One for the road

Lars Sundstrom, our Director of Innovation and Growth, who retires on 28 March, reflects on how much the West of England AHSN has achieved, and how we might fail better.

Clearing out my desk today deep down in the bottom of a drawer I found one of the first drafts of a strategy paper which Liz Dymond and I produced over 5 years ago. It was about wealth creation. Originally people thought AHSNs should be largely about that, before they became more synonymous with adoption of existing stuff into the NHS.

Rather amazingly we more or less did everything we set out to do and pretty much stuck to our original strategy for the first 5 year license, so I guess it wasn’t a bad plan.

I could look back and chalk that one down as a success and claim it was all plain sailing, but for some reason my thoughts focus much more on the difficult times we had along the way

So as a final blog I thought I’d pick up on one of my favourite topics – ‘failure’. This is not because of some sense of self-pity, but because throughout my life it has been one of the most important drivers for why I chose the paths that I ended up on.

Looking back at all that has happened in my working life I guess I can honestly say that I’ve taken some big risks. As a result I found myself in a few interesting places, like being chased by a pack of hungry wolves in the Canadian wilderness (it’s in BBC documentary If you don’t believe me). Maybe I’ll tell you about that one another time if you buy me a beer.

Curiously, my most vivid memories in reality are the failures, the times when it didn’t work out so well.   I don’t really remember the successes like selling my first start up business when I was in my twenties or having the highest cited scientific paper in my research field in my thirties (I didn’t even know until someone recently pointed that out).  I don’t remember what I learned from any of that. However, the really tough times are etched in brain forever, like laying off all the staff in one of my companies that didn’t go so well, that memory still hurts today and I never want to go through that again.

I played a video for some of the staff a couple of weeks back which made the point that failure is not the opposite of success, it is a stepping stone on the way to success and it is more our failures that shape us and make us learn hard lessons rather than the easy wins. Just look at Steve Jobs at Apple, one of the greatest innovators of our century, clearly spectacular at both failing and succeeding. Eventually his innovations changed the world forever.

Failure and taking risks is essential if you want to succeed in innovation, or rather the permission to fail is essential if you want to innovate. If we can’t try new things, we can’t innovate and without innovation we don’t progress as fast as we need to.

So let’s look now at healthcare and particularly the NHS. Being honest, it’s not the easiest place to do innovation. It has everything going for it though, so it and should be the best place in the world to innovate, but it isn’t and it generally follows others. It lags way behind other sectors, why is that?

There are many reasons, but I believe a major one is the NHS’s low tolerance to risk and it’s fear of failing. It seems to me that the fear of a few bad news headlines has a greater impact with people than celebrating the successes that happen in the NHS every day.

In a way that’s not a bad thing. After all people’s lives could be at risk, so treatment has to be safe. I wouldn’t want doctors or nurses trying things out on me for the first time unless it was a well-controlled trial.

Nevertheless, the point is that innovation also saves lives. If we are afraid to innovate, and instead stick to the old ways of doing things, in the long run we will actually do more harm than good. Do no harm does not mean don’t do anything different for fear of doing harm.

I don’t have all the answers to this conundrum. It seems to me a big part of the problem is a risk averse culture and a system which seek to improve by punishing failure rather than rewarding those trying to succeed. An answer must be to create a place where we can innovate and fail safely in the NHS and it seems to me that’s what AHSN should really be about rather than just a distribution channel for existing products into the NHS.

There are 2 things I know we can do:

1) Create an effective and safe test bed system where we can try new things in the full understanding that they may not always work out. Let’s encourage people to think of new ways of doing things and stop penalising them for trying, even if they don’t succeed at first.

2) Have a more open and honest dialogue with the public and bring them on the innovation journey with us. They should understand why we might not always succeed at first and why we need to keep trying.

Above all we need to be brave enough and ambitious enough to be the best we can and that means being bold enough to try things we have never done before.

I was recently told that there are more people alive today than have ever died, so if that is true, we can’t simply improve on what we already have, we need a step change in the way we deliver care. We can only do that through innovation and it will be disruptive by definition.

So my hope for AHSNs is that they retain the ambition to be brave enough to take risks and become the home of innovation in the NHS, rather than just measuring the number of new products which are taken up and used by the NHS.

If you have read my previous blogs you will know that I am one prone to mock politicians (particularly US ones). Who wouldn’t, given their current inability to govern on either side of the Atlantic? Occasionally, however, the Americans do turn out a few great ones, usually when times are tough.

