At its most recent meeting, Highland Marketing’s advisory board discussed the health tech response to the coronavirus outbreak: and what will be needed to consolidate the rapid shift to digital first working when the crisis is over. Lyn Whitfield reports.
The novel coronavirus has caused huge disruption in a very short space of time. Some of the changes are obvious: prime minister Boris Johnson instructed the country to “stay at home” on 23 March, with a huge impact on the economy, housing and education.
The following day, NHS England / Improvement confirmed that it was building a 4,000-bed Nightingale Hospital at ExCel London, with others to follow in Birmingham, Manchester, Harrogate and Bristol. Some of the changes have been less obvious; at least to the public.
Healthcare technology, for example, has been adopted at a speed that was hard to contemplate even six weeks ago, when visitors to Digital Health Rewired were still discussing the potential for remote working and whether the crisis would encourage GPs to try video consultations.
Since then, NHS Digital has deployed Microsoft Teams to everyone with an NHS email address and seen usage increase by 300% in a week. GPs have moved as much as 90% of their work online almost overnight, and outpatient departments have followed suit.
Meanwhile, health tech firms have been scrambling to create or modify solutions to help the NHS identify Covid-19 patients, support those with symptoms in and out of hospital, enable the shift to ‘digital first’ working, and track the progress of the epidemic.
So much so, that James Norman, healthcare CIO, EMEA, at Dell EMC, told the Highland Marketing advisory board that the first few days had been “pandemonium”, with government IT agencies struggling to process the volume of offers coming through, and to match them with requests from the service.
“What this showed was that we should have had a system for co-ordinating the digital response in advance,” he said. “Nobody could have planned for the exact nature of the crisis, but there should have been a way for suppliers to come on board, to get staff working from home, and to get the comms in place.”
Change agents – leadership, money, vendor offers
Andy Kinnear, the former director of digital transformation at South, Central and West Commissioning Support Unit, was not too worried about this. “The vendor community is coming out of this looking great,” he said. “They might be pushing ahead so quickly that the NHS is struggling to keep up, but that is a nice problem to have.”
On the other hand, he had mixed feelings about the NHS response. “It is great to see so much good stuff going on,” he said, “but we could have pushed on further, faster, earlier – and then we would have been in a better place when this hit.”
What has changed to enable the NHS to move as fast as it has? There has been some strong leadership from the NHS’ central bodies, and a flattening of procurement and decision-making structures; Teams was just rolled out in four days, NHS 111 services are being procured nationally, GP triage and consultation procurements have been run in hours.
There is more money around. Chancellor Rishi Sunak promised the NHS “whatever it costs” to get through the crisis. Just as importantly, NHS England / Improvement has suspended the contracting mechanisms that could make redesigning a service and pricing up its digital elements tortuous – and told organisations to get on with it.
Some of the information governance blocks on sharing information and using commercial communications tools have simply been suspended. And many vendors have been making their software adjustments or services available free.
As Andy Kinnear argued: “I have been saying in conferences for years now that nothing should matter except making things better for patients and in the current crisis that is very, very stark. It’s the only thing that matters, and what you see is the value of folks doing it.”
The challenge is sustainability
Still, there are challenges. The NHS central bodies have stepped-up and stepped-in, but Andy Kinnear pointed out that this was putting a lot of pressure on a few individuals that cannot be sustained. Local organisations are making rapid procurement decisions, but some of them will be bad decisions.
It’s unclear whether the NHS internal market will return, but it’s certain that, at some point, the NHS Data Guardian and the Information Commissioner’s Office will take a keener interest in some of the data sharing that is going on. And there will be a financial reckoning.
“I see lots of companies offering products and services for free and I also see software companies offering additional licences for the short-term,” said board chair Jeremy Nettle.
“That’s a great response to the ‘call to action’, but I can see that there may be bills mounting up in the background that will have to be settled come the day of reckoning. There is no such thing as a free-lunch so there will need to be some interesting negotiations to be done on the back of this.”
