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NHS Should Focus on Clear End-User Outcomes – Not Technology

Robin Wright

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Robin Wright, Former Director of Health Information Technology at NHS Greater Glasgow and Clyde, reflects on his time in the NHS and gives a perspective on future Digital Service development.

When Uber was being developed as an idea, I feel sure that the ambitions of investors, developers and other stakeholders went beyond the better automation of a business model that was established in the early 20th Century. That the Uber model is an alternative form of demand responsive transport is not in doubt. What is doubtful is whether its creators looked to incrementally build on the model that had been in place since taxi transport began.

Similarly, other paragons of digitally disruptive business including Airbnb and Amazon didn’t hinder their ambitions with the constraints of the long-established room rental or retail markets. Rather than look to augment or supplement existing industries, they tore up the old model and engineered services from a blank canvas.

What is clear in all examples of digital businesses that have disrupted traditional service delivery models, is that there was absolute clarity about what was trying to be achieved from the outset – central to this was a focus on the needs and aspirations of the consumer.

The luxury afforded in the commercial world is one that is not available within public service organisations.

The luxury afforded in the commercial world is one that is not available within public service organisations. Parallel approaches are almost impossible to create, meaning that change needs to be more organic and delivered against a ‘live’ environment.

My experience of 30 years in Healthcare I.T. is that the focus was, and remains on process automation, improvement and connectivity, largely focused internally with little regard for the needs of the ‘consumer’. In fact, the shortcomings and perceived misgivings of the ‘consumer’ in terms of access, competency, security concern or mistrust in the system are often the excuse that gets in the way of progress.

In defence of the NHS and the army of highly committed individuals who work in it, the above does not reflect apathy towards the ‘consumer’, rather it reflects an ill-defined definition of what a digital future looks like, and a lack of investment in winning the ‘hearts and minds’ of senior stakeholders and the practical difficulty in steering a massively complex, deeply interconnected system in an alternative direction.

The mantra of ‘digital health’ has emerged through an evolutionary approach. Data Processing became Information Technology which became ICT. Then along came Health Informatics followed by eHealth, mHealth, dHealth, Big Data, Machine Learning, Telehealth and AI – all now wrapped up in the current ‘Digital Health’ zeitgeist.

It needs to be established and accepted that ‘digital’ is not in itself an end – rather it is a means to an end. Clarity of objectives and outcomes is therefore essential.

There is little facility to ‘stop the bus’ and change its design and direction

In addition, it needs to be accepted that unlike those industries discussed above, where new models have been developed in parallel to those currently operating with a view to disruption and displacement. The NHS in the United Kingdom is a ‘dependency’ service, meeting the health and care demands of a population of some 70 million that is under extreme pressure on a 24/7/365 basis – there is little facility to ‘stop the bus’ and change its design and direction. Nor is there a ‘risk environment’ that lends itself to a speculative approach to change. Rather, the political obsession with, and concomitant scrutiny of Health and Social Care creates an environment within which internal stakeholders are extremely risk averse.

In my pre-NHS career in a large manufacturing organisation, there was a well-established ‘research and development’ approach. This enabled products, processes and services to be de-risked and thoroughly tested in a safe environment in advance of them being produced and offered to customers. Whilst the NHS operates in the context of an ‘evidence base’ regarding the introduction of drugs, treatments and other interventions, there is little by way of process improvement methodology at play beyond the good work that is undertaken in central agencies to set out best practice – utilisation of such tools is poor and restricted to the margins of the change agenda.

In Scotland, the eHealth Strategy 2014-17 will become the Digital Health and Care Strategy 2017-20nn. Clarity on the outcomes that are expected from this shift are not well documented and the recently published Health and Social Care Delivery Plan, whilst acknowledging that Digital will have a more prominent role in ensuring its triple aims of ‘Better Health’, ‘Better Care’ and ‘Better Value’, does little to elaborate on what ambitions are to be fulfilled by digital means. The Health and Social Care Delivery Plan commits to:

  • a review led by international experts of our approach to digital health, use of data and intelligence, to be completed in 2017, which will support the development of world-leading, digitally-enabled health and social care services;
  • a new Digital Health and Social Care Strategy for Scotland, to be published in 2017, that will support a digitally-active population, a digitally-enabled workforce, health and social care integration, whole-system intelligence and sustainable care delivery.

Early progress in these 2 areas will be essential to ensuring that the current model, future plans and ongoing investment are in line with future ambitions.

On a positive note, there is much to be commended in NHS Scotland’s current state. Excellent progress has been made in ensuring that all NHS Boards have the ‘foundations’ in place from which a more joined up, citizen centric, digitally supported service model can be developed and delivered. Governance also works well at a regional and national level where individual organisations collaborate well and deliver common solutions against a commonly agreed set of outcomes.

eHealth colleagues who have worked so hard to achieve this need to be supported to make the transition from these well established and dependable transactional systems, to being able to support the disruptive, transformational approach that will be essential to ensure the enhanced safety, effectiveness, integration and sustainability of services in future.

In terms of data science and informatics, Scotland has been active in this area for many years and is well positioned to support and develop new medical technologies including genomics and stratified medicine. Collaboration between the NHS, the Pharmaceuticals industry and Academic Institutions is in place and making good early progress on exemplar projects.