So I’ll end by paraphrasing JFK : ‘We choose to send people to the moon, not because its easy, but because its hard; because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one we intend to win

Below is a short film reflecting on the change in attitude he has seen towards the role of companies and innovators in healthcare:

Polypharmacy – benefits vs risks

Mark Gregory, our Lead Pharmacist, reflects on the risks associated with polypharmacy and the benefits of deprescribing.

In 1995 only 2% of the population over the age of 65 years were prescribed 10 or more medicines. By 2010 this figure had increased to 5% and by 2018 increased further to 8%. For those over the age of 85, almost 1 in 4 of the population are now prescribed 8 or more different oral medicines.

This level of ‘pill burden’ represents a significant multi-drug dosing of the elderly population. Taking this amount of oral medication two, three or even four times every day also presents a practical challenge, even if we can assume  full cognitive functioning.

No doubt the individual clinical benefits of each of these multiple medicines outweighed the risk of potential harm at the time they were started. However, the results of clinical trials of individual drugs do not give us an detailed understanding of the long term effects of the complex interactions within these cocktails of pharmacological active chemicals within the body . A number of years on, particularly for the frail elderly, the potential harms vs benefit equation changes for many of these medicines, increasing the risks of adverse effects. This is the basis of the increasing interest in the application of the concept of ‘deprescribing’ as one approach to aiming to achieve ‘appropriate polypharmacy’ for medicines optimisation.

Academics such as our own Bristol Uni expert on this subject, Dr Rupert Payne, inform us that one of the ‘gaps in the evidence base’ on this subject is the lack of evidence on the proven benefits of deprescribing – a subject of research interest. However, whilst recognising that even in the frail elderly, there is clearly a strong case for the ongoing prescribing of many drugs, individual patient feedback on the quality of life impact in practice resulting from selective deprescribing are convincing enough for many of us to promote the application of  deprescribing principles in pursuit of ‘appropriate polypharmacy’.

At our recent West of England  AHSN polypharmacy event, a useful reminder of this was hearing the experiences of a local patient, Ann, describing her difficulties with managing her multiple medication regime and the medicines supply pathway associated with it. Her wish was for ‘regular and effective medicines reviews to be undertaken to ensure that people don’t remain on medication they don’t need to be on’.

Patient experiences of long term polypharmacy were further highlighted at this event in the presentation of a successful polypharmacy project by our colleagues in Yorkshire and Humber AHSN. In particular, the story of an elderly patient with dementia in a care home who had been on more than 10 different medicines for a number of years. He was showing increasing symptoms of BPSD and disturbing behaviour. Following an extended, patient centred polypharmacy medication review, it was possible to stop nine of his medicines. The impact was summarised in a quote from his wife – ‘I cannot remember when we last played dominoes together and we have now done it every day this week’.

Actual patients’ experiences are powerful reminders of a key question that underpin our pursuit of ‘appropriate polypharmacy’ beyond the published evidence:  What is most important to individual patients in the wider context of their current lives? Fully understanding individual patient’s values and engaging in shared care prescribing decision making, takes time. This adds pressure on already pressurised patient consultations – the practical implementation challenge!

Therefore, when I recently analysed the prescribing data on polypharmacy metrics across the West of England AHSN healthcare systems, it was pleasing to see that this clearly indicated that positive progress is being made in achieving improvements in polypharmacy across our area. One of the key aims of our medicines safety programme as an AHSN is to support and further build on this trend, to help to maximise the benefits patients across the West of England obtain from their multiple medicine regimes, whilst minimising undesirable side effects and avoiding unnecessary negative impact on daily lives from individual patients own perspectives. It is in all of our interests to ensure that consideration of deprescribing principles become embedded in routine prescribing practice – as after all, based on current prescribing trends, all it is likely that many of us ourselves will be prescribed multiple medication regimes in our old age…

Read more about our polypharmacy programme here

Read the report from our polypharmacy event here

Innovation, five years on….

Lars Sundstrom, our Director of Innovation and Growth, reflects on our annual conference and how much the West of England AHSN has achieved in the last five years.

A couple of weeks ago we had our big annual gathering – this year themed as a Healthcare Innovation Expo. It’s always a time that serves as a reference point on how far we have come on this journey together with all of you. To me this was special – it was my last one as I’m retiring in March.

The day was as busy as ever, with around 250 people dashing about, chatting away, visiting company stands, attending talks or workshops. As it was drawing to a close and I slumped into a soft chair in a corner to try and switch my brain off I could see our comms team making a bee line for me. ‘Ah shucks’ I thought (or something like that) as I remembered I had promised to do a piece to camera for the event.

