Changing the NHS – New Technology – 4

In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).

Developing Alternative Financial Incentives

My previous post discussed the NHS Confederation report on new financial flows for the NHS and social care. Today I’m returning to the various changes that are necessary if we are to implement greater use of technology into the NHS.

I want to turn today to the need to explore developing financial flows to ensure tmuch more rapid investment in technology.

Over the next five years It is certain that nearly every aspect of technology that the NHS and social care will be using to help improve health care and health will be bought from private sector companies. I would hope that many of those with be spin-offs from British universities working with the NHS. They may be large or small but definitely private companies. For tech to deliver the maximum impact for British public health and care, the way in which money flows from the NHS into private companies will be crucial.

I am sure a few blog readers may be bemused by starting at this point in the financial flow. However, to be brutal about it, if we don’t get this relationship between public finance in the DHSC or NHSE and private companies to develop and supply technology right, we can kiss much tech enabled health and health care improvement goodbye.

In 2024 one of the main reasons that the NHS is so minimally tech enabled is that it is very bad at buying it. Whilst some of this is NHS specific (too many people in the NHS see it as being a sort of anti-capitalist project) most of the problem comes from the way in which the public and private sector interoperate.

This is a problem for most public services. Contracting processes are slow, ask the wrong questions about the capabilities of products, and are too short term.

What to do? I have been a bit despairing of my own imagination about this. Suggesting a review of how this is carried out is so mealy mouthed. And I am informed that since 1950 there have been 30 reviews of the way in which NHS procurement takes place. Carrying out number 31 doesn’t seem to be likely to bring about the necessary changes.

Then out of the blue – from another Department – a review which has the nerve to raise fundamental questions about how this is done.

A year ago, the Prime Minister created the Department of Science Innovation and Technology (DSIT), and Tory peer Lord Willetts was asked to review the way in which the Department of State carried out its business case and approvals process

I know this is a pretty nerdy thing to get excited about but if DHSC and NHSE were to implement these changes we would have a much better chance of getting a tech enabled NHS.

Why does this matter?  The English civil service does have a strong reputation (Covid PPE being an exception) for propriety in buying goods and services.

The Permanent Secretary, explains the problem: –

“I am the Accounting Officer for DSIT, with personal responsibility for justifying our use of public funds. I take that responsibility seriously, and we should not be afraid of assessing spending proposals thoroughly and robustly. However, we know that our business case processes have become too cumbersome, and are particularly ill-suited for the deliberate risk-taking that is necessarily involved in spending money on R&D”.


This goes to the core of the problem of the interaction between public finances and technology, because so much of what technology can do is new and occasionally completely transformative it is inherent that these advances in technology contain some form of risk. (Just as health care does).

If you have a process – such as the one public sector contracts for technology try to achieve – that tries to circumvent risk – there is an inevitable clash. And our problem at the moment is that in that clash it is the use of technology for public service that is missing out.

This is a long quote but worth it,

“The business case is a key tool for managing public spending. The BC can provide the framework for transparent and evidence-based decision-taking. It obliges departments to think through what outcome they are trying to achieve and how. It can help Government avoid committing resources to projects that should not proceed. But the BC was developed for conventional public spending – buying services and building stuff – not for promoting inherently uncertain Science and Innovation. It assumes more capacity to forecast costs and benefits than is possible when the Government is funding innovative and risky R&D. Moreover, the BC became in BEIS and DCMS a slow, time-consuming, labour-intensive bureaucratic process, producing long reports which make it hard to extract the key information and issues for decision – a source of frustration to the Treasury itself. Such processes are a significant barrier to delivering the Government’s Science Superpower strategy. The creation of the new Department for Science Innovation and Technology is an opportunity to replace the legacy processes with a much more agile regime more suited for discovery science and innovative technologies.”

Introduction p5.

Lord Willetts is correct about this process hindering the current Government’s strategy. He would also be correct that this process would hinder any future government strategy that was trying to make the NHS fit for the future.

How does he see the outcome of the current process?

“UKRI, DSIT’s largest arm’s length body (ALB), suggests that it takes on average 17 months to develop an investment proposal and make a decision.”

Main report p6.

It is that wasted 17 months that is the outcome of the current problematic financial flow between the public finance and technology. In the application of technology 17 months is a lifetime.

Over the years I have met many entrepreneurs who want to sell their products to the NHS. 6 months into that 17 months they get frustrated.  After all, by then they are starting to develop the successor product to the one they are trying to sell the NHS. After a year they get angry and decide that they can get quicker responses from another country.

It’s not that they expect every pitch to be successful, but it’s the hanging around that puts people off.

The Willetts review agues for speed. Not reckless speed but speed. In trying to do away with risk too many public servants engaged in the business case process are missing out on the possibilities of the future.

To linger on that word – future. If we want an NHS fit for the future, we will need to develop public sector processes that don’t keep procrastinating.

This report goes on to use an example from astronomy to make a very big point.

“The great American astronomer John Bahcall was pressed about the likely results from federal spending on the planned Hubble telescope and replied:

“I believe that the most important discoveries will provide answers to questions that we do not yet know how to ask and will concern objects that we cannot yet imagine.”

Now it is rare for something in health care to be providing answers to questions we do not know how to ask. But in the next 5 years we will need to use technology to answer very important questions that we are not certain about. Rather than hesitating at the very beginning of the process of buying it we need to be prepared to take some risk – buy it, use it, and, if it doesn’t work, stop using it and move on to the next product.

At the moment this review has just been looking at the business case processes in one new Department of State. If we want to have an NHS fit for the future, DHSC and NHSE need to take these ideas on board as quickly as possible.

In changing its model of delivery the NHS can’t afford to use processes that persuade technology developers to give up on it.