Asking why not rather than why?

Technological innovation is a double-edged sword. It has brought huge benefits for all of us by reducing suffering and extending life. But it has allowed healthcare to do more – in all developed countries people are increasingly ‘overdosed, overtreated, and overdiagnosed’, as Ray Moynihan and colleagues put it in a 2012 BMJ paper.

This is nothing new. In 1976 Ivan Illich wrote in Limits to Medicine that the medical establishment has become a major threat to health. A BMJ theme issue, Too Much Medicine, in 2002 cited Amartya Sen’s observation that the more we spend on healthcare, the more the population is likely to regard itself as sick.

So what can be done – and where does innovation fit in? What we must guard against is new technology simply allowing us to be more efficient in running the existing inefficient and high-cost models of healthcare. This means making sure that innovation disrupts current practice where it needs disrupting.

Since it was first introduced in the late 1990s, Clayton Christensen’s concept of ‘disruptive innovation’ has become part of the currency of management and innovation research and practice. It is increasingly used in healthcare. But it is often misunderstood, used as a label for any kind of innovation that is seen as ‘radical’. And now the growing interest in ‘frugal innovation’ – cheaper, simpler innovation lessons from lower income countries – is further muddying the water.

A disruptive innovation is one that brings to a market a much more affordable product or service that is simpler to use, and thus more likely to be taken up by less demanding customers. As Christensen puts it in an interview in Health Affairs:

‘It allows a whole new population of consumers to afford to own and have the skill to use a product or service, whereas historically, the ability to access was limited to people who have a lot of money or a lot of skill.’

Disruptive innovation is daunting for the incumbents. But when it comes to thinking about new approaches to deliver healthcare services, too often the response is ‘why?’ We need to be more prepared to ask ‘why not’, to experiment with new business models and play, as CK Prahalad called it, in the innovation ‘sandbox’.

Ray Moynihan, Jenny Doust, David Henry. ‘Preventing overdiagnosis: how to stop harming the healthy.’ BMJ 2012; 344:e3502.

Ray Moynihan, Richard Smith. ‘Too much medicine?’ BMJ 2002;324:859.

Mark Smith ‘Disruptive Innovation: Can Health Care Learn from other industries? A conversation with Clayton M. Christensen.’ Health Affairs 2007; 26(3), w288-w295.

CK Prahalad (2006) The innovation sandbox. Strategy + Business 44 (autumn).



An intuitive belief in early detection, fed by deep faith in medical technology is arguably at the heart of the problem of overdiagnosis. Increasingly we’ve come to regard simply being “at risk” of future disease as being a disease in its own right. Starting with treatment of high blood pressure in the middle of the 20th century, increasing proportions of the healthy population have been medicalised and medicated for growing numbers of symptomless conditions, based solely on their estimated risk of future events.

Ray Moynihan, Jenny Doust, David Henry. ‘Preventing overdiagnosis: how to stop harming the healthy.’ BMJ 2012; 344:e3502

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