Disruptive Women UK will be launching Tuesday, September 30th in the House of Commons. This post is a part of a series running up to the launch welcoming Disruptive Women UK.

So you’re officially a health innovator. You have a product that works, so now you just need some people to use it. Broadly, you have two options at this point – to get users to pay for it themselves, or to sell it to a healthcare provider to use with their patients. Selling direct to the public is great if you have the right sort of product, but it might be trickier in the UK than in the USA or in some parts of Europe because there isn’t much of a tradition here of self-payment for healthcare. It might be possible to sell to private health companies or clinics in some form, but this isn’t likely to be an option for most innovators.

This means that most UK health innovators are going to need to try to supply the NHS. Old hands tend to offer doom-laden prophecies at this point, saying that selling to the NHS is absurdly difficult and – more trenchantly – that the NHS is responsible for the failure of many viable, sensible innovations. Is this fair? Three interlinked factors immediately come into play: regulation and approval, the structure of the NHS market, and the way that services are procured. These are some of the most boring words in the world, but for many entrepreneurs they can mean the difference between glowing success and another job in a cafe.

Regulation and approval are broadly speaking not the responsibility of the NHS itself. The Medicines and Health Regulatory Authority or the National Institute for Health and Care Excellence may be relevant, although many providers will not need to come into contact with either. The MHRA is in charge of deciding whether drugs and medical devices are effective enough to be sold, and they define their terms quite widely: medical devices include condoms and contact lenses, as well as some types of health software and apps. NICE is responsible for deciding whether a treatment is cost-effective for the NHS: which means that it needs to be worth spending money on – based on the cost per quality adjusted life year, or QALY. NICE comes in for a lot of criticism, usually from pharmaceutical companies who have just had a drug rejected, and sometimes from patient groups (who may or may not be linked to the pharmaceutical companies). It has certainly made some peculiar decisions, but has the merit of being pretty transparent – and its international reputation is such that a number of other jurisdictions simply borrow its decisions.

People often assume that a NICE recommended innovation is on its way to success, but the NHS doesn’t always listen. NICE has no legal power to enforce its suggestions – so it’s down to individual NHS buyers to decide whether to take up a new product. There are a lot of these buyers: in England alone, 211 Clinical Commissioning Groups (CCGs), 160 acute trusts, 56 mental health trusts, and ten ambulance trusts. Any one of the 437 could decide to buy a new product or service: and even if a product has been NICE recommended, they could all decide not to buy it because there’s no room in their budgets, or they have an existing system in place which they don’t want to change.

Unlike individuals and businesses, most NHS managers can’t simply decide to buy a new product or service. Tendering rules, designed to make the best use of public funds, mean that the majority of larger opportunities are published and potential providers invited to submit applications for them. This can lead to some intriguing adverts – public sector hubs often occasionally include requests for bouncy castle testers and totem pole constructors, alongside cleaning services and supplies of surgical gloves.

The principle of this arrangement is sound: formal tendering prevents managers from simply paying their small children to test the bouncy castles. But it can have nasty consequences for small providers: it takes considerable effort and skill to write a good tender response, and having a good product is often unrelated to being a good writer. A sensible desire to choose a reliable, low risk provider can make opportunities difficult if not impossible for small businesses to win. And commissioners will sometimes advertise opportunities when they already have a provider in mind: meaning that the only effect of the rules is to waste everyone’s time.

Perhaps most problematic for innovators is that the tendering process forces buyers to define what they want to buy far too early in the process. If you’re looking for a city flat to rent, but then decide once you’ve started looking that you’d prefer a suburban terrace to buy, that’s fine. If you were the NHS, estate agents would only be allowed to show you the rental flats. For entrepreneurs, this means that tender opportunities may never arise, because it’s hard for the NHS to describe a need for a product it doesn’t know exists. This means providers must devote significant energy to building a market for their product – always with the possibility that they’ll be beaten by one of the big players if it goes out to tender.

This isn’t a counsel of despair. The NHS is a huge and complicated beast, but most of its oddities are a function of its size and massive responsibilities. It has thousands of staff who want the best for patients and will work with small providers to make that happen. And everything from paracetamol to pacemakers was an innovation once.

Claire Harding is the Research and Development Manager at Big White Wall. Claire worked for four years in public sector consultancy, specializing in community engagement and research. She is a history graduate and particularly interested in social policy. Claire is currently focusing on research for digital health interventions, and recently completed a post-graduate certificate in Health Economics.

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