Helen Bevan, Chief of Service Transformation, NHS Institute for Innovation and Improvement

If we are going to sustain a universal healthcare system for future generations, we need to think differently about the relationship between cost and quality.

Innovation – doing things differently – has a critical pre-requisite: thinking differently. In my opinion, it is impossible to innovate at any scale without standing back, enabling more creative thoughts and, as a result, seeing connections and potential for change that were not apparent before. Every situation in history where large-scale change has been achieved and sustained started with leaders who were able to shift their mindsets away from the mental constraints of the existing situation and see other possibilities.

The reality is that it is difficult to envisage how to deliver improvements in quality and productivity in any other way than the methods we already know. As healthcare leaders, we tend to instinctively adopt a 'first order' way of thinking about change, perceiving change activities as doing more or less of what we do already, using the same mindset. In unconsciously viewing the existing methods of service delivery as relatively fixed, the trade-off between quality and cost comes to be seen as inevitable, despite our best intentions.

As the focus on innovation grows inside the NHS, I have heard a growing number of leaders talking about the need for 'disruptive innovation'. This term relates to radical, innovation-driven changes that 'disrupt' long-established practices in organisations or systems. A disruptive innovation is one that typically originates from 'left field', from innovators who are more likely to come from outside of the existing system. Their innovations reinvent or introduce products and services in ways that the existing system and existing customers do not expect. Over time, these disruptive innovations redefine the nature of value within the system. They create new markets and demands for services and go on to displace previous ways of organising things. However, too often, people respond to the conversation about disruptive innovation in the NHS by suggesting that it 'can only come from outside the system'.

I appreciate that we need fresh pairs of eyes, radical new perspectives and sweeping changes in the way we work – and I have met brilliant but frustrated innovators from outside the NHS, who have developed new products or delivery methods that could make a huge difference in achieving NHS quality and cost goals yet, despite a compelling business case, can't find a way into the existing NHS system. At the same time, I feel aggrieved that we sometimes underestimate the potential of our own talented workforce and leadership community to deliver radical change.

Where do the most radical, disruptive innovations come from? Do they have to come from outside or can they come from inside the NHS? One fact seems clear. They are least likely to come from policymakers or very senior leaders within the existing system. It has been suggested that in senior leadership teams there is often an absence of the diverse points of view that stimulate innovative practice and existing leaders often have an emotional investment in the status quo without even realising it. In these circumstances, leaders tend to maintain or improve existing processes rather than asking difficult questions about what change might really be needed.

It may also be easier to use traditional logic to promote the benefits of modifying the existing system than to prove that something innovative and new will pay off.

A study across Commonwealth countries found that 82% of public sector innovations come from staff at multiple levels of the system, rather than from leaders of the system. The most frequent initiators of innovations were visionary middle-level and frontline public servants who took risks to innovate despite disincentives in the system that discouraged them from doing so.

It is also clear however that in certain circumstances innovation that originates within existing organisations may not be radical enough to deliver sufficient change in the required timescale. Hence the need for change through disruptive innovation.

There is a profound leadership challenge here. In situations of economic constraint and uncertainty, people's propensity to think creatively and build innovation into their practices wanes significantly. Fear has a stronger dampening effect on creativity and productivity than almost any other emotion. It sucks innovation out of organisations. In the current NHS context, we have to respond. As leaders, we have a disproportionately large effect on the cultures of our organisations or systems. We create the conditions that help or hinder innovation. The factors that contribute to a culture for innovation are well documented. These include risk taking, creating a climate that enables people to feel psychologically safe to try out new ways of working, rewards, rituals and symbols that recognise innovative behaviour and are mostly non-financial, relationships enabling people with a variety of experiences and perspectives to innovate together, and sharing knowledge as the fuel of innovation.

By explicitly focusing on these factors, we can avoid fear-based approaches and tap into the potential of people to contribute, and be creative and internally motivated.

This isn't about 'either/or'. We need 'both/and'. The slow, limited way that the NHS has often dealt with radical innovation to date will be insufficient for the future. On the other hand, if we just concentrate on large, dramatic changes from outside, there is a risk that we will underestimate the changes required in the wider system to accommodate the innovation, fail to ignite the innovative potential of our workforce and miss the incremental impact of multiple small changes.

The future healthcare system is likely to need both incremental and disruptive innovation, internally and externally generated, to deliver its quality and productivity challenges.

Moving forward, our key leadership role in innovation is to explicitly hold and manage the tension between external and internal, large-scale and small-scale innovation, so we can get the best of both worlds and the people we serve can experience the benefits.