An interview with Prof. James Barlow conducted by April Cashin-Garbutt, MA (Cantab)
How do you define innovation and why is it so important in healthcare?
I think innovation is one of those rather slippery terms that means different things to different people. First of all, I would make a distinction between innovations that are essentially about a new, physical product and innovations that are more to do with services or processes.
Having said that, I think it’s difficult in healthcare because with many new medical devices, for example, you find there are organizational or service delivery changes wrapped around that innovation.
Innovation implies it's something new, but this doesn’t mean it has to be new to the world. Very occasionally, you might get some sort of wholly new innovation such as the internet, but generally speaking, it all depends on the context.
In healthcare, you may find that there's a new drug that's being used widely in one particular context or one country, but not in another. Eventually, it gets taken up in a second country and, in that context, it then becomes innovation. It all depends on context.
Also innovation is not just about invention, it's about the whole process of taking something and transforming it from an initial idea or invention into a product or service that's actually taken up and used widely.
So “innovation” can be difficult to define and that's why people tend to use the term very loosely, with it meaning different things to different people.
Why is innovation so important to healthcare? I think, again, that we need to make a distinction between the process and organization innovations that really are all about improving performance and ensuring that hospitals are more efficient, eliminating wasted resources and keeping costs down, and on the other hand the exciting new medical technologies - the new drugs and new devices that can do amazing things.
We need both. I would argue that we need more of the innovation in how you organize healthcare services and how you deliver them than we do in new drugs and new medical devices.
One thing I would say about the technological innovations, the drugs and devices, is that a specific problem in healthcare is that they often drive up costs because they allow you to do more things. You can treat more people, you can treat older people for longer, you get better diagnostics, you can pick up more problems that need to be treated.
In the long run that might bring down costs because you're diagnosing somebody's cancer, for example, at an earlier stage and intervening earlier, but in the short run costs tend to go up. Therefore, innovation is a bit of a double-edged sword for policy makers and those who have to pay for health services.
What type of innovation do we actually need?
I think that today in developed health systems in Europe, North America, Australia and so on, the really useful innovations are those that are going to allow us to organize services in a way that makes sure that we deliver the best quality care for as many people as possible, without breaking the bank.
That means possibly rethinking what it means to go to the hospital or go to the GP and accepting that care can be provided from other sources. For example, using services such as telehealth and the mobile phone would allow us to self-diagnose much more and organize health in ways that are more appropriate for the 21st century.
Basically, we still do things in the same way that we did in the 20th century. We send people to very expensive hospitals for diagnostic tests when increasingly they can be done out in the community – in GP surgeries, in pharmacies or at home. It's really those organizational innovations that are far more needed now than a lot of new, exciting pieces of equipment.
But having said that, technology such as telehealth and telemedicine will underpin the organizational innovations. It will help redesign care services and allow them to be delivered out in the field, away from expensive settings.
So you need the new technologies, but you also need them to be deployed in a way that they deliver services in newer and more effective ways.
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What are the main reasons why innovation uptake in the NHS can be slow?
Typically, it’s not the technology itself; that’s be tested, prototyped, trialled and it works. It's usually to do with a whole mix of factors around the fragmentation of the health and social care systems, especially organizational silos, professional silos and funding silos. These mean that the part of the NHS that makes investment in a new innovation isn't necessarily the one that gets the benefit - the benefits might fall somewhere else in the system.
You've also got entrenched ways of doing things, which are difficult to change. In my experience, and that of others involved in the introduction of new technologies, it’s often the GPs who make up the part of the system that is the most resistant to trying new things.
Why do you think that is?
There’s probably a whole mix of things there. There are certainly issues around job demarcation and job security. A lot of things can be done by nurse practitioners, pharmacists or patients themselves, but clearly that possibly takes work away from GP practices.
I've been involved in projects of diagnostic tests, which can now be done in a GP surgery rather than hospitals. The technology works but there are simple things to think about such a where the patients go when they're waiting 20 to 30 minutes to get their results back, because they're occupyng a busy waiting room. Or GPs wonder where to put equipment, especially if the practice is not very big. It could be as simple as that. There are a lot of cultural and work practice related issues as well as the costs and benefits.
