It's Complicated: The NHS and Innovators' Complex Relationship Dynamics

As it's Valentine's Day weekend, this week's newsletter explores the turbulent relationship between the NHS and digital health innovators.

Actually, it's beyond complicated. It's the kind of relationship where one partner keeps showing up to couples therapy with grand declarations of commitment and promises to change. The other partner shows up with a running list of unresolved issues on their phone, because they've heard it all before.

The NHS wants innovation. It really does. It publishes 'love letters' in the form of 10 Year Plans and the recent National Cancer Plan, declaring it wants to become "the most AI-enabled health system in the world."

The NHS talks about transformation, about it all being different this time, words about really wanting to make it work.

And then innovators try to actually engage. They encounter the same old issues as before.

It's not that the NHS is lying about wanting to change. It's that wanting change and actually changing behaviour are two different things. And unlike a failed romance, this relationship dysfunction has real consequences for patient care.

The NHS 10 Year Plan commits to three "big shifts": hospital to community, treatment to prevention, and analogue to digital.

The commitment to the digital shift is foundational and significant. By 2028, the NHS App is to become the front door to the NHS, with a Single Patient Record unifying data across trusts, GP surgeries, and ambulance services. The ambition to become "the most AI-enabled health system in the world" comes with at least 3% of annual spend reserved for digital service transformation.

Last week's National Cancer Plan reinforced these commitments, including "universal digital-first prehabilitation by 2028", with cancer care and pathways delivered via the NHS App, and more virtual care "closer to home" and out of hospitals.

The policy language is impressive. But when digital health innovators actually try to engage with NHS procurement, they encounter a different reality.

They face NHS frameworks that run for three to four years; once a framework closes, new solutions are effectively locked out until it reopens. Innovation does not operate on three to four year cycles, so the system routinely excludes emerging products and fast-moving improvements.

They then face procurement routes that require prior experience of delivering NHS contracts, creating a circular barrier for SMEs. In practice, you need an NHS track record to win NHS work. G-Cloud, the Government's Digital Marketplace, now requires organisations to already hold a government contract and provide references in order to join the framework. This leaves innovators stuck: they cannot secure NHS customers without being on frameworks, and they cannot get onto frameworks without already having NHS customers.

Despite repeated government commitments to support SMEs, this structural contradiction creates a real barrier for innovators offering solutions the NHS genuinely needs.

The burden is compounded by the cost and complexity of applying. Framework applications are expensive and time-consuming, particularly when companies must apply to multiple frameworks for essentially the same product. Mandatory certifications such as ISO standards introduce high entry costs, disproportionately affecting small organisations.

A 2024 PLOS One study by the University of Liverpool examined barriers and opportunities for SMEs in NHS procurement through qualitative interviews and surveys with small business owners navigating the system. They found procurement structures fundamentally misaligned with how innovation happens.

SMEs reported limited access to key NHS stakeholders and fragmented, protracted decision-making processes within NHS Trusts. One innovator described the problem:

"Consultants who are working are so busy they don't have time, so you can't even have the conversation with them to explain that we've got the solution to their problem."

Another quote captured the financial risk SMEs are expected to absorb:

"We were very reluctant, as a small business, to embark on something which could have the very real capability of sinking our business... the call to SMEs or anybody innovative is to jog alongside us for two to five years at your own risk in order to possibly come up with something we might buy from you."

Two to five years. At your own risk. For something the NHS might buy.

Dr Marcus Baw, a GP, clinical informatician, and software developer, describes the procurement problem as a mismatch between procurement processes and modern innovation cycles:

"Procurement cannot cope with agile development, research, learning and iteration, preferring immutable contracts, lengthy specifications and clunky systems which don't update with user needs because specifications are set once at the start and they can't be changed without a new procurement."

The ultimate result of all these barriers is that SMEs capture only 19% of public sector procurement spend.

Decision-making complexity. No individual owns innovation decisions — instead there is collective ownership spread across multiple teams and stakeholders, which creates paralysis. With often lengthy gaps between meetings, it is not uncommon for innovators to wait six months just to get an answer. Even when there is a clinician champion who believes in a solution, there's often a significant gap between that clinical vision and the wider organisation's willingness to actually adopt it.

