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1 October 2015

Transforming the NHS’ management of illness and disease

Can the NHS continue to be a global leader in the use of innovation and technology in healthcare?

By Becky Slack

“We use the internet for shopping, banking, for so many aspects of our lives. Yet we’ve barely scratched the surface when it comes to health-care, which is curious because health-care matters more to us than any of those things. So, here is the question – can Britain step up to the plate and be the global leader in the use of innovation and technology in health-care, in the way we have done so often in the past?”

This was the challenge that Jeremy Hunt, Secretary of State for Health, set the NHS when speaking at the NHS Innovation Expo in Manchester earlier this month.

Of course, in a country where only 2 per cent of interactions with the national health service take place online and some medical centres still rely on fax machines, meeting Hunt’s challenge isn’t going to be easy.  However, it is going to be essential if we are to close the widening gaps between the health of our population, the quality of care provided and the funding of these vital services.

The challenges our health service faces are well documented: an ageing population; increasing cases of chronic disease, such as diabetes, heart disease and cancer; unhealthy, sedentary lifestyles. These all threaten to destabalise and potentially cripple our most treasured institution: the NHS.

The solution, as identified in the Five Year Forward View, published by NHS England in October 2014, is to complete a “radical upgrade in prevention and public health”, particularly around obesity, smoking, alcohol and the other major health risks that cause avoidable illness. The way people access health services also needs to change; patients are to be given far greater control of their own care while services are to be delivered in a way that supports the individual as a whole, not just a single disease. And all of this needs to be achieved while saving some £30bn from the budget. It’s a tough call, but not impossible, say companies such as Philips, a global leader in HealthTech. Not least because of new technologies and innovations that use data-driven, patient-centric approaches, and which have the potential to make significant improvements in population health.

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There are already major steps being taken towards reducing the cost and burden of managing long-term chronic conditions. Take diabetes as an example.

People with diabetes type 1 make around 200 decisions a day regarding how best to manage their condition. From the moment they wake, until they go to bed, they are thinking about how they feel, testing insulin levels and making sure they have eaten the right foods. Although these decisions and the information upon which they are based could provide a doctor with useful insight into how better to care for the individual, they are not recorded; instead patients are forced to rely upon memory or their own notes if the doctor ever requires further information. Meanwhile, their previous notes are held in a file, where the patient cannot see them.

Imagine how much more effective it would be to manage diabetes type 1 if the individuals blood sugar and insulin readings were recorded and analysed electronically and in real-time – and could be accessed immediately if needed. Imagine how much easier it would be for the individual to cope with the psychological strains this disease places upon them if they had online access to health-care professionals, other patients and a social community who understand what it is like to live with diabetes.

This is what the future of diabetes care looks like and – thanks to a new prototype app from Philips, being tested by Radboud Medical Centre in the Netherlands – that future is here.

“Sometimes people with diabetes do everything by the book but still their readings can be high. Rather than having to wait for a doctor’s appointment, this new technology allows them to stream their data to a nurse who can respond immediately,” explains Jeroen Tas, chief executive of health-care informatics solutions and services at Philips.

This isn’t the only area where managing illness and disease is about to be transformed. Within heart health, the technology now exists to determine which patients with chest pain are likely to have a heart attack. Three-dimensional printing is allowing surgeons to better analyse the adjustments they need to make to vital organs before they operate. Clinical grade genome analysis and decision support tools are in development that will allow doctors to interrogate all known human genes for pathogenic mutations, which may be the underlying cause of a patient’s inherited disease.

“Philips has looked at patients presenting with a variety of different illnesses, including serious, life-threatening conditions such as heart problems. With each new connected technology we develop, supported by a digital health platform that captures and analyses historical and personal health data, we see better diagnosis and less invasive forms of treatment,” says Tas.

Meanwhile, 2018 could usher in a time when all patient records are electronic, allowing both the patient and health care professionals to access the most up-to-date medical records from anywhere (including an individual’s mobile phone) at any time.

This is just a small sample of the exciting innovations that are taking place within our health service and which have the potential to transform both outcomes for patients and the way in which we plan and deliver health care.

