How can technology adoption be speeded up in the NHS?
Iestyn Williams, of the Health Services Management
Centre, University of Birmingham, discusses the reasons for the slow
uptake of medical technology in the NHS in England and how to overcome
the barriers to adoption. 20 June 2008
Technological innovation has long been central to improvements in
healthcare. Whether in the form of new products, procedures and
treatments, or health-related application of ICT systems, new
technologies can help to make patient care more flexible and responsive,
and ensure efficiency in use of scarce public sector resources.
Furthermore, technology ‘adoption’ by decision makers and
professionals is increasingly supported by an evidence base relating to
the effectiveness and cost effectiveness of new interventions.
Repositories of systematic reviews and economic evaluations are
available from sources such as the Cochrane Collaboration, the National
Institute for Health and Clinical Excellence (NICE)
technology appraisals and clinical guidelines programmes, and the NHS
Economic Evaluation Database.
Although uneven, these sources of research and analysis have
gradually spread to non-pharmaceutical technologies and methods for
assessing a greater range of innovations are being constantly refined.
What’s more, recent times have seen a burgeoning literature focussing on
how health care organisations and systems can respond to innovation in
The momentum behind the evidence-based movement in healthcare has
been supported and promoted in government policy and independent reviews
of NHS performance including Wanless 2004 , Cooksey 2006  and Darzi 2007
The rationale for improving rates of technology adoption has a number
of strands. Replacing outdated practices with more effective innovations
will help deliver on the UK government’s plans for a ‘world class’ NHS
which is at the forefront of quality in healthcare. New developments in
telecare also promise to aid the shift from an acute-based service to
one in which prevention, self-care and patient choice are to the fore.
The increasing need to make efficiency improvements in the NHS is
also supported by investment in cost saving interventions and
implementation of ICT-based record keeping and decision making systems.
Underpinning each of these aspirations is the importance of technology
in shifting from a monolithic and risk-averse system to one in which
learning and innovation are actively encouraged in the pursuit of
Despite this context and an estimated annual spend of some £3 billion
on medical devices, the rate of adoption of technology into healthcare
practice in the UK is commonly considered to be poor. The English NHS is
considered to lag behind adoption in non-healthcare sectors as well as
healthcare systems elsewhere.
This has led to an increasing recognition that whilst generating an
evidence base may be a necessary condition of technology adoption, more
needs to be done. This is reflected in both the recently instituted ‘NHS
Technology Adoption Hub’ and in the focus on implementation of best
practice within NICE.
Despite these developments, the adoption gap remains stubbornly in
place. Research in this area suggests the existence of a number of
barriers preventing the routine uptake of potentially beneficial and
Features of technologies themselves can trigger or inhibit adoption.
Put simply, the message is that usefulness and ease of use are key
factors. If the benefits of new practices are not clearly visible and/or
its adoption requires substantial changes to professional practice, it
will struggle to make an impact.
This is a tricky issue to negotiate as clearly one of the key
objectives of technological advancement is to disrupt and, in time, to
replace outdated practices.
However, the message remains clear: the extent to which new
technologies require significant changes to job roles and practices will
affect patterns of resistance and acceptance. If individuals believe
their work will be adversely affected as a result of the technology, or
if it is perceived to be difficult to implement, there is an increased
likelihood that they will reject the new technology.
Indeed, research suggests that patients and the public are generally
‘readier’ for change than are those providing care. There are good
reasons for this resistance. The range and volume of both information
and reform that healthcare professionals are required to manage has
increased at a phenomenal rate, leading to a reported overload.
Subsequent uncertainty and fatigue will inevitably make adopters
risk-averse. These concerns are often reinforced by concerns over the
nature of the proposed implementation.
Individual adoption is only one component of the diffusion of
technologies and a number of aspects of organisational context have been
found to impact on adoption.
