Technology: switching on

New technology is at the heart of the NHS long-term plan. The digital enabling of primary care and outpatients grabbed the headlines, but the proposed changes are wide-ranging. If the vision is realised over the next decade, technology will be in the vanguard of the prevention and patient support movement.

It will enhance safety and efficiency by giving clinicians anyplace access to patient records. High-quality clinical care will be supported by increased use of decision-support systems and artificial intelligence. Patients will make virtual visits to their GP practice and outpatients and systems will use powerful population health management tools to help them predict the individuals most likely to benefit from different support and interventions.

James Hawkins, director of strategy at NHS Digital, acknowledges that it can be difficult for NHS organisations under constant pressure to deliver critical services to adopt new technology and digital systems. But he believes the NHS is starting from a good base.

‘We’ve made great strides in technology in the NHS over the past few years, helping to lay the foundations for the now and working towards the demands of the future,’ he says.

He points at the NHS spine, one of a series of platforms operated by NHS Digital on behalf of the NHS to connect organisations across the health and care system. He says it carries a volume of transactions similar to major credit card systems. More than 90% of England’s 7,300 GP practices use electronic prescribing, enabled by the spine. And the e-referral platform covers every hospital and GP practice.

Even so, Anne-Marie Vine-Lott, Oracle’s UK healthcare director, believes that the NHS needs to get the right IT architecture in place if it wants to realise the ambitions set out in the long-term plan.

‘The back office, including IT, has suffered from significant underinvestment due to financial constraints over a number of years,’ she says. ‘NHS trusts all come from a different starting point, but there needs to be a focus on getting the basics right to improve security and enable interoperability – both of which will lead to greater digitisation of care.

‘We have very fragmented systems that have been taken forward at a varying pace across the numerous organisations that make up the NHS, each with different levels of investment, capability and knowledge,’ she adds.

In some places, this is as basic as organisations not working on up-to-date operating systems. There is also limited use of new technologies such as machine learning to reduce processing, and predictive analytics to support planning. 

Modernising IT and back-office operations such as finance will drive productivity and provide information and analytics to support more efficient, effective decision-making. This is essential for developing new service models that will better support the front line through digitisation and the use of technology, which covers everything from wearable technology to complex electronic patient records.

‘Health and care systems should have an overarching digital strategy, with partnering organisational delivery plans aligned with this. And they need to start with getting the basics in place,’ says Ms Vine-Lott. ‘Digital strategies are too often based on what organisations want to achieve; they need to be more about how the vision will be realised and who will do what.’

She adds that the service also needs to change its approach to building business cases, as years of funding restraint have led to short-termism in investment strategies.

‘At the moment, unless programmes can deliver savings today, there are often no available monies. But we need a longer term approach that recognises strong technology investments will become self-funding over time and make a significant difference to both patients and staff.’ 

Key focus of the plan

The long-term plan envisages technology being used in five key areas:

• Empowering people – using apps to access the NHS and support specific conditions and giving people access to care records (see Phone support box)
• Supporting health and care professionals – increased use of mobile devices and improved digital skills
• Supporting clinical care – digital options for providing advice and care, accelerated roll-out of electronic patient records (see EPR box) and new digital exemplars
• Improving population health – deploying predictive tools to identify people at risk of adverse health outcomes
• Improving clinical efficiency and safety – using pathology and diagnostic networks and developing decision support and use of artificial intelligence.

One of its most eye-catching commitments is the promise to give every patient the ability to access a GP digitally and opt for a virtual outpatient appointment, where appropriate, within five years. In fact, January’s new GP contract framework goes further than this, saying online and video consultation will be live by April 2021 in areas where it is realistic to make early progress.

Babylon Health’s service, GP at Hand – hosted by a four partner GMS practice in Fulham, south-west London, and involving up to 200 mostly salaried part-time GPs – is perhaps the highest profile example of a digital first practice.

It is available to anyone living or working within 40 minutes of one of five London clinics, using the out-of-area registration scheme to sign up patients from a broad catchment.

The service provides access to video or telephone consultations via a dedicated smartphone app or the website. Appointments are available 24/7 and the service claims patients are usually ‘seen’ within two hours of making the booking. Face-to-face appointments can be arranged if needed.

The service has proved popular. Launched London-wide at the end of 2017, it now has more than 45,000 people signed up – reportedly including health secretary Matt Hancock. In February, Babylon was given the green light to expand to Birmingham.

Impact on CCG

The service has also had an impact on the practice’s host clinical commissioning group – Hammersmith and Fulham, which picks up the bill for prescribing costs and for patients referred into secondary care who would previously have been outside the CCG’s catchment area. In March, the CCG confirmed it had taken GP at Hand costs of £10.2m to its bottom line after failing to get any assurances that this would be paid by NHS England or CCGs outside of north-west London.

