Innovation as a Driver of Quality and Productivity in UK Healthcare

Study Context, Aims and Approach

The National Health Service (NHS), as with all health and care systems, is under pressure to meet the growing and changing demand for services with limited resources. A growing proportion of the population in the UK is aged over 65 and people are more commonly living with multiple long-term conditions. More widely, the changing nature of the disease burden and more diverse service-user profiles add to the complexity of meeting health and social care needs (Age UK, 2017). At the same time, new technologies, products, services and ways of working provide opportunities to respond creatively and effectively to growing demands from all age groups. The shaping of innovations to respond to changing health and social care needs must take place within well-recognised resource constraints and in accordance with efforts to achieve efficiencies in how healthcare is delivered (Appleby, Galea, and Murray, 2014). In this context, realising productivity gains while improving the quality, safety and effectiveness of care is a policy priority. Recent reviews, variously focused on improving quality or cost-effectiveness, include the Kennedy Report (Kennedy, 2009), the Berwick review (Berwick, 2013), the Keogh review (Keogh, 2013), the Francis enquiries (Francis, 2013), the Carter review (Carter, 2016) and the Accelerated Access Review (AAR) (Department of Health, 2016). In different ways, these reports (along with a much wider body of research literature) all inform thinking about how best to support improvement efforts and innovation in the health system. The AAR and the Five Year Forward View (National Health Service, 2014) sharpen the focus of innovation by emphasising that it should reduce inequalities, improve access, strengthen quality and close efficiency gaps.

Against this background, RAND Europe and the University of Manchester have been commissioned to conduct a three-year study to examine the potential of innovation to respond to the challenges the NHS faces, and to help deliver value-for-money, efficient and effective services. "Innovation" in this study refers to any product, technology or service that is new to the NHS, or applied in a way that is new to the NHS, aimed at delivering affordable and improved care. The aims and focus of this research also evolved on the background of this changing landscape. The three-year study consists of two stages. Stage 1 was a scoping stage and examined the implementation and outcomes of the Innovation, Health and Wealth strategy, which had set out the Department of Health's delivery agenda for spreading innovation throughout the NHS, at the time (Department of Health, 2011). In stage 1, we explored the role of the Innovation, Health and Wealth strategy in the national health innovation landscape and its key associated initiatives for taking forward innovation in the NHS (Bienkowska-Gibbs et al., 2016), with a view to capturing key lessons and informing the design and implementation of more in-depth work in stage 2. Given the evolution in the national policy landscape, particularly in connection with the AAR (Department of Health, 2016) and Five Year Forward View (National Health Service, 2014), the stage 2 design takes account of learning from stage 1 but also focuses on a more comprehensive and timely set of issues.

The core aims of the stage 2 research will be achieved by answering four questions:

• How do organisations working in, and closely with, the NHS perceive and understand innovation, and how does this influence their actions?
• Who drives and contributes to innovation and how might successful innovation have greater scale, scope and impact?
• Innovations deliver benefits through complex pathways involving many organisations, regulations, incentives and processes. What practical changes to policy, culture and behaviour can support system-wide improvements to these pathways?
• How can we measure the contributions of innovation to the social and economic performance of the healthcare sector (i.e. how will we know whether we are innovating well)?

Central to answering these questions is a detailed understanding of what innovation-friendly environments look like and how they might be nourished. We recognise that support for innovation involves local, regional and national levels. Effective alignment between these levels has historically faced diverse challenges related to issues such as organisational structures, long-standing professional identities, a need for better-developed approaches to patient inputs, and a historical separation between innovation processes and the processes of commissioning and managing services. This study will be practical and pragmatic; it will identify lessons on how to improve the innovation process and its outcomes and impacts, and help identify the steps stakeholders need to take to catalyse more innovation-friendly environments. This is also an academically robust study intended to contribute to advancing knowledge about health innovation systems. Although the context in which this research was commissioned predates specific health innovation policy developments such as the AAR, it will interpret findings in light of the evolving policy landscape before making final recommendations. The policy interventions that may be introduced will impact on preexisting systems. A nuanced understanding of the structures, relationships and behaviours in the health system in which new policy will be implemented will provide important learning relevant for NHS receptiveness and implementation.¹

