Social Science & Medicine 192 (2017) 143e151

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Shaping innovation in health care: A content analysis of innovation

policies in the English NHS, 1948e2015
Tomas Farchi a, *, Torsten-Oliver Salge b
a
IAE Business School, Mariano Acosta 1600, B1629WWA Pilar, Buenos Aires, Argentina
b
School of Business and Economics, RWTH Aachen University, Kackertstrasse 7, Room B136, 1st Floor, 52072 Aachen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Governments around the world seek to design policies that enhance the innovative capacity of public
Received 16 March 2017 service. Hence, identifying the underlying meanings attributed to innovation concepts in public policies
Received in revised form is critical, as these very understandings inform not only the policy discourses, but also the overall
28 August 2017
institutional landscape regulating innovation activities. This paper examines such fundamental defini-
Accepted 20 September 2017
Available online 22 September 2017
tional aspects in the specific context of the National Health Service in England. For this purpose, it traces
the evolution of the innovation concept in policy discourse based on the analysis of 21 key policy doc-
uments published or commissioned by the English Department of Health between 1948 and 2015.
Keywords:
Innovation
Systematic analysis of these texts reveals that policymakers’ conception of healthcare innovation
Innovation policy broadened considerably over time. English health innovation policy initially focused on basic biomedical
Health care research. Subsequently, it entered a transitional period, zeroing in on science- and technology-based
National health service innovation. Finally, this focus gradually shifted to a broader conception of innovation translating into
health, economic, and service design benefits.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction
In recent years, the theme of innovation has reached consider-
able prominence in health services discourse and practice (Hartley,
2005). This increased interest in innovation results not least from
the belief that generating, developing, and implementing novel
products, services, and processes will be pivotal to quality
improvement and cost containment in public services (Salge, 2011).
The white paper ‘Innovation Nation’, published by the English
Department for Innovation, Universities and Skills, is a telling
manifestation of the growing hope placed in public service inno-
vation, which is considered a priority for England (DIUS, 2008:2).
Although innovation in the public sector should not be consid-
ered a virtue in itself (Hartley, 2005), a growing body of evidence
suggests that generating and adopting innovations is likely to
enhance public sector performance (Damanpour and Schneider,
2009). It is therefore not surprising that policymakers are dedi-
cating more attention to promoting innovation (Courvisanos, 2009;
Woolley and Rottner, 2008). Clearly, the question of “how to design
* Corresponding author.
E-mail addresses: tfarchi@iae.edu.ar (T. Farchi), salge@time.rwth-aachen.de
(T.-O. Salge).
policies that stimulate innovation has become a hot topic at various
levels of government” (Fagerberg and Verspagen, 2009:218).
In the field of healthcare innovation policy, recent studies have
furthered our understanding of the innovation concepts that
inform particular policies. These studies have primarily focused on
specific sub-areas, such as health research (Shaw and Greenhalgh,
2008), pharmaceutical biotechnology (Rosiello and Orsenigo,
2008), and nanotechnology (Woolley and Rottner, 2008), among
others. Similarly, prior research has explored specific stages of the
innovation process and their implications from a policy perspective
(Savory, 2009). Yet, there is a distinct lack of systematic and in-
clusive analyses of the evolution of the innovation concept in
broader policy areas, such as healthcare public policies (Osborne
and Brown, 2011). Understanding this evolution is essential, since
it has deeply informed not only the policy rhetoric at different
levels (e.g. Secretary of State for Trade and Industry, 2000), but also
the overall institutional landscape regulating innovation activities
(Liu et al., 2011), validating certain types of innovation and out-
comes (Savory, 2009) and guiding financial investment (DH,
2000a,b).
To this end, we explore the evolution of the concept of inno-
vation as articulated in successive healthcare policies, investigating
how its definition has changed over time. This is of considerable

https://doi.org/10.1016/j.socscimed.2017.09.038
0277-9536/© 2017 Elsevier Ltd. All rights reserved.
144 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
academic and practical interest given that policymakers’ under-
standing of innovation determines the form and level of institu-
tional support innovation receives. Moreover, understanding why
certain types of innovation are given priority over others might
help uncover and overcome systematic biases in public sector
policy, as policymakers tend to take the innovation concept
axiomatically with little critical analysis (cf. Vallgårda, 2015).
We start to examine these questions in the specific context of
the English National Health Service (NHS). Although policy efforts
to promote innovation target a broad range of public sectors,
healthcare has long been one of the primary foci of governmental
innovation policy (Savory, 2009). Innovation policy has thus had a
particularly significant influence on this sector (Windrum and
García-Gon ~ i, 2008).
The remainder of this paper is organized as follows. In the next
section, we introduce the conceptual background for our study.
Then, we describe our inductive qualitative research methodology,
with particular emphasis on our data collection and analysis pro-
cedures. We next present our findings, arguing that the evolution of
innovation policy in the English NHS falls into three distinct phases,
each based on a different understanding of innovation. Our
comprehensive policy content analysis illustrates the core concepts
associated with each phase, as well as the process of conceptual
change and its performative effects on the institutional landscape.
In the last section, we discuss the main implications of our study for
public administration research, practice, and policy and sketch
possible directions for future research.
