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Editor's blog 26 April 2009: Who wants to be a millionaire, NHS-style?

No, this is not going to be about redundancy pay-offs for sacked chief executives. What were you thinking?

No, this is going to be about Lord Darzi's 'Innovation for a Healthier Future' scheme, announced today. £220 million is to be made available across the ten SHAs over the next five years to encourage innovation. The National Endowment for Science Technology and the Arts (NESTA) and the Young Foundation will work as advisers to the SHAs.

As part of this scheme, each SHA will set up 'Innovation Challenge Prizes' - subject, of course, to Parliamentary approval. The rules for these will be set by each SHA. But the underlying idea, according to a report leaked to The Observer yesterday, is that individual NHS staff could scoop up to £5 million per innovation.

A thoroughly good scheme - potentially
Now, I find myself slightly astonished to be saying this about a DH initiative of recent vintage. But that is a thoroughly good scheme - potentially. There is one big reservation, and there are two medium-size concerns.

Why is it a good scheme? Because it offers a very simple incentive to ensure that the people who know how to make genuine changes, front-line staff in all disciplines, can actually reap a reward from seeing their project through to fruition. That incentive is financial.

NHS staff of all kinds are often very dedicated people, and have been used to going the extra distance for patients. Yet if the 'doing the right thing' motivation were going to unlock their knowledge and empower them to make changes, then it would already have happened on a broad scale.

Too often in the NHS, innovative local schemes have had very short-term funding, lacked time and proper evaluation to prove their worth, not been communicated effectively, and fallen apart when the instigator(s) or leader(s) move on.

No, money it is. And the reason I am glad it will potentially be a large sum is because this is going to focus attention very keenly (particularly the attention of the media) on what is being done and whether it is working.

Moreover, the kind of innovation that should be a winner ought to be able to make genuine cost-savings and / or quality improvements to the NHS - this should, in fact, be key to the prize.

And despite what certain parts of the knuckle-headed press will doubtless be saying tomorrow (public sector featherbedding blah blah blah ... scandalous waste of taxpayers' money blah blah blah ...), some of the people who have been making hard-to-justify millions out of the NHS have been management consultants and the PFI industry. As Jacky Davies of the NHS Consultants' Association wrote to The Guardian on Saturday, even advocates of private involvement such as Professor Paul Corrigan (briefly commissioning chief of NHS London) admit that "asked ... to produce the evidence that the private sector delivered cheaper, better-quality care with more innovation ... he said it was 'too early to tell'."

If NHS staff can prove that their innovations will make a sustainable difference, then they should be joining the ranks of the deserving rich and we should be, in Mandy's lovely phrase,  "intensely relaxed"about it.

The E word
The big concern is evaluation. While it is on balance, probably more sensible for SHAs, who should have more knowledge of local challenges and needs, to do the assessment rather than a new national quango (or NICE, who increasingly seem to be doing everything else), it is a concern that the launch did not even mention any outline principles for success.

While judgments and systems should reflect local priorities and needs, some national guidance on how to measure success is unquestionably required. Without it, the scheme will be a wasteful failure. (Remember the NHS University?)

A clear set of national measures for success are needed. They should include evaluation of the innovation's cost-effectiveness and clinical effectiveness over a reasonable period of time; a 'scaleability' element (although efforts to improve niches of care should not be unduly disadvantaged); a 'reporting back' duty lasting at least five years (so that the impact and stories of winners' projects can be tracked over time); and a deliberate balance to reward innovation in primary and community care and public health, so that traditional acute capture and cost-inflationary risks are mitigated.

The medium-size concerns: over-literalism and Stalinism
One of the medium-size concerns is of an over-literal emphasis on innovation. Some things that could make a huge difference to care are not particularly innovative (active case management for patients with long-term conditions; better focus on hospital meals and nutrition; attention to levels of antibiotic prescribing). They are the boring and well-known basics, but they are not well-sustained in many organisations. In certain departments and even whole trusts, depressingly, doing the basics properly would be innovative.

The other medium-sized concern is that the "legal duty to promote innovation and support the diffusion of innovative technologies and solutions throughout the health service" is to be put with the SHA. There are more permissive and more facilitative strategic health authorities (and NHS North West appears to be the outstanding example), and in those ones, things will probably be fine as the practice seems to be to spread responsibility locally. Interestingly, NHS North West keeps on being a top-performer in things like world-class commissioning assurance. Maybe letting go a bit helps?

The problem here will arise in the more Stalinistically-inclined (naming no names, NHS London and NHS South West) SHAs. More broadly, it is a problem of general understanding about where duty should lie.

If we need to create a duty to innovate, and I am prepared to believe that we do, then it must be at the most local level of NHS administration. That means it's definitely a PCT thing, and arguably, if we are serious about world-class commissioning and practice-based commissioning (and the jury is well and truly out on this one), possibly even a PBC consortia thing.

This is for two reasons: because you always want to give responsibility to those who are as close to the front-line as possible if you are running a high-trust system (which healthcare certainly should be); and because meaningful innovation is - has to be - a local thing.

A duty to innovate, pushed by the SHA, is simply a target in drag.