John Craig, Chief Executive of Care City, blogs about their experience of innovation and improvement through their work as an NHS England Test Bed.
Saturn V launched the first space station, but legend has it that the plans for the rocket were lost. In recent years, NASA scientists looking to re-energise lunar exploration have not been working from documents – they have taken a 40-year-old Saturn V into their workshop, and tried to fire it up.
Is it a farce that NASA’s engineers have to start again? Not at all. The story that the plans for Saturn V were lost is false. Plans just aren’t as valuable as we think. NASA’s plans didn’t get close to capturing what it really took to make the rocket’s 1 million components, let alone how to make them work together.
Abstracted from the people who use them – and the culture in which they work – brilliant tools and plans make much less sense than we might expect. The problem for health care is that this kind of abstraction happens a lot.
Many improvement teams are clinically dominated, and spend most of their time working inside single health care organisations. Abstracted from the development of new tools and approaches, they can struggle to challenge prevailing orthodoxy.
At the same time, too much innovation is outside-in, driven by technologists and entrepreneurs rather than clinicians and patients. Abstracted from the people who use their products, they can focus too narrowly on specific transactions, and miss the bigger picture.
At Care City – through our work as an NHS England Test Bed – we have seen first-hand the effect of overcoming these divides, and better connecting technologists, entrepreneurs, clinicians and patients.
Even the best and most radical innovations require the same painstaking improvement cycles to really work and achieve excellence. No matter the quality of training, support and information, clinicians – like those NASA engineers armed with reams of blueprints – have a huge amount to do to make sense of an innovation and to make it work. Implementation is a creative act.
Equally, clinicians who only want to improve outcomes for their patients can drive dramatic innovation. Care City worked with Alivecor’s Kardia Mobile – a mobile ECG – looking at its potential for the atrial fibrillation pathway. We tested the technology with a huge range of stakeholders to generate ideas. We tested screening services, both within GP practices and community pharmacies. Building on what we learned, we tested a new pathway, enabling community pharmacies to refer directly to a one-stop clinic at Barts Health. The evidence suggests that this pathway is quicker, more cost-effective and has the potential to prevent 1,600 strokes nationwide.
But who was the innovator in this example? In the language of the Test Bed programme, it is Alivecor, but their product is unchanged by the process. Leaders and clinicians on the other hand – like Dr Sotiris Antoniou from Barts Health – have led the development of a new pathway.
As Care City reflects on its first Test Bed programme, it is absolutely clear to us that the Health Foundation is right that improvement across health and care will not be achieved without the infrastructure, skills and relationships to support it.
We also reflect on some of the distinctions we take for granted in health care. First, health care still distinguishes strongly between improvement and innovation. Both are useful terms, and the way innovations introduce a ‘new dimension of performance’ is distinct. However, do these activities need to be pursued separately, by different people, in different organisations in different ways? This distinction may reinforce both the insularity of improvement work and the disconnection of innovation from the needs of health systems.
Relatedly, health care thinks of improvement as a science and innovation as an art. Is there much more to this than the personalities and habits of those engaged in the work? Improvers must retain ambition for dramatic progress, and be open to uncertainty and to the toughest challenges we face. Innovators must remember that – however beautiful the app or the tool – the only real benchmark is better outcomes for people using the innovation.
Lastly, we believe we should be more sensitive to the number of conversations that are about innovations or workforce, but not both. As shortages not just of money but also of people intensify, we need to be clearer that the purpose of all innovation is productivity. Developing our people and the tools they use should happen together, and that will be at the heart of Care City’s work for the future.