The Victor at COP26 is Systemic Incompetence. UK SBRI funding plays its part
As the gathering of 196 nations in Scotland's starts to wind down, the latest climate models show we are headed for a 2.6 degree average temperature rise. Missing the global temperature rise target by a full 1.1 degrees. The same temperature rise will achieved in the 29 years to 2050 as we have released in the near 200 years of post-industrial civilisation.
At the same time, we reflecting on the seriousness of the NHS commitments to get itself down to Net Zero and our time trying to help the NHS solve this problem amongst others. The NHS and UK Health Security Agency pay for what they value. When it comes to health, innovation, they have the expertise to do that.
We also received our own feedback from applications we put into the NHS to help them in their journey towards Net Zero. This is not the NHS core skillset and because it needs a fundamentally different approach to evaluating health technologies, which the NHS is not currently equipped to deploy, they had to be open to new innovation even in thinking. There is no time to waste.
The first sign of promise, was the Net Zero report of October 2020. A useful guide to consider, but didn't present a lot in the way of actual logistics to get there.
Despite this, it hinted at an openness to work with external agencies and industry to deliver on the plans.
When it comes to climate, the trouble with the NHS, is it doesn't have the skills in-house but arrogantly often assumes it does. Evaluating options without a true, objective or analytical understanding of climate problems at hand. With climate change (and impacts) there are huge pitfalls with that. One is that skills in medical statistics are woefully inappropriate for modelling and understanding climate effects on health-economics and the nonlinear dynamical systems ubiquitous in climate change. Yet, many default to it because that's all they know.
An integrated approach, one that views climate change and its solutions as an overarching, nonlinear ecosystem with interacting components and feedback loops, is necessary to deliver the changes needed to prevent the global catastrophe we're now facing. Not least because the effect on the system as a whole needs to be understood. After all, that is why climate scientists build those models and not rely on primitive frequentist statistics.
SBRI: A Road to Nowhere
The Small Business Research initiative is an NIHR run research grant that helps small businesses with promising innovation trials with a view to adoption by the health and social care system. In practise, it's a right of passage that healthtech innovators must go through to get the necessary awareness and trial data for conformance certification and that inimitable UKCA mark.
SBRI 18 of July 2021, provided the NHS with an opportunity to try and address its particular climate weaknesses by onboarding research that solved four main themes they had selected.
This interested us greatly. Automedi had lots of options for all 4, but equally, it concerned us. Because this segmentation is symptomatic of silo understanding of the problem. Often caused by the policy segmentations of Greenhouse Gas Protocol scope emissions. As I covered elsewhere this is suboptimal at best.
Our solutions solved both care miles and surgical waste and our health-climate-economics paper also helped with N2O and low carbon decision making. Plus, we wrote the paper on health-climate-economics that not only quantified these nonlinear dynamical interactions, but optimised them and provided a rapid way of comparing them against incumbent “do nothing” options. (https://osf.io/rdt36/ ).
Automedi is an amalgamation of nine different innovations, not just one. It was designed from the start to meet 16 of the UN's 17 Sustainable Development Goals. 13 of them immediately. In other competitions around the world, organisations look for innovation that don't separate their expectations from the SDG’s. After all, the work to segment impacts into the SDG's has already been done. Why does the UK public sector think it's not good enough for them that they have to make a new one? This SBRI showed why this was a collapse of strategic understanding by the service.
The NHS's itself doesn't have the skills to do it, yet chose a model that didn't simply score them on those 17 criteria. Not only does using the SDGs directly provide a way for the NHS to better align with the UN commitments directly, making it easier and much less work to report and manage for the UK Health Security Agency, and UK government as a whole, the work is already done for them and standardised internationally. If they don't know what to do, default to that!
The fact the NHS did that was a strategic mistake. Demonstrating a lack of maturity in the NIHR's approach to evaluating and deploying innovation in this space and a systemic appreciation of risk outside the tangible.
Predicting the Future
Alas, reinventing the wheel was on the agenda and all the NHS had was square making tools, but OK. Part of the SBRI was them asking for more tools, so perhaps they are aware they don’t know stuff, right?