This document presents insights from interviews and stakeholder workshops that have been conducted as part of the second stage of this study.² It covers one stage of the wider review. As an emerging insights report, it should be understood as an assessment only of the research completed to date and not as an early draft of the final report. We share what we have learnt so far about the types of activities and initiatives that are taking place in the health system to try to support innovation, and highlight some areas to consider in future capacity-building efforts.

We cannot at this stage propose a final and definitive set of recommendations—the second phase of our study will be concerned with identifying solutions and priority areas for action. This stage of the research aims to understand the attitudes of those involved in innovating in and around the NHS. However, this emerging insights report goes beyond problem identification to include an understanding of what those engaged in delivering health innovation believe the potential solutions to be. We believe that their insights about what works and what could work better are a vital part of identifying realistic solutions. We also suspect that historical improvement and innovation approaches in the NHS have frequently been hampered by too little attention being paid to understanding the problem before arriving at perceived solutions. We pushed research participants to go beyond identifying only problems and encouraged them to identify potential solutions and share their experiences in this regard. In the next phase, we will build on the insights gained thus far.

Overall, we aim to gain a richer understanding of how national policy can support regional success, and how in turn regional policies and practices can help shape national policy and strengthen its implementation. We consider both regional and national policy through the prism of how they support actual and specific innovations on the ground (i.e. we are not assessing these against an abstract model of innovation but against their contribution to actual practice). We will look to identify and characterise the priority actions that stakeholders can take to catalyse more innovation-friendly environments in practice and in relation to different kinds of innovation. This will require considering what—among the diversity of current efforts and further capacity-building needs and opportunities that we have identified thus far (and discuss below)—is most relevant, feasible, acceptable, sustainable and likely to facilitate impact at scale and at pace.

We aim to establish practical recommendations for stakeholders across policy and practitioner communities. This will be done by: locating the analysis presented in this summary in the context of evolving national priorities; establishing new evidence and insights through qualitative case studies of the uptake of a range of innovations and through engagement with stakeholders to help prioritise actions to support innovation; developing supportive quantitative health economics analyses on the determinants of uptake of proven innovations and on the cost-effectiveness of innovation activity; and triangulating these new data against what we already know from the existing literature. Please note that a literature review is ongoing; it is not discussed in this emerging insights article, but will be included in the final study report.

The study design is rooted in a systems perspective on health and innovation and adopts a mixed-methods approach, applying qualitative and quantitative data-gathering and analyses (e.g. desk research, key informant interviews across stakeholder groups, case studies, economic modelling). This approach might encourage a longer-term and whole-system perspective (which we support) but we also recognise that decision makers (and commissioners in particular) need to make immediate decisions in the short term which can balance immediate pressures with long-term transformative goals.

This emerging insights article, based on the first phase of research, draws evidence primarily from workshops across four different regional health economies and key informant interviews with health and care providers, commissioners, higher education and research representatives, charities, patient and public involvement bodies, private-sector and local authority stakeholders, and innovation institutions and networks.

To select the regional sites, the research team conducted desk research and a document review, and consulted with representatives from the Department of Health, the Office of Life Sciences, NHS England and additional experts. The regional health economies were selected to reflect a range of experiences, approaches and geographies, and to solicit diverse stakeholder views on important areas and organisations to learn from. The four regions are: Eastern, Greater Manchester and North West Coast, South West, and University College London Partners (UCLP) and related actors. Through this process, we have engaged with 221 individuals with expertise and substantial experience relevant to health innovation. The scale and scope of this research have enabled us to establish a uniquely nuanced and intricate understanding of the different ways in which innovation manifests itself across professions, organisations, geographies and disciplines in England.

