As the focus on innovation grows inside the NHS, some leaders have suggested that the really radical “disruptive” innovations that the NHS needs can only come from external sources. But where do the most radical, disruptive innovations come from?

Do they HAVE to come from outside the system as followers of Clay Christensen, the instigator of the concept of “disruptive innovation”, suggest or can they come from inside the NHS? What is the relationship between internally and externally generated innovation and between large scale and small scale innovation?

Across the NHS system, we are seeing a definite increase in actions to speed up and scale up diffusion and adoption of innovation. There is a growing sense that the only way we will be able to deliver the outcome goals of the NHS within available resources is by taking action (innovating) to design and provide services in different ways.

I also hear a growing number of NHS leaders talking about the need for disruptive innovation. This term, as defined by Clayton Christensen, relates to radical, innovation-driven changes that “disrupt” long-established practices in organisations or systems.  However, too often, the conversation about disruptive innovation in the NHS gets followed up with a comment that “of course, disruptive innovation can only come from outside of the system”. 

I totally appreciate that we need fresh pairs of eyes, radical new perspectives and sweeping changes in the way we work. I’ve enjoyed the ‘Outside the Box’ series of interviews that the Health Service Journal is running with business leaders and thinkers from outside the NHS whose ideas could help the service tackle its challenges. At the same time, I feel aggrieved that we sometimes underestimate the potential of our own talented workforce and leadership community to deliver radical change if we can create the conditions where innovation can flourish. Every time I hear someone say that disruptive innovation HAS to come from outside the NHS (that is, by insinuation, that people in the system are incapable of implementing radical new ways of delivering care), I feel like shouting “please don’t write us off yet!”

At the same time, I have met a number of brilliant but frustrated innovators from outside the NHS through my innovation and improvement networks. These innovators have developed new products or delivery methods that could make a huge difference in achieving NHS quality and cost goals yet, despite a compelling business case, can’t find a way into, or traction with, the existing NHS system. These innovators have a sense that the NHS doesn’t want new ways of working that it hasn’t initiated itself, so they conclude that the potential for truly radical innovation in the NHS is, in reality, limited.

So let’s dissect some of these issues. Where do the most radical, disruptive innovations come from? Do they HAVE to come from outside the system as followers of Christensen suggest or can they come from inside the NHS? One fact seems clear. They are LEAST likely to come from policy makers or very senior leaders within the existing system. Gary Hamel suggests that this is to a large extent a generalisable consequence of corporate life, which applies across multiple sectors and industries. Hamel says that in senior leadership teams, there is often an absence of the diverse points of view that stimulate innovative practice and existing leaders often have an emotional investment in the status quo without even realising it. In these circumstances, leaders tend to maintain or improve existing processes rather than to ask difficult questions about what change might be really needed. It may also be easier to use traditional logic to promote the benefits of a modification to the existing system than to prove that something innovative and new will pay off. A study across Commonwealth countries found that 82% of public sector innovations come from staff at multiple levels of the system, rather than from leaders of the system. The most frequent initiators of innovations were “local heroes”, visionary middle-level and frontline public servants who took risks to innovate despite disincentives in the system that discouraged them from doing so.

It’s worth all of us reflecting on these findings. We might want to talk explicitly with colleagues in our leadership teams  about how we might be missing opportunities to innovate, identify what we can do to overcome our own unconsciously constraining thinking patterns and be aware of the limitations they might be creating for us when it comes to our next major decision.  We might also want to consider setting explicit innovation goals within our quality and cost improvement strategies.

It is also clear that innovation that originates WITHIN existing organisations may not be radical enough to deliver sufficient change in the required timescale. Hence, Christensen and colleagues promote the need for change to organisations and industries through disruptive innovation. A disruptive innovation is one that typically originates from “left field”, from innovators who are more likely to come from outside of the existing system. Their innovations reinvent or introduce products and services in ways that the existing system and existing customers do not expect. Over time, these disruptive innovations redefine the nature of value within the system. They create new markets and demands for services and go on to displace previous ways of organising things.

Technological innovation often provides the foundation for disruptive innovation. Telehealth and Telecare have been identified as forms of disruptive innovation in the NHS. And of course, all the typical reactions and discussions that come with any form of disruptive innovation are currently being played out in the NHS when it comes to Telehealth. The Review of Innovation by the NHS Chief Executive concluded that the NHS has the potential to adopt these technologies on a scale that would put it at the forefront of the management of chronic diseases globally. This conclusion is underpinned by the report of the Whole System Demonstrator Programme which suggests that Telehealth has the potential to deliver significant benefits in both quality and productivity.  At the same time, some commentators have questioned the projected cost benefits of Telehealth and have asked whether the wider availability of these new technologies (and the rising user expectations that come with them) might, rather than reduce costs, create challenges for cost control.  In addition, technology in this field is moving so quickly that the care system is struggling to keep up with it. The main problems in introducing Telehealth appear to be about behaviours and mindsets, organisational and system issues, which brings us to another issue.