This manifestation of systemic weakness, gave me an itch I had to scratch. It led me to dig around. Being the first SBRI I had ever submitted, I was keen to understand how SBRI linked into the wider innovation landscape and I was shocked to discover that they're actually run by UKRI.
Now from my previous posts people will be aware of the incompetence that exists within InnovateUK already. They are pathologically incapable of evaluating systemic innovation but they are given responsibility for it and can't find experts in it. I'm unapologetic in my view they should be disbanded.
… but instead of disbanding, the latest budget gave them control of more money.
... despite that a large percentage of the UK R&D research is already waste.
Go figure!
Realising UKRI are involved in the process led us to radically reduce our engagement with it. Our list of nine possible projects then immediately reduced to three. The rest put on the back burner to be run in other nations’ innovation funding streams via Axelisys’ sister company.
At the same time, we worked closely with both our AHSN academic Health Science partners and our clinical contacts to shape the text of the applications.
Enabling Tech: Just not for this
like sitting a GCSE science exam and your spelling, punctuation and grammar are 83% of the marks, with the science only 17%.
If you're not aware, the application system (ccgrantracker) is clunky and has set word limits (not ideal for systemic innovation) and inclusion of images is not always possible, though better than UKRI's IFS system. Of course, this still means evaluations are made on wordy descriptions not verifiable objective evidence. As we know, that biases applications in favour of how they are written and the language used, over scientific or analytical validity, in ratios of the order of 5 to 1. That's like sitting a GCSE science exam and your spelling, punctuation and grammar are 83% of the marks, with the science only 17%.
…and you’re not allowed to submit the science.
Perhaps true to form, the grant tracker system had repeated problems and disadvantaged project best practise. Especially if it was lean.
For example, we don't normally use the basic form of risk register the UK public sector uses. That's because, like dominoes, risks chain. Often when one risk occurs, it can trigger other risks and all that takes time and energy away from the value chain which in turn creates more risks and issues downstream.
Instead, we use what's known as a Failure Mode Effect Analysis (FMEA ). A term that will be familiar to people who six-sigma black-belt certified. This combines a risk register with a matrix model of how the risks interact through an implicit adjacency matrix. Making it much more comprehensive and and able to calculate risks like a decision tree. It's comprehensive and robust and crucially, for a panel that understands project management, it something that differentiates the capability of teams for the norm. The crucial term being "understands it". If they did, the system would innately support it, but the grantracker system doesn't, so they didn't to put the requirement in, or didn't value it.
Many don't realise the software they use. mirrors the organisational structure that uses it. Whether that's because they asked for it, or it was trained into them, the value delivery chain aligns through the use of software.
Furthermore, where the domains of Greener NHS and external innovators meet on funding, grant systems manifestation what behaviours the tendering service values. An innovation that is substantially Carbon negative, such as Automedi, isn't valued systemically by the health service if it isn't funded. The same is true of some of the other innovators I've personally met on this journey.
The AHSN: Yorkshire and Humber
Luckily we had the AHSN to proof read our application. They requested the PDF download, which we obliged with.
…and ccgranttracker chopped it off. 11 columns. Gone! We had absolutely no idea until it was sent back to us!
That led to a flurry of emails asking the grant management team whether the panel would be reading off the PDFs or through the application as submitted on ccgranttracker’s screen. It should have been a really simple question to answer but it took two emails to get a “They would use the PDFs”. Meaning we had to find a way to get grant tracker to at least put SOME of the information in, without exceeding the word count. But we couldn't add it, as it would exceed the page length while remaining legible. So the grantracker system didn't accept it.
That took another several emails before a suggestion was made by the grant management team that we include this with the Gantt chart, because there’s no page limit, after a suggestion we try to attach it at the end, which had only a single attachment with single page limit and we were using it for the study design. This obviously wasn’t satisfactory as we'd be replacing it, so we had to pile the whole thing into body of the text, without 5 of the columns and limit the risks we would cover and just hope we get away with it!