Caveats

There are some caveats to consider when interpreting the findings from the first phase of this study.

First, though we have engaged with a large number of stakeholders from four regional health economies, we recognise that there are still other individuals and organisations with valuable insights whose views we are yet to include. Our focus was largely on individuals who are in some way engaged with innovation and supportive of it (and who could help us understand enablers of good practice). We are aware that elsewhere, in and around the NHS, there may be other priorities—or even cynicism—and that innovation may be regarded with less enthusiasm. However, we have been struck by how much the individuals we have so far engaged with have both been aware of other views and recognised the diversity of contributions needed for the overall health innovation system to function effectively. Given the range and nature of individuals consulted, we believe we have obtained a balanced and rounded view of the current landscape and future opportunities. Going forward, we will aim to achieve additional nuance in stakeholder views on innovation-related issues in the coming phase, and enhance engagement of specific groups (e.g. patient and public representation, private sector) to complement the current focus on those working in and around the NHS.

Similarly, while the key messages arrived at largely apply across the regions with which we engaged, there are also specific regional differences which have implications for future capacity-building efforts. Some regions have historically focused on one or another aspect of innovation and are at different stages of capacity development for innovation. Similarly, there are differences in the scale of expertise and focus on product versus technology versus service innovation. Also, key innovation institutions within regions (such as Academic Health Science Networks [AHSNs] and Innovation Hubs) have played varying roles. As our work evolves in phase 2 of the study, we will explore these regional dimensions in greater depth through case studies and additional stakeholder engagement, to understand what they imply for the prioritisation of regional activities and for connections between regions.

However, while we recognise the importance of regional and national agencies and policies in delivering innovation, we are also well aware of the existence of a global health innovation system. Global R&D, global corporations and global markets all shape national and subnational innovation systems. Although we will discuss global innovation issues as they arise in our research, a specific focus on the global health innovation system is out of scope for this study. In addition, we recognise that variations occur not only in regional innovation systems but also by technology sector (e.g. medicines, devices, service model innovations, digital).

Finally, the emerging findings discussed in this article were derived from data collection conducted prior to the publication of the AAR final report, and prior to the announcement by the Department of Health England and the Department for Business, Energy and Industrial Strategy of: a new package of support for innovation (focusing on support for AHSN roles in innovation uptake; a digital technology catalyst; assistance to small and medium-sized enterprises (SMEs) to enter early-access pathways; and pathway transformation funding to help overcome practical obstacles, such as those related to training and skills) (Department of Health and Office for Business, Energy and Industrial Strategy, 2017). However, we believe the emerging findings presented here remain highly relevant and offer important insights on the implications, opportunities and challenges for policy. These include insights on the critical determinants of successful policy landing and implementation in practice, with stakeholders and in regions. We highlight some key issues for consideration below, and will be exploring them further, as well as developing practical recommendations, in the next phase of our study.

With these caveats in mind, the messages we identify below should be understood as well informed but provisional.

Key Emerging Findings: Creating Receptive Places for Innovation

Successful innovation happens when combinations of drivers come together. We are not alone in emphasising that there is no single "magic ingredient." These combinations can be thought of as creating receptive places for innovation which have in common: (i) innovation skills, capabilities and leadership; (ii) networks and relationships that connect the different parts of innovation pathways; (iii) incentives and accountabilities in the system that reward managed risk-taking, long-term approaches and service transformation; (iv) financial resources, commissioning and procurement environments and associated governance and regulation that provide the necessary funding, time and permission from management to allow innovators to thrive; (v) engagement with patients and communities who can create added pull for patient-facing innovation at pace and scale; and, critically, (vi) an appropriate information and evidence environment in which to make sound decisions—locally, regionally and nationally.

