Everyone’s talking about innovation – but what does it really mean? David Newton of the Commercial Procurement Collaborative explains why the NHS may sometimes fear medtech innovation, but can’t get by without it.
How does the NHS define ‘innovation’ in terms of its own priorities where medical technologies are concerned?
The priorities are laid out in various strategic documents from the Department of Health. Innovation is one of the things we’re targeted with providing – which is odd in itself, because if you’re an innovator you can’t really be schooled in how to innovate: you just come along with an innovation.
In practical terms the NHS is looking for three things. One is incremental change to processes, practices or equipment – something like the electric kettle being developed into the cordless kettle. But then there’s process change, whereby the innovation is a wholesale movement from one set of practices to an alternative set of practices for delivering the same piece of healthcare. The third type of innovation is where what you’re attempting to do is changed, as well as how you achieve it.
Medical technologies fit into all three of those areas. But also, innovation can use an existing device in a new context. One recent technology I saw was a well-established piece of kit where someone had said: “Oh, I can do this with that and it will make a difference in healthcare.” That ability to adapt something from the food industry, the car industry or whatever, I call ‘poaching’ innovation.
Then there’s using technologies to change where healthcare is delivered: making better use of information flows, the ability to make things smaller and more resilient. That can lead to wholesale step changes, such as the movement of care from an expensive delivery mechanism to a less expensive one or one whereby more people can benefit. That’s the key thing about some of the community programmes we’re now seeing: they deliver because they allow a greater number of people to access a healthcare facility simultaneously.
An example of a major step change is remote monitoring. When I started in nursing back in the 90s, one of the new technologies we had in the hospital was a system that allowed us to monitor the heart rate and rhythm of a cardiac patient from another ward via radio waves. Now I see pilot studies that enable us to monitor patients in different counties: they stay at home and we’re able to screen them remotely, we’re able to make sensible diagnoses. So in two decades, we’ve come a long way.
The risks of coming into hospital are nullified for many of those patients, because you can say that the best treatment for a patient’s cardiac condition is a specific drug therapy, or an intervention that requires hospitalisation, or just further monitoring. All of those options are opened up without the patient needing to access hospital care, with immense benefits for the patient and for the NHS.
How does the NHS define ‘value’ and ‘cost’ in healthcare? To what extent is the former replacing the latter as a driver of NHS procurement decisions?
There is ostensibly a lot of talk at a very high level in the health service about ‘value’, and we’re starting to hear people talk about ‘investing to save’ and programmes of that ilk, whereby a value is placed on spending money on resources that will enable an overall betterment and a saving downstream. But that’s only starting to be talked about by the hierarchy, and it may take the next 48 months to filter down to the ground level where the impact will be experienced by people trying to put products before the procurement teams. Procurement teams have talked about value for a long time, but in my view a lot of that has just been talk.
Value is about a full assessment of where a product will bring benefits across a broad range of areas. Are there patient benefits, benefits to healthcare staff, benefits to the delivery system, overall corporate benefits to the organisation? There is an attempt to place numbers on those, so we can say: “If we do A, B and C, the overall impact of that is a cost of £1m. If we do X, Y and Z, the delivery outputs are the same but the overall cost will be £500k.” There is overall recognition that that’s how we should be thinking.
However a lot of people haven’t broken free of the shackles of cost. They talk of ‘unit prices’ and the like – even though we’ve moved from the attitude that it’s better to buy a 50p pen than a £1 pen to the consideration that we’re also interested in how long the pen will give us ink. People have moved to a whole-life view, a view where you take into account the costs of purchase, use and disposal, instead of regarding unit price as the bottom line. But this isn’t going far enough into what value truly is, and that’s where we’re still struggling.
The NHS is putting a lot of investment and time into looking at the environmental impact of the way that we purchase things and of the things that we purchase. There’s an increasing awareness of our corporate responsibility. For example, the vehicle footprint of the NHS, the logistics of moving kit around, is something we’re very focused on at present. There’s also a lot of thought about inward investment: how we can contribute back to our communities. It’s well established (from the Black report and others) that a poorer community is less healthy. So we’re trying to work with local communities, using the regional development agencies to help make people aware that a product manufactured locally may be just as good as one from overseas.
But one of the biggest barriers is still silo mentality. That won’t be news to anyone in medtech, I’m certain. I think we’ve got another two or three years before we can start to see the behaviour of senior managers moving away from a protective stance towards more collaboration. That’s the whole point of Invest To Save: it will span over these silos, enable the redistribution of monies and create a compensation mechanism, so that when a clinic in the community is able to carry out a procedure, the fact that it takes ‘business’ away from a hospital isn’t seen as threatening: it’s seen as facilitating other things the hospital can do.
These changes are themselves innovative. Part of the process is ‘show and tell’ – for example: “This project we’ve done in Scarbororough has moved asthma care back to the patients’ homes. It’s meant that in the hospitals, you’re actually able to see five other patients off your waiting list in the time that you would have allocated to caring for asthmatic patients.” The benefit was there – but unfortunately it threatened the income for the budget holder, because they weren’t being paid for procedures in the tariff system. So ward resistance was quite high. This must frustrate people in medtech. If someone’s paying but doesn’t feel they are gaining benefit, there will be resistance. Purchasers have been asked (and strategically appointed) to be very inward-looking for the last 10 years or so, and now we’re saying, “You’ve got to look at the broader picture.”