This will not be a technology led agenda. From the current ‘I.T. Management’ approach there needs to be a greater emphasis on the establishment of Chief Information Officers (CIOs) and Clinical Chief Information Officers (CCIOs) – The former to propagate the digital agenda within Boardrooms, and the latter to ensure that there is appropriate engagement, encouragement and commitment from clinical staff to the changes that will result. In addition, there will be a need to engage the public to enable them to be assured of the approach that is being taken to protect their interests in terms of governance, consent, security, confidentiality and integrity of information and processes.

In England, Matthew Swindells, National Director for Operations and Information at NHS England, has stated: “The challenge of digitising is not at its heart technological – it starts with a clear vision and strategy for the health system and organisation……”

The digital programme is a key pillar of the entire system transformation journey that is underway…

Professor Keith McNeil, Chief Clinical Information Officer at NHS England, states “The digital programme is a key pillar of the entire system transformation journey that is underway, guided by the Five Year Forward View………Our aim here is to create a national movement, of which the global digital exemplars are one important piece of the jigsaw.”

These ‘global digital exemplars’ however, look very much like the incremental model that has been in play thus far – based on the notion that if the ‘fittest’ get to the finishing tape, they will be able to train the rest to a similar level of performance. What is positive in England is that the digital ambitions of Health and Social Care ‘communities’, stated as outcomes and benefits are being built into Sustainability and Transformation Plans (STPs) and Local Digital Roadmaps (LDRs) and are seen as key deliverables in the NHS England ‘five year plan’. In addition, NHS Digital is taking a lead role in a range of underpinning programmes that will ensure the appropriate governance, people, skills, infrastructure and procurement environment, as well as the partnership with suppliers (both established and innovative start-up).

In Ireland, I have been following from afar the developing environment there and am encouraged by the emphasis under the leadership of Richard Corbridge on outcomes rather than technology. Despite not having an infrastructure comparable to the NHS in Scotland and England, Irelands ambitions are well defined, founded on the need to have a people and organisational development focus based on pragmatism within a set of sound strategic aims.

The shift that will be required in the UK is to an approach that recognises and addresses the potential impact of digitally engaging both internally and with the population. There has been historical emphasis on electronic patient records (EPR) to transform care. But EPRs are just one element in a bigger digital health environment. While most doctors say they use some form of EPR, only a small number of them would consider such systems sophisticated enough to meet their increasingly complex and specialist clinical needs. For example, systems that can handle granulated, condition specific and often very large data, send preventive care reminders to patients stratified according to their morbidity status, or even share electronic drug records and prescriptions between clinicians in different health and care environments.

Digital health technology has great potential, but it will have limited impact if it is not aligned with a very clear set of outcomes

Digital health technology has great potential, but it will have limited impact if it is not aligned with a very clear set of outcomes, expressed in a way that both clinicians and the public are able to commit to.

There should be an early emphasis on reducing care fragmentation where individual care decisions are made without considering the patient’s full picture of health and social care. Such fragmentation leaves clinicians and patients frustrated and increases errors, missed diagnoses, and service costs. It is highly likely that NHS staff and the public alike would embrace change based on a desire to de-fragment.

When citizens, patients, doctors, pharmacists, and other specialists are connected to the same electronic health and care record system, the health and care system can be expected to deliver better outcomes. Patient information is in one place, helping make better decisions. For example, a pharmacist looking for a patient’s medication allergies would be able to remind that same patient that it’s time to schedule a cancer screening.

The ability to share health information in real time gives everyone connected to the system — doctors, specialists, nurses, patients and administrative staff — the opportunity to promote preventive care and make better treatment decisions.

Amongst the best example of connectedness between patients, the population and health organisations are in the Kaiser Permanente organisation in the United States, and in the City of Canterbury, New Zealand.

In both of these systems, they have emphasised the importance of population health and citizen/subscriber engagement. Both have established a single shared electronic record making it easier to connect care providers and patients to their health information. They have multiple care provider environments and in KPs case 38 hospitals where a common system is used by clinicians, administrators and patients. Such a system makes it possible to share data across clinical and care groups and to engage patients in accessing and managing their own records. As telemedicine and mobile applications grow, the need for connected health information will be even more important.
Whilst the context within which Kaiser Permanente operates is highly motivated by commercial factors, the healthcare environment that has been created – where close coupling between subscribers and health and care services, around a common set of systems and processes seems to be a reasonable benchmark against which NHS digital ambitions can be set.

In achieving these ambitions, the emphasis will need to be on:

  1. Understand the ambition, thinking about the outcomes that are desirable and achievable, using these as measures of success
  2. Build a digital understanding and awareness, not spending a lot of time talking about technology, but focussing on new service models—and how these can be implemented
  3. Ensure that ‘form follows function’, once service models are defined and tested, think about the technology
  4. Reuse the best of what you have, taking advantage of proven technologies and existing data, exposing it to innovative specialist applications where appropriate
  5. Use data to inform decisions, data will be at the heart of digital services and needs to be organised and governed appropriately.

Digital Health is not a panacea for success. However, an unclouded vision of future services, clarity on how they will be supported by digital technologies, and a workforce and population that is committed to them will contribute greatly to better and more sustainable services in future.

Robin Wright

Director - High Parks Consultancy

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