In the content below, we summarise key insights and messages from the work we have so far conducted, as they apply to each of these drivers. We overview the types of initiatives taking place across the regions we engaged with to ensure vibrant health innovation ecosystems.³ This marks an important, extensive and, we believe, valuable drawing together of innovation-oriented activities taking place at (case-study) regional levels. This could support further learning. We also show what study participants highlighted as important areas to consider as this research evolves. However, we are aware that participants in this study, although diverse, were not fully representative of all stakeholders delivering (or resisting) innovation. In line with qualitative methods for conducting purposive sampling and interview-based studies in health (Bowling, 2002), a deliberately non-random approach was used, aiming to capture diverse views and experiences but not a strictly numerically and statistically representative sample. We will consider potential gaps as the work progresses, and note (for example) the question of improving engagement with charities, patients and other public- and private-sector stakeholders.

Within these constraints, we aim to share learning that is relevant both for policy makers and practitioners of healthcare and innovation.

1. Skills, Capabilities and Leadership

A diverse but not infinite set of skills and capabilities are needed to deliver successful innovation in the health system. A variety of initiatives at national levels, as well as in the regions we engaged with, are seeking to build innovation-related competencies. This includes strengthening the skills base via: (i) training and professional development programmes to support innovation supply or capacity for innovation uptake in the health system; (ii) leadership training, coaching and mentoring schemes; (iii) strengthening professional networks to create connected communities with sufficient knowledge-management capacity to access and use innovation-related information and evidence for responding to service improvement challenges; and (iv) well-facilitated problem-solving and idea generation events and forums bringing together entrepreneurs, healthcare professionals, investors, mentors and the wider health and care community. There was also a perception among the individuals we consulted that innovation capability-building in the UK has historically focused more on the supply side of the innovation pathway than on skills for adoption and scale-up. However, the perception was that this imbalance is gradually being redressed.

Our research to date also suggests that strengthening skills, leadership and capabilities for innovation may in addition require attention to be paid to the following aspects of capacity-building, to be examined further in phase 2 of the project:

• Scaling-up of skills and training programmes in specific aspects of innovation, including skills and capabilities for: needs assessment and problem articulation; networking, brokerage and leadership; matching innovation supply and demand; more sophisticated health economics analyses; enhanced evaluation and data analytics as well as interpreting and communicating evidence; implementation and change management; and making a more compelling business case for innovation uptake. These capability-building areas are all important when considering the scale-up or evolution of existing programmes (e.g. Clinical Entrepreneur training, the NHS Innovation Accelerator [NIA], regional Innovation Lead training) or the introduction of new skills-focused initiatives.
• Embedding innovation thinking and training into educational curriculums and Continuing Professional Development (CPD) for both clinical and management staff in the health system.
• Strengthening capacity to engage with innovation through cross-sector learning (e.g. greater engagement with the private sector especially around ways to conduct public sentiment analysis, and business case and commercialisation skills).
• Sustaining investments in existing regional institutions such as AHSNs and Innovation Hubs. These are important for strengthening skills to match innovation supply and demand, and to broker relationships and ensure a critical mass of connected innovation leaders, required for progressing innovations throughout the pathway from idea generation through to development, adoption, diffusion and scale-up.

2. Motivations and Accountabilities

There are diverse mechanisms within health and care organisations to incentivise innovation, although at present there is little evidence on the cost-effectiveness of different approaches. Improved quality of care for patients, financial incentives for individuals and organisations, opportunities for professional development, reward and recognition are seen to be key motivators for individuals and organisations to innovate. Other approaches to translate motivation into action include: releasing resources (time, funding) to incubate ideas and pursue innovation-related activity; sharing evidence on impacts from innovation; and establishing reward and recognition schemes, financial returns and performance-related incentives. Alongside such approaches designed to motivate innovation are diverse formal innovation roles and functions in provider organisations (e.g. Innovation Leads, Innovation Scouts, Directors of Innovation and Improvement). Often working together in regional and national networks, these seek collectively to support innovation-friendly environments.

