We live much longer than our ancestors and it is likely that our children and grandchildren will live longer still. Diseases that used to kill millions are being steadily eliminated around the globe. Conditions that were once inoperable are today amenable to successful surgery. Behind all of these achievements lie advances in scientific knowledge and the development of new technologies, including medicines, medical equipment and digital devices and networks.
Healthcare systems across the developed world are facing both rising (and more complex) demand for services and increased constraints on the funding and resources available to them. New technology is a vital ally in meeting these twin challenges, because it is one of the few tools that is demonstrably capable of achieving the ‘holy grail’ of public policy: better outcomes at a lower cost.
Nevertheless, in England and Wales, the National Health Service (NHS) is not as effective as it could be at adopting new technologies and allowing or encouraging them to spread quickly. This paper asks what we can do to change that.
The challenge: increased demand and fewer resources
The NHS is widely regarded as one of the best health systems in the world: the Commonwealth Fund recently ranked it first out of 11 developed nations’ health systems (Davis et al 2014). In the same evaluation, the US was ranked 11th, despite spending over twice as much per person on healthcare (World Bank A).
However, demand for NHS services is rising and becoming more complex. Across the UK, the number of people aged 80 and over is projected to rise from 3 million today to 8 million by 2050 (Cracknell 2010). As well as increasing the sheer number of potential patients, longer lives also mean more complex patterns of disease: 58 per cent of people aged 60 and over have a chronic condition, and the number of people with more than one condition is rising (DH LTC 2012).
Increased demand for services means additional resources will be required in the future. NHS England estimates that it will face a funding gap of £30 billion by the end of the 2015–2020 parliament. It has committed to finding over £20 billion in increased productivity gains to help to close this gap, and has argued for additional government funding to meet the remaining shortfall (NHS 2014a).
There are many things that the NHS can do to meet this challenge. It needs to shift the model of healthcare from one focussed on treating people in hospital to one that supports people to stay well at home. It needs to provide care that is integrated around the individual patient, rather than being fragmented between different organisational and clinical silos. It needs to reconfigure its workforce so that it is better equipped to deal with changing patterns of disease. And it needs to empower citizens so that they have a greater capacity to design and manage their own care and support.
However, one of the most important things that the NHS could do is to make better use of innovative technologies. As well as supporting all of the necessary changes noted above, innovation would help to ensure that the NHS is able to boost productivity gains above their historical average of between 1.5 and 3 per cent, which is essential if it is to meet its commitment to closing part of the funding gap (Roberts 2015).
Performance so far: adopting and spreading innovations in healthcare
Technological innovation should be a powerful tool for improving healthcare outcomes in a constrained funding environment. New medicines should save or improve millions of lives by tackling diseases that are currently incurable, such as cancer or dementia. Breakthroughs in pharmogenetics should radically improve our ability to predict and prevent disease at the individual level. Digital technology, including wearable technology and electronic patient records, should mean that individuals are able to monitor their own vital signs, helping to prevent and manage illness. One day, robotics and artificial intelligence could help to provide care for frail elderly and disabled people in their own homes.
However, when it comes to embracing new and innovative technologies, there is evidence that the UK is lagging behind. The Richards report (2010) compared the level of uptake for key best-practice drugs in the UK and 13 other countries, and found that the UK ranked just eighth overall. What’s more, it finished in the bottom four in the case of seven out of the 16 clinical-need types: cancer drugs launched within the last five years and within the last 10 years, second-generation antipsychotics, and drugs for treating dementia, hepatitis C, multiple sclerosis and rheumatoid arthritis.
Another frequently cited example is that of insulin pumps for people with type 1 diabetes. There is evidence that using a pump – compared with self-management – leads to a reduced number of unplanned hospital admissions, complications caused by mismanagement (severe hypoglycemia and diabetic ketoacidosis), and long-term deteriorations (heart disease, stroke, blindness, kidney disease or nerve damage). However, a study by the Medical Technology Group found that uptake averaged just 3.9 per cent in the UK, compared to the benchmark of 12 per cent recommended by NICE. Uptake in the US, Sweden, France and Germany is between 15 and 35 per cent (MTG 2010).
Uptake also varies greatly across the UK. The Innovation Scorecard1 looks at the uptake of drugs and technologies approved by the National Institute for Health and Care Excellence (NICE) across the UK. It shows that, for example, the use of statins, which is highly recommended for people with high cholesterol, varies between 68 per cent of expected usage at the low end to 196 per cent at the top end. Indeed, significant variation is seen across all 76 medicines and six medical technologies that are included in the scorecard.
Poor uptake of new technologies is not just a problem for medicines, but also affects medical devices and digital tools. Healthcare across the UK is lagging behind other sectors of the economy in its use of digital services. For example, 59 per cent of all UK citizens have a smartphone, and 84 per cent of adults use the internet. However, when asked, only 2 per cent of the population report any digitally enabled transaction with the NHS (NHS 2014b).
In its key report on innovation in healthcare, Innovation, Health and Wealth, the Department of Health concluded:
‘Whilst we are good at inventing and developing new technologies, the spread of those inventions within the NHS has often been too slow, and sometimes even the best of them fail to achieve widespread use.’
DH NHSIE 2011
NHS England and the Department of Health are aware that in order for the NHS to reach its full potential the service needs to get better at spreading – or ‘diffusing’ – the best innovations. This acknowledgment has led to a range of initiatives to address the problem.
