Supporting Healthcare Innovation - A dual framework approach for a dual purpose

Caitriona Heffernan, National Clinical Innovation Lead, HSE Spark.

Across the globe, health systems are facing the converging pressures of aging populations, rising rate of chronic disease, constrained resources, workforce burnout, and increasing demand for personalised, digital, and equitable care. As an outcome of these growing challenges and needs we find ourselves in a position where innovation is required not as a luxury, but as a necessity. Despite the international focus on digitally enabling healthcare in line with other industries, innovation is not just about apps, AI and new technologies. It’s about finding new and better ways to deliver health services that improve outcomes, reduce costs, and make work more meaningful for those on the front line of health services.

But this raises a fundamental question: who is responsible for healthcare innovation?

“Top-Down” or “Bottom-Up”? The two faces of innovation

Healthcare innovation can emerge from two directions: top-down and bottom-up.

• Top-down innovation refers to large-scale, centrally driven efforts—national programmes, digital transformation strategies, new models of care, or government-led reforms. These are typically informed by strategic priorities, evidence reviews, international benchmarking, and formal business cases. A good example is the implementation of an electronic health record (EHR) system across a national or regional health system. This type of innovation is not always considered ‘novel’ by international standards but it is often new to individual healthcare systems and as such will ‘innovate’ current practice and represent a real ‘step-change’ at a system and service level.
• Bottom-up innovation, on the other hand, comes from those working closest to the problem - clinicians, doctors, nurses, health and social care professionals, porters or administrative staff. Their proximity to patients and service users ideally positions them to gather valuable insights and engage in co-design and co-creation with the very people who will benefit from changes to the existing ways of working. Innovation ‘at the edges’ of the system are often small, early-stage ideas driven by lived experience of the system’s pain points, and the passion to improve them. That, of course, is not the undermine or underestimate the potential for ‘edge led’ or ‘bottom up’ efforts to yield huge impact where the right conditions in terms of time and resources are made available.

There is an essential need to understand the continuum from:

Though concrete distinction is difficult, in simple terms, one supports the optimisation or incremental improvement of existing services and models with varying degrees of ‘innovation’ and the other is concerned with potentially redefining and remodeling of our health service through the adoption of new (to our system) or radical (new to all systems) innovations or innovative ways of working.

Both types of innovation are critical—but they are not the same thing. And trying to manage them through the same structures and expectations is a mistake.

Different logics, different needs

Though influenced by each other and built on shared foundations of population need, regulation and compliance, top-down and bottom-up innovations differ in their origin, pace, governance, risk appetite, and resource needs.

In short: ‘bottom-up’ innovation needs space to breathe, develop, ‘fail’ and find its way in a complex adaptive system, while ‘top-down’ innovation needs a different type of structure to support successful implementation and delivery at scale within that same system.

Why Public Healthcare Systems need a dual framework

In a publicly funded healthcare system, we need both types of innovation and crucially, we need innovation frameworks that support both.

Yes, we must implement national priorities and adopt and implement the best solutions at scale. But we must also create the conditions for those on the frontline to try something new, learn from it, and adapt it to local contexts. Innovating is a tough task and requires muscle and muscle memory. Frontline innovation, even when not successful in the traditional sense of the word, builds this muscle so that the health services workforce build their innovation capabilities and are (at the very least) better prepared engage with innovation and innovative practice due to their familiarity with the process.

When we only support strategic innovation, we miss the daily opportunities to fix what’s broken and ‘make things better’. When we only focus on grassroots ideas without considering sustainability, we miss the power of scale and the ability to ‘make better things’ on a grander scale. The answer lies in a dual-framework approach to supporting healthcare innovation - two distinct but interlinked systems that work in harmony.

One supports intrapreneurs at the point of care, providing small-scale support, feedback, and flexibility. It allows for piloting of ideas or proof of concept efforts. The other drives large-scale implementation, with formal mandate and strategic oversight. Between them lies the innovation pipeline, where promising ideas can move from prototype to policy when deemed to be of high potential value.

This isn’t just theoretical. It’s evidence-based.

What the research tells us

This dual approach that supports ‘bottom up’ efforts as well as ‘top down’ is not simply an ideology, it’s backed by years of social science, organisational theory, and innovation research.

• Damon Centola's work on social networks in reminds us that change spreads through “loose ties”, not top-down mandates. Innovations spread when people see others like them experimenting successfully—not just when they're told what to do (1)
• Ben Bensou argues in Built to Innovate, that the act of innovating is as important as the innovation itself. It’s not just the outcome that matters, but the process—creating a culture where experimentation, co-creation, and adaptation are ongoing (2)
• The literature on effectual and asset-based innovation (such as work by Saras Sarasvathy and others) shows that successful innovators often don’t start with a grand plan. They start with the resources they have, the relationships they trust, and a willingness to adapt as they go (3)
• Everett Rogers’ seminal work (4) on diffusion of innovation reminds us that for innovations to spread and scale, people need: To see it working (observability) To try it without major risk (trialability) To shape it to their context (adaptability) To trust who’s doing it (social credibility)
• The Observatory of Public Sector Innovation’s work on pluralistic strategic in innovation activities states that a portfolio approach to innovation helps public services manage uncertainty and foster different types of innovation. It ensures a balanced mix of efforts—such as enhancement, mission-oriented, adaptive, and anticipatory innovations—aligned to strategic goals (5)

Frontline innovation taps directly into this. It makes innovation visible, tangible, and human. This is a critical part of how new innovative practices gain traction.

So, whose job is it to innovate in health systems?

It’s everyone’s.

Innovation is not the exclusive domain of strategy teams or executive leadership. Nor is it something that can thrive only in passionate pockets at the clinical coalface. If we want meaningful, scalable, and sustainable change in healthcare, we must create the right frameworks, funding, and supports to support both grassroots experimentation and strategic implementation.

That’s how we move from the theatre of innovation to real system transformation.

References:

1.      Centola, D. (2021) Change: How to Make Big Things Happen. New York: Little, Brown Spark.

2.      Bensaou B. M. (2021). Built to Innovate: Essential Practices to Wire Innovation into Your Company’s DNA. McGraw-Hill Education

3.      Sarasvathy, S. Sarasvathy, Dew, S. & Wiltbank, R. (2016). Effectual Entrepreneurship (2nd ed.). Routledge.

4.      Rogers Everett, M. (1995). Diffusion of innovations. New York, 12.

5.      https://oecd-opsi.org/publication-tags/facets-brief/