Even when there is strong evidence and mandatory NICE guidance has been produced (NICE guidance on interventional procedures is not mandatory), this does not ensure adoption, as the process is left up to individual trusts, who may not have put effective arrangements in place to manage implementation.50
Furthermore, managers may selectively shape‘evidence’to align it with their own goals and preferred practices.51
Some NHS organisations have been found to have more structured processes than others for making decisions about the adoption and implementation of new interventional procedures.52Hospital
procurement and evaluation committees often play a part in decision-making, with doctors having a key role in defining desirable characteristics of the technology and accompanying support, and in reviewing evidence on costs and benefits,53although their involvement is often ad hoc. There is generally a lack
of organisational capacity and resources with regard to the purchasing of technologies, with little co-ordination of purchasing among organisations locally, regionally and nationally.53
The nature of stakeholder involvement at different stages of the process can affect the decisions made and the outcomes. A study on the adoption of new technologies for infection prevention and control (IPC) by NHS organisations54produced a number of pertinent findings. Stakeholder involvement at initiation
impacted on which technologies and IPC areas were considered. Those involved in the adoption decision influenced how the technologies were critiqued and what was finally selected. In the organisations where wider consultation occurred early, more diverse approaches to IPC were considered. Support by senior management at the point of decision-making facilitated implementation by mobilising resources and providing increased legitimacy to the initiatives. Involving technology users such as front-line clinical staff from the start of the decision-making process increased their commitment and provided feedback to suppliers, which could be used to help ensure that the devices procured were compatible with working practices and organisational policies. Lack of wider stakeholder engagement in implementation planning was observed to have a negative impact on implementation. Late involvement of the procurement team, due to inexperience or negative perceptions of staff, extended the process.
Lettieri and Masella55suggest that when a hospital makes a decision about technology adoption
it should consider the expected contribution to value generation and the level of sustainability.
Considerations related to value generation include effectiveness, patient or family satisfaction, revenue generation, cost containment and gains in image or reputation, and, in the longer term, creating
knowledge by developing new services and health-care technologies and building up new communities of knowledge.55Considerations related to sustainability include the degree of self-funding and ratio of fixed
to variable costs (economic sustainability); coherence to strategic goals, technology acceptance among physicians and uncertainty in clinical practice (organisational sustainability); technology life cycle and fit with the existing technology portfolio (technological sustainability); and training intensity and coherence of human and physical resources (resource sustainability).55Context sustainability issues of coherence to the
legal framework and to generally accepted ethics are unlikely to be relevant where a technology has already been approved by national agencies, but will be crucial if the hospital is involved in the development and testing of an emerging technology.55
Onget al.45suggest that three types of decision-making models are used in NHS hospitals with regard
to investing in new technologies: maximising profit is generally favoured by finance directors and managers; maximising competitive advantage is generally favoured by chief executives, marketing directors, research/teaching hospitals and private hospitals; and maximising utility (health outcomes) is generally favoured by clinicians and patients.45
The types of information that have been considered in business cases prepared in support of new technologies have included efficacy, alternative treatments, training, cost, potential savings, duration of procedure, safety, benefits, numbers affected, length of stay, pre-operative assessment and cost-effectiveness.52
It is widely believed that business cases are only likely to succeed if they show evidence of efficiency or cost savings; demonstrating quality improvements alone will not be sufficient.45The criteria for medical device
procurement are discussed by Sorenson and Kanavos.53Price is the most important criterion because of
cost pressures, especially for‘standardisable’products. Quality criteria do, however, tend to be more ISSUES WITH REGARD TO TECHNOLOGY ADOPTION IN THE NHS
maintenance requirements, and innovative characteristics or technical merit. Therapeutic benefit and cost-effectiveness are sometimes, but less often, considered in purchasing decisions. The emphasis on price may lead to manufacturers focusing on reducing production costs rather than investing in research and development, reducing access to innovative technologies in the long term.
Three main external influences on adoption decisions have been identified in innovators’accounts: (a) economic, such as a focus on cost containment; (b) political, such as the existence of national regulators; and (c) ideological, such as fitting with the‘spirit of the times’.49
More formal involvement of physicians in procurement generally might help health considerations to be more prominent in adoption decisions.53Centrally planned implementation could also be more efficient
and less costly.45