However, despite the variety of individual and organisational motivations, there is a lack of scale, connectedness and consistency in these incentive mechanisms across regions and at the national level. Addressing this requires further system-level interventions to enhance incentives and accountabilities for innovation. In addition, approaches for further exploration as suggested by study participants include:

• Strengthening and scaling up permission to innovate in provider organisations.⁴ For example, some potential avenues that we will explore further in phase 2 of the project might include: (i) buying out programmed activities; (ii) embedding innovation into job descriptions and performance reviews; and (iii) funding incentives to address the upfront costs of innovation and to facilitate benefit-sharing.
• Mechanisms to build a collective identity and sense of community for innovating health and care professionals, including efforts aimed at health professionals' education and early career development (e.g. visible and stable leadership for innovation at different organisational levels, teamwork on innovation challenges).
• Addressing risk cultures in the NHS, through the promotion of responsible and accountable risk management (e.g. through the creation of standards, clear communication from leadership, and engagement with other sectors to exchange insights on risk management).
• Additional incentives for innovation uptake specifically, as well as associated decommissioning (e.g. awards for the uptake of proven, high value-for-money innovations developed elsewhere; improved information and evidence flows on innovation performance; performance indicators linking innovation to accountability).
• Additional incentives for being entrepreneurial, including through clarity around financial benefits and innovation priorities in the NHS, and clarity on NHS intellectual property (IP) policies and benefit-sharing arrangements for innovators.

3. Information and Evidence

The current knowledge exchange and knowledge management landscape on innovation is characterised by a plurality of efforts including: (i) regional innovation and health improvement networks which play a role in facilitating the spread of innovation-related information and evidence; (ii) individuals with innovation roles in regions who serve as an important go-to source of information and as boundary-spanners and entry points into relevant networks; (iii) regional- and national-level face-to-face and virtual platforms for sharing ideas and evidence of impact from innovation, within and between organisations (e.g. meetings, committees, institutional Boards, Trust websites, national platforms like the Academy of Fabulous Stuff); and (iv) legal mechanisms to reduce blockages to information- and evidence-sharing (e.g. Non-Disclosure Agreements [NDAs], royalty arrangements).

There is a wealth of information and evidence on innovation available in the health system, but the sources are fragmented and the content often lacks appropriate communication and targeting. Addressing this will require capacity-building to curate, interpret, translate and better target relevant information at various stakeholder groups. Among other steps, this will involve:

• Responding to key information priorities, including: (i) improved evidence on population needs as they pertain to proposed innovations; (ii) platforms for better signposting to identify innovation actors; (iii) information about innovation opportunities to raise awareness among frontline staff; (iv) information about available means of commercial support for innovators; (v) information about opportunities for bringing innovations into the NHS; and (vi) baseline and outcomes data (including real-world evidence) to inform decision making by commissioners and providers. Better evaluative evidence, including on factors for successful implementation, is also needed to support the commissioning and scaling-up of innovations in the NHS. It would also help to clarify to innovators the standardised expectations of the burden of proof required to justify innovations.
• A more explicit strategy for managing and communicating information and evidence at national and regional levels. This should be based on a mixed-methods approach combining digital and real-world face-to-face interactions. For example, there may be a role for a national but targeted and interactive information platform, complemented by strong regional information-exchange environments based on face-to-face interactions, and investment in interoperable information technology (IT) systems for data-sharing and linkage. There is a need for an active strategy, rather than overreliance on passive communication mechanisms.

4. Relationships and Networks

The value created by the innovation landscape is in part determined by diverse initiatives, relationships and networks within and between regions. These span institutions such as AHSNs, Vanguards, Test Beds, Innovation Hubs and Catapults which are linked to national transformational initiatives but are managed at the regional level. In addition, there are various region-specific catalysts of innovation, including health R&D networks, patient safety collaboratives, quality improvement networks and entrepreneurial initiatives such as Accelerators and Incubators. Regional collaboration is increasingly central to the health innovation system's architecture, with new and evolving roles for AHSNs and other actors.