It was one fiasco after another, but equally the silver lining was having the AHSN as a really useful just as a sounding board for how an application comes across. If they got it, there's also a high chance the Greener NHS panel would get it. So simplifying the language was a key part of the exercise and they helped a lot with that. Can't fault them.
Yet, the problems with ccgranttracker and the process continued, as we were subjected to problem after problem. Even our clinical contacts hated the platform. I’ve heard SBRI are considering a move to IFS, but that’s even worse! As there is precisely zero chance of a safe systemically appropriate appointments using that.
If you haven’t completed grant applications before, there's always uncertainty about where to pitch it and who to target. We assumed the NHS Net Zero plan was a safe baseline, given the organisational needs and the fact Greener NHS themselves, wrote the report. It is essential to assume some level of competence in any grant evaluation panel, otherwise there is never enough words to expand on concepts to each them the whole of primary education to master degree within a grant process.
It relies on the understanding that a Greener NHS panel will have read it and had a good understanding of concepts like Circular Economics and understood that 3D printing and extrusion of plastics takes place at 200+ degrees etc. So we built on that, gave them an understanding the devices were desktop and used mains, battery or solar panels for power. What we didn't expect, as you'll see in a moment, was them to not have any idea how small a battery for it actually is?
Yay! We Made the Shortlist
Luckily we were shortlisted for one of the applications out of the three we were primary applicants on. We put together the video in accordance with the notes, and sent it in. It was suggested we use a pitch style and it would be a maximum of 3 minutes long. The project we were shortlisted for was a formative testing project. The nature of the innovation cutting across both perioperative waste and supply chain together, meant needing to recruit several people for the study, many of whom had a cognitive gap to understanding circular economics and true systemic change. Demonstrating the platform in a mock environment was crucial and it was this that covered much of the proposal. Phase 2 would then have the healthcare partners from up and downstream [of the patient] silos, where the real work begins on a larger trial to gather enough data on use. With the Green NHS team including some doctors, we did expect a more competent analytical baseline.
Boo! We Didn't Make Funding
Equally as a first SBRI, I was very keen to understand what we could have done better. I had to wait a week for that info and when it came, it was a shock to the system. The only way to explain it is yet more systemic incompetence. They clearly didn’t read the application, nor did they have an understanding of their own report, circular economics, or in one case basic arithmetic!
Grant feedback is an opportunity to provide useful information for applicants to help shape the offering. Different places do it better than others, but UKRI is so terrible at evaluating applications or even finding skilled people to do it, that it’s feedback is almost always useless. Non-credible evidence is as good as no evidence at all and this feeds into wider issues with procurement competence in the UK public service more generally.
Concepts like circular economics are amplifiers of benefit. Couple that to start from waste streams (so no seed material) and it becomes Carbon negative by generation 2. The issue here is the Greener NHS did one of two things:
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Both of which result in the decision not to appoint. However, both also forget about the NHS' role in the use of the project. As with the path of pandemics, R(e) is behaviourally a function of both it's R(0) and the behaviour of the public health system, so is the use of Automedi. The configuration allowing the service to save more or less CO2 based on what it does, not what's innate in the service. You can lead a horse to water...
This particular grant was not an area of specialism for the NHS. They should have started from the position of assuming they knew nothing and being totally wrong and the people that come to them have solutions they need but the NHS don’t understand. It’s a weird ego trip that makes some groups within the service think they have more skill in a topic like climate change than those who wrote the books, started the UN campaigns or built the models, but it does happen and the UK grant system facilitates that ignorance. Stunting progress and wasting inordinate amounts of UK public funds on people who can talk and not do.
This particular grant was no different. The Greener NHS team didn't start from the position of using the SDGs as a measure. So hobbled itself because it didn't have the standardised way to draw on for the evaluation. They had to make it up on the spot and chose completely the wrong evaluation method.
SBRI don’t come around that often. Indeed, this is the first time a climate one has been run. So every mistake, takes 2 years (at best) to then put right and as we know with climate change, earth is not waiting for you to get your act together.
Enough: What Happened?
