Getting the best from innovation
Lord Nigel Crisp is an independent member of the House of Lords, where he co-chairs the All Party Parliamentary and co-authored Group on Global Health. He works extensively on health in low and middle-income countries and was formerly the chief executive of the NHS and permanent secretary of the Department of Health in the United Kingdom. He has written several influential books and reports on health globally.
Risks and benefits
There are several quite specific and technical meanings for how the term innovation is used in different contexts. In health, however, it has been applied very generally to new ideas and developments of all kinds: whether they be therapies (an innovative new drug); disruptive technologies (emails and video-conferencing rather than traditional clinic appointments) or new ways of delivering services (nurse prescribing, for example, or self-treatment).
Sometimes, innovations in one setting may simply be old practices transferred from somewhere else. Sometimes, they will be about creating small incremental improvements, which together add up to a significant change. More rarely, they will be about re-imagining the world and re-conceptualising the problem. Thus, for example, Henry Ford and other motoring pioneers didn’t set out to create a faster horse but to provide a different solution to transport needs; lap tops replaced mainframes; and the mobile phone is supplanting many only slightly older technologies as it develops at pace. These innovative leaps will often have the greatest impact.
In my own country, the UK, innovation has come to embrace both these great disruptive changes and the incremental improvements to mean anything that moves away from our traditional or accepted ways of doing things. The UK policy statements are now full of “new ways of working” and “new service models” as well as new approaches to promoting innovation and creativity. This is very welcome because it takes us out of our comfort zones, challenges complacency and vested interests and can offer completely new solutions to long-standing problems.
There are enormous potential benefits but also considerable risks from an over-emphasis on innovation. We will all be familiar with the disappointments from over-hyped innovations and bitter experience has taught us that the benefits from some great innovations in genetics or IT, for example, may take years to realise. We can also be distracted by the excitement of innovation and spend too much time on the development of ideas and not enough on implementation. We might discard old ideas and methods that still work. We can pursue innovation for its own sake or simply for profit – such as new drugs that are marginal improvements on older ones but sold at a significant premium. The commercial development of truly new drugs is an enormous benefit to humanity but marginal improvements often only benefit the investor. There is a lot of money to be made from marketing innovation, whether it adds real value or not.
There are great dangers in abandoning old practices that are effective. I well remember how, as we brought about big reductions in waiting lists in England, we realised that the most effective “innovation” would be to implement what we already knew about best practice 100% of the time. That really would be innovative!
This is the same point addressed by the Institute for Healthcare Improvement (IHI) when it presses home lessons on patient safety – safe aseptic technique needs to be used all the time, it is not acceptable for even one patient to become infected through poor treatment in a clinical setting. Good health care delivery requires innovation – and IHI has developed innovative methods for 100% delivery – but it is based on the grind of doing the right thing time after time after time. In the old saying, it is 90% perspiration and only 10% inspiration.
In this short article, I took at where we might most usefully target innovation to achieve the biggest impact and how best to deliver the gains from the process. First, however, I consider the sources of innovation.
Sources of innovation
There is now a growing understanding that innovations occur all over the world and that innovation should be sourced globally. We may reasonably expect to see the great scientific and systems innovations and developments coming from the Western countries and, increasingly, the fast-growing economies of the East. However, there is also a lot to learn from poorer countries, which have minimal resources but, crucially, do not have the baggage of history and vested interests to hold them back.
In Turning the World Upside Down, I identified five areas where there were many innovations that richer countries could learn from poorer ones. These are shown in table 1. [1]The first area was where people had engaged the community and particularly, families and women in improving health and delivering health care. By contrast, people in the Western countries have become disempowered over the last few decades as professionals have taken over and commoditised tasks and services, which used to be done by families and individuals themselves. The example of Mothers2Mothers (M2M) where women with HIV work with pregnant women with HIV in order to help them avoid passing it on to their babies illustrates this very well in Southern Africa while BRAC in Bangladesh works to educate and empower women alongside offering health services.
BRAC is also an excellent example of the second area because it links together education, health improvement and – through its micro-finance scheme and other routes – the capability to earn a living. In the West we separate them, even though we know education and prosperity are key determinants of health.
There are many examples of social enterprises and businesses with social goals, covered in the third area, in countries throughout the world. Health services don’t need to be delivered by either government or commerce. There can be, and are, all kinds of creative partnerships between them and with citizens, NGOs and others which bring the strengths of each party to the task in hand. This requires us to think in different ways, adopting a new mind set. So too, does the fourth area of building links between public health workers and clinicians. The Health Extension Workers in Ethiopia are community health workers who carry out preventative and curative roles and tasks – the linkages between the two making their work even more effective.
