Introduction The fast paced landscape for drug development creates huge opportunity for improvement in patient care but simultaneously creates a problem around how the NHS will manage access to these novel drugs. Two key challenges faced are around the cost of the drugs and the supporting services required for safe and clinically effective prescribing.

Whilst there is often a central budget held for new high cost drugs to financially support integrated care systems, due to commercial agreements including confidential pricing, business as usual processes prevent the transaction of medication outside of secondary care.

Furthermore, careful assessment is required as to what supporting services are needed. The balance lies between increasing the workload of often overburdened existing services versus creation of new models of care delivery.

It is essential the NHS adapts to the changing healthcare environment in order to allow the UK population access to innovative treatment.

Aims and objectives of the research project or activity The aim of the project was to create a mechanism that would support the delivery of novel drug therapy in settings outside of secondary care. Not only did the above challenges need to be met, it had to be done within financial, resource and time constraints.

Financial constraints were in the context of nationwide financial deficit partially due to current work-force strikes, resource constraints were limited by various organisational restructures creating barriers to joint working and access to specific skills sets, and time constraints set in conjunction with healthcare stakeholders in line with population need.

It was evident this should be developed at national level. However, creating change at this scale is complicated, fraught with bureaucracy and often lies in politically charged areas of clinical policy requiring input from multiple stakeholders. Furthermore, legislation is inflexible and frequently doesn’t allow the NHS to embrace change and test new pathways at speed.

Method or approach Initially, the process was broken down into its component parts and time invested into information gathering and scoping the art of the possible.

Over time it became evident that due to the highly complex nature of the problem, there was no single ‘expert opinion’ who might be able to solve the problem. Multiple iterations of solutions were designed and tested. Often upon solving one problem, a new challenge was raised. It seemed the more people consulted the further away from a solution we moved. All involved started to see the challenge as a ‘wicked problem’ with a real risk of failure.

Although we aimed to involve stakeholders from an early stage, the process of enabling stakeholders to work together did not reach fruition till much later and ultimately held the key to finding a workable and sustainable solution.

Findings The crucial element was in collaboration; by joining disparate teams across multiple healthcare organisations and disciplines it allowed information sharing, group brainstorming and learning from previous experiences. New conversations created a safe space for sharing new ideas.

As a result, we were able to design an initial potential solution. The blueprint created is not specific and therefore reproducible for future healthcare interventions that lie outside of business as usual processes. Upon reflection, it demonstrates how collaborative leadership can work well in order to empower the wider team to find solutions.

Coordinating various stakeholders with, at times, competing agendas was not always an easy process. Virtual meetings allowed easier logistics but it was most resource intensive in regards to time. By allowing each team time to voice their opinions it allowed increased understanding of others views and thus opportunity for joined up thinking.

Key messages The key message is the importance of stakeholders when faced with a wicked problem; knowing who they are, involving them early and creating an environment in which they can collaborate.

Next steps are to maintain internal and external stakeholder involvement upon transitioning to implementation stage is required and to utilise diverse skills sets and draw upon joint expertise should any barriers be encountered.

It is highly likely the market for new high cost drug interventions will continue to increase. As such it is essential that feedback from all involved is gathered, to consolidate learning from this process and transferable components used to inform future projects.

In summary, the NHS must continue to develop a more flexible way of operating to enable interaction between stakeholders that allows the healthcare services provided to patients to adapt within an increasingly complex system.