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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 3; 335(7626): 913.
PMCID: PMC2048864
Body Politic


Nigel Hawkes, health editor, the Times

Managers in the NHS do not innovate because there is nothing in it for them

Here's a puzzle. How did Britain lose its motoring industry at the same time as it came to dominate motor racing? This may seem a long way from the politics of health, but bear with me: there is a parallel.

Racing cars are the cutting edge of vehicle engineering, a testbed for new ideas. In the 1950s and 60s the designs of John Cooper and Colin Chapman transformed Grand Prix motor racing. From this emerged a small and dynamic industry—Lotus, McLaren, Lola, Williams, Cosworth, among others—that had no need of government advice or sponsorship. These companies quickly became a dominant force in racing car design and, 30 years or more later, remain extraordinarily influential. It was to a British designer, Ross Brawn, that Ferrari turned to transform its fortunes in the 1990s.

Yet this coincided with the long death of the motor industry in Britain. Foreign manufacturers have set up plants successfully, so vehicle production is still important to the UK economy. But of Morris, Austin, Hillman Humber, and even Rover—once names that rolled off the tongue like battle honours—we hear no more. They are dead, defunct, or in the case of Rolls-Royce, a subsidiary of Volkswagen.

What, exactly, has this to do with the politics of the NHS? While the British motor industry was dying, the racing car designers proved we did not lack for talented engineers, skilful artisans, or entrepreneurs able to create new businesses. They did so outside the established structures, which were dominated by trade union power, entrenched rules and customs, centralised management, and a practised disregard for what the customer wanted. See where I'm coming from?

The NHS is widely and accurately regarded as slow to take up new ideas. Hardly a week passes without some company ringing me with a bright idea that, for some reason, they cannot persuade the NHS to buy. They get a dry laugh, I'm afraid. Selling new technology to the NHS is like stuffing a goose with corn, except that it's unlikely to produce foie gras.

There is a wider parallel. During the years of British industrial decline, dozens of bodies were set up to try to force innovation down British industry's throat. The biggest of these was the National Economic Development Council (Neddy), which was constantly telling businessmen of the need to invest. There was also a chain of research associations, each devoted to an industry sector, that largely cast their advice to the winds. Top-down advice has never worked if the climate for innovation is chilly.

Today, while the NHS makes do with old ideas and yesterday's cures, British medical research continues to compare well with anywhere save the US, and pharmaceutical laboratories based in Britain have produced 20 of the top 100 drugs in use today. Innovation is alive and well in health care, just as it was in car design and engineering as the motor industry imploded.

Enter Lord Darzi and his interim report which, among other things, recommends the creation of a Health Innovation Council, chaired by himself and funded by £100m provided equally by the Department of Health and the Wellcome Trust. This idea is as appealing as an embrace with a blancmange. Here is Neddy reinvented, a council of the great and the good wasting perfectly good money on a scheme that anybody with five minutes' acquaintance with the NHS could see is unlikely to work.

Managers in the NHS do not innovate, because there is nothing in it for them. In Japan, when CT and MRI scanners emerged, clinics sprang up everywhere providing them, paid for by personal medical insurance—Japan has 10 times as many of these machines as we do in the UK, and they can provide a scan for as little as £50, at a couple of days' notice. In the UK, scanners were seen not as an opportunity but as a cost. Radiologists had to struggle to get them, and even now they are poorly used. (And don't say this is because Japan spends more of its gross domestic product on health than we do. It doesn't.)

I could multiply examples indefinitely. The NHS is not only unfriendly to innovation, it is actively inimical. Like the British economy before Thatcher, it is run by staff on centrally negotiated contracts, full of unacknowledged restrictive practices, and subject to periodic and ill considered changes of government policy. That means that more than half of the extra £40bn provided in the past five years has gone in salaries and wages, and we are still not providing the medicines that patients in other countries take for granted.

My point is a simple one. The UK is not slow to adopt new technology, but the NHS stifles the entrepreneur in us all. One reason is that we set equity as a higher ideal than innovation. If all patients are entitled to equal access to a service or a medicine, we have to wait until the price is low enough for it to be “rolled out”—as they say in NHS-speak—across the whole service.

True innovation does not occur this way. Imagine if we had all had to wait until mobile phones were cheap enough for a centralised bureaucracy to buy them for us, out of taxes. We'd still be waiting. In fact, don't trouble to imagine it—just try to recall how impossible it was to get any sort of telephone installed when the Post Office ran a monopoly. So long as equity rules the roost, the NHS will always be five years late, regardless of Lord Darzi's council. So the next time somebody extols the “fairness” of the NHS, bear in mind that it comes at a cost.


Lord Darzi recommends the creation of a Health Innovation Council . . . This idea is as appealing as an embrace with a blancmange

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