has also highlighted the value of creating broader Social Investment Partnerships (SIPs) in health and care.

Such Social Investment Partnerships encompass approaches to address social needs which include Social Impact Bonds but also wider forms of collaboration where commissioners, providers and investors share risk and pool knowledge and experience in the design and delivery of services. Highlighting partnerships reflects the need for commissioners, investors and providers to work collaboratively and flexibility, rather than the more adversarial separation between ”purchasers” and ”providers” of services that has characterised the NHS in England for the last 30 years.

For example, in a Social Investment Partnership to improve community-based end of life care, we have been working collaboratively with commissioners and providers for six months to scope out the need jointly. The investors and commissioners have then jointly considered which organisation would be best placed to develop the service; sometimes through a competitive process, sometimes by just building on an existing service.

Alternatives to outcome-based contracts
In such partnerships, we have also found that an outcomes-based contract is only one way to transform services. A focus on the underlying outcomes enabled by a service is important: an outcome-based contract can have significant advantages in terms of allowing service flexibility and providing focus. But for other areas, it’s impossible to capture the full range of people’s needs with a focus on a small number of objectives.

That is why, for example, in our partnerships to develop better Shared Lives social care (the Shared Lives Incubator), we have invested directly in the provider without an outcomes-based contract. Creating the conditions in which someone wants to share their home with another person in need of care is difficult to stipulate in a contract which prioritises one or two impacts. So the investors and commissioners jointly identify the provider, based on their overall qualities and experience. The investor then provides the upfront funding for developing the local service and repayment is made simply as proportion of the service revenue, if and when it grows. In other partnerships, risks are likely to be shared on the basis of a capitated budget – a set amount of funding for the population.

Drawing in investment from a range of sources
Finally, I have found that the concept of a “Social Investment Partnership” draws attention to the need for new resources and capacity and a long-term approach when tackling social challenges, rather than focusing on a particular type of financing. In some of the partnerships which we are building, such as those that develop better employment support for people with health conditions, the source of the funding is a mixture of public sector, charitable and external socially motivated investment. In nearly all such partnerships, we are combining financial investment with access to clinical and operational support. For example, because Health and Employment Partnerships operates across multiple areas, it has the scale to able to employ clinicians and service managers with deep experience of managing similar services before and is helping to manage NHS innovation funding as well as social investment.

I’m proud of the pioneering approaches that my team and colleagues across the sector are engaged in through Social Impact Bonds such as Reconnections. By broadening the approach to developing Social Investment Partnerships, we now have the opportunity to enable a wider range of contractual forms, further blur traditional adversarial relationships, and draw in resources from a number of sources.

These partnerships, whether traditional Social Impact Bonds or a not, are united by a passion for supporting communities and the most vulnerable in particular. They also recognise the importance of both innovation and rigour to achieve social change and ensure that organisations and systems have the capacity to adapt.

Ben Jupp is a Director at Social Finance. He was Director of Public Services Strategy at the Cabinet Office. He has also been Director of the Office of the Third Sector in the Cabinet Office.

Council information brokers could help technology to play vital role in dementia care

By Martin Knapp and James Barlow

There’s no shortage of gadgets. But users and carers require help to make the most of what is available. Industry also should focus more on understanding what people really need from assisted living technologies, argues a new PIRU report.

In 25 years’ time, when many of today’s middle-aged population can expect to be living with dementia, technology will play a big part in their care. It will help them to stay in their homes longer and to avoid being institutionalized. It will also support their carers.

But right now, this isn’t happening enough, even though there is no shortage of gadgets developed by industry. “Why is this?” we ask in our report entitled “The Case for Investment in Technology to Manage the Global Costs of Dementia”. What can be done to accelerate the adoption of assisted living technologies, given the high levels of need among those who have dementia, the stress and isolation of their carers, and the urgency with which the cash-strapped health and social care systems need to control demand for costly treatment and support?

Slow adoption is partly explained by the particular characteristics of those whom we expect eventually to adopt these technologies – people with dementia themselves, their carers – and the local authorities and NHS bodies that might facilitate change. More on these issues in a moment.

Supply-side industry issues
However, responsibility also sits with those who develop the technologies. Research programmes which have looked into the use of assisted living devices continue to find that industry fails to optimise the user interfaces of technology, whether for health and care professionals or the general public.

That said, industry ought not to take all of the blame. It does, given the right circumstances, create and sell low-cost, user-friendly health-related technologies such as Fitbits, which many older people feel comfortable adopting. And most older people have mobile phones. So why doesn’t the large but niche market for people living with dementia show a similar level of growth and development?

Partly, it is because industry has not been as sensitive to this market as it has been to more able-bodied and -minded consumers. It can produce some really helpful, easy-to-use innovations, such as weight-sensitive mats that tell carers remotely whether someone has got out of bed and is walking about. However, as far as more sophisticated devices are concerned, research shows that suppliers often still tend to blame users when technology doesn’t work well. They should instead ask themselves more searching questions that would identify often simple design difficulties in their products.