I think the third big thing is evidence for the benefits of an innovation. We talk about the need for evidence-based medicine, but one of the problems is that it's often very difficult to get the right kind of evidence for a lot of new technological and organizational innovations in healthcare because so many things are changing at the same time. A neat randomized control trial is just not appropriate or feasible.
We've seen this problem with telehealth, remote monitoring of elderly or ill patients in their homes. There may be around 12- 15,000 published papers in refereed journals on the evidence for telehealth, but it's still not widely accepted and people just view the evidence differently.
GPs, nurses and specialists and managers in hospitals will all take different views. In my experience, the lack of evidence is often used as an easy way of saying “no” to innovation.
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In a recent talk at the Forte Medical Forum at the Royal Society of Medicine, you mentioned that it is often too easy for purchasers in the NHS to say ‘no’. Please can you expand on this statement?
I think there are far more reasons to say no than there are to say yes, typically. They may give reasons such as: “it's too difficult”; “we're going to have to train people”; “we're going to have to keep the existing service going and bring in the new innovative new service model parallel to that.”
They may say there isn’t any evidence or the evidence has been gathered in some other context such as another country or another hospital. It's just very easy to say no, for all those reasons.
“Give me a business case” is usually code for "I'm not going to do this. I'll just stick this document about your new idea in the draw and lock it away." Basically, I think it's far easier to say no than it is to say yes.
What do you think needs to be done to change this?
If you're talking specifically about the NHS, certainly there are things that can be done in terms of payment, reimbursement and tariff. You can adjust the tariff for particular conditions or procedures in a way that you reward people who are doing new things or taking on board a new innovation. That might cost a bit more money in the short run because you're having to double run the service; you have to run the old model, but at the same time bring in the new one. You have to train people or purchase equipment.
That's certainly been done, in renal care and home dialysis, for example. A way of incentivizing people to take up an innovation is through financial rewards.
Then, you can just mandate things. NICE can say “This is now a recognized best practice and therefore you will do it.” We know that doesn't necessarily mean that everybody will do it but it does lend a bit of weight to innovation. There's a lot being done in terms of knowledge sharing, knowledge networks and trying to get people together… getting specialists in a particular condition to share best practices and experiences.
Targets can help. When the 4-hour emergency care target came in and was introduced in Scotland, which was after England, what NHS Scotland did was to set up a national knowledge sharing and support network so that people who were trying new things around the 4-hour target were given guidance and help. They were able to share experiences and that was actually very successful at driving down the waiting time in hospitals.
People were given permission to innovate; they were being told by NHS Scotland "Okay here's the target. You might not like it, but go away and think about how you're going to meet it. Get together with your peers. We will support you and you're being given permission to be innovative."
As soon as people started to realize that was happening, it unleashed a lot of bottom-up, innovative activity. I think there are a lot of things that can be done and are all being done, but I think they’re just being done in a patchy way.
Do these barriers exist across other countries? What can the NHS learn from other systems?
In my experience, you get a lot of similar issues arising, particularly the ones around cost and benefits and who pays for what. All health systems are fragmented into primary care providers, secondary care providers and social services and you get the problem of cost and benefit sort of spilling over in unpredictable ways, across the boundaries in the system.
When you have a system like the Veterans Administration in the US, where effectively it's one health system with primary and secondary care, then it is potentially easier. They make an investment in telehealth, for example, and the benefits are all within the VA system.
I don’t think the NHS is particularly behind other health systems, but it doesn’t perform especially well either. It depends on the condition really and certainly there are issues around particular medical conditions in the NHS where the uptake of certain drugs is more advanced in some countries. However, the NHS might be behind for good reasons – the innovation may just not be cost effective.
Certainly , there is an argument that the US is too willing to take up new technological innovations. There's a whole imperative to take on board the latest technology as it’s a way in which hospitals compete. They can say "we've got the latest scanner; we've got a robotic surgery device ahead of the next neighboring hospital."
There's been a lot of research on the impact of that on costs in the US and anything between about 25% and 50% of all the cost inflation in its health system since the early 60s has been due to the take up of new technologies driving up costs.
So I think the NHS sits in the middle. It's no better and no worse than other places. But sometimes you do wonder why the NHS doesn’t just take on a new medical device when the evidence is there and it costs pennies. It's a no-brainer.
What do you think the future holds for innovation uptake in the NHS?
