Real-world application of Health System Adoption Diligence across complex NHS systems.
The Think Precision Arc is an assessment framework refined through application in live NHS systems. It was first applied in NHS England and subsequently taken into NHS Scotland, demonstrating replicability across distinct system contexts. This is exemplified in the case studies below.
The framework is designed to reveal interdependencies, structural constraints and hidden opportunities across complex health systems. It follows a disciplined sequence of enquiry: identifying system ripple effects, translating these into credible adoption conditions, integrating implications across services and sectors, and providing assurance so that decisions are taken with full visibility of risk, trade-offs and system consequences.
The role of assessment is to make consequences visible early enough for judgement to be exercised deliberately, rather than under constraint.
In both cases below, the central question was not whether change was desirable, but how the system could align to allow for safe and sustainable adoption.
In practice, these assessments reflect what Think Precision Healthcare now formalises as Health System Adoption Diligence: a structured approach to understanding whether and how innovation can be safely adopted within real health systems.
The following case studies illustrate this approach in practice.
In a geographically remote English region, patients requiring allogeneic stem cell transplantation were referred to tertiary centres outside the region, typically for inpatient stays of around 90 days, often followed by frequent high-acuity readmissions.
Locally, haematology services were under sustained strain. Specialist bed capacity was limited. Highly complex patients were treated on non-specialist wards. Specialist expertise was dispersed across a large site, creating workforce strain and pathway inefficiency.
Capital funding was constrained, estate was limited and workforce supply tight.
Access to innovative therapies was constrained and required improvement.
Regional transplant uptake appeared lower than national averages. On the surface, this weakened a demand-based case for developing a local tertiary service. Expansion was therefore hard to justify.
In this case, the presenting question was framed as a service expansion challenge. The underlying question, however, was more fundamental: how could the system align to allow for safe adoption of specialist cellular therapy locally?
Wider system impact assessment examined the situation beyond utilisation statistics and beyond single-innovation or single-service considerations.
This revealed several critical insights. Lower transplant uptake did not reflect lower clinical demand.
Patients faced travelling hundreds of miles for a high-risk intervention that could last several months. For some, the prospect of undergoing life-saving treatment far from family support influenced the decision to decline treatment. Demand was therefore suppressed rather than absent.
At the same time, absence of local tertiary capability produced wider system effects:
What appeared to be a discrete service expansion question was in fact a structural inequity with operational, clinical and reputational consequences across the wider system.
Adoption was understood as a multi-service and multi-sector system issue, not solely an operational one.
Multi-layered assessment identified what would be required for safe and sustainable adoption across the region, including workforce recruitment and training, regulatory accreditation and governance thresholds, financial modelling relative to the London tariff and specialist commissioning arrangements.
The analysis also incorporated equity of access, university research capability, patient and third-sector perspectives, political and reputational implications and national commissioning dynamics.
Accordingly, the central question shifted from whether the region could develop a specialist commissioned transplant service to how the system could align.
Whole-system consequences and interdependencies were made visible to leaders.
Assurance focused on whether readiness conditions were credible, resourced and owned across the system prior to commitment.
Additional system benefits were identified at this stage. For example, financial modelling demonstrated that local provision could reduce tariff-related outflow if accreditation and commissioning conditions were secured. Workforce, safety and governance considerations were also positively impacted.
In effect, by making risks, trade-offs and operational realities explicit before commitment, leaders were able to more carefully balance risks and proceed with greater confidence.
Accredited local facilities were established and specialist commissioning arrangements secured.
Access to innovative therapies improved as local provision eliminated out-of-region referrals.
Equity strengthened. Specialist expertise was consolidated. Research capability increased. Financial sustainability improved. Pre-existing system inefficiencies associated with the existing haematology configuration were addressed.
The assessment discipline was subsequently applied to inform further decisions, leading to expansion.
A suppressed structural inequity was corrected through disciplined system assessment, enabling safe adoption through alignment rather than assumption.
In southeast Scotland, demand for systemic anti-cancer therapy and precision oncology was rising at approximately 11 percent per year. Services were severely challenged across multiple hospital sites. Central treatment capacity was constrained. Facilities were overcrowded. Emergency departments were managing oncology patients without consistent specialist presence.
In this context, access to innovative therapies and trials was constrained and varied across district hospitals serving populations with significant deprivation.
There was no spare capital or revenue funding to address these issues, and no realistic prospect of expansion, as previous capital funding bids had been unsuccessful.
A forthcoming medicines optimisation presented approximately £1.2 million per year in potential savings but would significantly increase chair-time demand within an already stretched chemotherapy service. No clearly articulated safe model for adoption had been established.
This apparent financial opportunity exposed wider structural pressures across capacity, workforce and system flow.
The underlying question was not whether to proceed, but how the system could align to allow safe adoption without displacing pressure elsewhere.
System impact assessment reframed the medicines switch from a discrete financial decision to a system-level intervention.
Implications were mapped across emergency pathways, oncology workforce capacity, estate utilisation, pharmacy models, supportive care services and academic trial infrastructure. An underused ward in Livingston was identified as a possible site for redistribution of activity. However, it functioned as the hospital’s only escalation capacity, raising legitimate concerns regarding bed management and acute risk.
The central question was reframed: under what conditions could the system align such that adoption would improve access and system performance, rather than displace pressure elsewhere?
Assessment clarified the conditions required for safe and sustainable adoption across two sites.
Workforce recruitment and skill mix requirements were articulated alongside chair capacity thresholds, governance safeguards, acute oncology cover models, pharmacy configuration and escalation planning.
Financial modelling defined a structure in which 50 percent of medicines savings could be reinvested in enabling capacity, with 50 percent contributing to broader financial resilience.
The analysis incorporated clinical trial capacity, university partnerships, patient and third-sector perspectives, and the political and public legitimacy of redistributing specialist oncology services geographically.
Risks, opportunities, trade-offs and operational realities were made explicit before commitment, enabling alignment across services prior to implementation.
Whole-system consequences were presented transparently to system leaders.
The proposed model strengthened access to innovative therapies, addressed central overcrowding and patient flow, aligned workforce expansion with projected demand growth and safeguarded trial delivery capacity. Estate repurposing was evaluated against escalation risk and mitigation planning.
Assurance focused on whether readiness conditions were credible, resourced and owned across services prior to implementation.
Delivery remained the responsibility of cross-site system leadership. The assessment role was time-bounded, providing structured challenge and validation to support safe adoption.
Post-implementation review examined whether anticipated system effects were materialising.
Self-funded new systemic therapy and trial capacity was established across Edinburgh and Livingston.
Redistribution of activity relieved central pressure. Access to innovative therapies improved.
Oncology workforce numbers grew locally during a period in which national growth plateaued.
During the pandemic, NHS Lothian was the only Scottish health board not to cancel systemic anti-cancer therapy appointments and continued to expand its oncology trials portfolio.
Subsequent expansion to East Lothian Community Hospital and extension of community and home-based delivery followed demonstration of readiness and learning.
Structural barriers to access to innovative therapies were reduced without new funding or displacement of risk.
Capacity was redesigned to reflect whole-system conditions rather than isolated opportunity.
Equity, workforce resilience, trial capability and system performance improved together, producing a positive net system effect across interconnected services and hospital sites.
Leaders proceeded because they were assured that interdependencies, trade-offs and all relevant system considerations had been surfaced and aligned before commitment.