Supporting and organising efforts to create and use innovative technologies is more difficult than ever but a recently developed set of future scenarios may help spur some creative planning, write Clive Savory, Joyce Fortune and Geoff Peters.
Organising and planning for innovation in the NHS is very important but it is never straightforward. Recent events in the NHS make predicting how the innovation territory is going to develop particularly difficult. Clearly, the impact of the Health and Social Care Bill and the requirement to meet the Nicholson Challenge are all going to be important, but there are a myriad of other factors that may or may not affect the need, direction and form of innovation support required by the NHS.
There are, of course, many things that can be treated as certain in the future: financial cuts, an aging population, rising demand, advances in healthcare technologies, and changes to how services are provided. However, these “knowns” are only one side of the coin, there are at least as many uncertainties. Will care migrate from acute settings to the community? Will the NHS become an uneasy coalition of willing providers? Will innovation be led by clinicians or will the NHS be a laggard-follower of what has been tried out in other healthcare systems?
Knowing how these questions will be answered in six months is difficult enough, but what about longer planning horizons? How will NHS innovation policy and support look at the end of this parliament’s term in 2015? Obviously it is not possible to know the future, but becoming sensitive to what the unknowns are and how they may possibly develop can, at the very least, inform and improve the decisions made between now and 2015 about building innovation support.
A recent workshop, hosted by the Open University, asked these questions of a range of NHS managers and innovation experts. The workshop’s aim was to develop a view of how the future technology innovation in the NHS might look in 2015. They produced an interesting set of cameo views of different, yet plausible futures. Some were little different from the current picture while others illustrated how in even a few years the innovation landscape could change radically.
The workshop followed a rapid scenario planning process (figure 1, see right). The first half involved a discussion of the knowns and the uncertainties facing those supporting innovation in the NHS. The second half compared the divergent outcomes of pairs of uncertainties to generate plausible, yet very different views of the future. For example in figure 2 (see right), diversification of NHS provider organisations was juxtaposed with the pace of technology adoption in the NHS.
Though not producing precise predictions of the future state of NHS, the resulting four scenarios provide a basis for discussing and planning future innovation support:
“John Lewis NHS”
The John Lewis NHS is a paternalistic organisation in which trusts only adopt technologies where there is robust clinical evidence to support their take-up. National directives allow strategically-focused adoption policies to be developed across the NHS. Individual trusts have well developed technology-scanning and implementation functions that are responsive to the demands of an increasingly knowledgeable, and relatively powerful, local patient population.
Although adoption decisions can take months or even years, once they have been taken implementation is rapid and comprehensive across the whole NHS service. Staff are very responsive to the need for change. The technologies adopted are generally focused on solving problems in priority areas so “Cinderella” health areas with less political backing tend to remain well behind the technology curve.
NHS as a technology-led market place
Technology adoption is driven by opportunities for provider organizations to gain strategic advantage over competitors. For technologies that speed up or streamline processes without reducing income to the provider elsewhere, adoption is virtually automatic. The difficulty of building a business case for technologies that eliminate income generating activities or provide much longer term health improvements makes their adoption slower. The problem of budget silos has increased with the diversification of the provider market, making the re-configuration of across-boundary services more difficult. Though providers often use the latest technologies for specific procedures, patient-pathways lack co-ordination across organizations. Diversity between providers means that there are significant regional differences in the technologies used.
Over the past five years the NHS has evolved into a market for private providers. NHS services are now delivered predominantly by private companies providing highly specified services using approved processes and their associated technologies. Provision is high quality in terms of conformance to specified service agreements. NHS operating costs have been reduced substantially. However, the highly specified contracts make it difficult for individual providers to adopt new technologies. Clinical practice has become highly procedure-driven and there is little incentive for staff to use their professional judgment. Staff are trained for specific jobs, rather than more general professional roles with the result that the NHS is no longer regarded as an effective provider of training. In this scenario, research within NHS organizations is now minimal, with rates of internally generated innovation severely curtailed when compared with the early 2000s.
NHS as an arm’s length body
The NHS remains dominated by NHS trusts that provide 90 per cent of NHS services. Most have foundation status and carry significant power in technology adoption decisions, mediated by the expectations of commissioning organizations and central government policy. Large, block-based contracts give a stable basis on which investment appraisal of new technologies can be based. Technology adoption tends to be conservative and relatively slow and the NHS is generally regarded by the healthcare technology industry as a late adopter of technology, the only exception being where technologies address key national healthcare priorities. For these technologies, central government gives significant incentives for rapid adoption, with severe penalties for trusts that do not adopt mandated technologies. NHS provision is generally consistent across the country, though quality of care is below that of the top ten healthcare systems globally.
