Helen Bevan: my report card on the state of innovation in the English National Health Service

A shorter version of this article was published by the Health Service Journal, under the title of Three steps to a new innovation strategy.

Helen Bevan

Helen Bevan

Over the past couple of years, I have visited many healthcare organisations within the English National Health Service, reviewed multiple local transformation strategies and spoken to hundreds of leaders and frontline teams involved in innovation. I have also had discussions with some of those charged with promoting innovation at a system level through the Academic Health Science Networks (AHSNs). So this piece is an opportunity for me to share some of my own conclusions about the state of innovation in the NHS.

For me, innovation is essentially a process that converts ideas and knowledge into benefits for people and organisations. In an era where healthcare finances are so constrained, the need to develop effective innovation strategies is a no-brainer. We face clear choices as healthcare commissioners and providers. We can seek to contain costs by restricting services, or requiring often overstretched staff to work even harder. OR the alternative approach involves thinking differently, often in a radical manner, about the way that services can be delivered within available resources and taking action (innovating) to design and deliver services in different ways.

But what kinds of innovation should we as healthcare leaders be adopting to give us the best chance of delivering our transformational goals? It’s helpful to differentiate between three kinds (or levels) of innovation in health and care:

  • process innovations
  • service innovations
  • strategy innovations

Examples of all three are shown in this table:

Examples of process, service and strategy innovations - Helen Bevan

Examples of process, service and strategy innovations – Helen Bevan

Process innovations are the most common type of innovation in healthcare. They involve reducing or eliminating unwarranted variation and/or activities that do not add value from an existing process. They tend to be narrower in scope than service innovations, focusing on a discrete part of, or contribution to, a wider service, typically without changing the nature of the overall service or patient pathway or requiring a different paradigm about care. Generally, process innovations are less complex and quicker to implement than the other types of innovation because they cross few organisational or service boundaries. Consequently, they offer less potential to deliver significant outcomes in terms of quality and productivity improvements.

Service innovations seek to improve (incrementally) or transform (radically) an offering for an entire service or pathway of care for a specific group of patients, typically covering multiple processes. Seven years ago, I worked with colleagues from the Health Services Management Unit, Birmingham on a project called Making the Shift (to primary and community based services). We created a typology for service innovations that is still the best one that I have seen anywhere and I continue to use to this day. The types of service innovation are:

  1. Integration: creating more effective relationships between the contributions to the health and social care system which result in seamless, integrated care
  2. Substitution: providing higher value, lower cost care for patients or service users through:
  • location substitution: substituting high tech clinical environments for community based settings
  • skills substitution: enhancing the skills of specific groups of staff to undertake roles previously undertaken by those with a higher skill level, for instance enabling nurses to prescribe drugs, a role that was previously only carried out by doctors
  • technological substitution: maximising the use of new technologies in the service. A specific type of technological substitution is channel shift by which organisations seek to encourage their service users or patients to access or interact with services via channels other than those to which they are accustomed. A typical channel shift is moving from face to face or phone interaction to self-service online.
  • clinical substitution: moving from a medical care model to community care or family or self care model
  • organisational substitution: looking at a wider range of providers to those who have traditionally delivered NHS care, for instance voluntary and community groups and social enterprises.
  1. Segmentation: grouping patients by their specific requirements and designing discrete services around that group of patients in ways that enable them to get the service they want and need at the time they need and want it.
  2. Simplification: counterbalancing the risk of creating extra structures and extra complexity, ensuring that every step in the care process adds value for patients and minimising the potential for additional costs as a result of the innovation. An importance aspect is reverse innovation– decommissioning an activity that is shown to have no added value or that has been replaced by something new or better.

Service innovations in healthcare may involve any combination of these four types of change. Sometimes, a change programme doesn’t utilise a broad enough spectrum of the four types of service innovation. For instance, a commonly reported scenario is one where a service innovation is introduced with the intention to substitute a hospital based service with a more cost-effective community based service. However, the change is not followed up with simplification. This means that the hospital service continues to operate in parallel so the service ends up being “doubled up”, in multiple locations. This makes an important point about the relationship between innovation, quality and cost.  Innovation per se does not necessarily lead to better quality and reduced costs.  It only creates quality and efficiency if it is implemented and diffused in a way that leads to more effective outcomes from the resources invested. If innovation is not managed effectively, it can end up costing more.

Service innovations bring more risk than process innovations because they are more complex and innovations are more likely to cross existing departmental or organisational boundaries. However, the quality and productivity gains of service innovations are typically more significant than those of process innovations.

Strategy innovation means thinking in an entirely new way about the basis on which the organisation, system or industry operates. As Gary Hamel who pioneered the concept concludes: “the question today is not whether you can re-engineer your processes; the question is whether you can reinvent the entire industry model”. Most organisational innovation is at process and service level, but these innovations may lack the pervasiveness to deliver change at the scale or pace required.  Strategy innovation is relevant when the demographic, financial or technological challenges that we face can’t be met without abandoning the prevailing management model and rethinking the system.

