Introduction by Croakey: Concerns were raised in The Guardian last month about the transparency of a federal government grant awarded to the University of Sydney in 2017 for the development of mental health platform Innowell.
More specifically, concerns were raised that the $33 million grant was awarded without a competitive tender.
Transparency International Australia’s chief executive, Clancy Moore told The Guardian: “The decision to award a one-off closed grant to a for-profit entity, which the then-national mental health commissioner, a position appointed by the government, had shares in does raise obvious conflicts of interests and a clear risk in the awarding of the grant.”
Additionally, The Guardian reported concerns about the efficacy of the platform and taxpayer’s value for money.
Below, Professor Ian Hickie AM, Co-director, Health and Policy, at the Brain and Mind Centre at University of Sydney, explains the history of the development of the Innowell platform and addresses these concerns, stressing the importance of the application to practice and policy of knowledge gained through research.
Ian Hickie writes:
Recent media reports have raised questions about government involvement in the development of the mental health technology, evaluated under Project Synergy, Phase 2 (2017-2020).
I have been involved in this initiative since its origin in 2010 and am currently a 3.2 percent shareholder of its parent company, Innowell Pty Ltd.
I welcome this opportunity to outline to Croakey readers the long background and evaluation of this clinical platform and respond to the criticism that has been made.
A mental health tool
Innowell Pty Ltd is a joint venture, for profit, spin-off company of some of the digital technologies developed by the Brain and Mind Centre (BMC) at the University of Sydney (USYD).
The main product of Innowell is a clinical platform that supports people with mental ill-health and clinicians to deliver a well-established and evidence-based service, namely measurement-based care. It’s not an app but rather a practice-based tool, like many other software programs that medical practices use to manage their clinical, administrative, financial or record-keeping operations.
Innowell operates as ‘Software as a service’ (SaaS), where the software is centrally hosted and then provided under licence to healthcare organisations.
Its ongoing R&D is an iterative cycle to optimise its use in different populations including youth, older people, defence personnel veterans, people with eating disorders as well as in different health service settings including headspace services, primary care and specialist mental healthcare.
History of Innowell
The development of the clinical platform started in 2010 when BMC joined with other major academic and social enterprise groups to establish the not-for-profit ‘Young and Well CRC’, funded by a competitive grant from the Australian Government Science and Technology, Cooperative Research Centres Grant Scheme.
The Young and Well CRC (2011-16), secured $27.5m in direct grant funding, shared across 70 partner organisation and 14 essential partners, including the BMC at University of Sydney. Those partner organisations themselves invested $8.3m in cash, over $80m in-kind, and their background IP to that first ever ‘social impact’ CRC.
The CRC had a number of different streams, one of which was led by BMC and focused on digital interfaces to deliver highly-personalised and measurement-based care (HP&MBC). The engagement of young people with lived experiences, and ongoing co-design, were essential components of this stream.
The first phase of evaluation within health services was augmented with a direct $5.5m grant by the Australian Government (Project Synergy, Phase 1, 2014-16, reported in MJA supplement 2019).
At the end of the funding period (2016), Young and Well CRC ceased to operate, and the relevant IP for Stream 3 was transferred back to the University of Sydney. The implementation of technologies within mental health services was continued by the BMC, which also held a nationally-competitive NHMRC Centre of Research Excellence Grant ‘Optymise’ (2013-2018), focused on implementation of highly-personalised and measurement-based care for young people with emerging mood disorders.
In early 2017, the University of Sydney, in partnership with PwC Australia, formed a new joint venture, Innowell Pty Ltd, to take forward the commercial development of digital tools previously developed by the BMC. Professor Jane Burns took up the position as the inaugural CEO of that new entity. My own (unpaid) ongoing role is as Scientific Advisor to the Company.
In forming Innowell, the partners allocated the respective shareholdings, 45 percent to USYD, 45 percent to PwC, and 5 percent respectively to me and Professor Burns, recognising our roles in creation of this capability. The company has its own independent Board (inaugural Chair, the Honourable Michael Ronaldson). The University of Sydney is represented on the Board by its own nominee from the office of the Deputy Vice Chancellor, Research.
In 2017 Innowell received funding directly from the Australian Government Department of Health to support Project Synergy, Phase 2, to build on work undertaken by the CRC. The terms and conditions were set by DoH and the continuous reporting of activities and relevant expenditures were overseen by the Department over the life of that grant.
The clear expectation was that beyond 2020, Innowell would be at a stage where it did not require any additional government or university funding and could be commercialised.
Innowell’s digital products are now actively used by healthcare organisations in Australia and in Canada.
