Making innovation contagious
Everybody has their own favourite cure for the NHS. Trish Lorenz suggests that new ideas, technologies and processes are the key to a brighter future.
You probably think the last thing the National Health Service needs is another initiative. Decades of political, financial and bureaucratic change have put almost every aspect of the organisation under the microscope.
Operating theatre (Getty Images)
The service’s ability to meet targets, the demarcation between doctors and nurses and the quality of its healthcare have provided much sport for the media and, albeit very occasionally, some thoughtful analysis. So it seems fitting that when the NHS decided to embrace open innovation in 2007, the media hardly noticed. But this shift in strategy could alter the bleak prognosis for a service whose future is often framed in lurid headlines and apocalyptic predictions.
“When Lord Darzi, a surgeon and inventor who pioneered the use of robotics in surgery, became under-secretary of state for health, he felt that the NHS was full of brilliant people with brilliant ideas who didn’t know how they could develop them,” says Miles Ayling, director of service design for the Department of Health (DH).
“Innovation had a low profile. There wasn’t funding, priority or the evidence that it could make a difference to the bottom line, which was defined by reaching targets. People saw innovation as something that was done by men in white coats and couldn’t see how it might benefit them.”
The NHS faces many well-publicised challenges. Like other public bodies, it is under pressure – partly because of the economic downturn – to do more for less, and to cut its £110bn annual spend. The good news is that medical research and new technology may save lives and money in the long term. Innovations already in the pipeline – such as motion sensors in the home, implants that can predict heart attacks, and online medical consultations – mean we can look forward to improved, better-value healthcare. The bad news is that chronic diseases, such as diabetes, and the UK’s rapidly ageing population will ratchet up costs.
As Ben Page, chief executive of market researchers Ipsos MORI, says: “At the current rate of NHS inflation, by 2050 we wouldn’t have the budget for anything else in Britain except the NHS – no army, no schools. People are living longer and treatments are getting more expensive. Clearly, the organisation will have to do something very clever.”
The NHS opened its Institute for Innovation and Improvement in 2005, but after Darzi took up his appointment in June 2007 the organisation made encouraging innovation centrally and locally a top priority. Initiatives have included a £220m fund over five years to enable ideas to be developed and tested; £20m to be spent over four years on a public consultation competition for medical breakthroughs; and the NHS Evidence IT system that ensures the latest clinical research is at the fingertips of staff and public.
The DH has even legislated for a ‘Duty to Promote Innovation’ – a statutory requirement for the ten Strategic Health Authorities to publish an annual report on new methods they have introduced. But can innovation really curb rising healthcare costs, or is it just another fashionable panacea that won’t live up to the hype?
Learning from lean
Innovation, Ayling believes, is not a tap that can be turned on and off: “Concepts like the iPod can take years, and now is the time to be investing in the future to develop ideas that can improve the quality of care and help reduce costs.” Some look to prevention – better diet, more exercise – but Tim Brown, CEO of design and innovation consultancy IDEO, says prevention alone will not create a sustainable, affordable healthcare system. He believes productivity is just as important (see page 9). American healthcare provider Kaiser Permanente, for instance, reduced the time it took nurses to change shift from 40 minutes to 12 after exploring working practices through design thinking.
These ideas succeeded, in part, because they came from the ward floor. Dr Lynne Maher, head of innovation practice at the NHS Institute for Innovation and Improvement, calls it experience-based design – where knowledge contributes to more effective care. “When you talk about innovation, people think of gadgets, but we also need to focus on process and practice,” she says. At Luton & Dunstable Hospital, cancer patients and staff together identified 43 changes that could preserve dignity and improve communication, efficiency and safety. Now the DH has asked the Design Council to help hospitals maximise privacy and dignity.
NHS managers recognise this approach can save money and improve care. “In the past, the NHS was all about top-down targets,” NHS chief executive David Nicholson acknowledged in a recent speech. “The future is about identifying what works around the world and applying that locally.”
Nine in ten innovations may fail. But the one in ten that succeed would have a huge value Miles Ayling, director of service design, Department of Health
The Productive Ward initiative, launched in 2008, took the car industry’s ‘lean’ methodology – cutting out unnecessary steps without affecting the end product – and applied it to wards. “The NHS isn’t a production line,” says Maher, “but we do want to reduce waste and improve quality.” The initiative found that nurses were regularly interrupted during their medicine round, lengthening the task and endangering patients. A ‘do not disturb’ jacket reduced the time it took to complete their round by 65%. “It’s a ridiculously simple innovation,” says Maher, “but it has had a massive impact.”
Other improvements included reducing shift handover time by 33%, achieving significant cuts in food wastage (£10,000 of unnecessary meal requests a year were identified in one ward alone) and shrinking stock bills by £400 per ward on average. “If you scale these possible savings across the NHS, it makes a big difference,” says Maher. There were non-financial benefits too. “Direct patient contact was increased by 20% to 25%, which just shows that small interventions can transform care.”
Of course, product design does make a difference, as the Design Bugs Out project, a collaboration between the NHS and the Design Council, has shown. Four teams of designers and manufacturers devised hospital furniture prototypes to reduce the spread of infection, including a chair, commode and cabinet. The initiative started just 14 months ago, but some of the products are already in use.
