PPL Perspectives

‘Better, faster, stronger’ - How could a focus on entrepreneurial behaviours in the NHS encourage innovation and improvement?

07 August 2018

Vish Valivety, Senior Consultant

With a £124 billion budget, 1.5 million employees, 65 million ‘customers’ and a 70-year history, the NHS is about as far from an early-stage start-up as one can imagine. Like many private corporations that have grown to an impressive size, the NHS is now a hulking organisation where changing the status quo is an increasingly difficult task. This springs from the growth of the NHS occurring in an era of top-down, command and control type management, resulting in a complex structure that is not conducive to innovative working. This has become most readily apparent over recent years as the need for innovative new ways of providing services has spurred a series of Vanguards, Early Adopters, Pioneers and more. These drives for innovation have required the backing of a lot of funding but the results often fail to reach the heights promised in their applications. A big part of this mismatch is a lack of entrepreneurial behaviours being fostered and displayed by those responsible for these ‘innovations’.

If the NHS is to tackle its growing problems around sustainability and quality of care, it will need to ensure that the way care is designed and delivered undergoes a transformation that allows for innovation and entrepreneurial thinking to be implemented and celebrated.

What does it mean to be more entrepreneurial? Four characteristics spring to mind:

  1. Working with a minimal viable product - Instead of requiring a completely polished product to be developed before launch, entrepreneurs tend to focus on getting something that does the job and continuously adding/subtracting to it based on how the market reacts to its initial offering
  2. Making decisions quickly - When an opportunity arises to make something happen, entrepreneurs encourage quick decisions (‘pivots’) and rapid testing periods as opposed to asking for permission or waiting for ‘the ideal moment’ to make a change
  3. Working with the customer to define the product - Entrepreneurs understand that it is the end-user that will define if an offering is successful or not, and so they work with customers to design what the offering will be and iterate new versions with them to improve as time goes on
  4. Recognising that failure can be valuable - There is often a lot at stake for entrepreneurs - savings, reputation and sleepless nights - but understanding how to learn from failed ventures makes it easier to try new things

There are two key reasons why these behaviours aren’t exhibited as richly as they should be in NHS innovation projects: accountability to the public, and risk avoidance around people’s health. The natural fallout is innovation projects that are sometimes not very innovative and a culture of non-entrepreneurial behaviours, such as:

  • Creating strict waterfall project plans to finalise all elements of a new service before any type of launch takes place or is tested
  • Requiring all decisions about changes to go through extensive governance before they are signed off and applied
  • Testing pathways and models of care that have already been developed with the public instead of asking them from the start what needs to change and building a new way of working with them
  • Requiring success for a project in all cases so that funding for innovations stops if an initiative does not provide benefits immediately

The natural response, therefore, is to ask: what needs to change within the NHS for entrepreneurship to be more embraced and more embedded? In my view, there are four paths to consider:

  1. Agile provider teams - As more ICPs take shape, there should be a focus on allowing small, dedicated teams within provider partnerships to have time and space to take control of testing and refining different aspects of innovative models of care
  2. GP practice led innovation - By devolving decision-making to GP practices, local areas can make quicker changes that are tailored to the needs of their neighbourhoods, creating a service that is right for them and allowing GPs to be agents of change
  3. Start-up utilisation - There are many wonderful and ambitious start-ups developing ways for patients to take charge of their care, for clinicians to gain more capacity, and for services to improve outcomes. Giving these quick-moving businesses opportunities to work with commissioners and providers can be a great way to bring their entrepreneurial spirit into NHS innovation projects
  4. Stratified approach - Creating a balanced structure where life and death/complicated cases would be tightly controlled but allowing for looser control and more entrepreneurial ventures in other instances

I’ll be exploring each of these in further detail in upcoming perspectives to identify:

  • Where the approach has been used successfully
  • Which scenarios these approaches will work well in
  • What needs to happen for an area to adopt the approach

Before any change is made, however, it is vital that we recognise that there is both a gap and an opportunity in entrepreneurship and entrepreneurial behaviours, especially if we truly want an innovative health service.