Adoption of Frugal Innovations in the NHS

Research Stream 1: Identifying Frugal Innovations for the NHS

Objective: To identify examples of frugal innovation, particularly from low-income countries, and develop the evidence base for their effectiveness and business cases for adoption into the NHS.

Frugal innovation in healthcare aims to create affordable solutions that meet the needs of resource-constrained health care systems. Frugal innovations are not limited to technologies and products, they also include processes or policies that aim to do more with less. A critical review of the definition of frugal innovation is provided in our paper published in BMJ Innovations.

In the United Kingdom (UK) and United States of America (USA), rising healthcare costs contribute towards unsustainable spending thus there is a need for affordable technologies and systems to provide good health care. Low-income countries have needed to do more with less for a long time so looking to their expertise is important, however adopting frugal innovations from low-income countries into high-income countries (reverse innovation) is challenging.

Examples of frugal innovations we have researched include:

1) Arbutus Medical

Orthopaedic drills in the UK cost £30k but devices used in sub-Saharan Africa cost only £100 because they use a sterile bag around an ordinary hardware drill to make them safe for surgery. Our research has shown it is safe, effective and causes no increase in infections compared to the expensive alternative. If used at scale in the UK, it could save the NHS £100m. Our research has been published in BMJ Innovations and the Journal Of Orthopaedic Trauma.

2) Kangaroo Care
Used throughout Africa, Asia and South America, this skin-on-skin technique is a safe, effective and low-cost alternative to incubators in stable, pre-term infants. Research has shown that barriers to its scaled use in the UK include lack of clear guidelines, training, and space for families to use it in the neonatal units. Our research has been published in BMJ Innovations.

3) Community Health and Wellbeing Worker-based models of primary care

Community Health and Wellbeing Workers understand and know their community better than any health professional ever will. In countries like Brazil, Pakistan and Ethiopia, they are used at national scale and have resulted in significant impact on individual and public health outcomes.

Our research has explored the potential benefits to the UK if we were to adopt a scaled, system-wide approach to primary care based on CHWs and we found it to be highly attractive as a policy option. Our research has been published in the Journal of the Royal Society of Medicine.

Community Health and Wellbeing Worker Logo

4) Mosquito net mesh for hernia repair
Mesh is used to repair inguinal hernias and in the UK cost around £150 per unit, sometimes even more than that. However, mosquito net is made of basically the same material, and throughout India and sub-Saharan Africa it is used instead of commercial mesh. Controlled clinical trials have shown it to be as safe and effective as commercial mesh, but 10000 times cheaper per unit. Our research shows also that mosquito net is more similar to abdominal wall muscle, in terms of tensile strength and stiffness, than commercial mesh, and so there is a good case for its use in the UK. Our research has been published in BMJ Innovations.

5) Intra-uterine balloon tamponade devices
Control of post-partum hemorrhage with balloon tamponade devices that cost around £200 each can be achieved just as effectively with simple condom-catheter devices, known as Sayeba’s Method. Our research, which formed the basis to a Masters dissertation, explores how obstetricians and midwives in the NHS consider the value of such a technique in this situation.

6) Aravind Eye Care System
Aravind Eye Care System developed an innovative and effective model of care centered around a standardised process inspired by McDonald’s, applying the principles of mass production to ophthalmic surgery whereby it focuses on time and resource efficiency. Aravind performs 1000 surgeries per working day with better outcomes and lower complication rates than the UK and USA. A critical component of Aravind’s model is the lean healthcare design focusing on task shifting, where routine responsibilities range from administrative to perioperative and postoperative assessments.

7) Early medical abortion services delivered in primary care
In the UK, women requiring a pregnancy termination can only obtain this service through third sector providers or in hospital settings. However, early medical termination has been provided in low-income settings in primary care services, and by nurses or even Community Health Workers. An example of a frugal innovation, our research systematically reviewed the evidence regarding the safety and acceptability of this service considering whether it will be suitable for the UK to increase access and reduce costs. Our research was published in Globalization and Health.

