All Change Please

January 6, 2009




“Even when backed by clear evidence, new technologies and practices inch their way too slowly through the vast web of structures that make up the National Health Service. !is is one of the reasons ourstandards often fall below those of comparable countries. Data collected by theWorld Health Organisation shows that
premature deaths from causes that are preventable with prompt and effective healthcare are higher in the UK than Germany, Canada, Australia and France. A lack of MRI and CT scanners can lead to long waits for diagnostic tests, while shortages in radiotherapy equipment are a factor in our comparatively poor cancer treatment. Among European countries, the UK is consistently below average in the adoption of new drugs for the treatment of certain common cancers. And within Britain, too, there is an unjustifiably wide variation in outcomes of care – the postcode lottery.

The final report of Lord Darzi’s review of the NHS, High Quality Care for All, published in June 2008, addresses the need for more and better information about clinical performance and examines ways to strengthen existing incentives to improve practice. But the work could be bolder about reducing costs, reforming procurement systems and simplifying the 40 plus organisations that have been created to improve rates of innovation.”


Organisational capacity for innovation and adoption

“The public service history of the NHS may mean that managers do not focus on the success of their organisation. NHS managers are not judged by how innovative they are or even necessarily by how far they improve services for patients. They are judged by how well they stay within their budget and meet the tasks demanded of them, such as the latest central government target or National Institute for Clinical Excellence (NICE) directive. Thinking of new ways to meet the needs of patients is not a priority – indeed current structures may even discourage it.

The health and social care systems are hugely complex, with messy lines of communication and spheres of responsibility, which encourage power struggles and bunker mentalities. As a result the barriers to the successful implementation of new technologies are greater in the NHS than in our other public services. Successive waves of NHS restructuring have not removed these barriers.

The landscape for procurement is heavily fragmented – the UK healthcare market consists of 426 NHS trusts, ten evolving or actual regional purchasing groups (known as collaborative procurement hubs), the NHS Purchasing and Supply Agency (PASA, created to provide procurement guidance to trusts), six private healthcare organisations, 11,000 healthcare suppliers and two nonpharmacy wholesalers.

These organisations buy and sell goods and services worth about £21 billion a year. Improving the effectiveness of their trading relationships and using contractual mechanisms to stimulate innovation require more attention, but despite its centrality in the spread of new technologies, procurement was neglected in the Darzi review……


“The UK spends over £8 billion a year on innovating, refining, piloting, evaluating, appraising and diffusing new healthcare ideas, including annual public sector spending of approximately £2.7 billion. But our research suggests that £2.4 billion is spent on the creation of new ideas, £0.1 billion spent on the adoption of these ideas, £0.06 billion on appraisal of these ideas and £0.15 billion on the spread and implementation of ideas. In other words, nearly 16 times more is spent on invention than diffusion. !e discrepancy between spending on creation and the appraisal of innovations is striking – the latter receives just 2% of the total public funds. Funds are too heavily weighted towards creation. After all, ideas are of no use if they are not applied. And the alphabet soup of organisations created by the Government to assist hospital trusts lacks a clear, joined-up strategy for spreading these ideas.”


“The capacity for innovation in NHS organisations suffers from an endemic aversion to taking risks. A study of change capability in the NHS by the Office of Government Commerce in July 2006 gave the NHS a score of only two out of a possible five points for seven out of nine categories assessed.

The NHS got low scores in the use of change management methods, staff development approaches and change leadership. Blame for failure outweighs the reward for success. Leadership has been described as being predominantly about “survival in a heavily orchestrated world”. Managers in the NHS tend not to act like leaders – engaging staff with the core mission of improving services for patients, and creating a collaborative, innovative environment for organisational development. Instead they focus on meeting directives and managing a budget. If an initiative is not demanded from above, then its financial and managerial burden is not balanced by any reward for success; failure, on the other hand, meets with immediate censure. And even if there is a potential financial or reputational gain, past experience of the difficulties in managing change and realising benefits contributes to extreme caution in assessing risks.”