Despite a fertile and diverse landscape of actors, it is not clear that the system—as it currently stands—has the capacity to manage and take full advantage of the complexity of opportunities and initiatives. In terms of future needs, stakeholders interviewed in our study or participating in workshops identified the following areas for further consideration as the research and policy landscape evolves:

• Clarifying and making more visible the roles, remits and complementarities of specific initiatives that would reduce barriers to collaboration arising from exacerbated competition and unclear or duplicated mandates or remits.
• Scalable joint working mechanisms, such as secondments, dual roles and greater multiprofession representation at senior levels on Boards, should be considered as potential levers for further strengthening cross-network (e.g. AHSNs, Vanguards, Test Beds), cross-sector (e.g. NHS/health and social care and voluntary) and cross-profession (e.g. primary, acute care) collaboration. However, their feasibility, acceptability, appropriateness and sustainability will need to be further examined as the work evolves and they are not likely to work in isolation from other levers.
• In general, collaboration between the NHS and the private sector is perceived by study participants to be less developed than relationships between the NHS and universities, research institutes or charities. Areas for attention include capability in the private sector to articulate a compelling business case for the NHS (i.e. which addresses issues such as decommissioning needs and the practical realities of implementation), and improving the NHS's ability to articulate its innovation needs to the private sector and clarify routes to the NHS market (including via broker organisations and networks such as AHSNs).
• Our respondents suggest that AHSNs are primarily geared towards providing information, evidence, network brokerage and innovation functions that can support the progression of innovations across the pathway. However, specific regions highlighted additional areas where AHSNs might also provide support, such as implementation, legal and IP advice and evaluation expertise. AHSN metrics will need to be revisited to reflect the evolution of their roles and to address some unintended effects of the current metrics approach (such as a lack of focus on incentives for uptake of innovations developed elsewhere—i.e. non-home-grown innovations). AHSNs also need to be supported to work together as a national network, to exchange information and evidence of best practice, and to raise awareness of local priorities.

While most of our data collection involved individuals who are engaged in innovation activities, they were also well aware that the core functions of a far larger number of NHS staff do not include innovation. However, even those less directly involved have an important role to play in making the NHS, as a whole, a welcoming and receptive place for innovation. This has encouraged us to reflect that there is a division of labour in which a small number play a role fully committed to leading both innovation initiatives and cultural change in the NHS, with a larger and more distributed group routinely managing and facilitating innovation and a third, even larger group whose roles do not include innovating as a core function, but whose behaviour will determine whether the NHS is receptive to and uses innovation or not. Each group requires a different kind of engagement and each is important for overall success.

5. Engaging Patients and the Public with Innovation

There is growing recognition that a sustainable and effective health innovation system needs to involve patients and the public throughout the innovation pathway (i.e. in prioritising needs, articulating demand, contributing to innovation programme and project implementation, and enabling and advocating for the uptake of effective innovations and their evaluation). Across the regions considered in our research, health and care actors are working to engage patients with health innovation through dialogue, awareness-raising, advocacy with the third sector and demonstrations of innovations at wider community events, or through web-based platforms and institutional patient and public participation or reference groups, as some examples.

However, and despite progress in the area, achieving effective patient and public involvement was seen to be very challenging, resulting in some concerns over tokenistic attitudes and limited, fragmented and highly variable practices. In terms of building further on current momentum and effort:

• Our insights suggest that the research and charity landscape, including the efforts of the National Institute for Health Research (NIHR) (e.g. INVOLVE, the James Lind Alliance), medical charities, umbrella organisations (e.g. National Voices) and patient engagement portals (e.g. Health Unlocked, Patients Know Best), offers lessons for patient and public engagement in the innovation space.
• In addition, many of the patient engagement initiatives that currently exist within regions span quality improvement, research engagement and innovation spaces, suggesting that a more coordinated approach to public and patient engagement across these complementary spaces might lead to greater efficiency and effectiveness.
• Insights from interviews and workshops highlight that empowering patients to engage with innovation requires improved information and evidence environments, multistakeholder commitments to involve patients at all stages of the innovation pathway and training programmes for effective engagement. These should be geared at both public and patient representatives and health professionals.
• Sharing examples and evidence of positive experiences and their outcomes was also seen as important for enabling wider-scale change in attitudes across the system.