2. Conceptual background
2.1. Innovation
Given the growing popularity of innovation and expansion of
the concept domain (Fagerberg and Verspagen, 2009), ‘innovation’
has come to resemble what Hirsch and Levin (1999) refer to as an
umbrella concept. As such, it is used to describe a vast range of
empirical phenomena (cf. Damanpour and Schneider, 2009). That
said, a consensus is emerging on several key attributes of the
innovation concept. In particular, it is now recognized that ‘inno-
vation’ can describe a process as well as an outcome, that it can
originate from within the focal organization or be acquired exter-
nally, and that it can pertain to a product, service, process or
business model that is novel to the focal entity or the entire orga-
nizational field (Crossan and Apaydin, 2010).
While typologies pertaining to innovation outcomes abound,
process-centric typologies of innovation are still scarce. These latter
typologies may be valuable for the policy analysis presented in this
article. In particular, fundamental differences in policymakers’ un-
derstanding of the process whereby new products, services, and
processes emerge in the healthcare sector, are likely to shape the
nature of policies they consider effective and hence seek to
implement.
The growing literature on modes of innovation offers useful
insights in this regard, as it presents stylized typologies of ideal-
type innovation processes (Hollenstein, 2003). Jensen et al.
(2007), for instance, contrast what they refer to as “Science, Tech-
nology and Innovation” with a “Doing, Using and Interacting” (DUI)
mode of innovation. In line with subsequent research (Salge, 2012),
we adopt the more concise labels of science- and practice-based
innovation to describe the two endpoints of the spectrum of
innovative activities. Science-based innovation focuses on the
development of novel products, services, and processes fueled by
major scientific and technological advances. In contrast, practice-
based innovation refers to product, service and/or process de-
velopments that occur as an integral part of daily work activities,
typically fueled by the resources at hand (Salge, 2012). They are
triggered by often mundane challenges encountered during regular
work activities. Innovation ownership tends to be distributed
across the entire organization irrespective of hierarchical level or
functional specialization.
2.2. Innovation and public policy
Once the importance of innovation at the national level was
recognized, general policy frameworks aimed at fostering fertile
environments for innovation emerged. These attempts included
“policy actions to raise the quantity and efficiency of innovative
activities” (European Commission, 2000:9). Even in non-
interventionist economies, innovation policies have been favored
as a way to stimulate innovation (Dahlman and Ross-Larson, 1987;
Enos and Park, 1988) and as a remedy for market failures, infra-
structural inadequacies, and international competition
(Hadjimanolis and Dickson, 2001; Stein, 2002).
Notwithstanding, the very understanding of what innovation is
varied significantly across countries and over time (Shapira et al.,
2001). Early innovation theories, and the policies based on them,
saw innovation as a linear process centered predominantly on
supply-side factors and represented by university and technolog-
ical sectors (European Commission, 2000; Hadjimanolis and
Dickson, 2001; Liu et al., 2011). These early science-centric con-
ceptions were gradually abandoned in favor of a broader and more
encompassing understanding of innovation (Lundvall and Borra s,
2005:614), considering not only major scientific discoveries, but
also small, incremental, and marketable advances (European
Commission, 2000).
Such variation in the innovation concept seems to have affected
the mix of policy tools used for its promotion. While earlier policies
focused on direct interventions in science and technology, the focus
has gradually shifted to more indirect financial and fiscal policies
(Hadjimanolis and Dickson, 2001). In their study of the evolution of
innovation policies in China, for example, Liu et al. (2011) examined
the shift from an initial Science and Technology (S&T) focus to in-
dustrial policies and, more recently, the development of financial,
tax, and fiscal policies.
Public sector innovation policies have followed the broader
trend toward more encompassing government interventions,
including practice-based and commercial-type innovation. For
instance, Shaw and Greenhalgh (2008) analyzed the increasing
pressure since the early 1990s for government departments in the
UK to produce science and innovation strategies with commercial
emphases (cf. Secretary of State for Trade and Industry, 2000:41).
Similarly, Rosiello and Orsenigo (2008), in their analysis of inno-
vation policies in life science, described the shift from so-called
linear models based on basic research, to non-linear, interactive,
and systemic models.
Nevertheless, many authors have argued that key policy de-
cisions are still informed by a scientific and research-based un-
derstanding of innovation (Savory, 2009). For instance, Osborne
and Brown (2011) problematized the definitional question of
innovation in public services in UK government policies. In
particular, they argued that the understanding of innovation that
permeates many policy documents inherits its core meanings from
manufacturing models; as a result, innovation is viewed as
continuous improvement and positioned as a normative “good”
(2011:133).
Such contrasting views have triggered recent calls for systematic
analyses of the evolution of the innovation concept in domain-
specific public service policies (Osborne and Brown, 2011). In this
context, we examine the following research questions:
 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
 How has the innovation concept evolved in healthcare policies in
England?
 What are the prevalent definitions of innovation articulated by
policymakers?
By addressing these questions, we provide a detailed analysis of
the phased evolution of the innovation concept in healthcare inno-
vation policies. Our analysis goes beyond semantic contributions (i.e.
identifying the definition of the innovation concept articulated in
each phase) by exploring how these definitions have evolved over
time. We show that change at the policy discourse level was not
linear or clear-cut. Rather, we find evidence of re-significant through
the introduction of new concepts and meanings into an established
innovation policy discourse. Finally, we inductively explore the
performative dimension of concept change through the analysis of
the institutions promoted in the policy documents.
3. Methods
3.1. Setting
Our study focuses on innovation-related policy discourse in
public healthcare services in England. Innovation has become
increasingly relevant in the English NHS, where the development of
new services, products, and/or processes is perceived as a favorable
solution to the dual challenge of quality improvement and cost
containment. The emphasis on innovation at the policy level has its
counterpart at the organizational level, and is reflected in the fact
that the NHS employs around 24,000 scientists in 50 disciplines
and manages more than 23,000 distinct R&D projects at any one
time (Salge, 2011).
