The NHS and the lust for certainty
Over the years I’ve worked with many innovators trying to sell excellent, even transformational products into the NHS, and seen what an enormous battle it can be to gain a contract. While there are some exceptionally forward thinking people within the NHS who do manage to put new technology to work, I think it would be widely acknowledged that the health system struggles to fully exploit the potential of new technologies to help patients.
Recently we hosted an event designed to understand and improve this situation. Challenger Business Events are a series run by the Cabinet office and BIS which bring together innovative businesses to understand the barriers they face. Potential solutions are then funnelled up to senior ministers who marshal government resources to make them happen. This event brought together a number of innovative businesses working in “personalized and preventative” healthcare. These include assistive technology, m-health and e-health, patient owned records and a host of other innovations which are not traditional Medtech.
A complete write up of the event’s key ideas can be found here; as you’ll see it was a very fertile afternoon. I’m not going to attempt any sort of comprehensive analysis of the host of ideas that emerged here; instead I’m going draw out one theme that particularly resonated with me. If you attended, or if you have a view, do chip in in the comments below.
“Has it occurred to you that the lust for certainty may be a sin” – The Rt Rev John Habgood, Archbishop of York (83-95)
While the clergy are few people’s exemplars of innovation, this quote has always stuck with me. Demanding certainty in a situation where there is none is a sure route to either bad decisions or no decision at all, which can be the worst option of all. Personal and preventative healthcare is not an area where there is a body of tried and tested approaches; instead innovation is often competing with simple tradition or nothing at all; proof is absent on both sides. Further the interaction between individual behaviours, complex institutions and pathways, and fast changing technology leads to an irreducible level of uncertainty as to impact and ease of implementation. In these circumstances certainty is rarely available and judgments under uncertainty are unavoidable.
This is subtly but distinctly different to the old accusation that the NHS should take more risk. Instead I’m suggesting that the reaction to unavoidable uncertainty is often inaction without timely and accurate assessment of the risks and benefits. Inaction is as risky as action, but psychologically easier.
Institutional reluctance to bite this particular bullet is seemed to me to underlie a number of the blockages innovators encountered, including evidence, procurement processes, regulation and standards. This is by no means uniform across the NHS – there are plenty of people doing great work, but there is also a huge amount more to go for. To illustrate the problem I’ll go into a bit more detail on a couple of these issues.
Businesses were happy to produce evidence; however they found a number of problems in doing so.
- Special Snowflake Syndrome: Evidence was not portable. Each client demanded a trial on their own site, and found it difficult to accept that impact achieved elsewhere in the country was likely to be repeated.
- Evidence Catch-22 .Smaller businesses are caught in a bind. They are not large enough to generate the quality of evidence required, but without it cannot grow.
- Better the devil you know. The status quo is often entirely unevidenced, but new entrants are held to a much higher standard.
So at the extreme, buyers were demanding site specific evidence, at an unrealistic level, and when it wasn’t forthcoming, remaining with the status quo, even that was poorly evidenced. In other words they needed evidentiary certainty to make a decision, and in its absence make no decision at all.
“ I had to complete a 200 page document for a £50,000 order”
Participants reported decision making process that required years of meetings, and documentation required being wildly disproportionate. The contrast with private healthcare sector, where decisions can be made within one or two meetings, was felt to be stark. I’ve yet to meet anyone who thinks the private healthcare sector is making consistently worse buying decisions. What then do these ornate processes achieve? Perhaps only the illusion of certainty at the cost of innovation? Excessive paperwork and process give some comfort against uncertainty, but do not improve the decision making, and retard the adoption of innovation.
A corollary of this is that the incentives designed to drive the adoptions of innovation were not seen to be working. QoF initiatives or CQUINs may be instituted, but usually only for a year, too short for the investment horizons necessary. Occasionally a national programme may be put in place, but this often cuts out some smaller and more innovative companies whose product may not fit existing categories.
Many of the solutions that the participants came up with were attempts to solve this problem either by reducing uncertainty, or increasing the incentives for and culture of decisiveness. Here are some that stuck with me…
- Quick Commissioning. That the commissioning process be streamlined, especially for those areas where the status quo was inadequate – analogously with “Orphan” drugs, where treatments for certain rare conditions have a less onerous route to approval.
- Kitemarking. To overcome variable and disproportionate evidentiary standards, the companies asked for a kitemarking system. This would involve an independent agency validating the quality of the evidence of efficacy and efficiency, increasing portability of evidence.
- Message from the top. The NHS leadership needs to send a message that championing new ideas is part of the job of the NHS, and exemplify this by themselves championing some early stage Innovations at beacon sites. Of particular importance would be leaders being honest about any failure.
- Stable priorities. An effort should be made to focus on longer term incentives and priorities, allowing a longer investment horizon, and reducing unnecessary risks.
- Focus on Outcomes. An increased focus on health outcomes rather than activity would be an incentive to adopt.
There’s no magic bullet here, a lot of detailed work required to flesh out these ideas. However these feel like they have some significant potential.
I’ve been lucky over the years to work with plenty of determined and visionary people who are trying to improve the health service, and it would be grossly unfair not to acknowledge all the work that goes into improving the system. However the comments of innovators like those in the challenger event are far too consistent and coherent to ignore. If personalised and preventative healthcare is going to help the patient, then we need to find ways to help the health service make better decisions under uncertainty.
Do you have an idea for solving this problem? Or something to add to the debate? Do leave a comment below: