Comment: Evolution, not revolution: How innovation can drive sustainable healthcare

Chris Barker of Spirit Healthcare calls for a different approach to digital transformation, arguing that the best gains will come from CCGs exploring more-localised, smaller and more-integrated initiatives

Chris Barker

When Sir Clive Woodward’s England team won the Rugby World Cup in 2003, his coaching philosophy may well have provided an early clue as to how the NHS could drive improvements in care.

Technology is not a panacea. There is no ‘single solution’ that fixes everything or ‘transforms’ care overnight

Success, he said, was not about doing one thing 100% better, but about doing 100 things 1% better.

Fifteen years later and the concept of marginal gains is not only familiar to us all; it can be applied to pretty much any strategy for human or business improvement.

But, in the modern NHS, where technology is so often hailed as the great enabler of transformative change; the evolutionary approach has arguably been kicked into touch and replaced with the pursuit of smash-and-grab ‘digital transformation’.

The rhetoric implies instant gratification – the promise that digital ingenuity can quickly and effectively cure all ills. The reality, though, is far more complex. If we want to get over the gain line, it’s time to reset the scrum.

Digital transformation is a great hope but, arguably, an unrealistic aspiration.

But sustainable NHS improvement will not be found in a magic bullet of digital transformation. It’s about evolution, not revolution

Technology is not a panacea. There is no ‘single solution’ that fixes everything or ‘transforms’ care overnight. The healthcare gains of tomorrow will come from incremental innovation – and lots of it. Doing 100 things 1% better.

To get there, CCGs primarily require two things; a forensic understanding of their patient pathways, and the courage to explore new ways of approaching the challenges within them.

The potential solutions will be many – and technology will inevitably play its part. But sustainable NHS improvement will not be found in a magic bullet of digital transformation. It’s about evolution, not revolution.

The challenges of healthcare delivery are local, specific and complex – they’re driven by individual contexts, diverse behaviours and fluctuating dynamics.

Addressing each one requires a tailored response based on a holistic view of the current pathway and clear outcome goals to improve it.

There are no off-the-peg solutions. However, we can undoubtedly learn from others and, where appropriate, apply the strategies that have succeeded elsewhere

There are no off-the-peg solutions. However, we can undoubtedly learn from others and, where appropriate, apply the strategies that have succeeded elsewhere. Our challenge is to build, share and evolve the evidence-base.

To get there may require a departure from pursuing large-scale ‘transformation’ initiatives designed to fix everything in one go.

CCGs should instead adopt a mor- agile, incremental approach. By exploring a range of smaller, but crucially integrated, innovations; NHS organisations can make tangible cumulative gains.

Step 1: Evaluate

So how can we make progress? The answer is not to think digital first, but to think pathway-first.

At the macro level; the NHS’s challenges are general; there’s a chronic imbalance between demand and supply fuelled by an ever-increasing population and diminishing resources.

The impact of those national challenges naturally cascades down to individual services at the local level. It’s there where we need to address them.

To drive improvement, CCGs – in partnership with providers and practices – must first establish a deep understanding of their current pathways in the services where they face the biggest challenges. What currently happens? Who goes where and how does it work?

By process mapping it to establish how people and resources are utilised, it becomes easier to identify the barriers within the pathway and the points at which new interventions could be made. Which aspects can be changed and how? If you change them, what happens? Could technology drive improvement? If so, by how much? And what does the evidence look like?

The process of service improvement starts not with identifying a digital deployment that can ‘transform’ care, but with understanding the pathway and all the behaviours you need to change to get the outcomes you need. And the answers won’t come gift-wrapped in a single solution.

Step 2: Collaborate

After the evaluation comes collaboration. NHS leaders have a great understanding of their patient pathways – their challenge comes in knowing how to optimise resources to solve the problems within them.

It’s here where technology can – if properly integrated – augment resources, drive productivity and improve care.

However, with an understandable capability gap in harnessing the power of technology, CCGs need help.

The most progressive are those that have built that deep understanding of patient pathways and invited the market – fellow NHS organisations or private companies – to propose creative solutions that have helped them unlock better ways of delivering services.

Step 3: Innovate and iterate

The ideas and innovations are out there. Furthermore, the majority of successful service redesigns are underpinned by technology that has helped reimagine processes and unlock healthcare gains.

Success is not about doing one thing 100% better, but about doing 100 things 1% better

However, in the best examples, the focus is never on finding a technology solution, but in understanding how technology can be integrated with people and capabilities to drive demonstrable outcomes.

The evidence-base is building. For instance, there are examples within COPD where telehealth has been able to reduce unplanned admissions by over 60% while at the same time increasing the number of patients each specialist nurse can handle. The net result? Patients get a better deal while the hospitals don’t need more nurses they can neither afford nor train quickly enough.

Moreover, the technology sits inbetween – supporting patients and healthcare professionals in delivering better outcomes for all. Crucially, this model wasn’t approached as a telehealth service, it’s a COPD service. It started with an analysis of the pathway and a willingness to explore alternative ideas that ultimately unlocked an effective solution.

It’s a similar story in ophthalmology, where patient demand is growing at an alarming rate and many NHS services are operating at capacity. Detailed analysis of a cataract service in the East Midlands identified barriers along the pathway that were exacerbating the problem and significantly impacting patient care and hospital resources.

The introduction of an interactive planning tool that forecasts demand for the service – and predicts the resources required to meet it – has helped better plan the service.

However, the benefits of these analytics were only enabled by concurrent work to remove long-standing obstacles within the pathway.

These combined activities formed part of a holistic service redesign that increased the number of cataract patients the hospital treats each week – without requiring additional resources.

It underlines the point: the effective integration of people, technology and processes is fundamental to driving improvement. Technology does not work in isolation.

Step 4: Evolve

In a NHS environment fixated on transformation, the challenge for CCGs is to stay within the realms of the possible.

Transformation is a wonderful ambition, but it sets the bar too high. Healthcare organisations should instead strive for incremental innovation; evolution not revolution.

Transformation is a wonderful ambition, but it sets the bar too high. Healthcare organisations should instead strive for incremental innovation; evolution not revolution

The smartest approach is to think imaginatively, try new things and measure them relentlessly. If they fail, discard them. But, if they work, maintain and embed them into routine practice. If they’re built on a fundamental understanding of patient pathways, they’ve more than a fighting chance.

In conclusion

Digital technology will undoubtedly play a huge role in the healthcare of the future; it provides our best chance of optimising resources and expanding the capacity of the NHS without increasing costs.

But it’s not a panacea. We must not use technology for technology’s sake. We should only use the tools that can help us meet our goals and that are proven to work. The evidence is out there.

NHS improvement won’t be achieved by bold, sweeping singular initiatives – but by incremental innovation that responds to real-world needs.

Sir Clive Woodward was right: progress is not about doing one thing 100% better, but about doing 100 things 1% better. And, if we keep pushing, we will get over the gain line.

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