These various scenarios raise several interesting points. Each of the scenarios identify key changes in the nature of the NHS that have consequences for innovation. For example the Franchise NHS scenario highlights a significant reduction in both professional autonomy and research activity. These changes could significantly undermine the scope for internally generated innovation.
Similarly the “John Lewis NHS” scenario highlights the problem of increasing numbers of Cinderella health areas and the Technology-led Market Place scenario flags up how the number and complexity of providers has increased the barriers to innovation caused by budgetary silos. Hence the discussion of the scenarios needs to consider how to address some of the root causes of innovation barriers that develop in the future.
The Franchise NHS and NHS as an Arm’s Length Body scenarios, are indicative of futures where the rate of technology adoption continues to be slow, irrespective of how services are organised within the NHS brand. These scenarios may be useful in developing discussion about how future innovation support can actively increase the speed technology adoption, while taking into account the uncertainty around structure organisation in the NHS.
The John Lewis NHS and NHS as an Arm’s Length Body scenarios on the left-hand side of the matrix are perhaps closest to the status quo. The implications of a significantly more fragmented NHS, as suggested in the right-hand scenarios, set up very new challenges for how innovation support across the NHS can and should be managed.
In simple terms scenario planning is a strategic planning tool that often involves a group of organizational stakeholders carefully considering what is predictably and unpredictable about the future and then combining these to generate a set of very different named descriptions of that future.
The ‘important uncertainties’ about the future and the drivers of change are given particular attention and often a set of mini scenarios are produced before concentration on two or three incompatible but complementary scenarios are worked on in depth. Scenario Planning can, as in this exercise, be a relative ‘quick and dirty’ set of approximations using existing organizational knowledge or it can be a very thorough, lengthy and quantitative activity that takes months or in some cases years and also involves outside experts and consultants. Companies like Shell have led the way in regularly producing company scenarios for more than 40 years.
Scenario Planning has a number of advantages when future strategy is being considered. First, it deliberately encourages organizations and managers, in the widest sense, to consider a range of possible futures rather than either settle on one ‘predicted’ or ‘official’ future or be intimidated and overwhelmed by the unpredictability of it all.
Retaining a set possible futures and then testing short and medium term plans and progress against them all can help ensure that plans are more robust or at least interrogated more intelligently. Indeed, although scenarios are invariably chosen to reflect widely differing views of the future, they can help reduce uncertainty and make planning easier.
For example, a recent review of UK energy supply over the next 50 years or so reportedly came up with widely different international contexts and a range of ideas about the likelihood of technological change and energy demand. However, the same exercise evidently also concluded that these very different scenarios had little impact on immediate policy about the balance of fuels to be used in the next 25 years.
The second and often equally strong advantage of scenario planning is that it can engage a wide range of internal stakeholders and provide an opportunity for them to voice and hear their potentially incompatible professional and role-based perspectives. While this can be true of many strategic planning activities, the opportunity to work together with unfamiliar colleagues in a sustained way on conceiving and honing individual scenarios is often reported as a significant long term gain from the activity.
Finally, like some other strategic planning tools scenario planning provides an opportunity to engage with experts outside the organization who either have insights into allied fields or in some cases future developments that may seem peripheral but throw light on the important uncertainties such as the social or technological climate.
Putting the scenarios to work
The workshop at the Open University produced several sets of scenarios based upon a number of juxtaposed uncertainties. In common with the set described above, they all provide scope for informing strategic planning of innovation support. The sets of scenarios can be used in many ways. Given the luxury of time the ideal way of using scenarios is to build your own that relate specifically to your own NHS organisation and its specific focus. This is the ideal, as the act of discussing the key uncertainties faced by an organisation and how they play out in the future is a remarkably effective way of helping staff understand the environment in which their organisation is working. This builds scenario planning as a way of thinking that will endure through future planning.
If you do not have the time or opportunity to build scenarios you may find it useful to use some of the scenarios developed at the workshop. You could use them for building awareness of factors affecting innovation in the organisation. This might simply involve discussing what innovation support is needed in each of the scenarios in a set. A more sophisticated approach would be to stress-test your current innovation support system against each of the scenarios. This would allow decisions about what to change to be made in a way that takes into account the key uncertainties affecting the NHS.
All the scenarios developed in the workshop are available on request. If you would like a complete set or would like any further advice on using the scenarios or the scenario planning technique then please contact Clive Savory.