'Nakamura invented the light bulb'

Would Nakamura invented the light bulb if he was working in the NHS?

Nakamura invented the light bulb, that is what we might probably say one day, that Nakamura invented the light bulb or to put it correctly that Nakamura re-invented the light bulb. Shuji Nakamura's inspiring story has been told before but here is an ultra-short version of it

Nakamura gets a masters from a relatively small university in a small city in Japan, goes off to work in a small company in a lab competes against the big companies, discovers many right things and makes products that would not sell.

Times get difficult, his department shrinks. He goes to his boss and wants to make a product that the big boys have tried to make and failed; with his record, he gets turned down. He goes to his boss's boss and gets some support to make it, despite his record of making nothing that sold, his company chairman gives him money, $2mil actually and he reinvents the light bulb. Well, he actually gets the blue component of the LED to work and the rest is history.

What is interesting is that Nakamura was a non-PhD working in the industry as a lab scientist who then gets a doctorate from his local university and within 5 years is head hunted by University of California and becomes a professor.

Nakamuras in NHS?

Let us imagine a scenario of a doctor who becomes a consultant in a DGH in the NHS and wants to do something that the big boys tried and failed.Then the DGH consultant fails as well, fails repeatedly - what are the chances that he will not be performance managed out of his/her activity and driven to the end of his wits.

What are the chances that the medical director or CD will be over-ruled by the CEO or Chairman and a doctor provided funding to carry on despite a record of 'failure'? What are the chances that even after this doctor discovered something interesting a big place will head hunt and make him/her an 'academic'? In fact he/she should be grateful if the GMC and the rest of the regulation did not land on him/her and crushed him/her out of existence.

Getting real

Now a lot of you are going to say that reinventing a light bulb while surely profound is unlikely to involve any damage to real human beings. You might say that any lurking Nakamuras in the NHS if supported could end up hurting patients. Good logical argument. Is that what is really hurting patients? Probably not. It is not any innovation by enthusiastic people that harms patients, it is the bureaucratic nay sayers who use the language of clinical governance and risk yet know very little about process capabilities, refuse to learn shared baselines, practice unimaginatively poor leadership who perpetuate harm in healthcare. They refuse to fix the system instead try to 'fix' the people in the system. Of course the medical profession does not do itself any favours by its ego, jealousy and macho attitude which will aim to shoot down anything that arises outside its hierarchical constraints by treating them as bad apples and recommending the use of evidence the origins of which  can probably attributed to the Abilene paradox.

In healthcare especially in the NHS it is pretty much impossible these days to take an extra breath without CD, CG, R&D, GCP, LREC, NREC, NICE, and every other alphabet in the soup wanting to spoil it for you, while claiming to support you. It is when people who are typically NHS managers and every other hierarchical bureaucrat stops behaving like researchers and most doctors who are not researchers begin to look at operational evidence as a valid method of creating a new practices, innovation and improvement that healthcare will be truly successful.

Allowing and managing 'Nakamuras' in healthcare is not easy but will be rewarding; eliminating the healthcare 'Nakamuras' will allow the managers to sleep peacefully but might push true healthcare innovation into a coma.

If you know of any 'Nakamuras' in the NHS please let me know by leaving a comment below.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Links & reference
The dream of the blue laser diode
http://engphys.mcmaster.ca/undergraduate/outlines/4e03/Nichia%20%27s%20Shuji%20Nakamura%20Dream%20of%20the%20Blue%20Laser%20Diode.htm
Time magazine short feature on Nakamura
http://www.time.com/time/magazine/article/0,9171,1604891,00.html

New Research Area: Scientific Research vs Healthcare Delivery Research

Conventional Scientific Research Vs. Health Care Delivery Improvement Research: Both are important

I write with the confidence that many of you would already know about this..........

Research is about finding out if a proposed intervention works better than the current one. Is a new drug, operation, investigation, procedure, etc effective compared to an existing one? To find that out by definition research is a must and RCTs are essential (as RCTs are considered to be the highest form of conventional scientific research). Since the question is about the proposed intervention (and not about anything else) the confounding variables are reduced to minimum (inclusion and exclusion criteria etc). That will be conventional scientific research.

We all know real life clinical practice is not delivered under controlled research conditions.

Healthcare Delivery research (operational research) therefore becomes important. The question here is, what worked elsewhere and how to make it work for us in real practice where there will be all sorts of variables. This kind of research is important for two reasons: a) to put into practice the good things discovered by research (introduction and roll out of research findings - could probably be called innovation) and b) to discover what actually works (or does not work) in our location and to see if we can do better (clinical improvement)

I believe an example is the critical care outreach teams; apparently RCTs have not conclusively shown that they work. But in some hospitals they work very well. Now, we have such outreach teams in all hospitals; however it works in some hospitals and does not in others (again so much like RCTs finding different things when variables are changed) obviously the operational variables are different in each hospital. The point though is not if critical care outreach teams have been proven by RCTs but why it works in some places and do we want to make it work in our place?

So in practice, the question for healthcare delivery research is not whether something works (as that is an RCT question); the real question would be 'it works in St Elsewhere (even though it may or may not have been proven in RCTs); how do we make it work for us?' Where we know what works it is also about how to deliver that to every patient in our care.

As a surgeon I can say that the common operation of laparoscopic cholecystectomy surged to popularity even before any strong RCTs were done.

Let me state very clearly, that I am not for a moment supporting/encouraging dubious practices. I am talking about the existence of a different branch of research in which doctors have not been engaged actively in the past. I am suggesting that for most of us practising in normal day to day circumstances clinical operational research and/or management to benefit healthcare delivery could be equally relevant in providing good care (as RCTs). Most often the ideas for operational research comes from proven conventional research findings.

I would fully understand if trainees do not engage in this due to the expectation that they do conventional research. Doctors who are not in training ie consultants, SAS and specialty doctors could consider getting involved in this kind of work (clinical operational improvement work). This is not operational research from a management or administrative perspective. This is clinical care delivery operational research. If you thought this is managerial or admin work, sorry, you are mistaken. This is as directly clinical as it gets.

Clinicians have been taught what is best. This new area of activity and research shows us how to deliver that best to every patient at all times.

You could make a start by learning more about this. Check out IHI various courses including the on-line ones, NHS Institute's courses and of course the CQI course at NLG NHS are basic starting points to kindle interest in the area. Warwick's CSI course is reputed to get you thinking in this direction.