I'd like to think the current crisis will spur innovations that will help find better ways of managing the growing demand for services and still provide high quality care. I'd like to think it will stimulate a proper discussion about new ways of delivering healthcare and the better integration of services.
However, the problem is that everybody’s just got their heads down and they're desperately trying to survive the current climate. The last thing people really want is to be told "you've got to be innovative and there's some really good ideas coming from the Netherlands, for example, why don't you take those on board?"
People say "don't let a good crisis go to waste." Actually, it's very difficult to innovate when you've got junior doctors on strike, billions being taken out of the budget and you have lengthy waiting lists. It's easy for me to say we need to rethink how we deliver healthcare, but actually doing it is another matter.
There’s a world of difference between what might be a rational innovation and what can actually be achieved on the ground. Shifting stroke care, for example, so it is provided in a handful of advanced hyper-acute stroke units rather than every single district general hospital led to an outcry and local politicians jumping up and down.
I think the prognosis for the NHS and innovation should, on paper, be good. We should use the current period as a way of really discussing how we need to organize health services such that they are able to put people at the center of services, integrate care around us and use technology wisely.
I'm a “glass is half full” sort of person. Things do change and things have improved over the years. If you look over the long term, healthcare has clearly improved hugely.
In what ways do you think antimicrobial resistance and climate change will impact public health and what role do you think innovation will play in tackling the upcoming challenges?
Those are both big unknowns. If we take climate change first, the issues are around the impact of global warming on the incidence and spread of disease. The concern is that you're going to get tropical or vector borne diseases spreading to areas where, previously, they'd either been eradicated or hadn't been seen.
I was in Japan about 18 months ago and there was great concern about dengue fever, which is now becoming more prevalent. With global warming you may see more of that kind of thing happening. This is reinforced by the mobility of the population and explosion in air travel.
Then there are heat events: heat waves and the effect they have on elderly people. A few years ago, in France, about 20,000 elderly people died as a result of a heat wave and there will be more of that. That's climate change. This is not my area of expertise, but I know health systems are beginning to plan for more frequent heat waves and the spread of infectious and vector-based tropical disease.
On the subject of antimicrobial resistance, the concern is the spread of superbugs that are resistant to the current armory of antibiotics. Nobody really knows what the impact might be, but there are some very scary projections of the possible number of deaths and cost to the global economy.
The innovation needs associated with AMR are partly about developing new antibiotics, but that's sort of postponing the problem really. It's about better diagnostics, so we can be more discriminating in which antibiotics we prescribe to people. The problem now is that somebody arrives with a condition and it takes too long to diagnose, so the wrong kind of antibiotic is prescribed. Diagnostics is one of the big areas for innovation.
And it’s also about behavior change, both in terms of prescribers and patients. Changing people’s attitudes, so they don’t just demand antibiotics at the drop of a hat is key. Things are happening in Europe and other developed countries, but it's really places like India and China that are the big problems: places where you can just buy these drugs online or buy them from a pharmacy.
Then, there’s the whole animal health world, but I get the impression that, actually, they're beginning to get to grips with the problem of over-prescribing the antibiotics to animals, certainly in Europe. Yes, so innovation is needed.
Where can readers find more information?
In my book: Managing Innovation in Healthcare
About Prof. James Barlow
James Barlow is Professor of Technology and Innovation Management (Healthcare) at Imperial College Business School. Previous appointments include SPRU (Science Policy Research Unit, University of Sussex) and the Policy Studies Institute. He was educated at the London School of Economics and Political Science.
James has over 20 years’ experience working on the adoption, implementation and sustainability of innovation in healthcare systems in developed and emerging countries.
He was a founder and co-director of Imperial College Business School’s Innovation Studies Centre and during 2006-2013 was Principal Investigator of HaCIRIC, the world’s largest research programme on innovation in healthcare infrastructure. He has also worked extensively on the adoption and impact of telehealth technologies.
Since 2013 he has been associate director of research and evaluation for Imperial College Health Partners. In 2014 he was appointed as the new President of the International Academy for Design and Health, representing the built environment industries involved in healthcare.
James has been a member of many expert panels on healthcare innovation, both in the UK and internationally, and has worked with a wide range of companies involved in healthcare technologies. He has published over 85 papers and his books include Managing Innovation in Healthcare, to be published by World Scientific in December 2016. Website: www.james-barlow.com