The four points raised by the panel were:
Point 1: The Panel agreed that the proposal met the brief and the concept of re-purposing NHS waste was viewed positively. However, the long-term plan for the technology was uncertain, since there was no indication of its use for re-manufacturing of medical devices. A more compelling articulation on how products would meet the required standards or be regulated would have been useful.
Since there was a word limit, there is a limited amount of space for us to submit that information. Especially as that’s a phase 2 requirement. not only that comment but it was clear that the panel didn't have any idea how the rest of the hospital runs. Because that is again not part of their silo. If they had facilities people on board who can explain the number about coming to have had a better chance of understanding it. However, we were clear on the scope of this application and what it would entail on risk. It’s in the risk register. This is the only place we could have put it without compromising the word limit elsewhere.
Notwithstanding that we also touched upon the use of our 3D printing models for customisable medical equipment.
Point 2: Concerns were raised around the logistical challenges of collecting and processing materials; an in depth description on the sterilisation of potentially infected materials and whether this would have an impact on implementation would have improved the proposal.
Interesting to note that it appears they didn't read the application. This was such a significant point there were four direct risks in the risk register just to address it and mitigations were also costed in.
Again, clearly they didn't understand they had to read the risk register. It's strange that the panel will ask for something like this without then reading it. Why would we cost something into the project that we don't need and also reference it within the body of the application?
Point 3: Consideration on whether the application of the technology would be scalable or potential carbon emissions arising from the 3D printing process itself would have made a more compelling case.
Perhaps the most trite of the lot. There was quite a lot covering this, but here you can see that we referenced it is low power and crucially the amount of CO2 we expect to save NET per appliance. we made a series of assumptions on the capabilities of the team to understand 3D printing. They were sent vids and pictures of the desktop devices and coupled to the lower power sources mentioned earlier, that was clearly referenced.
In terms of scalability, we were quite clear about horizontal scalability. But it clearly seems this concept is beyond the understanding of the panel. Think about taking a factory, chop it up into a million pieces and put each of those pieces right at the point of use. That means if a health care assistant needs a clip for something they go and 3D print it like they buy chocolate from a vending machine. There is no need to deliver it, because it's there and unlike a factory with serial machines, all your machines work in parallel. If you need 1 million items, you set 100,000 machines to print 10 at once and voila! Takes half an hour to an hour and it's "automatically delivered". This is true scale. Everything else is pretending.
Clearly in the panel’s head they're trying to fit an entire factory into a bay. Not only that, but by asking an innovation to prove it can vertically scale as a horizontal scalable service, is actually asking the question of the NHS itself. Because horizontal scaling just scales based upon how many you need and you put online. If you need more, you subscribe to more, press more buttons or click a print quantity button on a screen. Asking about vertical scale, which is totally at odds with horizontal demand-side scaling (its an anathema to it) and asking how many items can your factory make is like asking to prove the existence of God or unicorns. The answer is “how many do you want it to make?” because the person who controls the size of the factory, is YOU! The NHS Takes Control of Its Supply Chain. That's the USP.
What do they think this means?
Point 4: The Panel thought that increased support from the NHS for resources and from an operational perspective would have been beneficial. It was also recommended that the commercialization aspects were considered more closely.
Clearly it wasn’t read, again. We have pages on this. I would love to know what was going through the heads of the panel when they read this section. Especially the highlighted elements. Never mind that the commercialisation elements were provided on page 16 to 18.
We are not allowed to submit our cash flow forecast otherwise we would have submitted it. Another systemic incompetence in the evaluation process where a system that doesn’t allow the submission of a piece of evidence, leads the evaluators to assume the evidence doesn’t exist.
If there's one takeaway from this, it's that climate innovators should be wary that "Healthcare is a tough one to crack". It is not true because of the competence expectations of the panel on climate change. It's that they don't have the competence to evaluate you and deliver on the NHS pledges and you won't know the level of ignorance until you've been through a valuable process that overlaps their aims with yours. In general, if an innovation is not Carbon negative and doesn't meet the needs of all of the SDGs it's not worth funding. A false negative that happens in evaluation means the impact on climate change is huge!