Strategy innovation offers the greatest opportunity to deliver large scale change but it is also the highest risk of all three levels of innovation. It requires a fundamental shift in mindset, key people are likely to lose power and influence as we move to the new arrangements and the kinds of change programmes that result from strategy innovations are big and complex. Many change initiatives based on strategy innovation fail to deliver their objectives.

These case studies show examples of strategy, service and process innovations in practice.

There is a great deal of outstanding innovation practice in the NHS that the rest of the world can learn from and which makes me proud to be part of such an innovative NHS system. However, these are my overall (generalised) conclusions using the model of process, service and strategy innovation:

  • Increasingly, NHS organisations are adopting an ambition for strategic innovation in their transformation plans. However, the reality of innovation practice in the NHS is mostly at the level of process innovation. Innovation is typically happening incrementally, small gains at a time, even when bigger improvements are being sought.
  • Often senior leaders aspire to strategic innovation but what their organisations actually end up actually delivering is process or service innovation
  • I often observe a conflict or misalignment between corporate plans of senior leaders based on strategy innovations and the innovation activities of frontline teams at process or service levels
  • Often we lack a theory of change to guide our innovation activities; lots of process innovation can be a positive thing but it doesn’t necessarily shift the paradigm of thinking that is necessary for transformation. Multiple process innovations don’t add up to strategy innovation.

I’ve summarised some of these “mismatches” in the table below:

 

Type of innovation

Potential contribution to transformational change

Current prevalence in delivery of innovation strategies

 

Risk of

non-delivery

 

Process

Lowest

High

Lowest

 

Service

Higher

Lower

Higher

 

Strategy

Highest

Lowest

Highest

Source: Helen Bevan

So what should we do to align the different levels of innovation? These are my top four ideas based on the effective innovation practice I have observed in the NHS and other healthcare systems:

  1. Seek to match our level of ambition for change with the methods and mindsets for innovation that give us the best chance for delivering our goals. The organisations that I see doing this most effectively recognise that innovation is a structured and disciplined process, the product of the deliberate use of practical tools. They have adopted evidence-based human-centred design methodologies and invested in design capability. Leaders in these organisations work very hard to build shared purpose for innovation amongst those who and create a compelling narrative for change that unites people around the cause. They prioritise making the time for strategy innovation and act as deliberate role models in its execution. They measure the outcomes of strategy innovation efforts.
  2. Create a “roadmap” to guide innovation practice. In my experience, leaders are more likely to be successful in their innovation efforts if they design and work with a “roadmap”: an explicit model or theory that hypothesises how they will deliver large scale change through strategy innovation. The roadmap helps align and connect activities at all three levels of innovation and enables frontline staff delivering process and service innovation to make sense of how their activities fit into the bigger picture of strategy innovation. It reduces the risk of ambitions for strategy innovation being translated into the operational reality of service and process innovation.
  3. Build shared purpose for strategy innovation on a big scale. People will own what they co-produce. That means engaging those who will define the benefits of the innovation, those who are going to make it happen and those it will affect to be part of the innovation design effort. The wider the engagement and the broader the perspective, the less risk that the change effort will unintentionally converge into incremental process innovation. This means inviting patients, carers, staff, partners in the wider community, leaders from other care organisations and other industries to be part in our innovation processes.
  4. Always review and celebrate all attempts at innovating to make a difference, whatever the level of innovation. Do this regardless of the results, because it means that people are more likely to attempt further innovation in the future

In reality, the future health and care system will need a combination of strategy, service and process innovations to deliver its quality and productivity challenges. On one hand, innovation in the current NHS context has to deliver more than small scale process changes. On the other hand, if we just concentrate on large dramatic changes, there is a risk that we will miss the incremental impact of multiple small changes at the frontline of care.

The circumstances of scarce resources create the situation where we need to think about and deliver services in fundamentally different ways. They help create an environment where the biggest breakthrough innovations can happen. If we can align our efforts between strategy, service and process changes, we have the potential to do what might have previously seemed impossible.

Helen Bevan is Chief Transformation Officer for the Horizons group, a collective of thought leaders and activists who seek to stimulate new and disruptive approaches in support of healthcare transformation. They are supported by NHS Improving Quality.

All views are her own. Follow her on Twitter @HelenBevan

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3 thoughts on “Helen Bevan: my report card on the state of innovation in the English National Health Service

  1. Well done Helen.

    How can we scale up the knowledge and capability to affect strategic innovation – which is clearly a necessity as the economic climate continues to tighten. I think we struggle with letting go of our security and income levels within our disciplinary silos.
    Keep up the great work!

  2. This article raised the issue in my mind about the distinctions between “first-order change” improvement versus “second-order change” innovation. I have compiled a series of tables to help make these distinctions for group discussion purposes. Candor and critical feedback welcomed. I noticed that KP curriculum is for internal purposes only.
    How can healthcare embrace open innovation? Is that an innovation?
    Trying to develop a MOOC Development Forum
    http://www.wiziq.com/course/34421-cultivate-open-innovation-health-enterprises
    on cultivating open innovation health enterprises. http://vimeo.com/77884521
    Connect via linked-in if curious — looking to interview thought leaders and gather learning assets for this proposed MOOC.

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