Data architectures and cyber security are missing
Also, while the implementation of health tech and the shift to digital working has been impressive, it has not been uniform. There are gaps; and one of the big ones seems to be the collection and use of data.
At Digital Health Rewired, NHS Digital chief executive Sarah Wilkinson said her agency was developing a new algorithm to detect patients with Covid-19 and scripts to direct NHS 111 callers to the right service. Subsequently, NHS 111 Online has created a Covid-19 symptom checker and is offering text support to people self-isolating.
But Jeremy Nettle argued that this kind of thinking should have been more in evidence before the outbreak, to reduce underlying demand on hospitals. And James Norman argued that more e-care apps are needed, for example to help non-Covid-19 patients who are being advised to avoid hospital or finding it harder to access services than normal.
Andrena Logue from Experiential HealthTech argued that the technology the NHS is deploying now should put it in a better position to develop data driven services in the future, because it will be capturing more information for analysis to inform apps.
But Andy Kinnear pointed out that this would only happen if the NHS gets the data architecture right. And, for the moment, strategic thinking on data architecture has gone out of the window. Similarly, systems are being deployed with little thought for interoperability, or even cyber security.
Entrepreneur Ravi Kumar said the NHS really needed to stop and think about the last point. “A couple of weeks ago, we were probably opening up a handful of ports and now we are opening up dozens or hundreds,” he said. “We need some sort of defence force to monitor what is going on. Because if the network went down – who knows what would happen?”
The acute sector is still missing
Other gaps are shared care records, which appear to be on hold for the moment, and the acute sector. Trusts have been extending their electronic patient record systems to new services; most obviously, the Nightingale Hospital at ExCel London is using the Barts Health instance of Cerner Millennium.
They have also been working with suppliers to configure their EPRs to track the status of Covid-19 patients. But there hasn’t been much new thinking on how technology can help hospitals through the crisis or discussion of how enterprise IT can be extended to the quarter or more of trusts that still have no EPR at all.
Andrena Logue suggested there might be an opportunity to create a lightweight offer for these organisations that would deliver many of the functions of an EPR, without the procurement and deployment effort. “If we have disruption and innovation going on in response to it, this seems like a great opportunity to do things differently,” she argued.
Andy Kinnear agreed there might. “If you are saying could smaller, less agile trusts that have failed to invest over the years suddenly leap over others by taking a light-touch solution that makes use of 5G… then yes, they could,” he said.
However, he pointed out “there is a reason that these organisations are so far behind everybody else, and that’s [lack of] leadership, and funding, and capacity to deploy, and capacity to drive change.” To address these issues, he argued there needed to be a shift back to delivering IT at a regional level.
This would be in-line with international developments and with the new, more directional role being taken by NHS England / Improvement. The big challenge may be money. The digital aspirant programme, announced just before the outbreak, works out at roughly £1 million to each of 23 hospitals; nothing like enough.
“Covid-19 might change things,” Andy Kinnear said. “Hancock might say: ‘Right, here is the money, everybody has to have an EPR in place by 2022… but I am sceptical. Or optimistic in a realistic way. After the outbreak, if the economy is struggling, I think it will be difficult to get the money.”
Andrena Logue suggested that smaller suppliers could also be shut out by such an approach, stifling innovation. But most board members felt that scale and money were the bigger issues. “Spending on IT has got to rise,” Ravi Kumar argued.
“Nobody can do this free forever. As we were discussing earlier, people get tired, and they have bills to pay. So, if we want to sustain this, we need to have a conversation, soon, with the Treasury and the Cabinet Office. How the technology is then delivered is secondary. It has to start with the money.”
No going back
Overall, the board was impressed by the health tech response to Covid-19 and the speed at which sections of the NHS have adopted new ways of working. And members felt there was no going back. Both clinicians and patients are seeing the benefits of remote working, and commissioners and trusts are looking to build on that to drive service redesign in the future.