One of the competition’s judges, Richard Seymour of design consultancy Seymourpowell, is also the creator of a hospital bed that is easier to move and clean. “Reducing cost is not about cutting projects but finding ways to create greater efficiencies,” he says. “Designers can help create something new, but they can also identify behavioural change. Too often, procurement is about tendering for what you think you need and aiming to get it for the lowest cost, when you can reduce cost by enhancing performance.”
Redesigning A&E cut violent incidents by 80% in one hospital (Eleanor Bentall/Corbis)
When Maher commissioned service designers to evaluate hospitals, they noticed that anti-bacterial dispensers were the same colour as the wall, making them hard to identify. They were also too high for wheelchair users and children, and often empty. “Designers look at how people use a space,” she says. “This different style of observation is helping us identify problems and get systems right. You can have the best product in the world, but if it’s in a poorly designed process it won’t fulfil its potential.”
Such successes persuaded the DH to embrace open innovation, working with strategic partners such as the Design Council, suppliers and other bodies to focus on unmet needs. Ayling says: “We need to encourage both incremental innovations [such as the nurses’ rounds] and disruptive innovations [ideas that might create something completely new].
Agents of change
At Birmingham’s Heartlands hospital, the Intelligent Space Partnership were called in to assess its A&E department because violent crime, especially against staff, kept rising. Designers observed how staff and visitors moved around the department, and found that poor signage and no initial contact with staff meant the public wandered into the wrong areas, particularly the major injuries ward, exacerbating already stressful situations.
The reception area was relocated, signage was improved and surveillance by staff increased. Walls were replaced by transparent screens, more CCTV introduced and vending machines placed in easily overseen areas. Despite initial scepticism among staff, trouble has decreased by 80%, with aggressive incidents dropping from 13 a month to five. “A conventional solution would have been to look to visible deterrents, incentives and penalties,” says Ayling. “But that wouldn’t have made such a dramatic difference.”
Pursuing similar schemes around the NHS could save millions in insurance every year. But not every innovation, Ayling says, will yield such a spectacular dividend. “One of the initial difficulties we faced was that we had to tell people 90% of innovations would fail and that was all right, because that’s what happens in innovation. But the 10% that succeeded would have a huge value to the NHS, patients and taxpayers. And some innovations won’t reduce cost – they’ll just increase the quality of care. That’s fine.”
The next challenge is adoption. As research by the VHA Foundation revealed, when it comes to service delivery, as opposed to scientific discovery, a doctor from the 1950s would find little had changed if they did a round in a modern ward.
With 1.3 million staff, the NHS is the world’s sixth-largest employer, and rolling out change on that scale is a serious challenge. “The NHS is notoriously slow to change,” says Maher. “It takes 17 years on average for widespread adoption of new techniques.” The Productive Ward initiative has been taken up by 98% of UK hospitals, she says, “but most are only using it in one ward.”
“The important thing,” says Seymour, “is to identify where you can have the most dramatic influence and recognise where the organisation pivots. That’s where to put the dynamite.”
Prevention vs productivity
Tim Brown, CEO of design and innovation consultancy IDEO, on transforming healthcare practices
The current debate around healthcare reform is both interesting and depressing. As Matt Miller pointed out in Fortune magazine, prevention does not bring down the cost of healthcare. He argues that a high proportion of healthcare costs happen in the last months of life, and no amount of prevention can avoid the inevitable.
Few would argue that reducing obesity and increasing exercise does not have a beneficial effect. However, prevention alone will not create an affordable healthcare system. And system is the operative word here. Innovations have to occur across the whole system if sustainable change is to happen.
Productivity is just as important as prevention. The tendency is for the political argument to jump straight to rationing as the cost-control strategy, but I believe there is a wealth of opportunity for innovation that creates greater productivity. Some will come from technology, but much can also come from process innovation.
Read more at designthinking.ideo.com
Where design equals dignity
Rethinking the patient experience
Can design help improve patients’ experience of the NHS? And can it make a hospital stay a more dignified, less distressing experience?
These are the issues a Design Council-led project is exploring, after the Department of Health (DH) identified patient dignity as a key concern.
DH research revealed that patients feel systems on hospital wards are designed more for operational efficiency than their comfort. While a hospital stay is never likely to be pleasant, for some it can be a deeply unsettling experience, with a lack of patient-led information exacerbated by having to dress or discuss medical issues in an open setting.
The Design Council project has already begun consulting with patients’ groups to gather insights into improvements and innovations. These could include helping to provide same-sex accommodation through new design concepts, or maximising privacy and dignity where it isn’t possible to provide complete segregation.
Incorporating patient feedback has become increasingly important to the NHS in recent years,says Dr Lynne Maher. She recalls a stroke patient who disliked using the toilet because the toilet-roll holders were on the right-hand side of the cubicles – the side she could not use. She felt unsafe and worried about falling.
“Nobody had thought of that before,” says Maher. Installing holders on both sides has already had a real effect on comfort in stroke wards nationwide.
Find out more about this project
Article first published in Design Council Magazine, Issue 7, Winter 2009
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