Although organisational context is understood in different ways by
different research traditions, all agree that it is central to achieving
change in line with best practice or evidence. There needs to be a fit
between the technology and the prevailing decision making environment,
and with: existing technologies; workflow; the environment, and; other
Healthcare organisations are complex and difficult to change. Without
a clear vision of how all aspects of the organisation are implicated in
the introduction of new practices, it is difficult if not impossible to
make the necessary changes. Path dependence at both organisational and
institutional level can be a powerful antidote to change.
Once the system has ‘locked onto’ a specific path it is difficult to
change direction. As such, services may have a tendency to continue to
operate in a particular way, rather than adopting what might seem
rationally to be a useful innovation to adopt.
Bridging the gap
A number of strategies are available for disseminating evidence about
the benefits of new innovations. These include conferences or workshops
to disseminate best practice in the adoption of technologies, and more
commonly, guidelines for practitioners.
Of these, the evidence suggests that clinical guidelines are
marginally more effective in facilitating behaviour change amongst
professional groups, although little is known about their cost
More recently, electronic support for technology adoption has been
developed, including electronic guidelines, medical informatics,
decision support and reminder systems, and computer-based record
These offer some extra benefits when compared to traditional
paper-based approaches. However, although it is notoriously difficult to
measure the impact of such strategies (primarily due to the complexity
of healthcare organisations) the overall message appears to be that they
do not adequately overcome the aforementioned barriers to adoption.
Networks and knowledge exchange
One of the keys to triggering greater rates of adoption appears to be
moving from transfer of knowledge to facilitation of knowledge exchange.
A number of studies and reviews have indicated that social
interaction is a key catalyst of change management and best practice
Direct interaction with researchers and product manufacturers is thus
likely to be critical in overcoming uncertainty and resistance.
Furthermore, the reassurance provided by ongoing interaction with peers
and experts might address concerns relating to the risk of technology
Successful adoption depends on individuals’ capacity to buy into the
changes required and this cannot be wholly imposed through a top-down
model of dissemination.
Skills and leadership development
It seems likely that improving the information-processing capacity of
implementing organisations will help to overcome some of the current
barriers to information access, interpretation and evaluation of
Well designed training programs have been shown to promote end user
acceptance of technology both through improved understanding and
increased feeling of involvement in decision making. The identification
and nurturing of adoption ‘champions’ and ‘leaders’ will also help to
overcome resistance to change.
Implications for manufacturers
Overall, the evidence suggests that adoption depends on the creation
of a receptive context. The ability of organisations to absorb and act
on new knowledge will be influenced by effective leadership, strong
networks (both formal and informal) and an appropriate knowledge and
A compatible strategic vision and a favourable approach to risk
taking and experimentation are also important. Investment should be
targeted towards multi-level tools and frameworks for technology
adoption which take enhancing ‘absorptive capacity’ as their primary
Development of technology-adoption training should also be
investigated, alongside programmes for nurturing adoption champions and
However, there is also a role for the technology-manufacturing
sector. Firstly, it is important to recognise that developing an
evidence base is only the start. Ease of implementation is of equal if
not greater importance.
Technology producers should incorporate the principles of knowledge
management in the design and production of innovations and actively plan
for adoption and implementation.
Key questions to ask prior to introduction of new technologies are:
- what is the value added of the innovation?
- is it easily evident to those who carry it out as well as to
those for whose benefit the innovations have been introduced?
- can the added value be demonstrated?
Learning from the diffusion of innovation literature suggests that
adoption strategies need to engage those responsible for adoption as
active change agents rather than passive implementers.
People actively seek out, experiment with, evaluate, learn about,
work around, discuss and modify technologies, and each of these
activities will influence both feelings and behaviour regarding
adoption. End-user participation in all stages of technology design and
implementation will make adoption far easier.
Lecturer, Health Services Management Centre, University of Birmingham,
1. The 'Wanless Report': Securing Good Health for the Whole
2. The 'Cooksey Review': A Review of Health Research Funding, 2006
3. The Darzi Report: Our NHS Our future: NHS next stage review —
interim report, 2007.