Can technology save the NHS?
The NHS is undoubtedly in crisis. One in ten GP practices now regard themselves as being financially unsustainable, according to the British Medical Association; hospitals are “close to breaking point”, the same organisation warns; and estimates for the funding shortfall facing the entire service range from the tens to the hundreds of billions.
In 1948, political momentum, “big enough data” and “good enough technologies” turned three simple principles into a world-revered health system. Those principles were a national health service that met the needs of everyone, was free at the point of delivery, and based on clinical need, not ability to pay. But with an ageing population and proportionally fewer people chipping into the pot, those three principles are under severe threat. Can anything save the NHS?
Politicians seem long on rhetoric but short on answers, and even shorter on the cash required to plug the funding gap. Could technology be the white knight everyone’s searching for? We’ve canvassed the opinions of ten health industry experts, all of whom are involved in driving technology into the NHS in Greater Manchester, one of the devolved administrations that has been able to run pioneering trials of new technology without being dragged down by the weight of the NHS. They’ve identified and piloted practical ways in which technology and Big Data could help solve the crisis – but are they confident that their groundbreaking work won’t simply be lost in bureaucracy and endless funding battles?
Conquering the data mountain
If there’s one thing that the NHS isn’t short of, it’s data. As Dr John Moore, clinical director of adult critical care at the NHS’s Central Manchester Foundation Trust, explained, his hospital alone has “data on over a million patient hospital admissions with over 100 million clinical observations or test results”. It’s what – or what isn’t – happening with that data that gives cause for concern. Too much patient data is held in silos, trapped within proprietary systems and formats at a trust or department level, or not shared with related departments such as social care and transport.
Most concerningly of all, patients have little or no control over their own health records. Making full use of the data available can deliver amazing results, such as easing bed-blocking, where patients remain in hospital for longer than they need to. “Understanding patient recovery with electronically recorded four-hourly observations and patients’ blood test results will allow us to model when patients can go home safely and continue their recovery,” said Dr Moore. “Utilising technology in this way will allow us to incorporate machine intelligence into our medical planning and reliably predict a patient’s recovery pattern dependent upon their admitting condition, other health issues and demographic factors. This will promote both early discharge and the identification of those patients that may not require admission in the first place.”
Specialists believe that too many people are admitted to hospital unnecessarily because risk-averse clinicians simply don’t use data to make brave decisions. “Technology offers us an alternative to crude binary thinking, which all too often oversimplifies healthcare,” said Professor Rick Body, a specialist in emergency medicine. “Clinicians conventionally seek to ‘rule in’ and ‘rule out’ important diagnoses. However, the popular reaction to underdiagnosis means that our tolerance for both is low. The resultant paralysing risk aversion can mean that, for example, patients are admitted to hospital if there’s even a 1% probability that they have a serious diagnosis.”
Plugging in patient-led data
Nowadays, it’s not only the professionals who collect medical data about patients, but the patients themselves. That heart-rate monitor you wear when you go jogging, the dietary information you plug into a slimming app and the sleep data recorded by your smartwatch could all help make better clinical care decisions.
“Healthier lifestyles can be supported with passively and proactively collected data”
Currently, however, there are few ways of feeding patient-generated data into the health system. “People can contribute personal health information and home monitoring to inform better care,” said Stephen Critchlow, founder and CEO of Evergreen Life, a business in Manchester that harnesses NHS data in apps for patients. “Healthier lifestyles can be supported with passively and proactively collected data, which are becoming the digital byproducts of everyday life. Combining clinical, self-care and wellbeing information in this way could reduce NHS pressures (for example, unnecessary clinic visits when home monitoring will do), make us all healthier and free up resources for the neediest.”
The case for accelerating the use of data collected by patients themselves is strong. For example, many strokes are preventable if only patients with an irregular heartbeat were picked up and treated with anti-clotting medication. A GP putting her/his finger on a patient’s wrist to feel for a sporadically irregular pulse (the sign of atrial fibrillation) is much less likely to pick up the condition than a device worn for a week that reports back to the GP. Medical technologies for this purpose are expensive, but an irregular pulse is a crude signal that even cheap consumer health devices, such as wrist-worn heart-rate monitors, could help detect.
Even without the benefit of continuous monitoring devices, it’s not a great technical leap for an “NHS app” to ask a patient to put their finger on the back of a smartphone with a juxtaposed light source and camera. This could detect the heart rhythm (or lack of) from the change in light passing through the skin, as small blood vessels fill up and block the light after each heartbeat. Simple, everyday technology that could save lives, if only there were some way to feed that data into the system and marry it with other potential data clues, such as previous family history of heart attacks, high blood pressure or near-miss strokes.
The Greater Manchester medics have already seen positive, cost-saving results when patients are asked to record their own health symptoms via their mobile devices. “We’ve demonstrated that patients with rheumatoid arthritis are willing to report symptom data regularly using a smartphone app incorporated into their medical record,” Will Dixon, professor of digital epidemiology at the Greater Manchester Connected Health Cities programme, told us. “We’ve proven that access to data on chronic disease symptoms improves clinical consultations. In time, we’ll be able to better prioritise outpatient appointments using this data, providing better care at lower cost. Such data also has the power to uncover unknown patterns of disease and response to treatment.”