The NHS was established on 5 July 1948 with the objective of
providing every resident of England with tax-funded care that is
free at the point of delivery (Ministry of Health, 1948). Accounting
for nearly 90 percent of national health expenditures, the NHS is
now the world's largest publicly funded health service. Although
the NHS is centrally funded, England, Northern Ireland, Scotland
and Wales manage their NHS services separately. This study focuses
on England, where nearly 90 percent of UK NHS staff are employed.
3.2. Research design
Traditionally, inductive and qualitative research approaches
have been favored when studying innovation policies (e.g. Nelsone,
1993). Liu et al. (2011) sustain that this methodological preference
is consistent with the nature of the phenomenon under study: the
number of the policies regulating a specific area is generally small,
but each policy is highly complex. Hence, qualitative approaches
relying on case studies and content analysis are well-suited to
address the richness and uniqueness of policy documents. In this
vein, a number of authors have recently suggested that policy an-
alyses should pay even closer attention to policy discourse and
narratives (e.g. Borins, 2012; Shaw and Greenhalgh, 2008), if more
implicit meanings and within-policy structures are to be elicited
(cf. Osborne and Brown, 2011). This paper qualitatively studies a
corpus of texts (i.e. health innovation policies in the UK) to unearth
the evolution and variation of the innovation concept. We perform
an inductive analysis of thematic and semantic consistencies across
the documents and conceptualize the predominance of certain
meanings associated with innovation and the decay of others
during the period 1948e2015 (Greimas and Courte s, 1982).
3.3. Data collection
We began data collection by compiling a preliminary list of
145
policy documents related to innovation in the NHS. To do so, we
conducted a scoping review of all innovation-related policy docu-
ments authored or commissioned by the English Department of
Health (or its constitutive organizations). To identify policy docu-
ments missed in the scoping review, we also performed a
comprehensive literature search in the SSCI database of published
papers in English using the basic keywords ‘innovation’ and its
derivatives and ‘health policy’. We used these broad selection
criteria to maximize the inclusion of all relevant policy documents.
Subsequently, we sent the initial list to a panel of experts for peer
validation. To ensure a sufficiently broad analytical scope, we fol-
lowed Davis (1992) recommendations and selected reviewers with
expertise in either innovation research or innovation-related poli-
cymaking. Our final panel comprised five academics from five
different institutions (all with published papers on innovation and
policymaking) and two health policy experts in the UK. To align the
panel's assessments with the objectives of our study, we sent each
member a brief summary of the study, together with the pre-
liminary list of policy documents from the scoping review. We then
asked them to assess the relevance and completeness of the list. In
particular, we asked them to evaluate the list by paying particular
attention to potential omitted policies (“Can you think of any other
official policy document not included in the above list that had
significant implications for R&D and innovation in the English
NHS?”) and irrelevant ones (“Do you think that any policy docu-
ment familiar to you and included in the above list has been
irrelevant for R&D and innovation in the NHS?”). This process ul-
timately resulted in 21 policy documents that have shaped the role
of R&D and innovation in the NHS (see Table 1).
3.4. Data analysis
Guided by the research question and the literature review, we
developed a provisional list of codes (Miles and Huberman, 1994),
which was completed with a set of recurrent concepts and themes
grounded in the policy documents. Finally, a coding protocol, in the
form of a list of structured codes, was elaborated. To begin, each
author independently coded the same policy document. At that
point, we discussed any differences in coding and refined the cat-
egories. We then proceeded by mutually coding the remaining
policy documents. Once the policy papers were coded, we devel-
oped detailed summaries of each and used them to generate
higher-level understandings of the main characteristics of each
document. We paid particular attention to the content (main sub-
stance, innovation definitions, core and peripheral concepts), the
actors (main identified agents for innovation), and contextual fac-
tors (external factors influencing the purported innovation pro-
cesses). We completed the analysis of the 21 policy papers by
conducting a cross-documents comparison, searching for and
analyzing patterns.
On the basis of this analysis, we integrated these first-order
innovation definitional codes into higher-level abstract concepts
(see Table 2 below). These second-order concepts, as described by
many exemplary studies using inductive categorical analysis (Gioia
and Thomas, 1996; Jarzabkowski, 2008), reflect more general
themes that encompass the key definitional aspects of the inno-
vation concepts. These more abstract concepts were labeled using
general categories that subsumed the initial, inductively emergent
first-order codes.
Finally, the second-order categories were assembled into three
distinctive phases in policy discourse (column 3 of Table 2). These
aggregate evolutionary phases of innovation concepts are: Expand-
ing research focus: from science-based to needs-oriented, Embracing
innovation and development as a collective endeavor, and Translating
innovation into health, economic, and service design benefits. In the
146 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
Table 1
Description of the policy documents included in the analysis.
# Document
1 Report of the Committee of Enquiry into the Cost of the National Health
Service. HMSO January 1956. Lead author: C. W. Guillebaud.
2 The organization and management of government R&D, in: Cabinet Office, A
Framework for Government Research and Development. London: HMSO.
November 1971. Lead author: Lord Rothschild.
3 House of Lords Select Committee on Science and Technology. Priorities in
Medical Research. Third Report. 1988. Lead author: Lord Nelson of Stafford.
4 DH. Research for Health. A Research and Development Strategy for the
NHS. 1991. Lead author: M. Peckham.