“It tends to be the top few per cent of the population that places a heavy load on the health-care system. By collecting and analysing data, we are able to spot patterns and establish how people move through the risk classes and what may trigger their illness. Clinical programmes can then be organised around those needs – and importantly can help identify appropriate prevention strategies,” says Tas.

Successful adoption of such technologies, however, is dependent on a number of critical factors. Some are barriers that need to be removed – NHS IT capabilities and a willingness by health-care professionals to adopt new ways of working. Others are focused around the tech industry itself, such as the way in which it interacts and collaborates with the NHS when developing new systems and processes to improve health-care provision.

Long memories
Some aspects of NHS digital infrastructure have been successful – NHS Choices (a public-facing website containing information about conditions and services) receives 40 million visits a month while the NHS Spine (the infrastructure that connects clinicians, patients and local service providers to essential national services, such as the Electronic Prescription Service and the NHS e-Referral Service) handles 200 million interactions a month-. However, others have not gone so well.

Ministers, NHS leaders and industry experts have all explained how lessons have been learned and they say that things will be different this time.

“In future we intend to take a different approach. Nationally we will focus on the key systems that provide the ‘electronic glue’, which enables different parts of the health service to work together. Other systems will be for the local NHS to decide upon and procure, provided they meet nationally specified interoperability and data standards,” the Five Year Forward View reads. And Hunt told the audience attending the NHS Innovation Expo at the beginning of September that the current track record of the NHS on delivering IT projects has given him confidence in what else it can achieve.

The use of new technologies such as the ones already highlighted relies on the collection, exchange and analysis of data, which in turn raises important questions about data security and the potential for data breaches. Hunt has stated that he has faith in the NHS to tackle this issue with the support of Dame Fiona Caldicott, the National Data Guardian. Encryption will also help – particularly when it comes to streaming data between patient and doctor devices.

“When banking online was first touted as an idea, lots of people said it would never happen because of the security concerns, but today it is an everyday secure solution used by millions. There is no reason why we can’t make it work for health”, says Philips’ Tas.

He says that part of the reason why previous tech projects haven’t worked is that “the model was wrong and didn’t fit the need”.

“It’s not about the technology, it’s about how you organise around it. You need to change people’s minds and the way in which they work,” he says, emphasising how technology projects shouldn’t neglect to focus on the cultural elements in favour of the hardware and software.

The whole picture

These changes need to extend beyond IT infrastructure and into the entire architecture of the NHS. For example, current financing and staff reward structures create incentives that can ultimately be counter-productive – such as hospitals being paid and staff performance being judged by the number of people they treat, rather than their ability to heal.

“Nurses are measured on activity not on the health of the patient. It has been designed this way because we didn’t have the data required to show accurate health outcomes. Now we do,” Jeroen Tas says. Our ability to collect, store, analyse and manage data in huge volumes is enabling us to understand the impact of our health-care systems and services in ways that previously we were unable to do. And that information can then be used to streamline, personalise and integrate these systems and services across the entire health continuum in ways that also haven’t been possible until now.

It would appear that Bruce Keogh, medical director for NHS England, is on a similar wavelength. Speaking at the same NHS Innovation Expo as Jeremy Hunt, he recognised that “the payment system introduces perverse incentives” and can influence organisational approaches to tackling specific procedures. This needs to be changed “quite quickly”, he said. 

Public-private partnerships
There are clear benefits to developing and strengthening partnerships with some industry providers, particularly those within health-care technology. The NHS is not a technology company. It does not have the skills, the resources or the public will to create, test and build the innovations that are needed and to shoulder the associated risks. Private companies do, and so in that sense collaboration with industry is a welcome and necessary element of transforming and improving our health service.

Likewise, the previously mentioned switch from an activity-based model to one that is outcome-based could help that relationship become more effective, particularly when it comes to costs, reckons Philips’ Tas.

“We want to enable the transformation of the NHS from a patient outcomes perspective. We can share the risk with the NHS by avoiding large upfront investment and costs of equipment. We provide services in which we share the burden and responsibility for improved patient outcomes. Our fee structure is dependent upon outcomes. By working in this way we can shoulder some of the financial risk and reduce the bill – we believe we can reduce costs by up to 20 per cent by keeping patients out of hospital,” he says.