Risk-averse leadership. Senior leaders are held accountable for delivering national innovation mandates. Yet their day-to-day reality is more often operational crisis management. Ruby Bhatti, Chair of the Quality and Safety Patient Panel at Bradford Institute for Health Research, describes:

"Chief officers are fire fighting everyday issues in the NHS and really don't have time, investment and sometimes the understanding of how innovation can change and support patient care. They only commit to innovations that have an immediate positive result, but not the time to invest in innovations that may need time to develop."

Accountability structures that punish failures more than missed opportunities. A trust that tries an innovation that doesn't deliver ROI gets scrutinised. But a trust that never tries an innovation, missing opportunities for better patient care, faces no equivalent accountability.

This asymmetry creates "pilotitis" — where Trusts run endless pilots because pilots feel safer than procurement commitments. For innovators, this means providing free or heavily discounted pilots across multiple trusts, absorbing implementation support, training, and data collection costs, without any guarantee of a contract at the end.

Procurement separated from clinical outcomes. Procurement is driven by incentive to reduce purchasing expenditure rather than to secure improved patient outcomes. This works against Value-Based Procurement principles that promote measurement of overall impact and value across entire patient pathways.

Cultural resistance. The NHS operates within a culture that resists learning from how the wider technology sector works. There is a lack of understanding of how commercial decisions are made and the value of iterative, agile delivery.

Make Value-Based Procurement the default. Current pilots are running across 13 trusts in specific clinical areas. The results have been reassuring: selecting products based on outcomes across patient pathways rather than just upfront costs leads to better clinical decisions and can reduce whole-system expenditure. Value-based procurement needs to become standard practice across all clinical areas and digital health categories.

Remove the requirement for existing NHS contracts to access frameworks and ensure frameworks remain continuously open to new entrants. Create fast-track approval for innovations that directly address 10 Year Plan commitments.

Align procurement processes with the realities of product development. Create procurement pathways for innovations likely to benefit from iterative development. Allow specification changes during contract periods based on user feedback and reduce documentation burden.

Create clear accountability. Designate single senior responsible owners at ICB and Trust level with overall responsibility for innovation adoption.

Integrate clinicians into procurement decisions from the start, not after specifications are written.

Create networks to enable sharing of digital health innovation evaluations, so evidence generated in one trust can be accepted by others. Endless pilots cost innovators money they don't have and will ultimately reduce the availability of innovations the NHS needs.

Invest in procurement capability. Train procurement teams in commercial partnering, not just contract compliance. Create incentives based on patient outcomes, not just cost savings.

Before you engage

• Map your solution to 10 Year Plan commitments
• Identify which service-specific plans your solution addresses
• Research relevant frameworks and their requirements
• Understand NHS structures and who funds what (ICB vs Trust vs national)

Build your evidence base

• Secure contracts outside the NHS first if possible
• Document outcomes in NHS-relevant language (patient pathways, clinical outcomes, productivity)
• Invest in health economics analysis showing whole-pathway value
• Gather user testimonials from clinicians

Navigate procurement access routes

• Explore Health Innovation Networks and SBRI Healthcare for funding
• Attend "Meet the Buyer" events
• Find clinical champions early, but recognise they can't guarantee procurement approval
• Use multiple entry points simultaneously

Position your product to demonstrate value

• Frame solutions around patient outcomes, financial resilience, and whole pathway value
• Show evidence of reduced readmissions, complications, or emergency attendances
• Quantify productivity gains for clinical staff
• Demonstrate contribution to health equity

Manage expectations realistically

• Expect 18–24 month sales cycles as a minimum
• Budget for this
• Plan for lengthy decision delays
• Recognise you may need to educate procurement teams about your product category

Every relationship counsellor will tell you the same thing: what matters most is not the grand gestures. It's whether words and promises align with actions; whether understanding deepens; and whether behaviour actually changes enough for the relationship to thrive.

The NHS has been clear about what it wants. The 10 Year Plan and the National Cancer Plan set out explicit digital commitments. What's missing is procurement reform that works at the pace products are actually built, that makes it easier for innovators, lowers barriers for SMEs, prioritises value above lowest cost, and creates real accountability for digital transformation outcomes.

We also need a more honest acknowledgement of where risk currently sits. Too often, the NHS procurement approach transfers risk onto SME innovators. And when innovation is blocked, that risk ultimately transfers to patients — who miss out on solutions that already exist.