So after being miked up, I hear “rolling…”

Uh… what do you want me to talk about?

“How about what was different this time?”

Uh ok, so I launch into it. I can’t recall exactly what I said but you can see the video here.

Anyway, that left me thinking how far we had actually come in reality.

Our first big meeting in 2013 was totally different. There were no companies for a start. This was partly because some in the AHSN were worried about inviting them in case they tried to flog us something. They probably wouldn’t have come anyway since they had never heard of an AHSN.

All we really talked about was what was happening in the NHS and what we intended to do in the AHSN; we had a few things in motion but no impact to speak of.  There weren’t many of us around either – for example we didn’t even have a comms team.

So roll on five years:

Companies are now becoming our trusted partners on the journey to building our Innovation Exchange; slots for them to present at our events are fought over and around 50 of them had stands at this year’s event. Last year we helped around 500 innovators through our business development programme (now used by many other AHSNs), with over 90% of responders to independent surveys saying they valued our help. Our Health Innovation Programmes are now cited as national case studies by NHS Confed and the AHSN Network, and are also oversubscribed several fold.

We are democratising the innovation process through rolling out hyvr – the first ever swarm intelligence platform dedicated to healthcare, changing the relationship with the public and putting them at the heart of the innovation process. Watch out for that one to grow next year!

We are pushing the boundaries on open innovation in health through our Create Open Health Programme in partnership with Creative England and the Wellcome Trust. They are bringing us totally new technology partners from outside healthcare like crytopcurrencies and blockchain and a whole load of stuff that makes my head explode.

We are further refining our test bed and challenge methodology, embedding these now into practice in innovation hubs within our member organisations as a way for them to articulate unmet needs and find innovators to work with.

Our Patient Safety and Transformation programmes like the National Early Warning Score (NEWS) and PReCePT are having a clear impact on people’s lives. There is so much more I could say here but have a look for yourself at all the news stories on our website to see what else we’ve been up to.

Most importantly we have become a net exporter of our programmes to other AHSNs and many of them are now being spread nationally.

But the biggest achievement for me is that we have now become a net importer of talent; our job vacancies are massively oversubscribed so we can recruit the very best. That means lots more ideas keep being generated by a lot of hugely talented bright young people (well, younger than me at least). I think the future is pretty safe in their hands for the next five year licence period.

So the point is this:

If you had asked at our first expo if I thought we could ever have achieved all that in five years, I would have said “Well if we can really do all that in five years, I will happily retire!”

Lars will be retiring in March 2019.

Keeping the A in AHSN

Lars Sundstrom, our Innovation and Growth Director reflects on the role of academia in encouraging innovation and experimentation, and the importance of this to AHSNs.

Last month we had our first get together as an AHSN Network. Around 200 fellow AHSNers, most of them considerably younger and much more energetic than me, got together to celebrate how fast and far we have come in our first five years. Bright eyed, bushy tailed and ready for the next challenge, how can an old-timer like me not be inspired by the next generation and their appetite for the future?

When I was a university professor, I always felt the best antidote to feeling blue or if things got a bit bogged down was to find some students and talk to them. You quickly realised that the world is driven by hope and belief in the art of the possible, but that over the years you accumulate fear and restraint to the extent that you focus more on the art of the impossible.

Anyway, at the AHSN gathering I felt like a milestone had been achieved, not just because we entered another five year licence, but because it completes a personal journey from invention to innovation that I have been on for the past 30 or so years.

Bench to bedside

As you have probably guessed, the path that led me into the AHSN was not via the NHS but through academia. I spent most of my career in translational medicine doing drug discovery and development both in universities and in industry. I tell the youngsters in the team that back in them olden days when I was young we didn’t have a word for translational medicine, and we didn’t even know how to do it. I tell them we didn’t have phase one, phase two and phase three clinical trials; we just gave people pills or injected them with stuff and saw what happened.

“No way man – how could you do something like that? That can’t have been safe!” Well it wasn’t, I say, but what else could we do? Somebody had to be brave enough to be the first!

Translational medicine was the buzz word at that time and the term ‘bench to bedside’ is often used to describe it. So what brought me to the AHSN was the next logical phase – to  scale up. Perhaps we could say bedside to bedsides. I was also attracted by a new buzz word ‘innovation’, which I believe is probably the most important word to ever impact the NHS, and I’ll explain why shortly.