5 Supporting Research and Development in the NHS. 1994. Lead author:
Prof. A Culyer.
6 DH. Strategic Review of the NHS R&D Levy. Report of Topic Working Group
of the NHS R&D Strategic Review. 1999. Lead author: Prof. M. Clarke
7 DH. Research and Development for a First Class Service: R&D Funding in
the New NHS. 2000.
8 DH. The NHS Plan e A Plan for Investment e A Plan for Reform. Secretary
of State for Health. July 2000. Lead author: A. Milburn.
9 DH. Science and Innovation Strategy. 2001.
10 DH. The NHS as an Innovative Organization. 2002. Lead Author: C M.Taylor
11 DH. Research for Patient Benefit. Working Party Final Report. 2004.
Chairman: Sir John Pattison
12 DH. Best Research for Best Health: A New National Health Research
Strategy - the NHS Contribution to Health Research in England: A
Consultation. Jan 2006. Chairman: Prof. S. Davis
13 HM Treasury. A Review of UK Health Research Funding. Dec. 2006. Lead
author: Sir David Cooksey.
14 DH. High Quality Care for All - NHS Next Stage Review Final Report. Jun
2008. Chairman: Lord Darzi.
15 DH. Creating an Innovative Culture. Apr 2009. Lead author: Andy King.
16 DH. Breakthrough to Real Change in Local Healthcare - A Guide for
Applications to Create Health Innovation and Education Clusters (HIECs).
May 2009
17 DH. High Quality Care for All: Our Journey So Far. NSR Implementation
Team, Jun 2009. Chairman: Lord Darzi.
18 DH. National Innovation Procurement Plan. Procurement, Investment &
Commercial Division. Dec 2009. Member of the Division: J. Warrigton
19 Secretary of State for Health. Equity and Excellence: Liberating the NHS. July
2010. Chairman: A. Burnham.
20 DH. Innovation Health and Wealth, Accelerating Adoption and Diffusion in
the NHS. December 2011. Chairman: I. Carruthers.
21 DH. 2010e2015: Government policy: research and innovation in health
and social care. 2013, updated May 2015. Chairman: The RT Hon Earl Howe
following section, we present a detailed analysis of each.
4. Results
Our inductive analysis indicates that the notion of innovation
has evolved in three distinctive phases, each marked by substantial
differences in the innovation narrative. The first phase was char-
acterized by a transition from the historically prevalent focus on
science to a more needs-oriented research understanding. This
phase ended in 2001 with the publication of the Science and
Innovation Report (DH, 2001), which advocated for innovation in
R&D practices. Next, policy discourse zeroed in on innovation e
albeit still a science- and technology-based form of innovation.
Starting with Cooksey's and Darzi's reports (DH, 2006, 2008), the
third phase shifted from the historical focus on research to a form of
innovation that translates into health, wealth, and service-design
benefits. This section describes how policy discourse has evolved
from one phase to the next, with the emergence of new associated
meanings and notions (summarized in Table 3 below).
Description
The independent enquiry examined the long-term issues of funding the NHS.
Research was not considered as cost-reduction activity and its related activities.
Rothschild's principle made the “Government” the 'customer' who commissioned
'contractors', the Research Councils and Universities, to do research.
The report's recommendations outline how decisions on priorities in medical
research should be taken. They advocate a science-led approach.
This report constitutes the first comprehensive NHS R&D Strategy. It summarizes
progress and charts the direction of the DH's R&D strategy.
This is the first comprehensive strategy set out for the funding of research within the
NHS.
This documents evaluates the NHS R&D levy and provides advice on decision-
making relating to its allocation process.
This document sets the policy context and describes a development program for the
management of NHS R&D Funding in England.
This is a plan for investment in the NHS with sustained increases in funding.
This paper describes the strategies to achieve the science and innovation goals of the
DH. It primarily focuses on those which are science- and technology-based.
It introduces professional management of intellectual property rights resulting from
R&D activities in the NHS.
It makes practical proposals for implementing earlier reports and discusses the
development of Clinical Research Collaboration/Networks.
It sets out core goals for NHS research and development over a period of five years
and expresses its commitment to creating a research environment that contributes
to the health and wealth in England.
It proposes a structure for the funding arrangements for the whole spectrum of
health research, with the objective of obtaining the maximum benefit from research.
The review focuses on the quality of care. Innovation is important in this process,
and the review recognizes that it needs to be supported and rewarded.
This is a best practice guidance document that intends to support SHAs in fulfilling
their legal duty to promote innovation.
A guide for applications to create Health Innovation and Education Clusters (HIECs).
This report details progress made in the implementation of High Quality Care for All,
one year on from its original publication.
It describes the importance of innovation procurement in underpinning quality,
productivity, and sustainability in the NHS.
It sets out the government's long-term vision for the future of the NHS. Primary
focus has been given to empower and liberate clinicians to innovate.
It emphases that the NHS needs to put innovation at the heart of everything it does.
Innovation concept is understood as any development that significantly improves
the quality of health and care.
It describes the importance of promoting and using health research and new
technologies as ways to secure the development of new, more effective treatments
for NHS patients.
4.1. Expanding research focus: from science-based to needs-
oriented
An analysis of thematic and semantic consistencies across doc-
uments issued before 2001 reveals a primary emphasis on research.
For example, Priorities in Medical Research strongly advocated a
science-led approach, with highly autonomous researchers setting
their own research agendas: “At the outset we should make a
statement which is self-evident to those engaged in research: sci-
entific research is undertaken by scientists; it is they alone who
generate new ideas and identify new lines of investigation” (HL,
1988:11). This definition, echoing the Haldane principle (HMSO,
1918), continued to prevail throughout the phase.