To build on that, the board suggested that a “lessons learned” exercise would be useful, that digital maturity models should be revisited to include new ways of working at a health-economy level, and that suppliers could be introduced to each other to support innovation.
Although NHS IT has changed in response to terrible circumstances, Jeremy Nettle thought it was in for an exciting time. “It will be interesting to see which changes stick and which don’t,” he said. “Will people say ‘We did this in the Covid time, but we’re not going to do that now’ or will they say ‘We did it in the Covid time, so there is absolutely no reason that we cannot do it now’ – and I think it will be the latter.”
January: The first indications of an outbreak of a novel coronavirus emerge from the Chinese province of Wuhan.
22 January: Screening for travellers from Wuhan starts at Heathrow, as Public Health England upgrades its risk to the public from “very low” to “low.”
29 January: Two Chinese nationals fall ill and test positive in York. A plane load of Britons is evacuated from Wuhan and put into isolation on Merseyside.
February: For most of the month, interest in the virus remains centred on specific cases; such as the outbreak on the Diamond Princess cruise ship moored off Japan.
11 February: The World Health Organisation names the new disease Covid-19 (the virus that causes it is SARS-CoV-2).
28 February: The death of the first Briton is announced; a passenger on the Diamond Princess. Stock markets crash.
W/b 2 March: Cases of Covid-19 start to surge and European countries try to limit its spread.
5 March: The death of the first person to die of Covid-19 in the UK is announced as the number of people testing positive in the UK passes 100.
W/b 9 March: Wednesday, 11 March: Chancellor Rishi Sunak unveils his first Budget. This promises the NHS “whatever it costs” to address the epidemic, starting with a £5 billion emergency fund for health and social care, alongside a £7 billion package of economic support.
Thursday, 12 March: The World Health Organisation declares a pandemic.
Friday 13 March: Premier League fixtures are suspended.
W/b 16 March: Monday, 16 March: Prime minister Boris Johnson starts daily press conferences. People are urged to work from home as pubs and restaurants are closed.
Tuesday, 17 March: Rishi Sunak returns to the Commons to unveil a huge package of state aid for companies that includes £330 billion of government-backed loans and £20 billion of tax cuts and grants.
On the same day, NHS chief executive Sir Simon Stevens sends a ‘dear colleague’ letter to the NHS, telling it to free-up 30,000 beds, suspend elective activity, and test operational readiness.
Wednesday, 18 March: Schools close.
Thursday, 19 March: The government publishes its Coronavirus (emergency powers) Bill.
Friday, 20 March: Rishi Sunak makes his third intervention, saying the government will pay 80% of the wages of employees who would be laid off otherwise. Remaining social spaces, including gyms, are closed – but people flock to hills and beaches over the weekend.
W/b 23 March: Tuesday, 24 March: Boris Johnson uses a BBC broadcast to tell people that they must “stay at home” and can only go out to work, collect supplies and exercise. NHS England confirms it is creating a 4,000 bed Nightingale Hospital at London’s ExCel Centre. Field hospitals are subsequently announced in Manchester, Birmingham, Harrogate and Bristol.
Sunday, 29 March: The UK death toll from Covid-19 passes 1,000. Deputy chief medical officer Dr Jenny Harries tells the daily Downing Street press conference the lock-down could last three to six months “and it is plausible it could go further.”
W/b 30 March: Thursday, 2 April: Amid concern about personal protective equipment and testing, health and social care secretary Matt Hancock outlines a five-point plan to carry out 100,000 tests a day by the end of April.
Friday, 3 April: Boris Johnson announces that after seven days of self-isolation he is going to continue in quarantine because he still has symptoms of Covid-19. Four days later, he is admitted to intensive care.
Health tech responses:
National action: Patient facing services: On 4 March, Sarah Wilkinson, the chief executive of NHS Digital, tore up her speech to the Digital Health Rewired conference to outline her agency’s response to the looming crisis. She said NHS Digital was sorting out access to the NHS Summary Care Record and ramping up NHS 111 and NHS 111 Online.