That is, the development of Innowell has allowed us to take our earlier university-based and not-for-profit R&D from a very local prototype to much wider commercialisation and international impact. Consistent with the intentions of the original CRC grant, and the subsequent investments by the government, it is no longer reliant on Australian Government funding for its growth or activity.
As stated by the CEO of Innowell Syed Ahmed, “since commencing commercialisation in 2021, the platform has well over 100,000 users. While it is still in early stages of growth, revenues are expected to total above $50m over the next three years”.
Responding to criticism
The criticisms of this Australian success story appear to fall into four categories: a partnership with PwC Australia; lack of participation in nationally-competitive grant processes; direct Federal Government investment in its development; insufficient evaluation; lack of engagement of those with lived experience; a waste of public monies (due to the wrong assertion that it is not in use in Australian healthcare), and, my undue influence on the allocation of national funds.
A response to each of these criticisms now follows.
The decision of the University of Sydney to partner with PwC in 2017 was driven by PwC’s commitment to invest in mental health in general (as evidenced by their support for a separate CRC application). PwC brought a capacity for commercialisation and internationalisation that complemented the R&D skills of the BMC.
Up to this point, they have derived no direct financial benefit from their participation. The subsequent actions of their partners in tax-related manners were unknown at the time. However, as of this week’s board meeting, PwC are no longer a shareholder.
The investment by two successive federal governments in this initiative followed its initial success arising from the nationally-competitive CRC Program. This was not thought unusual at the time. My advocacy for investments in digital mental health over the last 15 years has been open, transparent and supported by other leaders in the field (see MJA 2010).
It was not linked with my advisory position as a National Mental Health Commissioner (2012-2018).
The process of continuous R&D has been reported extensively in the academic literature over the life of this program. This process seeks to take a well-validated health service intervention – namely, measurement-based care – into wider application in a diverse range of mental healthcare settings.
The relevant form of evaluation of the health system impacts, barriers and facilitators to optimal use, and adaptation to various populations and health service organisations is not a matter of conducting one or more clinical trials of single interventions. It is an iterative process and uses appropriate qualitative and quantitative methods.
What has been learnt can be summarised as it is possible (in Australia and Canada) to incorporate the technology infrastructure to support measurement-based care in those healthcare organisations that genuinely want to improve the effectiveness and quality of their service delivery.
However, this is not easily achieved as it does require substantive rearrangement of many current practices as well as the adoption of new procedures (at the organisational and clinician levels) to respond to the information that is being fed back actively by service users.
There are substantial barriers to this process, most commonly presented by service managers (lack of funding support for digital transformation, need to reorganise basic intake, triage, review and escalation of care procedures) and clinicians (need to reorganise their own clinical practices to incorporate active information sharing with their clients; need to operate multiple digital tools across clinical, administrative, records and finance systems).
Over the last 15 years, a large number and variety of people with lived experiences have participated in this process, most notably young people where much of the work has been focused.
While many issues have been raised as to how best to organise and share information on this platform, the most persistent support for its use has come from those service users who perceive it to be empowering, and a key opportunity to be genuinely active partners in their care journey.
The ongoing use of the platform in Australia, and internationally, its links with very active quantitative and qualitative service evaluation and ongoing trials of new health system innovations, and its impacts on improving service performance stand in contrast to any notion that is has been ‘scrapped’ or has been a waste of public monies.
Some reflections on this process may be valuable.
Some academics and public sector advocates seem to object to private-public partnerships, and private investment, that potentially take the benefits of publicly-funded and university-conducted R&D to national and international commercialisation and impact.
The assumption appears to be that they should simply rely on continuous competitive Australian funding sources for their development and operation, and that the academics engaged in their development should not derive (directly or indirectly through IP held by their institution) any of the value of those developments. I don’t share that view.
It is common elsewhere in the world, and more obviously through the conventional development of patents and licenses, that substantial private investment is necessary to scale innovations (think new medicines, new diagnostics, new devices) and deploy them internationally.
This is now the case for medical software, and the needs and the commercial markets are large and international. If we want to develop our medical research industries in Australia, keep our smartest people engaged academically, and have the greatest return on Australian inventions, then I believe we need to address these issues.
The most important other issue I think at stake here is transparency of reporting personal interests and continuing our commitment to reporting the ‘warts and all’ of our work in the academic literature. I believe that I have done this throughout my engagement at all stages of the development of Innowell.
Perhaps what separates our work from that of others is our engagement with the spirit of the German philosopher, Johan Wolfgand von Goehte, “Knowing is not enough; we must apply. Willing is not enough; we must do.”
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