However, while the view that research should play a critical role
remained constant, the concept of “research” grew broader. The HL
report (1988) referred to clinical, public, and operational research.
In 1991, the Peckham report promoted increased interaction be-
tween the research community and NHS managers and doctors
through more applied research (DH, 1991:89). By 1994, in Sup-
porting Research and Development in the NHS, Anthony Culyer
 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151 147

Table 2
Overview of the progression of inductive analysis.

Illustrative First order codes Second order themes Identified phase

“(The Committee) advocates a science-led approach in circumstances which Scientific-led research First phase:
allow research to thrive. This demands well-funded laboratories, good Expanding research focus: from science-
medical schools and a strongly motivated and adequately supported body based to needs-oriented
of researchers” (DH, 1988:47).
“The Department will work with the NHS, universities and research funders to
define and deliver the research capacity needed to meet the country's
needs for public health, health services and clinical R&D” (DH, 2000a,b:7)
“At the outset we should make a statement which is self-evident to those Researchers autonomy
engaged in research: scientific research is undertaken by scientists; it is
they alone who generate new ideas and identify new lines of investigation”
(DH, 1988:11)
“[This report] makes no distinction between research and development” (DH, Emancipation of development activities
1994:14)
“The initiative places collective responsibility on the research community, and Broader responsibilities
on clinicians, managers, and other health sector staff” (DH, 1991:1)
“The imbalance between investigator-led research and problem-led research Disease- and needs-oriented research
has resulted in insufficient attention being paid to a wide range of issues
germane to health sector demands”. (DH, 1991:1)
“The same spectrum stretches from basic research in the pursuit of knowledge
to applied research to attain specific ends, but the distinction between
basic, strategic and applied research is less significant than in other fields”
(DH, 1988:7)

“In the NHS, innovation occurs in the delivery of patient care, in the education Innovation as a core semantic category Second phase:
and training of employees and in R&D programmes. Innovation occurs Embracing innovation and development as a
naturally in the normal course of employment.” (DH, 2002:i) collective endeavor
“As well as providing solid support for the national science effort, the NHS
must support R&D that is relevant to the national priorities of the NHS,
responsive to the needs of those who use the NHS” (DH, 2000a,b:3),
(This report) “does not attempt to capture all the innovative developments Science- and technology-based
being taken forward in modernising the NHS and social care; rather it innovation
focuses on those which are science and technology based” (DH, 2001:3).
“… by virtue of its role as the largest healthcare service delivery organization
in the world, the NHS should be focused on R&D that is ‘close’ to patients
and that results in direct improvement in their care and healthcare
outcomes” (DH, 2004:6)
“An innovation can be used to improve the health service in one of two ways. Economic exploitation of innovation
First, after suitable evaluation, it could be freely disseminated across the
NHS by knowledge management processes. Second, the evaluation may
show that it is best treated as an invention and the method of doing this is
the subject of this document” (DH, 2002:4)
“(…) we need to be successful in generating and disseminating knowledge Systematic knowledge management
and exploiting it for the benefit of patients, users and the public” (DH,
2001:6).
“Industry, the universities, other research establishments and the NHS are all Innovation as collective endeavor
sources of new ideas and new technologies; partnership between these is
critical to maximising benefits to patients and to realising wider
commercial benefits for the nation”. (DH, 2001:6)
“(…) horizontal national research networks in key topic areas to facilitate
translational research and trials, following the model of the National Cancer
Research
Network; - integrated/vertical research groupings to link basic scientific and
technological developments with research into service delivery (DH,
2000a,b:18)”
“Income from the successful exploitation of IP is often derived from R&D
undertaken collaboratively with universities. NHS bodies for whom this is
likely to arise should take care in setting their reward structures to ensure,
as far as possible, that their employees have sharing arrangements similar
to those of employees in their collaborating university.” (DH, 2000a,b:24)

“Our researchers have made a great contribution and will continue to do so. Broad definition of innovation Third phase:
However, too often innovation has been defined narrowly, focusing solely Translating innovation into health, economic,
on research, when in fact innovation is a broader concept, encompassing and service design benefits
clinical practice and service design.” (DH, 2008:55)
“If organized as we suggest [health research and innovation], we believe that “Value for money” of innovation practices
they will improve on the value for money achieved today and will
substantially deliver improved patient benefit”. (DH, 2006:9)
“The Review identified cultural, institutional and financial barriers to Translation into health benefits
translating research into practice in the publicly funded research arena.”
(DH, 2006:4)
“Without innovation, public services costs tend to rise faster than the rest of Translation into wealth benefits
the economy.” (DH, 2009a,b:9)
“Innovation can be culturally threatening and often the funding is just not Cultural aspect of innovation
there to take the risk.” (DH 2009:32 (NSR))
148 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
Table 3
Evolution of the innovation concept in NHS policy discourse.
First phase
Core semantic category Scientific-led research
Associated meanings Disease- and needs-oriented research
Researcher autonomy
Developmental area Support of development activities
Primary responsibility Collective responsibilities,
but primarily on research community
ranked development activities at the same level as research en-
deavors, claiming to make “no distinction between research and
development” (1994:14). In the same vein, Clarke et al.'s (1999)
report focused primarily on disease- and need-oriented research
(DH, 1999). Finally, the DH, 2000a,b document deemed develop-
ment activities to be critical.
As the concept of research shifted from a science-led approach
to a more applied, clinical focus, the introduction of development
practices paved the way for a new set of concatenated concepts.
First, while policy discourse still placed the primary responsibility
for innovation on the research community (e.g., DH, 1991), this new
shift brought a sense of collective responsibility, including clini-
cians, nurses, managers, and other health sector staff (DH, 1991).
Second, while researchers' autonomy was explicitly recognized, the
traditional curiosity-led approach was deemphasized. Rising cost
pressures and a clearly identified set of major priorities to improve
public health conditions prompted the notion of needs-oriented
research (DH, 1999). These later policy documents echoed Roths-
child's earlier principle (1971), advocating for aligning the activities
of scientists with the needs of the nation. Finally, R&D-related in-
stitutions fostered by these same policy documents proliferated.
While recognizing the importance of the Medical Research Council
(MRC), Medical Research Charities, and universities, several docu-
ments explicitly called for the creation of new institutions to better
foster clinical, applied, and locally-originated R&D. These in-
stitutions, conceived as catalysts for change and development,
included the Cochrane Centre, Regional Offices’ Director of
Research and Development (RDRD), the Modernization Agency,
and the National Institute for Clinical Excellence (NICE), among
others.
4.2. Embracing innovation and development as a collective
endeavor
The publication of the Science and Innovation Report (DH, 2001)
unveiled a more thorough incorporation of the innovation concept
into DH policy. Subsequent to this report, innovation became a
leading semantic category in policy discourse and the cooperative
nature of innovation endeavors was recognized. It is symbolically
revealing that this 2001 policy was the first DH document to feature
the word “innovation” in its title. However, the adoption of the
innovation focus was gradual; innovation coexisted with the earlier
research and development concepts throughout the second phase.
Thus, the second phase is a transitional one: core concepts from the
previous phase maintained their preponderance even as new ideas
related to innovation and its derivatives were introduced.
In the second phase, innovation appeared both as a higher-level
concept e one able to encompass both research and development
practices e and as an outcome of those very practices. “In the NHS,
innovation occurs primarily in the delivery of patient care, educa-
tion and training of employees and research and development
programmes” (DH, 2001:11; see also DH, 2002:i). Nonetheless,
policy documents primarily discussed science- and technology-
based innovation (DH, 2001). Despite the fact that some also
Second Phase Third Phase
Innovation as a central category Broad definition of innovation
Science- and technology-based innovation Translation into health and wealth benefits
Key role of knowledge management Cultural aspect of innovation
Economic exploitation of innovation “Value for money” of innovation practices
Collective endeavor across different sectors Collective endeavor across different sectors
attempted a more practice-based and encompassing definition of
innovation (see DH, 2001; 2002), the focus remained on a narrower,
science-led concept. Also, the primary emphasis on research still
permeated some of the documents of this second phase, as in the
cases of Research for Patient Benefit (DH, 2004) and Best Research for
Best Health (DH, 2006) e both reports viewed scientific/clinical
research as the main innovation driver in the NHS.
Moreover, innovation was now deemed a collective endeavor
spanning traditional scientific communities and including frontline
health professionals, managers, and NHS users and patients (DH,
2004; 2006). This emphasis on the collective aspect of innovation
is already present in the Science and Innovation Report (DH, 2001:6):
“industry, the universities, other research establishments and the
NHS are all sources of new ideas and new technologies; partnership
between these is critical”. Under this cooperative view, successful
innovation is linked to effective information and knowledge pro-
cessing (DH, 2001). Moreover, in this second phase, innovation was
also dependent upon its financial benefits. The 2002 paper distin-
guished between a type of innovation that could be freely
disseminated across the NHS and another kind of innovation that
needed to be developed commercially (called invention) (DH,
2002:4). The underlying rationale was twofold: fostering innova-
tion sustainability and securing income for the NHS. Although a
fuller realization of the link between health innovation and income
generation would appear later, the idea that innovation is the pri-
mary solution for both health and economic challenges surfaced
during this second phase (DH, 2006:6).
Finally, the conceptual emphasis of the policy documents on the
diffusion of scientific- and technology-based innovation had its
institutional counterpart in the fostering of a series of organizations
intended to promote a broader set of innovations (e.g. from the
creation of the National Institute for Health Research (NIHR) to the
New and Emerging Applications of Technology (NEAT) funds); and
the sharing of such advances through the National Research Reg-
ister (NRR), the National Electronic Library for Health (NeLH), and
the NHS Hubs e essentially technology transfer offices acting for
several NHS bodies.
4.3. Translating innovation into health, economic, and service
design benefits
The third phase started with Cooksey's and Darzi's reports (DH,
2006; 2008). Policy documents in this final stage highlighted the
need to maximize the “value for money” (DH, 2006; cf. also 2009b)
of innovation practices by aligning them with the UK's health needs
and economic priorities (DH, 2006, 2008, 2015). A special emphasis
was placed on identifying the barriers that hinder the translation of
innovation into specific benefits. Innovation is hence understood in
very broad terms, with its success viewed as depending not only on
funding characteristics, but also on systemic and cultural features
(DH, 2006; 2008, 2009a, 2009b).