Research Stream 2: Understanding the challenge of adopting frugal innovations

Objective: To investigate organisational, technical, cultural and cognitive barriers to the adoption of frugal innovation in the NHS.

1. Adoption and acceptability of frugal innovations in the NHS - NHS staff and patient perceptions

In our previous research, using a very robust experimental design called an individually randomized cross-over controlled study, we examined whether the source of a research article impacts on how clinicians rate it. We found that changing the origin of the research article from a high- to a low-income country negatively impacted on how clinicians viewed it. Using a method called an Implicit Association Test, used to measure unconscious biases, we have similarly showed that people tend to associate high-income countries with good research and low-income countries with bad research. Our research was published in Health Affairs and Globalization and Health.

Scaling frugal innovations from low-income countries into high-income countries (reverse innovation) is therefore challenging because of how people perceive these contexts. We continue this research by exploring the concept of acceptability for frugal innovations, and investigate how NHS staff and patients perceive these. This research forms the basis to a PhD project and our findings will help us identify barriers to the adoption and acceptance of frugal and reverse innovations in the NHS.

2. Using reading list analysis to understand regional emphasis in teaching global health in higher education
Findings from a small number of reading list analyses show that articles from Western Europe and North America are strongly favored compared to articles from countries outside of those regions, which may be overlooked or ignored entirely. This “geographic bias” may reinforce a marginalization of research and knowledge from countries outside of Western Europe and North America and make spreading and scaling innovations from these contexts more challenging. In this PhD research project, we have created a data extraction tool in collaboration with the Imperial College Central Library that, on a large scale, can automatically obtain geographic information for each author of each citation on a reading list. It allows course instructors to efficiently determine whether they could consider diversifying their teaching materials. The reading list analyses have already generated an appetite for constructive conversations and debates. We provide half-day workshops with the Educational Development Unit, to discuss issues surrounding diversity, inclusion, knowledge hierarchies and decolonisation.

Our research examining the impact of geographic bias on knowledge diffusion has been published in the journal Research Integrity and Peer Review.

Our research examining the development and impact of a reading list tool that analyses the geographic origin in courses in Imperial College London has been published in The London Review of Education,

Our research detailing the way reading lists can be converted into machine-readable code has been published in Scientometrics.

Research Stream 3: Adopting frugal innovations in the NHS

Objective: Through the development of a portfolio of exemplars, identify potential partner sites for piloting and adoption of frugal innovations within the NHS and evaluate the outcomes.

1. Community Health Worker (CHW) pilot in Westminster

Based on the Brazilian model, this CHW pilot, funded by Westminster Council, was launched in April 2021 in the Churchill Gardens ward in partnership with the local GP practice (Pimlico Health). CHWs are based at a local GP practice (Pimlico Health) and supported by a community team within Westminster Council. The CHWs conduct household-based outreach to the diverse community within Churchill gardens. Four CHWs have been appointed (part time) for 500 households.

Through regular, proactive and universal household contact (offered to all the households irrespective of specific needs), CHWs are expected to improve health outcomes and address health inequalities by identifying health and social care problems early-on, reducing social isolation, improve screening and immunisation uptake, health literacy, self-care, mental health support and other health promotion interventions such as uptake of NHS health checks. The CHWs programme also directly supports the Covid-19 immunisation agenda and the Re-Start Agenda by offering new employment opportunities in deprived wards.

The NIHR ARC NWL Innovation and Evaluation theme is the architect of this initiative, leading its evaluation, and supporting its scale-up and spread in London and UK. Through collaboration with the National Association of Primary Care, we have already secured interest in other localities in the UK (e.g. Calderdale CCG, Bridgewater Community NHS Trust, Royal Borough of Kensington and Chelsea) for this model, including co-supervision of an ARC-funded PhD studentship in the NIHR NW England ARC. Findings from the pilot are expected in June 2022. We have developed an operations manual to support other localities to implement this project.

For a short introductory video on the CHW project in Westminster click here: Putting Community Health Workers at the heart of primary care (News)