The ideas of innovation thinkers like Christensen are important in helping leaders determine whether an idea has “disruptive” potential. However, they don’t necessarily help leaders inside the system to embrace innovation or help solve the problems that (external) innovators will face when their concepts are put into operation within the system. The NHS is a great case study of this. If the large scale gains of disruptive innovation are to be achieved, disruptive thinking will also be needed in the way that new innovations are rolled out across the NHS. John Kenagy, who was a collaborator with Christensen in his early work on disruptive innovation in healthcare, now takes a different view to Christensen. Kenagy believes that the most effective innovations will come from inside, not outside the healthcare system as a result of a systematic and “adaptive” approach to innovation design that involves the entire workforce in change. Kenagy acknowledges the almost impossible task of introducing innovative solutions that run counter to prevailing structures and mindsets. His approach involves small scale (internally focussed) innovation incubators that he calls “learning lines”. In the foreword to Kenagy’s book, Christensen concedes that disruptive innovation is not the only way and suggests that there are “two critical pathways for improving the quality and reducing the cost of healthcare”. The first is Christensen’s own concept of disruptive innovation. The second is the Kenagy’s kind of internally focussed innovative design approach that gives existing organisations “far greater flexibility in adapting to the demands of the market than I [Christensen] had ever thought achievable”.

In meeting the quality and productivity challenges of the NHS, we need a multiplicity of sources of innovation. In a complex system like the NHS, no innovation, no matter how large scale or radical, will exist in isolation from the wider NHS system. It has to be accommodated within and interact with existing delivery and leadership systems. So, for instance in the context of Telehealth, technical innovation is only likely to  improve quality and  cost outcomes if it is matched  by concurrent changes in the way the work gets carried out. The NHS continues to struggle with reverse innovation; decommissioning and stopping the old activities when we have shown that the new innovation is better than the old system. Technology adoption on its own, without reform of working practice, is likely to have little or even a reverse impact on productivity.  In reality, many of the answers to getting greater innovation from within AND embracing externally generated innovation are contained within the same solution. That is how we build a mindset for innovation amongst our leadership community and a culture for innovation with our workforce and partners. 

There is a profound leadership challenge here. In situations of economic constraint and uncertainty, peoples’ propensity to think creatively and build innovation into their working practices wanes significantly. Fear, including fear of the unknown, has a stronger dampening effect on creativity and productivity than almost any other emotion. It sucks innovation out of organisations. In our current NHS context, we have to respond. As leaders, we have a disproportionately large effect on the cultures of our organisations or systems. We create the conditions that help or hinder innovation.  The factors that contribute to a culture for innovation are well documented. These include risk taking, creating a climate that enables people to feel psychologically safe in trying out new ways of working, rewards, rituals and symbols that recognise innovative behaviour and which are mostly non financial, relationships, enabling people with a variety of experiences and perspectives to innovate together and sharing knowledge as the fuel of innovation.  By explicitly focusing on these factors, we can avoid fear-based approaches and to tap into the potential of people to contribute, to be creative and to be motivated internally. The evidence is clear that leaders who create the right conditions engender higher innovation, motivation and productivity.

In reflecting on this topic, the overwhelming sense that I get is one of managing duality. This isn’t about “either/or” (externally generated disruptive innovation OR engaging the workforce in innovation at scale). We need “both/and”. The slow limited way that the NHS has often dealt with radical innovation to date will be insufficient for the future. On the other hand, if we just concentrate on large dramatic changes from outside, there is a risk that we will underestimate the changes required in the wider system to accommodate the innovation, fail to ignite the innovative potential of our workforce and will also miss the incremental impact of multiple small changes. In reality, the future healthcare system is likely to need both incremental and disruptive innovation, internally and externally generated, to deliver its quality and productivity challenges.

Nearly one hundred years ago, the author F Scott Fitzgerald wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function”. I think that this is pretty much spot on for our current innovation challenge. Moving forward, our key leadership role in innovation is to explicitly hold and manage the tension between external and internal, large scale and small scale innovation so we can get the best of both worlds and the people we serve can experience the benefits.

Some references and resources

Ashkenas R (May 2012) Managers don’t really want to innovate Harvard Business Review Blog

Barsh J (2008). Innovative management: a conversation with Gary Hamel and Lowell Bryan. McKinsey Quarterly 2008, no.1.

Borins S (2002). The challenge of innovating in government. In Abramson M and Littman I (eds) Innovation. Rowman & Littlefield. Chapter 3

Christensen C, Bohmer R, Kenagy J (2000).  Will disruptive innovation cure health care? Harvard Business Review, September-October

Christensen C, Grosman J, Hwang J (2009). The Innovator’s Prescription: a disruptive solution for healthcare. McGraw Hill

Department of Health (2011).  Innovation, health and wealth: accelerating adoption and diffusion in the NHS.

Goodwin N (March 2012) Where next for Telehealth? Reflections from the Kings’ Fund International Congress on Telehealth and Telecare

Hamel G (1998). Opinion: strategy innovation and the quest for value. Sloan Management Review. Winter 1998.

Kenagy J (2009). Designed to Adapt: Leading Healthcare in Challenging Times. Second River Press. 

Maher L, Plsek P, Price J, Mugglestone M (2010). Creating the Culture for innovation: A Practical Guide for Leaders. NHS Institute for Innovation and Improvement

NHS Confederation (2008). Disruptive innovation: what does it mean for the NHS?  Futures debate, paper five. September 2008