Innovation is a process that can significantly improve healthcare - at a price the NHS can afford, argues Sir Michael Rawlins.
There has, over the past few years, been much talk of the importance of innovation. Ara Darzi, as health minister, established a “Health Innovation Council” (of which I was a member) to promote it. The life sciences industries frequently talk about their “innovative” new products. Recently, Sir David Nicholson published his report “Innovation, Health, Wealth” to emphasise the NHS’s commitment to innovation. But what do we mean by the term innovation?
There is no shortage of definitions. And, as is so common in policy-making, the absence of a universal definition allows groups of people to appear to be in agreement without the need to nail down what it is they are agreed on. For me, innovation is a new product – or process – that significantly improves healthcare at a price the NHS can afford.
Product innovation is the area that comes to most people’s mind when using the term innovation. And there are, indeed, new products that significantly improve healthcare. The development and introduction of HPV vaccines offers the real promise of substantially reducing carcinoma of the cervix (not to mention anogenital warts). The development and use of endometrial ablation, in the treatment of menorrhagia, provides many women with the opportunity to have a day-case procedure rather than a hysterectomy (with a week’s stay in hospital).
Some forms of product innovation are cost-saving and NICE has recently established a specific Medical Technologies Evaluation Programme to help identify these. Others, however, are more costly and NICE’s technology appraisals programme is designed to assess the extent to which new products – though more expensive than existing ones – represent “good value for money” for the NHS. Many are, in the view of our appraisal committees, cost-effective - that is to say, the increased costs of these products appropriate to their increased benefits.
But it is not always the case. The anti-cancer drug bevacizumab (Avastin) for example, is not cost effective – in the view of NICE’s appraisal committees – for any of its licensed indications. Its use in the NHS would deprive other NHS patients with other conditions access to cost effective care.
And here is the problem with most definitions of “innovation”. If an “innovation” is cost ineffective it cannot – in so far as the NHS is concerned – be an innovation. Bevacizumab may be a cunning new pharmaceutical product, acting at a receptor site that has previously been inaccessible, but if its price means that its cost to the NHS is unaffordable, it is not innovative. I have explained this principle to members of the R and D departments of numerous pharmaceutical companies. Many are now starting “to get it” even though one senior executive said, after I had left the meeting, that he had to “hand out the smelling salts”.
Process innovation is often even more significant than product innovation. New approaches to the design and delivery of services, new ways of organising care, and new methods of providing improved care by so-called “process engineering” can immeasurably enhance the quality of care for NHS patients.
Process innovation is too often seen to be the sole responsibility of health service managers. Indeed, health service managers do have a critical role to play, but so do my clinical colleagues. The development and introduction of the WHO pre-operative checklist has already ensured the safety of patients undergoing surgical procedures. Assessment on admission of each patient’s risk of venous thromboembolism (VTE) will reduce rates of pulmonary embolism.
Process innovation is not confined to groups of patients but can also involve the management of individuals. At a recent meeting on innovation at the Royal Society of Medicine, David Dunaway explained how he and and his colleagues at Great Ormond Street Hospital separated eleven-month old conjoined twins. The twins’ heads were fused and - although their brains were separate - they shared, in part, a common cranium and their cerebral circulations were fused in an extraordinarily complicated manner. He and his team – and David emphasised the critical importance of “the team” – did not use individually novel techniques. Instead, they adapted existing methods to resolve a unique problem. The photograph of those beautiful twins six months later, separated and with no neurological deficits, was testimony to both his leadership and the wonders of process innovation.
Process innovation is carried out in many individual NHS trusts by their managerial and clinical staff. The tragedy is that others adopt these innovations too infrequently. When I worked in Newcastle we called it the “NIH (“not invented here”) syndrome” which has pervaded the NHS since its foundation. Breaking down the barriers to adopting both product and process innovations is not easy but we need to learn how to do it.