Suppliers are not necessarily fully cognisant of the need to match technology to the sensory and tactile skills that older people have. Major companies are sometimes naïve about both the basics of what ageing means for individual abilities and the markets for a product. Developers in the ICT industry are still seduced by bigger, more obvious markets in which less trouble has to be taken in show people how to use the technology.

Despite all the effort put into user-led design, there is also still a big gap between research and development and engaging users to ensure that products are right from the outset. There are also plenty of examples where researchers and companies appear to develop a solution that’s in search of a problem.

Lack of support for users and carers
Nevertheless, despite these supply-side concerns, perhaps the biggest issues with regard to dementia care and assisted living technologies are on the consumer or demand side. We can’t be scientific, but perhaps about 80 per cent of the challenge is human, organisational and funding, compared with 20 per cent of the problem being about developing the technologies in the first place.

Funding issues are acute in the UK, where, like in most countries, the health and social care systems are fragmented. That means the costs and benefits of assisted living technologies fall into different silos, which can block take-up of innovations.

From previous research we reckon that an eighth of the costs of dementia care fall on the NHS, a quarter on social care services and the rest on informal carers. As a result, it is sometimes difficult to persuade one system to fund technology when the cost savings might accrue elsewhere. This sharing of cost is particularly difficult in the UK because social care is means-tested while healthcare is not.

An underlying issue, which our report also highlights, is that these technologies can be challenging for everyone, but particularly for older people, many of whom are not competent or confident with what for them are new technologies. That is particularly true for people with cognitive difficulties arising through dementia.

Carers will generally not have the cognition issues – although many carers are quite old themselves, and may have their own health issues – but they may not be familiar enough with the technologies to take on new challenges and tasks within the care setting. Older carers in particular might not have spent much of their working lives using ICT. They may perceive broadband to be expensive, even though the actual cost is not particularly high.

People need reliable advice and support
Often advice and support that’s available from the local authority is neither confident nor competent. The Care Act 2014 requires support for carers, but this duty has coincided with a sharp reduction in social care funding and availability, so that implementation has not matched the ambition.

Our report finds that local authorities are not good at sign-posting technologies to carers or at providing other associated supports. This concerns not just the monetary costs of purchasing technology but the costs of learning new skills. Such help would require fresh investment by councils.

However, this support could be vital to carers who need sound advice around technologies that they themselves might buy. They are not alone in being in the dark: a whole range of people in the system – including commissioners and care homes – lack knowledge about what is available, and what it might achieve.

That is why we argue that the public sector should take on an information broker role, offering a source of unbiased advice on assisted living technologies. A council might even use its purchasing power to negotiate attractive deals with suppliers, so that people feel assured that they are buying the right product at the best possible price.

There are examples of healthcare professionals – including dentists, GPs and pharmacists – providing this kind of advice to vulnerable patients and carers, even if their own service cannot foot the actual bill. The Third Sector has also long provided important consumer support, going right back to the founding of the Consumers’ Association. Some of the charities that support older people are well-positioned to take on such a role.

It may well be that industry – keen to expand its own markets – has a part to play in easing this problem. It should consider how it can support delivery of unbiased information and support. Carers and patients need all the assisted living help that they can get. They can’t wait for another 25 years.

Martin Knapp is Professor of Social Policy, Director of the Personal Social Services Research Unit at the LSE, and Director of the NIHR School for Social Care Research.

James Barlow is Professor of Technology and Innovation Management (Healthcare) at Imperial College Business School.

Both authors are members of the Department of Health’s Policy Innovation Research Unit (PIRU). Their report, written with several other colleagues, “The Case for Investment in Technology to Manage the Global Costs of Dementia”, is published by PIRU.

SIBs don’t work for complex problems because they’re unaccountable to service users

By Stephen Sinclair, Neil McHugh and Michael J.Roy

Supporting change through social policy is an iterative process which develops participatory relationships with users. Social Impact Bonds fail on this front, rendering them unfit for purpose.

SIBs are intrinsically unsuitable for programmes that seek to transform people’s lives. That’s because such transformative interventions typically succeed only when they involve partnership with the people who are in need of help – and that’s not one of SIBs’ strengths.

SIBs are generally unaccountable to service users; they usually answer to funders. That’s their core failure and limitation. An inadequate relationship with service users means that SIBs typically lack sufficient understanding of – and sensitivity to – the causes of social problems that is required to achieve transformative change.

We should face up to these issues because, although there are only 32 SIBs operating in the UK, there is a considerable amount of enthusiasm for them. They have, and continue to receive, a lot of vocal and financial support from government.

Difference between technical and transformative interventions
In social policy, it’s helpful to distinguish between technical and transformative interventions. The former tend to be simple responses that encourage relatively uncomplicated changes and behaviour. Often they are about increasing service use, such as, for example, raising the uptake of vaccinations. SIBs could be suitable for such programmes and randomised controlled trials could be one way to evaluate them.

In contrast, transformative interventions try to generate profound changes in the dynamic between conditions and actions. So they must engage the agency of service users or the recipients of those interventions. These interventions address complex problems, often with multiple stakeholders, and try to ameliorate poor conditions. They’re very much contextual. Crucially, they’re about doing things with people rather than doing things to them. So, they might involve trying to reduce or tackle obesity and the problems around that very complex issue. Or they might seek to reduce health inequalities which are a major problem within the UK.