So back to the AHSN conference. After reminding people how AHSNs came into being five or six years ago, the speaker asked, “Hands up how many of you were around when it all started?” Apart from me, a few hands went up. She described the amazing progress made and we looked into the future and it felt great – except a bit of me felt that as the endeavour grows, that original pioneering spirit of adventure was slowly slipping away a little; that leap into the dark, that fear of the unknown. It all felt a little too safe, a bit too much like the NHS.

In the coffee break I bumped into my colleague and friend Tony. “What did you think of that then?” I asked. “It was great”, he said, “but I guess I’m still trying to figure out when it was that I joined the NHS?” “Yeah,” I said, “it feels a bit more like we’re in the NHSN rather than the AHSN.”

The conference concluded with a fabulous talk by Michael Seres, a patient entrepreneur and someone I have admired for many years. We once ran a conference on what it’s like to be an entrepreneur and inventor developing products for your own health issues – a ‘chief patient officer’ as Michael describes it. His message to us was clear: “Dare to be brave.” What’s  great about people who have come to this journey by misfortune in life is their spirit of adventure. It feels like they have nothing to lose and everything to gain, so they just hurl themselves into the unknown with unswerving devotion and energy.

People like Michael, Kevin Mashford, David Constantine are amazing – people who dare to be brave and innovate against all odds are the ones who will change the world.

What is innovation?

So back to innovation, this new buzz word. What is it? Well, like translational medicine in the olden days, we actually don’t really know how to do it healthcare. In 10-20 years’ time I will be able to tell you. I can tell you what it isn’t though. It isn’t about continuous improvement; it is about doing something that hasn’t been done before. Therefore it is also not 100% safe. I could write a blog on just that but in the meantime have a look at this excellent blog post by Alex Ryan and Jerry Koh on the subject.

I strongly believe, as I have said many times before, without innovation the NHS will not transform and will not be sustainable and it won’t survive. But like translational medicine back in the day, if we don’t try and we don’t fail, we will never learn and it will never be safe. So my message to the young AHSNers is: dare to be brave, learn from failures and then improve it, and it will become safe.

In the questions and answer section, I asked the chief officers where they would like us to be in five years’ time. Charlie Davie, Managing Director of UCL Partners, gave a great answer. He said, “I want the NHS to be known for being the best place in the world to do innovation, and in future the Americans come over here to learn, instead of us going over there to learn how to do improvement.”

As an academic, I know that all improvement and impact starts with experimentation. So I say, let’s keep the A in AHSN – where it stands for Adventurous, Ambitious and Audacious. If we see ourselves just as a safe distribution channel for innovation into the NHS we will have become NHSNs, and from there it is a small step to becoming the NHS and we will have failed to change anything.

So let’s dare to be brave, keep the academic mentality in the AHSN, and keep in mind the words of George Bernard Shaw:

“There are those that look at things the way they are, and ask why? I dream of things that never were, and ask why not?”

The Usual Suspects: ways to widen involvement in service improvement

Hildegard Dumper, West of England AHSN PPI Manager, reflects on ways to widen involvement and participation in service improvement.

This story is a composite drawn from real events with names and identifiable features changed.

Pamela came out of the COPD Steering Group meeting the other day feeling really upset, and determined to leave the project. One of the clinicians on the steering group had asked about increasing the number of public contributors on the group. He said that there was a need to make sure patient reps were more diverse and we needed to avoid ‘the usual suspects’. By this he indicated he meant ‘white, middle-aged and retired’ which of course is what Pamela is. Debbie, the project manager noticed she looked upset and asked her what was troubling her. When Pamela told her, Debbie tried to reassure her that she was still a valued member of the group.

However, the experience got Pamela thinking. She approached Debbie and asked her if she was willing for Pamela to look into this. They agreed that Pamela would draw up a plan for how they could engage with a more diverse group of people suffering from COPD. She would share it with Debbie and take this on in a voluntary capacity, claiming for expenses. The plan included the need to have a discussion with the advisory group about what was meant by being representative – the demographics of the population of the area served, or users of the services. Or was it just different voices they needed round the table. In which case they could promote the role amongst users of the service and encourage interested people to apply. It was felt that all three factors were of importance.

Drawing on information from public health, it was identified that COPD was something that affected the population they served in different ways. Communities from a number of different ethnic and socio-economic backgrounds were heavy smokers and at risk of COPD. Pamela identified visiting three different communities in the region that reflected this range (Somali, Polish, deprived white). She contacted someone who Debbie knew in public health and got the names of the health ambassadors (in different regions they are known by different names) who had contact with these different communities.