6. Funding and Commissioning of Innovation

The funding landscape for innovation is characterised by diverse sources of funding from both national funding pots and regional and organisational resources. However, this funding landscape is fragmented and often unable to achieve critical mass and scale to support innovations across the pathway—from idea generation through to uptake and scale-up across the system. There is a need for better visibility of the funding sources available and a mapping of where they sit in the innovation pathway, as well as for better coordination of current funding. This should happen within an environment that more explicitly recognises how commissioning and procurement can support innovation within the wider context of organisational, cultural and behavioural levers in the health system. New commissioning models which reward performance and evidence of impact on the healthcare system are being explored, and the scalability and uptake of some schemes (e.g. commissioning through evaluation, outcome-based commissioning) remain to be seen, given wider-level systemic changes that would need to happen concurrently (e.g. in terms of budget cycles and planning, decommissioning).

In terms of capacity-building, insights from our work to date suggest a need for commissioners and innovation funders to:

• Support promising innovations across the whole healthcare innovation pathway to ensure that promising innovations do not hit "valleys of death" and that those with a low likelihood of success fail "smartly." Achieving this will call for more strategic coordination between schemes and funders of different innovation pathway stages.
• Consider how longer-term needs and future scenarios can be factored into shorter-term commissioning decisions.
• Recognise the different timescales for the development and uptake of different types of innovations (e.g. medicines, digital, devices, diagnostics).
• Facilitate a hybrid model of governance and management of innovation funding at national and regional levels through a framework that would: (i) incorporate both national and regional elements in decision making and fund implementation and evaluation; (ii) consider accessibility by a broad range of actors to facilitate capacity-building for engaging with innovation across the system; (iii) balance nationally relevant and locally relevant needs, as well as recognising unmet niche areas and underserved groups; and (iv) balance support for transformation with meeting immediate financial targets.
• Respondents also highlighted the importance of factoring innovation into procurement and commissioning contracts—for instance, through the Innovation and Technology tariff, or by ring-fencing a proportion of commissioning budgets for commissioning by evaluation and outcome-based commissioning schemes. The successful implementation of such schemes will in part depend on the availability of a supportive data infrastructure.

Reflecting on the Emerging Insights and Evolving Policy Landscape

Recent policy developments such as the AAR lay out a framework and process for addressing the diverse drivers of innovation discussed above in a more coordinated and streamlined way, across the entire innovation pathway. Central to the AAR framework is improved alignment between national policy and actors (e.g. regarding regulatory approval, the National Institute for Health and Care Excellence [NICE] Health Technology Assessment [HTA], NHS England commissioning and reimbursement), regional innovation activities and actors, and local diffusion. The interventions outlined in the AAR resonate with many of the findings highlighted in our research. In particular, this applies to the need for enhanced coordination and clarity about health innovation activities and closer relationships between key innovation practitioners, health system actors and national bodies.

There will inevitably be both synergies and tensions in approaches that seek to integrate (i) collaboration, (ii) coordination and (iii) a degree of competition. The balance between these three forces is a critical issue for the health system more widely, and for the successful landing of innovation policy and practice within it. Better-coordinated collaboration will be critical for effectively managing the interdependencies between the innovation drivers we have discussed above and for strengthening the combinatorial dimension of health innovation. Interventions highlighted in the AAR, including the Accelerated Access Partnership, regional innovation exchanges, new pathways for patient engagement, transformative innovation designations (announced earlier this year by NHS England), and distinct pathways of support for different types of innovations (including the Paperless 2020 initiative for digital innovations), lay out an enabling infrastructure and receptive environment that can respond to the coordination and collaboration challenges.