Addressing the cherry-picking claim, Paul Bate (pictured), Babylon’s director of NHS services, says the age profile of its list is reflected in the practice’s funding. Average funding for GP at Hand per patient is about £90 compared with the national average of £140. This is because of GP at Hand’s younger than average population.

‘We also run services 24/7 and 365 days a year and 40% of our appointments are booked and/or take place out of hours,’ says Mr Bate. ‘So the accessibility of the service is much greater.’ In other practices, patients wanting to see someone outside of opening hours midweek or at weekends would probably use 111, A&E or out-of-hours services. But GP at Hand patients are more likely to call their online GP – leading to increased activity.

Mr Bate believes the use of these other services by people registered with GP at Hand will have reduced – he hopes an independent evaluation currently under way by NHS England will provide greater insight.

From this year (2019/20), further amendments are being made to the GMS funding system to acknowledge the arrival of digital first practices. These involve changes to the London weighting and rurality index payments, which on their own will reduce GP at Hand’s income further by between 5% and 10%, according to Mr Bate. Babylon is paid on a capitation basis by the practice for providing its service and Mr Bate says this will remain the case. ‘We don’t want to be in a fee-for-service market in the NHS context,’ he says, as this provides the wrong incentives.

Elsewhere, GP practices may look to meet the long-term plan goals by introducing video consultations alongside place-based services. In north-west Surrey, the NICS GP federation, covering 40 GP practices, has entered a contract with digital care provider Livi (founded in Sweden, where it operates as Kry) to deliver extended access across the patch.

This does not replace traditional GP practice but extends its capacity – providing a more convenient way for some patients to consult a GP and reducing the demand on the practices’ own GPs. If a patient calls a practice and there is no timely appointment available with one of the practice GPs, practices will try to offer an extended access face-to-face appointment.

If none of these is available that day, they might suggest the Livi service. In addition, patients can initiate contact with Livi directly through a dedicated app.

From a total population of 370,000, there had been 6,500 consultations by early March – the service went live last September. Usage has picked up to the point where there are now around 500 virtual consultations a week.

The service differs in one very obvious way from the GP at Hand model – Livi does not provide its own face-to-face consultations. Instead, if a patient needs to be seen face-to-face by a doctor, they would be referred back to the practice or to A&E as appropriate.

George Roe, chief operating officer at NICS, says the service is ideal for some conditions with feedback suggesting it has worked extremely well for some types of patient.

‘They won’t do tonsillitis, chest infections or ear infections – because those things you need to hear and see,’ he says. ‘But it is perfect for people who don’t need the continuity of going to see their own GP because it is a one-off type skin infection, for example. For these patients, the feedback is brilliant because you are giving patients very good access to a GP who is able to prescribe, see their notes, refer – everything a normal GP can do.’ He adds that the service has also proved popular with patients presenting with anxiety issues.

The Livi service is being run as a 12-month pilot, with the federation paying on a per consultation basis. Mr Roe says an audit has shown that 80% of the consultations to date would normally have gone to see a place-based GP. Some 14% would previously have gone to A&E, while 6% would probably have managed themselves – suggesting the increased capacity is not driving demand in a big way.

‘If these numbers continued, we’d be very happy,’ he said. He adds that all system partners are interested to see the impact in terms of prescribing and referral rates.

Mental health moves

The long-term plan sees a role for technology across the healthcare sector. But a report published in March by the Mental Health Network argues that the mental health sector in particular is ripe for digital disruption. It calls for NHS England to further expand its current global digital exemplars programme and for mental health services to be given access to significant levels of dedicated funding for digital innovation.

In addition, Using digital technology to design and deliver better mental health services identifies the need for a national vision for digital mental health and suggests that NHS England should consider commissioning some e-mental health services at a national level.

The report looks for lessons from emerging developments in Australia and the US. For example, it highlights the e-Headspace national digital delivery service for youth mental health in Australia, which provides online support and counselling to young people. It has proved particularly helpful for users making their first foray into mental health support and use of the service has grown by 12.5% a year over the six years it has been open. Report author Rebecca Cotton, director of policy at the Mental Health Network, insists resources are needed to support innovation.

‘The opportunity is here to capitalise on the potential digital technology offers us,’ she says. ‘We can ensure more people have access to high quality treatment, advice and support.’

It is an argument that could be applied to all parts of the NHS. People are surrounded by technology facilitating different aspects of their lives. There is a growing expectation that they should be able to interact with health services in this way – and that health services should be making the most of digital technology.

The NHS long-term plan sets its sights on this. The challenge for the NHS is turning the potential into reality.

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