A common thematic element in this latter phase is the under-
standing that research and development efforts only reach their full
potential if they translate into tangible benefits. This translation
 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
refers to either using findings from basic research to develop new
approaches for the treatment of disease (DH, 2006:15) or tackling
the rise of healthcare costs to ensure both “the best possible value
for money for taxpayers” (DH, 2008:21, also 2015) and that “the
NHS and healthcare maximize the opportunities for UK PLC” (DH,
2009a:7). Moreover, these documents explicitly depart from clas-
sical notions equating innovation and research: “… too often
innovation has been defined narrowly, focusing solely on research,
when in fact innovation is a broader concept, encompassing clinical
practice and service design” (DH, 2008:55).
In addition, these policy documents displace research commu-
nities as the leading agents for advancing innovation in the NHS.
This displacement unfolds in two ways: first, by reducing the lati-
tude of researchers to autonomously set their own research agenda
(DH, 2006), and, second, by attributing a primary innovation
agency to multiple groups, such as clinical and non-clinical NHS
employees working in primary, secondary and tertiary care; uni-
versities and colleges, industry, and DH arms-length organizations
(DH, 2008; 2009a). This broader organizational landscape with a
clear focus on translation was primarily fostered by the establish-
ment of a number of institutions such as the Office for Strategic
Coordination of Health Research (OSCHR), the Biomedical Research
Centres (BRC), the Academic Health Science Centres (AHSCs), and
the Collaborations for Leadership in Applied Health Research and
Care (CLAHRCs).
5. Discussion and conclusion
Much of the recent attention to innovation at the policy level
stems from the general belief in the benefits of developing and
implementing novel products, services, and processes in the public
sector. Understanding the conceptual scope of innovation is thus
critical, as policy definitions usually carry performative effects
(Austin, 1975). That is, semantic features within policy discourse
produce real consequences in extra-semantic reality (Martin and
Learmonth, 2012). However, empirical exploration and theoretical
elaboration of the evolution of the concept of innovation within
policy discourse has remained surprisingly limited. To start
addressing this limitation, we conducted a content analysis of key
policy documents published or commissioned by the English DH
since the inception of the NHS. This analysis yields several insights
and contributions.
First, our research contributes to recent studies that have
analyzed innovation in public policies. Many such studies have
referred to sustained trends in policy discourse, such as the shift
from science-led innovation to a more encompassing definition of
innovation (e.g. Liu et al., 2011) or from linear models to non-linear,
systemic alternatives (Rosiello and Orsenigo, 2008). Our analysis
shows that these trends have been distinctively articulated within
policy discourse. This, in turn, allowed us to inductively identify
three evolutionary phases. In the first phase, the very concept of
innovation is used in a limited fashion, and novelty is primarily
associated with research. In the second, transitional phase, inno-
vation becomes a central semantic category within policy
discourse. Still primarily associated with science and technology,
innovation becomes a higher-level concept that subsumes both
research and development activities. Innovation is also newly
defined as a collective endeavor that spans scientific communities
and involves other professional communities and industries. The
third phase is characterized by a very broad understanding of
innovation, with a strong emphasis on the ability to translate it into
both health and wealth benefits. This broader and more syncretic
definition reinforces the idea that responsibility for fostering
innovation should be distributed across a broad range of actors and
communities.
149
Second, our analysis reveals a series of incremental changes in
the concept of innovation. Existing concepts and meanings are not
radically modified or abandoned in successive policies; rather, they
are maintained while new ones are incorporated. A primary
example is the understanding of the role of biomedical science in
fostering novelty across the health system. While it is a critical
component in all three identified phases, its role shifts from a core
instrument for advancing innovation to one element in a broader
and more comprehensive innovation structure. This example
highlights a second characteristic of the evolution of innovation
within the policy discourse: while incrementalism prevents any
radical departure from previous concepts, every new addition
presupposes a rearrangement of their relative importance. A
similar process can be observed in the organizational innovation
literature, where every new model of innovation “does not imply
any automatic substitution (…); many models exist side-by-side
and, in some cases elements of one model are mixed with ele-
ments of another at any particular time” (Hobday, 2005:122).
Moreover, it becomes apparent that the understanding of what
innovation is evolved similarly in policy discourse and organiza-
tional innovation models (Dodgson and Rothwell, 1995; Rothwell,
1992). Chronologically, however, conceptualizations articulated in
policy documents lag well behind those formulated in organiza-
tional settings.
Third, this staged evolution e through the rearrangement of
established concepts and the introduction of new ones e both le-
gitimizes and problematizes certain aspects of innovation (cf.
Vallgårda, 2015). On the one hand, it has legitimized new roles for
hitherto absent policy actors, placing collective responsibility for
innovation on clinicians, managers, and other health sector staff. It
has also legitimized a broad spectrum of innovation outcomes. On
the other hand, it has problematized many aspects of innovation
that were previously perceived as unproblematic or taken for
granted, such as innovation disconnected from a nation's concrete
clinical needs or health challenges. It is relevant to consider the
context in which the innovation concept evolved, as these tensions
did not emerge in a vacuum. Rather, they are embedded into a
broader societal effort of legitimizing and problematizing specific
aspects of innovation. In contrast to mass media coverage of these
broader conceptual struggles, policy discourse appears to articulate
more sanitized and less contested arguments. For instance, in the
first phase, the media tended to glorify individual inventors as well
as science and technology more generally. Media coverage of DNA's
double helix (e.g., “Why You Are You: Nearer the Secret of Life”, News
Chronicle, 14 May 1953); the 1968 first heart transplant in UK (e.g.,
The Guardian, 4 May 1968), or the birth of the world's first test-tube
baby (e.g., The Telegraph, 26 July 1978), are just a few examples of
the media's optimism and hope about technological discoveries.
