In his first speech as health and social care secretary, Matt Hancock announced that one of his three priorities for his new department is technology. He even announced – or perhaps more accurately re-announced – what he described as a “half-a-billion-pound” package to “help jumpstart” innovation.
We shouldn’t underestimate the importance of high-level, ministerial backing for IT in the NHS; which in the National Programme for IT-era and beyond was frequently seen as boring, expensive, and liable to fail. Nor should we underestimate the importance of funding.
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Shiny, new things
However, as I read on, I found myself increasingly dismayed by Hancock’s focus on AI, digital GP services, and apps as the early hooks on which to hang his thinking.
Hancock has only just arrived from the Department for Digital, Culture, Media and Sport, so I readily accept it will take him a while to understand the complexities of the health and care system. But it isn’t the latest headline-friendly, consumer-facing technology that is going to make the real difference to its performance that is needed.
AI, apps, and innovations like Alexa, that Hancock also mentioned, will make a contribution; but it’s likely to be limited and over the long-term. What is missing is a connection to the reality of the NHS and social care system today and their immediate and medium-term needs.
The spotlight needs to move away from bright shiny new things to the difficult challenges of changing ways-of-working and processes at the coal face, with the adoption of current, proven solutions at scale.
Looking through the telescope from the wrong end
Focus also needs to be applied in the right places. At the moment, there is huge NHS, social care and media focus on the problem of delayed discharges (bed blocking) and the fact that circa 60% plus acute beds are occupied by typically elderly and often frail patients.
While this situation needs to be addressed, the attention it is getting needs to shift to the prevention of A&E episodes and subsequent inpatient stays.
I work with a company called Docobo that helps staff monitor and support patients in their own homes. We constantly see the knock-on effect of long-term care patients attending A&E and being put into beds.
That disrupts the elective admissions programme for the hospital the next and subsequent days. It also has a deleterious impact on patients. All the evidence is that once they are in a bed, their health status can deteriorate if they are not discharged quickly. Since many hospitals struggle to discharge, their problems can easily become greater than they were at the outset.
Long-term problems and short-term thinking
One reason this situation arises is the huge financial pressure that the health and social care systems are under. This skews local thinking towards managing often conflicting individual budgets. Daily we see clinical commissioning groups stripping vital community services to reduce costs and pay for redundancies.
The resulting policy driven ‘silo mentality’ fails to recognise that a holistic approach to keeping patients out of hospital, within local services, and in their own homes when possible will lessen demand on acute services, improve productivity and deliver better outcomes.
Or, perhaps, when this is recognised, it makes it difficult to act upon it. Clinical commissioning groups want to control expenditure; acute trusts want more revenue (without always realising that many of their patients are costing more than the tariff, hence the huge losses they are now facing); and community services are left in the middle with often inefficient working practices, such as too many home nursing visits (even though many are unable to fill posts)..
There is a solution, but it needs vision and direction. The Five Year Forward View produced by NHS England chief executive Simon Stevens emphasised the need for integrated working and led to the creation of sustainability and transformation partnerships to take it forward.
The most advanced STPs have morphed into integrated care services. These are a massive start; but, naturally, they will take time to become operational and effective. Meanwhile, there is much that can be achieved for a very modest investment; as long as that investment is put in the right place.
Don’t talk PHM, do it
The cohort of long-term conditions patients with multi comorbidities is where a combination of digital technology and a changed approach to working practices has a real chance to make a significant, positive impact on acute services, by reducing that flow to A&E, and to inpatient wards, and to delayed discharges.
Population health management, offers the means to identify those patients whose demands on the NHS are constant and significant, and who need more proactive interventions. The data analysis required, and the digital interventions that follow, are being undertaken across many parts of the NHS (a good example is the NHS Innovation Accelerator solution called ArtemusICS).
But it is often being done at a very low level. It is not being done to the point at which CCGs/emerging ICSs are seeing it as a real means to develop a holistic approach to planning health and care services for their citizens, patients and users.
Too many CCGs still operate blind, and individual services and managers struggle to use the new capabilities effectively. This is where ministerial leadership, promotion by the NHS’ executive management, and a national deployment to ensure consistency of approach could make a real difference and generate a change in performance.
Putting the patient first
Once the most demanding patients can be identified, the issue becomes one of intervention and that’s where home patient monitoring and support comes to the fore.
Docobo works in Liverpool, where the clinical commissioning group has given it an extendable three-year contract to scale-up the telehealth service, first tested with the More Independent Programme.
This completely rethought the delivery of community services to people living with lung conditions, heart failure and diabetes. The 6,000th patient has just been recruited to use the telehealth service in Liverpool, which is linked to a monitoring hub staffed by experienced community nurses, who offer advice and interventions when needed.
The problem is that in too many areas, the NHS has tried to adopt digital technology without senior management buy-in, without identifying the right cohorts, and without re-thinking services and working practices in this way. This has led to repeated ‘failures’ or disappointing returns on the investment made.
The absence of the widespread adoption of patient monitoring is not the fault of the concept or the technology but the underlying culture. Again, ministerial and senior management support, and guidance on how to make the most of the IT available, would make a real difference.
If much of the NHS could be encouraged to follow Liverpool’s lead, we would see great strides – this winter – long before AI or robotics generate the same levels of hospital admission avoidance or improved productivity.
App-ly the right thinking
As I said at the outset, it’s great that we have a health and social care secretary who is interested in technology, willing to talk about it, and up for spending money on it. But in his next speech, I hope Matt Hancock focuses less on new technology and more on scaling the proven technology that the NHS and supplier industry already have.
Rolling out population health management and effective monitoring for those patients that will otherwise end up in hospital will require leadership. It will require engagement, because technology without change does not work. And it will take money, because driving change needs financial support.
Hancock’s predecessor, Jeremy Hunt, was in post for six-years. With the uncertainty over Brexit, and the rapid change-over of ministers in the present government, Hancock may not get the same amount of time to make his mark.
Yet he has a huge opportunity, with a new ten-year plan for the NHS in preparation, a social care green paper promised, and the Treasury’s spending review due to ramp-up in the autumn.
Let’s hope he doesn’t continue to be distracted by shiny, grabby tech; and uses it to focus on the areas that can deliver right now and so put some investment into addressing the immediate challenges. The technology and solutions already exist and are proven and, unlike AI, can impact this winters’ A&E and unplanned admission numbers.