Innovation, Health and Wealth, launched in 2011, identified six main barriers to successful diffusion in the NHS:
- poor access to metrics and evidence on innovations
- insufficient recognition of innovators
- financial disincentives to innovate
- commissioners lacking the tools to drive innovation
- a leadership culture that is not pro-innovation
- the lack of a ‘systematic innovation architecture’.
On the back of this report, NHS England launched a series of policy reforms and initiatives to bring down these barriers. For example, it introduced a legal obligation on all clinical commissioning groups (CCGs) to offer NICE-approved technologies to patients, and created a single web portal for all new innovations, creating a one-stop shop for practitioners looking to purchase new products. It provided funding to establish 15 academic health science networks (AHSNs) to bring together academia, private innovators and the NHS to develop, adopt and diffuse innovations (see boxed text below). It introduced a new evaluation system within NICE for medical devices, where previously the regulator had dealt only with medications. And it set out reforms to the tariff system that were designed to reward innovation and allow commissioners to overcome the barriers created by divisions or ‘silos’ in their budgeting.
What are academic health science networks?
Academic health science networks (AHSNs) are perhaps the most tangible outcome from the reforms sparked by Innovation, Health and Wealth. That report identified ‘silos’ in the innovation process as one of the primary barriers to the adoption and diffusion of new technologies – academia, where the research underlying new innovations is conducted, and the private sector, where products are often developed and commercialised, tended to work at a distance from the organisation most likely to purchase and apply the innovations, namely the NHS.
The report argued that there was a need for a ‘systems integrator’ and ‘delivery mechanism’ to link the different ‘innovation silos’, and called for the creation of 15 AHSNs covering the whole of the UK to fulfil this role.
‘We will establish a number of Academic Health Science Networks (AHSNs) across the country, the first going live during 2012/13. Working with stakeholders from across the NHS and scientific community, academia, the third sector and local authorities, the AHSNs will link up the system and drive up diffusion of innovation.’
DH NHSIE 2011
The key objective of AHSNs, set out in a follow-up report, is ‘to identify, adopt and spread innovation and best practice across the NHS’ (NHS 2012). This is a huge task. Each AHSN covers a patient population of 2–5 million, and a healthcare establishment of hundreds of thousands of medical professionals, more than 10 CCGs, health and wellbeing boards, NHS trusts and local authorities, as well as hundreds of GP surgeries and community health providers. On the other side, they may have relationships with 10 or more universities and thousands of innovators and, in theory at least, they should be working across all medical conditions and all thematic health priorities (empowerment, integration, inequality and so on). And all this is to be achieved on a relatively small budget of around £3–5 million a year for each AHSN.
Individual AHSNs have taken on this broad and ambitious remit in different ways – the areas they chose to focus on and the tools they use to do so vary substantially from one to the next. Some of this variation is both to be expected and beneficial: at their core, AHSNs are autonomous organisations with devolved powers to reflect and respond to issues in their local health economies. However, our analysis also suggests that variation is more likely to be a result of the need to narrow their focus (given limited resources) and the lack of a clear and overarching approach across the NHS. In large part, this is because it is not yet clear what the most effective approach looks like.
Both innovators and the AHSNs themselves testify to this.
‘We have experienced huge variation in the kind of support provided to us by AHSNs across the country. Whilst we have had some good experiences – the best providing us with introductions in a systematic way and guidance on what evidence is needed and where funding can be found – some have been equally as unhelpful. Notably, some have said that we don’t qualify for their support, either because our product doesn’t fall into their thematic medical area of expertise or because they only look at products which have been adopted elsewhere in the system.’
Michael Brooks, PatientSource, online health records management system
‘The scale of the objectives AHSNs have been set – identification, adoption, diffusion and wealth creation over populations of millions of people and thousands of NHS organisations – has meant that they have had to target who they are going to help and how, at the expense of other innovators and other approaches. Furthermore, we don’t have clear evidence or criteria for which innovators or approaches to use in looking to achieve our aims. This is one of the primary causes of variation.’
Commercial director, AHSN
The challenge for AHSNs is how to most effectively use their limited resources to take a coherent, informed and targeted approach to facilitating the adoption and diffusion of innovations. The analysis in this paper is intended to help them achieve this.
The challenge ahead
The NHS is changing to support the adoption and diffusion of innovations. Innovation, Health and Wealth identified many of the key barriers faced by entrepreneurs trying to have their innovations taken up. The resulting reforms were both well-intentioned and sensible, and many have been implemented successfully – such as the new legal obligation on CCGs to offer NICE-approved technologies.
However, as we will show in this paper, a number of major barriers to innovation in the system remain, and further reforms are required. If the NHS is to meet the challenge it now faces – achieving £20 billion in increased productivity by 2020 – more must be done to facilitate innovation. As with Innovation, Health and Wealth, our approach has been to focus on innovators’ experiences, as they have sought to get their innovations into wider circulation.
In this context, then, we have set out to identify the most significant remaining barriers to the adoption and diffusion of innovations, and to distinguish between those that are systemic or related to the overall structure of the health economy and those that exist at the level of individual organisations. This, we hope, will help to guide policymakers at the national levels, and organisations within the NHS at the local level – including practitioners, commissioners and external bodies like AHSNs – to create a more innovative and effective health service.