The second, transitional phase we identified has its counterpart in
the mass media discourse focused on Blair's plan for the modern-
ization of and innovation in the NHS (e.g., The Guardian, 20 March
2000). The third phase in healthcare policies is anticipated in the
media coverage with a focus on fostering research that translates
into concrete health benefits (e.g., The Guardian, 20 September
2005). With the NHS's financial challenges as a permanent back-
drop, new developments are highlighted not only for their health
benefits, but also their financial impact (e.g., “HIV tests for GPs' new
patients could save lives and money”, The Guardian, 30 July 2017).
All in all, media discourse appears to be characterized by more
acute descriptions, a greater sense of urgency, and more conflicting
perspectives than the policy documents we analyzed. Future
research could seek to compare policy and media discourse in a
more granular manner e for instance, with regards to their inter-
dependence and the co-evolution of the nature of their respective
problematization strategies (cf. Martin and Laermonth, 2012).
150 T. Farchi, T.-O. Salge / Social Science & Medicine 192 (2017) 143e151
Moreover, the incremental broadening of the innovation
concept has a parallel at the institutional level. In each phase, the
policy documents promote a particular set of institutions to foster
each predominant concept of innovation. Consequently, as the very
concept of innovation has grown broader, so too has the institu-
tional landscape. During the aforementioned three phases, it has
shifted from a narrow field of institutions supporting scientific
endeavors to a wider set of institutions tackling diverse R&D
activities.
Our findings also expand recent studies that examine policy-
makers' understanding of the production of scientific knowledge
and innovation (cf. Nowotny et al., 2003; Perren and Sapsed, 2013).
Taken broadly, they tend to support the stylized conceptualization
provided by Gibbons et al. (1994) in relation to the two modes of
scientific knowledge production (i.e. ‘Mode 1’ and ‘Mode 2’).
However, our closer analysis of the historical evolution of innova-
tion policies depicts a more nuanced account, where non-linear
and multiple-stage changes co-exist with old meanings, and
where incremental trends and processes prevail over radical de-
partures from the status quo. The hybridity and coexistence of old
and new conceptual categories, albeit with different degrees of
importance, portray a more realistic picture of innovation at the
policy level. Just as innovation is not a homogeneous activity
(Edqvist, 2003), neither are innovation policies.
The fact that our research has focused primarily on innovation
policies in the English health system may raise questions regarding
the generalizability of our findings. That said, studies of innovation
policies conducted at national (Perren and Sapsed, 2013) and in-
ternational levels (Henriques and Lare do, 2013) seem to reinforce
our findings. Future research may want to explore whether, beyond
these commonalities, actual institutional arrangements and
different actor types perceived as primarily responsible for carrying
on innovation activities differ across industries or countries.
Another fruitful avenue for future research is to complement our
content analysis with a more detailed analysis of the accompanying
historical political context. For example, the first phase in innova-
tion policy discourse coincides with a period of strong faith in the
principles underpinning the foundation of the NHS. Even
Thatcher's radical reform to the NHS's internal organization (the
introduction of a quasi-market) in 1991 did not challenge the
general principles that guided the NHS from its inception. In
contrast, the second transitional phase in the policy discourse did
not emerge until well into Tony Blair's tenure as prime minister.
While the Labour Government came into office in 1997 with a
proclaimed strategy for transforming the NHS, it was not until 2000
that these reforms were put in place after the Government set one
of biggest public spending increments in the history of the NHS.
Analyzing this increase in funding, Klein (2007:40) sustains that it
brought two policymaking consequences: “On the one hand, the
extra funding created possibilities that had never existed before: it
was the increase in capacity which made the subsequent policy
changes possible. On the other hand, it reinforced the pressure
within the Government (…) for the NHS to deliver”. Finally, the
third identified phase began in a political context in which the
Labour Government tightened its financial control over the NHS
from the 2005/06 fiscal year onwards. The main goal was to ensure
NHS hospitals were able to deliver both in health outcomes and
financial terms, allowing the Government to enforce the “payment
by results” system introduced across the whole NHS (Klein, 2007).
In sum, the transition between the three identified phases corre-
lates with defining political moments. Future research could
further contextualize our findings and help disentangle the ideo-
logical and the technical aspects of the innovation apparatus.
Finally, our findings raise important questions for innovation
practice and policymaking. First, the current policy emphasis on a
broad definition of innovation (one that encompasses practice-
based developments) should incorporate a more realistic diag-
nostic of the daily demands and strains that front-line staff expe-
rience, and the lack of time and incentives to “depart” from normal
routines. Unlike science-led discovery, practice-based innovation
necessitates the formalization of time, processes, and incentives
into daily routines to come into fruition. Second, an excessive focus
on the external economic benefits of innovation could crowd out
initial health and service intrinsic motives, which have been found
more conducive to creative developments than extrinsic motives
(Amabile, 1988).
All in all, our in-depth analysis of the evolution of the innovation
concept offers a response to recent calls to provide a more nuanced
understanding of the subtle changes in the meaning of innovation
in policy discourse (Osborne and Brown, 2011; Perren and Sapsed,
2013). In this study, we characterize the historical evolution of the
innovation concept as non-linear and incremental, where the very
concept of innovation e as articulated in policy documents e has
been broadened, reshaping the relative importance of specific
meanings while fostering new ones. In doing so, our analysis un-
covered three evolutionary phases that contribute a more nuanced
account of the evolution of the innovation concept within policy
discourse, and e through the performative nature of policies e
affect the extra-discourse reality of innovation.
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