Sumit Nagpal, CEO of LumiraDX, a company that combines patient diagnostics with clinical records, says empowering patients to collect and share their own data can only be a good thing. “Such a model of care involves more accountability for our own health and lifestyle choices for each of us,” he said. “It delivers more proactive care by knowing what is happening to us, in real-time, via use of personal diagnostics, biometrics and social media. It arms our caregivers with a much more complete picture – always with our consent – of our health and social care history when we need their help.” And better still, it does so at reduced cost.
Eric Applewhite, director of the Greater Manchester Connect programme, agrees that greater citizen involvement is the key. “The future of better care is when residents meet us online at a time of their choosing, understand what we know about them, and use that knowledge to co-manage their care with us,” he said. “After all, how can we meaningfully talk about care co-ordination and improvement without them at the centre?”
Moving from digital health to digital self
It’s not only within the NHS that data silos must be broken down. Data must also move more freely between different public services if health data is to inform decision-making in social care, transport and other related areas, and vice versa. For example, increased levels of physical exercise across the whole population would have a profound effect on reducing common long-term conditions that consume the lion’s share of NHS resources.
Greater Manchester has a new tram system that could improve public health by giving residents the option to walk/tram to work rather than take the car, but there is a problem: its fares are the highest in Europe. Furthermore, those who can’t afford the tram/walk option tend to live in areas with much higher levels of ill health, as revealed by an infographic plotting average life expectancy at the different stops on the tram lines. Could Greater Manchester save tens of millions of pounds on long-term healthcare by reducing tram fares in areas with the greatest health problems? Quite possibly, but without access to the data, the decision-makers don’t have the opportunity to make such fundamental choices.
Smart cities of the future will hopefully react to their residents’ health data, adapting services for individuals and communities accordingly. “This information comes from across the public-service sector – health, social care, education, transport – giving a holistic view of the environment and place,” said Professor John Ainsworth, director of North England’s Connected Health Cities. “This increased connectedness will enable public services to be planned and managed to transform the NHS from a service that treats disease to one that maintains health.”
“It’s vital that we ensure data can be made available at the point of need, especially for patients”
Dropping our defensive attitude to sharing health data is key. “Changing how we think about data from ‘where is it stored?’ to ‘where it is needed?’ is the next big step toward a safer, more effective and efficient NHS,” said Gary Leeming, informatics director for the Greater Manchester Academic Health Science Network, which brokers technology development and novel applications between industry, academia and public services. “It’s vital that we ensure data can be made available at the point of need, especially for patients.” “Social bots will bring together communities and build support networks for patients and carers,” said Leeming. “Distributed ledgers will provide oversight and assurance around privacy and access. Combined, we can really start to use health data to transform the fundamentals of how we deliver care.”
Healthcare providers must also consider new ways of delivering services that patients will be familiar with, and be prepared to take bold experiments. For example, if patients accessed community nursing in an “Uber-like” model, they might avoid surge periods, thereby spreading the NHS load. Of course, this may also increase demand, but only experimentation will provide the answers.
Fear of change
Despite the application of technology and Big Data holding so much promise, there’s a widely held fear that healthcare professionals will be resistant to change, having suffered from so many poorly implemented experiments in the past. “As a clinician and researcher, too much of the technology innovation in the NHS that I see fails,” Dr Ben Brown, a GP and Wellcome Trust doctoral fellow in health informatics, told us. “Take the NHS Summary Care Record, for example. Doctors in out-of-hours services seeing patients at home or at walk-in centres couldn’t access patient records to see vital information about their current conditions and care plans, so a national solution of a Summary Care Record was developed. This was a technology-led development rather than technology pulled through to solve specific clinical problems.”
“There was little support from clinicians for this technology, because it had a clunky interface and lacked the detailed patient information needed to be ‘actionable’. Furthermore, it was widely deployed with relatively little user testing. So, can technology save the NHS? Well, it depends on whether the above criteria are met.”
Even if the technology is sound, other pressures on the health system could force doctors to resist new initiatives. The NHS is fixated on moving services out of hospitals and back into the community, in a bid to save costs. That has created a surge in demand for GPs and community nursing. So don’t be surprised if GPs push back at making access to primary care easier through apps for patients. They have been there before with the Summary Care Record.
Timing, problem-solving and local integration are essential if technology is to rescue the NHS. Dr Amir Hannan, a GP in Hyde, has spent 16 years rebuilding the trust of the patients, carers and community after taking over the practice of serial killer Dr Harold Shipman. He said: “The NHS is strapped for cash but has a potential army of activated patients, community leaders and staff who are vital to giving the NHS the resilience it needs going forwards.” Those driving NHS technology programmes are hungry for effective change.
“My view is that we’re on the cusp of exciting changes with NHS England, NHS Digital and the providers all pulling in the same direction to provide a health system where citizens’ data will be used to optimise their health outcomes,” said Rachel Dunscombe, CIO for the UK’s most digitally mature hospital, Salford Royal, and lead for the implementation of one of the new NHS centres of global digital excellence in Salford. “It’s not the technology per se, it’s the data and knowledge held within that data that can improve health outcomes greatly – the technology allows the collection of this data. Pair this with the interoperability to allow citizens to share data with their care providers to provide a lifestyle backdrop and we have a whole new picture.”
Technology alone can’t save the NHS. Nor can technologies that focus on clinicians, NHS organisations, care professions or even patients. The NHS is more than a giant franchise of organisations – it’s a social movement that can drive socio-technical health and care innovation. It just needs leaders with the vision, bravery and wherewithal to deliver it.
Professor Iain Buchan is Clinical Professor in Public Health Informatics at the University of Manchester’s Centre for Health Informatics