Subsequently, NHS Digital delivered a flag that identifies when a patient has tested positive for the disease. It has also delivered an algorithm to identify ‘vulnerable’ patients who need to ‘shield’, an NHS 111 Online symptom checker, and a text service for self-isolating patients.
Remote working and recruitment: NHS Digital has also rolled out Microsoft Teams to all staff with an NHSmail account; and is working with the company to develop clinical meeting and patient consultation functionality. NHS England is about to start trials of digital ‘staff passports’ that will make it easier for staff to move between organisations, including the Nightingale Hospitals. And it has worked with GoodSAM to recruit 750,000 people to the NHS Volunteer Responders scheme.
Data and tracking: NHSX has been focusing on data and industry challenges. It is working with large tech companies, including Microsoft and Palantir, on a Covid-19 capacity dashboard, is developing a tracker app, and running a Techforce19 challenge for IT that can be “rapidly scaled” to support older and vulnerable people, who have been advised to self-isolate for three months.
IG guidance: NHSX has also issued guidance, endorsed by the NHS Data Guardian and the Information Commissioner’s Office, to encourage data sharing. This says NHS staff are very unlikely to fall foul of information governance regulations if they are trying to provide care, and commercial apps like WhatsApp and Telegram can be used for team working, where no alternatives exist.
Digital first primary care: On 5 March, NHS England told GP practices to triage appointments by telephone or video and to run remote consultations where possible. Professor Martin Marshall, the head of the Royal College of GPs, said many practices did not have the infrastructure or computers to do this, and that online working posed regulatory and financial challenges.
Despite this, Sir Simon Stevens’ ‘dear colleague’ letter on 17 March reiterated that GPs should move to ‘digital first’ operation and only see patients face to face if absolutely necessary. NHS England subsequently issued a 48-hour tender for text messaging, automated triage, and video consultation technology.
Established providers have also moved to support new ways of working, with TPP bringing forward the launch of its patient-facing app, Airmid, and EMIS making its Video Consult service free to practices for 12 weeks. Partner providers like X-on have reconfigured their online and telephone booking platforms and patient contact services to support Covid-19 working, often at no charge.
Hospitals: Digital outpatients: Sir Simon’s letter of 17 March also urged hospitals to switch to digital outpatients, using “video, telephone, email and text message services” to cover “all important routine activity as soon as possible.” David Probert, chief executive of Moorfields NHS Foundation Trust, is leading a taskforce to help acute providers with the change.
Enterprise IT: In the acute space, large IT providers have been working with the NHS to support Covid-19 diagnosis and treatment. For example, CliniSys is working with Public Health England to make sure its laboratory information management system can run Covid-19 tests.
Trusts have also been configuring their electronic patient records to make sure that staff can identify patients with the disease and take appropriate action. Cerner told Highland Marketing that West Suffolk Hospital and Milton Keynes University Hospitals have created alerts that tell clinicians when test results are due or patients have tested positive for Covid-19.
Allscripts told Highland Marketing that its reference clients have taken similar steps, while Gloucestershire Hospitals decided to go-live with its e-observations system, so it could easily identify and respond to deteriorating patients. E-observations specialist Patientrack has built a coronavirus assessment tool for NHS trusts and rolled it out free of charge.
Free or time-limited support from health tech companies has been something of a feature of the response to the coronavirus outbreak, with cloud record suppliers, communication app suppliers and analytics companies scaling to meet demand, moving to create Covid-19 tools, or making offers to support the service.
DIY innovation: Away from the NHS, video conferencing and collaboration platforms such as Zoom have seen a huge increase in usage, to support home working, communication between family members who cannot visit each other, and services that can no longer be delivered face to face.
In the charity sector, Turning Point, which supports people with learning disabilities, has shifted from group-work and drop-ins to remote counselling and coaching via phone and video calls. And in the private sector, fitness coach Joe Wicks has become something of a social phenomenon for its early morning PE lessons, which have an audience of up to a million people.