Our findings also suggest that getting the best returns from the UK's health and care innovation requires designing approaches that:

• Use the interdependencies between health and care sectors as opportunities rather than barriers, drawing on the expertise of both clinical and allied health and social care professions and focusing on cross-cutting and complementary health-sector priorities (e.g. prevention and early intervention, self-care and management of long-term conditions, patient safety and health data infrastructure). Many innovations (e.g. digital platforms) are likely to require engagement from multiple sectors in order to achieve needed impact. Similarly, population needs across health and social care are likely to influence prioritisation processes for innovation—at regional as well as national levels.
• Attend to, and take advantage of, the relationships between macro-scale change (i.e. new policy developments driven by the national level), meso-level regional structures and processes (e.g. interconnected regional institutions that are both receptive to national policy and can help shape it) and micro-scale interventions (e.g. centred around individual and organisational motivations and incentives). Enabling conditions and receptive environments at the organisational level—in commissioning groups, in individual provider organisations and within specific communities of practice—requires alignment and mutual adaptation across these levels. Successfully landing the recommendations in the AAR will depend as much on formal structures, processes and resources as on informal relationships and networks. Together these can create clarity and opportunity in an evolving policy environment.
• Use both structural and behavioural interventions to progress innovations across the health innovation pathway. These include: institution-building (such as in the evolving role of AHSNs); nurturing boundary-spanning and brokerage roles; and supporting both formal processes and informal networks and communities of practice. Approaches will also allow individuals and groups to find the creative time to engage with innovation across acute, primary and social care pathways. A focus on creating enabling structures should not come at the expense of nudging behaviours across different levels in organisations, regionally and nationally.
• Coordinate innovation and improvement policies. The links between these are critical when prioritising investments and coordinating complementary efforts. They are also important for making a more effective business case for innovation to the NHS. Historically, healthcare professionals have become more familiar with the discourse of improvement than innovation, and understanding the place of innovation within improvement landscapes and efforts will be essential for the creation of "receptive places." Many initiatives simultaneously address both innovation and improvement issues.
• Adopt a portfolio approach to innovation—responding to both quality and cost considerations. This is critical for the transformation of the health system and for creating receptive places for innovation. It requires first taking a view on the total size of the innovation portfolio and ensuring the system has the capacity to absorb such a volume. Secondly, it involves attending to the balance of the portfolio, having considered not only different levels of risk but also the motivations of different stakeholders. Our expert respondents also recognised that different types of innovation require different kinds of "receptive places," and this needs to be considered in the planning of an innovation portfolio at national and regional levels. Medicines and vaccines, devices and diagnostics, service innovations and digital innovations all require the involvement of different scientific disciplines, patient and carer inputs, types of private-sector involvement, and delivery models.

Looking Towards the Next Phase of This Study

The next phase of our research will focus explicitly on what these (and other) issues imply for the development of targeted and actionable recommendations for stakeholders. These will build on the lessons gained thus far (as summarised in Figure 1) and respond to the recent policy developments, by bringing in new qualitative and quantitative insights. The focus will be on informing practical action, and on identifying and prioritising the highest-leverage combinations of actions that provider communities, commissioning bodies, innovators and patient and public representation bodies can take to ensure receptive environments at scale. Similarly, particular gaps highlighted by participants in the research (as summarised in Figure 2) will also be examined further in the context of arriving at capacity-building solutions and practical actions. At the same time, the goal will be to improve the evidence base on how national and regional bodies can work together most effectively. Last but not least, the detailed and comprehensive evidence we are gaining should enable us to contribute to a more interdisciplinary perspective on innovation theory and its links to improvement research as the next phase evolves.