In the same way Doctors don't want people to self-diagnose using Google "Doc" because it requires a specialist baseline skill to do that, climate change is the same. Doctors sadly aren't equipped with the tools to do it and the funding platforms can't allow the experts to present it. This SBRI showed the service isn't willing to take its own medicine. So it suffers from the same ignorance the late great Hans Rosling illustrated in the first five minutes of this .
Where that Leaves Us
For those people who understand the SBRI in detail, they are not pure grant applications. They are effectively tenders where tenderers are then appointed to deliver the R&D proposal they submit. They operate as if they are public sector tenders and are subject to the same rules.
The unfairness and prejudice in this application was so significant, we asked our legal firm to look at it. We have grounds to sue. It’s clear and unequivocal. Our legal team are comfortable with that positions.
However, the question then becomes should we?
My personal view is that the NHS and in particular the Greener NHS team, are supposed to have been the pinnacle of the sustainability agenda within care. Yet, they have no idea what they're doing and what forces the climate unleashes while the service dawdles. The climate doesn't stop for the NHS team to become competent and is precisely why our civilisation's efforts have failed to temper the risks of a 2.5 degree rise, but actively increased that risk in the meantime.
Yet, they are also the people driving that change others will look to for advice. Bad competence there will memetically spread through the service, much like an epidemic. They will clearly get it wrong whether intentional or otherwise and this means that this systemic incompetence will never resolve and may even magnify as the whole service does not enough or worse, more and more of the wrong thing. So, would suing the NHS really get the NHS towards net zero? Would it be in the public interest? Would a court case undo the year or two wasted before a potential future SBRI, when they paused it to delivers large swathes of innovation that's still important, if not clean?
It has enough on its plate already trying to deal with existing systemic problems in care that has primary and acute care doctors fighting one another. For all the statements, the empassionate appeals, the soothing words, the Greener NHS team are clearly their own worst enemy. So would it be better just to share this experience to give others, even with less systemically optimal solutions, a chance to learn from this feedback too? Perhaps.
Many will see calling out bad practise as "unprofessional" and a bridge burnt. This is a uniquely UK public sector thing. Yet, we don't work for the NHS and aren't subject to its whistleblowing pressures. Plus, this assumes we now want to cross the rubicon at all.
Plus, the nature of the process means we can't take this conversation private to provide the feedback to them to learn from. So here it is. In full view.
We're aware that inside the NHS there's plenty more systemic incompetence where that came from. Some of them harmful to patients and it's clear the culture is broken and shoving more sh*t down the pipe isn't going to solve that.
Yet, this also presents an opportunity for the NHS to learn. Whether it's arrogant inertia will let it do that is another matter of course. In any event, our civilisation doesn't have time.
The benefit of having this technology is its ability to adapt to context. While it’s my first SBRI, it’s not my first rodeo with NHS procurement and commissioning at all. Automedi was designed with that in mind because of the competence risks in the service and public sector more generally. So adaptability became a central factor of the strategy. As a result, Automedi can make and recycle nearly any plastic in nearly any context and you’ll struggle to find something that isn’t plastic and needs processing around your home, office or washed up on the beach.
It is for this reason that we are taking the decision to step out of NHS work upon completion of the Greater Manchester research piece. Bit-by-bit we will step out into the periphery and of course many of you will already know we have two brands building upon this technology. that are already live. While consultancy work will still be open, the product and platform work will dodge the service, but obviously we sit on the patents.
While it may seem paradoxical to say this, the incompetence of the SBRI evaluation system showed the NHS true colours better than any bluff, bluster or report ever could and we're grateful for that. It also exposes how difficult a job true climate activists and purposeful healthcare workers really have and how much higher and steeper the mountain is to push the boulder up. For us, being here is a waste of time, because the service can't see it for toffee.
But again, we expected it…
Founder at ReallyRecycle.com | "The only founder standing for true sustainability" | Circular Economy | CleanTech | Deep Generalist | Involuntary Activist | Voice Recognition Wrangler
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