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The final area is about training health workers for the job that needs doing and not just the profession and is the most challenging to receive wisdom and professional boundaries. There are now many examples, globally, of successful skill-mix change, task sharing and task shifting. There are, however, even more failed examples. These changes need to be introduced systematically and address all the relevant factors from good planning and training to support and supervision, which will together make them a success [2].
Sharing and learning in a creative process
This learning from poorer countries, from what is sometimes called – I think rather patronisingly – frugal, or reverse innovations, is now getting recognised both in academic literature and practice. Some major US institutions have set up programs with Indian partners to develop this learning and share innovation whilst[3] others are starting to recognise that, just as in any other industry, innovation in health needs to be sourced globally.
An important point about this discussion is that it is involves both parties in a partnership learning – everyone has something to learn and everyone has something to teach. Some of the most creative and interesting innovations globally come from people from different backgrounds, coming together, pooling their knowledge and attitudes to create new ways of doing things.
Innovation, too, can be thought of as a particular mindset or approach to the world. Don Berwick, formerly President of IHI, has talked of every health worker having two jobs – their job and the job of seeking constant improvement. Improvement and innovation have to be the mainstream activities for every health worker.
The most valuable areas for innovation
Innovation will be most effective when it tackles the biggest areas, attracting maximum gains. This would suggest that it should focus on health promotion and disease prevention, even more than it should on health care. In both it should concentrate on:
• Staffing
• The involvement of the public and communities
• Technology
The arguments for focussing on these three areas are very simple. The employment of health workers make up more than 40% of health care cost globally – and up to 70% in richer countries – and it is crucial that they are used as effectively as possible. This means enabling them to work to the full extent of their competence – a significant problem, for example, with nurses who are often under-valued and under-estimated – and supporting them with good management and technology wherever possible.
The second area is linked because the greater involvement of individuals and communities both in promoting health and in treatment will relieve health workers and, very often, provide sustainable solutions to problems. There is great-untapped potential here for enhancing health and health care enormously. We are already seeing growth in what is being called “asset-based health care” where health workers make use of all the assets of a community, including the knowledge of its people, to improve health and deliver services.
Technology in all its manifestations from IT and computing to pharmaceutical and engineering underpins these other two areas. The scope for innovation here is enormous and particularly from using the Internet – the organising principle of our age[4] –
Implementation and achieving the benefits
An innovation may be the most brilliant development in the world but it will have little impact if it is not implemented well. This is not just about the skills of the implementers, although these are important, but about the conditions that will allow it to be implemented well. In particular, I would draw attention to three features.
The first of these is the importance of measurement and evidence. How can we tell if something is an improvement without understanding the base line position and any changes the innovation brings about? Good data is one of the most important resources in health and can sometimes be neglected as people rush to implement a “good” idea. Evidence is ever more important as policy makers and practitioners strive to achieve the best value from their resources.
The second is systematic implementation and attention to detail. This is partly a repetition of the point about perspiration as well as inspiration, but it also refers to the importance of experimentation and “trial and error”. Innovations that are good in principle need to be tested in the specific environment and tailored to its circumstances. One size rarely fits all.
The third feature effectively encompasses both these features and more. It is the importance of there being an effective health system in place. It is only where this exists that innovations can be used systematically and consistently to deliver improvements for a whole population.
Innovation, whether we mean radical leaps of new technology or approaches, re-imagining the world, or continuous incremental improvement, is essential for health and health care. This is now the biggest industry in the world and one that is important to every one of us.
It is essential that we achieve the greatest benefit from innovation by acting rigorously, respecting evidence, targeting the areas of greatest benefit and creating health systems which provide the best environment for implementation. Under these conditions human creativity and ingenuity will bring untold benefit to the world.
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[1] Crisp N: Turning the World Upside Down – the search for global health in the 21st Century; CRC Press, 2010
[2] All-Party parliamentary Group on Global Health: All the Talents: July 2012 http://www.appg-globalhealth.org.uk/reports/4556656050Accessed 7 June 2016
[3] https://globalhealth.duke.edu/media/news/dukes-partnership-shiv-nadar-university-includes-global-health-rojects Accessed 27 August 2015
[4] Baroness Martha Lane Fox in a House of Lords debate on 26 November 2015. Lords Hansard p903