Recipe for social transformation
For social interventions to be considered transformational, they must engage with the means and the identities of those they seek to help. They should cultivate capability for independent living. There shouldn’t simply be a focus on producing outcomes. A good way of thinking about this is to consider education policy: it should be about cultivating independent and critical thinking rather than focusing simply on outcomes and achieving certain rates for test passes.

This approach should encourage us to rethink best practice. Where transformation is concerned, it shouldn’t be about uniform standardisation. Policy should respond to varying conditions and individual circumstances. What works in one area may not work elsewhere. We should resist the urge to scale up interventions indiscriminately.

Different approaches to evaluation
Evaluations should, in turn, provide insights that help us understand these very complicated human interactions and social conditions. Good policy development and evaluation should be about understanding interactions between agents and the subjective experiences of service users. It should be about getting to the bottom of why things work, which is a difficult and challenging issue.

There tend to be two approaches to evaluation. One tradition – let’s call it “positivist” – is exemplified by much of the evidence-based policy movement. It tends to favour randomised control trials in trying to attribute causality.

An alternative tradition – let’s call it “phenomenological” or “interpretivist” – regards policy in relation to complex social problems as less linear and more of an iterative process. It’s based more on reasoning from incomplete or imperfect data. It highlights, to some extent, the limitations of the evidence-based policy movement.

A great deal can be learned from the field of public health. It has a long history of engaging in, developing and evaluating complex social interventions. Indeed, the Medical Research Council (MRC) has issued guidance on how to develop and evaluate complex interventions. The MRC says it’s an iterative process and that the first step should be to understand subjects’ views and how they understand their own condition and treatment.

The political nature of social policy
So social policy, when trying to do anything complex or transformational, shouldn’t try to reduce issues to mechanistic terms such as providing inputs and then producing outputs. We should also recognise that the design of social policies is a political process. Indeed, simplifying complex conditions and problems into depoliticised inputs and outputs, far from being apolitical, is actually a form of ideology itself.

Nevertheless, SIBs tend to be represented as a technocratic and depoliticised approach to policy. They involve shifting responsibility for welfare policy away from government. In this vision, the role of government is diminished, becoming about purchasing or brokering public services.

SIBs are highly political
We would, instead, argue that SIBs are highly political in two key respects. First, they turn public services into commodities, rather than being services to citizens that require a relationship with those citizens. So SIBs “commodify” public services. Second, they give financial value to those fictitious commodities. So SIBs change what were non-monetary social relationships into financialised commodities.

This process diminishes and dehumanises service users who become reclassified as customers. This diminution is not immediately obvious because it is masked by language. Indeed the language of consumer culture – in which the key agent is the customer who is always said to be “right” – might seem to raise rather than diminish the status of the service user. But this is actually a fraudulent representation.

A real customer has control of the cash, providing him or her with consumer sovereignty. In reality, with SIBs, there is very limited consumer sovereignty because citizens’ welfare entitlements become transformed into contracts between organisations and stakeholders.

In this change, the quality of these services is altered. The previous public sector ethos is lost, replaced by a profit incentive. As a result, the service user, instead of being at the heart of everything, becomes an externality, a troublesome afterthought to the main activity which is a series of transactions between principal stakeholders.

What next for SIBs?
Where does all this leave us? SIBs encourage a focus on what is measurable. They also prioritise outcomes rather than trying to understand how these effects are actually achieved. We would argue that complex multi-dimensional social problems require a different approach that involves collaborative policymaking. This policy should involve trying to alter conditions for service users’ rather than imposing strict theories of change upon them.

Moving forward from SIBs
Recognising these deficiencies, we propose a different approach which prioritises service users’ perspectives and which is a first step towards co-determination of policy. A good way forward is to use Q methodology, a research tool used in psychology and in social sciences to study “subjectivity” (namely views, opinions, values and beliefs). It was developed in the last century by the psychologist and physicist, William Stephenson.

This approach is a well-established way to identify and describe viewpoints. First, a card sort (of statements) is used to generate data. Then, there is a form of factor analysis which identifies patterns and similarities between individual card sorts. These methods reveal the structure and form of subjectivity on a particular topic, allowing subjective perspectives to be described.

Q methodology has potential uses in policy development and evaluation because it could help to ascertain the relative importance of problems, the causes of problems, as well as potential solutions and policies. However, it’s just one practical, albeit important, way to actualise service users’ perspectives and so improve policy design and evaluation.

Crucially, this approach is aligned with genuine social innovation whose starting point is that it should empower service users. It should enhance their capacities. That’s missing in SIBs. If social policy is really going to make a difference, then we need to replace SIBs with more participatory approaches to policy development.

Dr Stephen Sinclair is a Reader in Social Policy in the Yunus Centre for Social Business and Health, Glasgow Caledonian University
Dr Neil McHugh is a Researcher at the Yunus Centre for Social Business and Health, Glasgow Caledonian University.
Dr Michael J. Roy is a Senior Lecturer in the Yunus Centre for Social Business and Health, Glasgow Caledonian University