That mindset change will come, but it will be another commissioning cycle before people really understand what it means. The community trusts will go through a cycle to commission all of the services over the next five years, and then we’ll start to see some real changes happening – because of the learning demonstrated by the braver community trusts, who’ve commissioned services from organisations working in innovative ways and with new technologies. When they can demonstrate how this has made a difference, that’s when it will take off. So the real shift from cost to value will be another five years in coming, but then it will move with exponential speed because people will have real NHS evidence.
How important is the shift of healthcare from the hospital to the home and the community in driving NHS uptake of new medical technologies?
From a strategic point of view, it’s obvious that it’s necessary. The difficulty comes in where the power base for the NHS has traditionally been. The NHS set a mentality in place that hospitals are the place of healthcare – because Bevan had to broker deals with the providers in those institutions to bring them into the NHS, and doing that built a corporate philosophy whereby the power sits with the acute providers.
There is an attempt now by the DH, with world class commissioning coming to the fore, to move some of that power base back to the community, back to local people so that they can start to make decisions as to how their healthcare should be provided. But you are fighting against the inertia of a very big system. A lot of investment has gone into the big teaching hospitals, and to a lesser extent the general hospitals – it’s hard to step away from that, and a lot of care will still have to be delivered in those environments.
But increasingly, for chronic illnesses that are more about managing people and improving their daily life than curing the presenting illness, much more of that care needs to be happening in the community. That’s where medtech can really help us. For example, each SHA prepared a document in response to the Darzi review to say what it was going to focus on, what was important in its region. In Yorkshire & Humber, the needs identified included obesity management, chronic respiratory illnesses and diabetes. In each case, there was a recognised need to enable patients to be cared for in their environment rather than coming into hospitals for tests and procedures. Medical technology facilitates a lot of that work happening.
The difficulty the medtech sector will face is the resistance to moving care pathways wholesale. For acute hospital providers, it means moving some of the work they’ve traditionally done. That’s a threatening shift for many people in personal terms. Recognising that is something the medtech sector needs to look at and work with: how to move people through a change process. It’s all very good to present us with a piece of kit that will benefit patients and the NHS – but what is often more difficult is to deal with the psychology of the changes. I think a better understanding of that would facilitate adoption more quickly and smoothly.
This is one of the issues that the new National Technologies Adoption Centre in Manchester is working through: when they put a new piece of technology through its paces with clinical staff, one of the main things they’re investing time in is the process of moving care from one arena to another, and how you make that acceptable to the incumbent providers.
Does the prospect of severe NHS spending restrictions over the next five years threaten the innovation agenda defined by Lord Darzi’s ‘next stage review’?
No, I think the exact opposite is true. I genuinely think it presents a real opportunity for the innovation agenda, because the only way we can meet and continue to meet the needs of our communities within the NHS framework – which is, as you say, one in which spending restrictions are predicted, certainly for five years and potentially for longer – is by doing things differently and in a much smarter way.
The whole solution is not medtech, but I think medtech is a big part of that solution: an advance in technologies, and an acceptance that technology we use in our own lives is also applicable at work. For example, someone might happily use a mobile phone with global positioning satellite technology to take, label and transmit a photo, but if you ask them to do that in patient care – by taking a photo of a wound in a patient’s home and sending it to someone 50 miles away to get immediate feedback and guidance – somehow they can’t make that step change.
But there is a growing realisation that we have to. Spending pressures are focusing people’s minds on how to adopt this new technology and demonstrate that it brings benefits in value and in delivering better healthcare. So I think it’s an opportunity.
A recurrent mantra in the medtech industry is “The NHS is resistant to innovation.” Is that true? What do companies that want to lead a new wave of healthcare technology need to keep in mind?
That mantra is also shared within the NHS. Individual organisations and people can be resistant to innovation because it represents change, which can be difficult to manage and to deal with. But it needn’t be the case. People are beginning to see that it’s OK to have an idea and to try something. So there’s a move away from being averse to taking a chance towards understanding that if you try something, providing you do so safely, then sometimes these new technologies and ways of doing things work beautifully to help everybody.
The biggest issue is not the technology itself. People can usually understand the process and the pathways that new technology might open up for them and for the patient. What is difficult for them is dealing with the change of practice. I would say to companies: be aware of that in the way you present your technologies to us. Not only saying ‘this is what it can achieve in the long term’ but also telling us what that journey will look like: how we get from where we are now to where the new technology can enable us to be. Filling that gap is partly the responsibility of the companies and partly our responsibility in the NHS.
Partnership working is something we’re trying to move towards, and certainly something we’re more and more keen on is a dialogue process so we can better understand what companies are offering us. How to get there is as important as why we should get there. Being more open to working together is something I would ask of my colleagues in the NHS as well as those in medtech.
David Newton is a Clinical Procurement Nurse Specialist, Co-Chairperson of the National Network of Clinical Procurement Specialists and member of the Commercial Procurement Collaborative (CPC).
I genuinely think [the prospect of NHS budget cuts] presents a real opportunity for the innovation agenda, because the only way we can meet and continue to meet the needs of our communities within the NHS framework is by doing things differently and in a much smarter way.