She contacted them and it was suggested she attended one of the team meetings that were held monthly. She could then explain to the team what she was trying to do and get their advice. The public heath ambassadors were very encouraging, but pointed out that the communities she was targeting were mainly people who were struggling with their own challenges related to language, surviving in a different culture and the day to day challenges of living with poverty. It would be difficult to find people with the practical wherewithal and emotional space to contribute what was needed at a strategic level to the development of a project. However, they told her about a number of community events and encouraged her to attend so that she could meet people and identify people who may be interested.

Some months later, Pamela went back to Debbie with a three point proposal. She suggested that an extra patient rep be identified from users of the service interested in becoming a member of the steering group. Having two lay reps is seen as good practice as it takes the pressure off one person having to speak for all lay people, and offers a different viewpoints being heard. Pamela has also got to know the health ambassadors. One of them has shown a particular interest in the service and has good access to inner city communities. Pamela suggests inviting her to be part of the steering group so she can act as a conduit to some of the affected communities. Lastly, Pamela suggests they run a series of road shows where members of the steering group attend local community events to talk to those attending about the service and how it can be improved. This would require a big time commitment which may not see any immediate impact, but would be the start of forming a relationship with the communities they want to reach.

It was a learning experience for all involved.

  • For the clinicians in the steering group, they realised that different methods were needed to communicate with different groups of people.
  • Another key point was that it takes time to build up the relationships needed to identify the right people.
  • For the health ambassadors, they appreciated the direct link with clinicians and the relationships that developed as a result.
  • The experience also enhanced their knowledge and understanding of the pressures on the services helping them to manage the expectations of the communities they worked with.
  • The communities valued the fact that people were listening to them and wanting to understand their experiences
  • They themselves had a deeper understanding of how things worked and were able to have a more realistic expectation of health services and their role in managing their condition

 

The answers are out there

Natasha Swinscoe, Interim Managing Director, explores some of the issues raised by the recent Nuffield Trust  paper ‘Falling Short: why the NHS is still struggling to make the most of new innovations’.

Many of the NHS staff I’ve worked with seem to be cut from the same piece of cloth. If you show them a problem needing a solution, they’ll either find the solution or work out how to. These people are proactive problem solvers, so if the thing they need isn’t on the market, they may well make one ‘Heath Robinson’ style.

At a recent conference I listened to clinicians from one of our local trusts outline some of the systems and solutions they’d been putting into practice to fix their problems. These ranged from different training methods to a sponge being used in an innovative way to stem internal bleeding. I was struck by their creativity and innovation. The question in my head was how we harness this creativity, recognise and celebrate it, and then spread the solutions to others in different hospitals to use. Professional networks often provide an adoption route, but even these don’t offer comprehensive coverage.

Shortly afterwards I read the Nuffield Trust briefing paper ‘Falling Short: why the NHS is still struggling to make the most of new innovations’. I knew it resonated with my experience when I kept underlining sentences in red, with a number of exclamation marks! Here are a few…

  • Innovation in the NHS relies on pushing products first and hoping people take them up!
  • Identifying problems and looking for solutions isn’t built into everyone’s day job!
  • Innovation needs Senior Exec level oversight and support!
  • Too often short term savings drive the need for innovation rather than transforming pathways!

These are all important points. We know clinical and non-clinical staff will always find solutions. What we can’t rely on is the culture within the NHS supporting innovation. If the culture doesn’t foster or support innovation then new solutions or ways of working will falter, stay hidden from others, or at worst fail to solve the problem.  A ‘let’s try’ environment is crucial.

In my role as a manager of Acute Services, I lost count of the number of times I had clinicians turn up at my door or stop me in the corridor with an ‘idea’ they wanted to try – frequently for little or no cost.  We often pursued these ideas with a positive ‘Ok, let’s give it a go’.  Out of this came some fascinating service and pathway changes benefiting patients and staff, and saving time or money that we could then re-invest.  There were many  win-win results,  but they relied on a team culture that encouraged and shared  ideas, kicked them around, and then had a go, without being sure if they’d be successful or not.

From April we’ll be working with Office for Life Sciences to support this innovation pathway ‘end to end process’. We will be looking for ways to strengthen and support trusts and commissioners to adopt tried and tested ‘oven ready’ innovations. We will be looking for ways to capture ideas from front line NHS staff to match with business sector innovators.

The answers are out there. The people working in the NHS every day, the ones facing the situations that need solving, embody a wealth of creativity. We should be asking them what they need to make their working lives easier, what they need to make services slicker, safer and cheaper. They know what’s needed. If we support them and pair them with innovators and creators in the commercial and business sector they will create the changes we need. Let’s all start by looking for our innovators, listening to them, and supporting them to give it a go.