Open access
One major potential barrier to the take-up of new health-care technologies is patients themselves, if feedback from delegates at the NHS Innovation Expo is any indication of mood. They were concerned that the benefits would be realised only by wealthier, healthier individuals who had the capacity to understand how the new tools worked. Would those who were too ill, or too old, or who have mental health issues find it difficult to access the new systems?

The answer is that there isn’t a one-size-fits-all model, and that systems and processes can be adapted to meet the needs of the individual.

“Technology can be a great leveller and, contrary to some perceptions, many older people use the internet. However, we will take steps to ensure that we build the capacity of all citizens to access information, and train our staff so they are able to support those who are unable or unwilling to use new technologies,” the Five Year Forward View says.

Behavioural economics, which uses psychological, social, cognitive and emotional factors to influence decision-making, also has a role to play in increasing take-up.

Professor Donal O’Donoghue concurs. The medical director of Greater Manchester Academic Health Science Network, who is also a mentor on the National Innovation Accelerator, said: “If we co-produce new tools with people and if we link it to behavioural economics, then you can make a 10 to 15 per cent difference to uptake. There will still be people who are challenging and have different health beliefs, which we need to work with, but if we go in with the mindset of all the sciences and all the skills that we have access to, and if we build it in with our local populations, then we can start to address the challenges we face.”

This co-production with both patients and providers – putting real-life needs and experiences at the heart of development –is key for effective innovation, stresses Philips’ Tas.

“We believe there is not a single party that can solve a complex problem [such as diabetes], so we like to partner with people who share in the same vision and that can bring to bear complementary capabilities,” he says. For instance, Philips is currently trialling a new digital platform called HealthSuite in partnership with Salesforce, which uses relationship management software to influence health choices by patients and to support decision-making by professionals. It believes this platform will eventually help people to maintain healthier lives and reduce costs for our health service.

Philips and other industry providers are being supported in their innovation programmes by the NHS itself. The National Institute for Health Research and its Healthcare Technology Co-operatives, for example, are bringing together a range of partners to help co-create new ideas and concepts. For its part, the National Innovation Accelerator (NIA) programme, set up by government with the express purpose of creating the conditions and cultural change necessary for proven innovations, is working to ensure that changes are adopted faster and more systematically throughout the NHS.

This is all well and good. However, to succeed, these advances need to be supported by health-care professionals, who will be required to work differently from the way they do at present. This in turn has an impact on medical curriculums.

So far, however, it would appear that medical schools have been slow to respond. As Davinder Sandhu, the Severn Deanery postgraduate medical mean at the Royal College of Surgeons, mused in a blog on the NHS website “doctors are training in a system that is outdated in terms of curriculum, patient expectations, and hospital structures”. 

Limited information is available publicly as to which medical schools are embracing, updated curriculums that focus more on innovation. However, it is understood that the University of Surrey is one of a handful that are looking to launch an integrated Engineering for Health degree promoting the use of technology in medicine.

For inspiration,we should look to the United States instead. The American Medical Association has launched a $1m initiative called Accelerating Change in Medical Education. This svheme is designed to encourage medical schools to change their curriculum. And the New York University School of Medicine offers a module that requires students to analyse a database of hospital admissions for clues around health trends.

UK medical schools need to step up the pace. NHS talent is central to the future success of the NHS. As Bruce Keogh told audiences at the Innovation Expo: “The intellectual capital to solve many of the problems we face on a day-by-day basis lies not in some darkened room in Whitehall, but within the minds, the brains and the ingenuity of those people who work within the NHS and associated services, people who are prepared to do the best they can for our patients”. 

Combine this intellect with the innovation and technologies that are entering the market and the NHS has access to a very powerful force. Harness that, and Jeremy Hunt’s challenge  just might be achievable after all.

This article is part of a thought provoking series on living health brought to you by New Statesman in association with Philips, that looks at how technology, innovation and big data are helping to improve your health and our health-care system.

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