The Government’s reforms to health and social care services have undoubtedly attracted degrees of controversy in their direction and ensuing implementation. Faced with a perfect storm of an ageing population and ever tighter public finances there has certainly been a fair case that their timing was also far from ideal.
Those working within and with the NHS have found the upheaval hugely disruptive in its ability to secure commitments to introducing new technologies and ways of working. With managerial redundancies, statutory responsibilities shifting and purchaser power limited, this is perhaps not surprising.
However, with the changes starting to bed down and take shape, the hope is that the new environment can finally see the NHS move into a new world of digital capability and connectivity the likes of which it has never experienced before.
Upon taking up his post as Secretary of State for Health, following the most recent Government re-shuffle, one of Jeremy Hunt’s main surprises was discovering how behind the times the NHS was in introducing new tools to improve the quality and experience of services.
A man previously based in the Department of Culture, Media and Sport, responsible for overseeing the roll-out of new high speed broadband services and the Olympics, was clearly bemused by a system in which much patient information continues to be written down and passed around the system (slowly and inaccurately) on hard copy. Hunt has thus put improving the introduction of new technologies at the heart of his tenure as Secretary of State through a number of eye-catching initiatives.
Hunt has made the NHS going paperless by 2018 a major Government priority, initially committing £1bn of funding to enable this to happen, through the development of electronic patient records which can be accessed by professionals anywhere in the country and allowing patients to book GP appointments online.
The Treasury has committed to release £3.8bn to closer integrate health and social care services from April 2015 and one of the conditions of the fund for local authorities and clinical commissioning groups is to ensure that the money is used to improve the flow of information between health and social care settings. Again there is a perceived financial benefit here, with patients able to be discharged from hospital into the community quicker and more effectively through the deployment of such funds.
In terms of new patient services, one of the main headline grabbing initiatives the Government has launched is designed to see telehealthcare technologies, which manage patients with long term conditions (diabetes, COPD etc) in the community delivered to 3 million people by 2017. These services use wireless and wired technologies to allow patients to take regular health readings at home and submit them to their clinician for review.
If readings are out of kilter then patients can be called in for check-ups and further tests. This earlier, more planned intervention assists capacity management and can improve productivity and efficiency. Again such technologies are seen by some as a key mechanism for reducing unnecessary hospital admissions and helping the NHS adapt to the changing demographics and health needs of the broader population.
Despite such initiatives there remain major barriers to rolling out new technologies and associated services in the NHS. The NHS IT programme continues to leave a large and unhelpful legacy in its wake in the procurement of services that involve new technologies. The programme’s high costs and lack of returns have scarred many healthcare professionals and have lead some to place IT and new technologies in the ‘too difficult’ to do box.
Trusts and commissioners are both risk averse and many are reluctant to be the guinea pig for a new service, the practical evidence base for which may not be clear. Indeed, even when there is an evidence base, suppliers will often say that there remains a nimbyism to NHS purchasing decisions, with scepticism that a model pioneered in Blackburn can be applied to East London, for example.
Linked to this remains the scepticism of some, particularly clinical audiences, in the benefits the technologies can bring. The use of telehealthcare, for example, was supposed to be made through publication of the largest randomised controlled trial of the service covering 6,000 patients in Kent, Newham and Cornwall.
However, despite positive spin from the Department of Health, the academic papers have at best provided a mixed picture of the service’s benefits, undermining attempts to roll-out the programme at scale. Whilst suppliers argue about the parameters of the trial, the findings from it have created an unhelpful inertia, freezing purchaser activity and resulting in some companies choosing to downscale their offer or, in the case of O2 Healthcare, exit the market completely.
A further barrier remains in upfront costs, particularly in the current financial climate. Many new services require an up-front investment either in terms of example capital or staff training. With many parts of the service struggling to meet their local efficiency targets (the whole system has a target for making £20bn of savings by 2015), additional costs for a new service, with promises of savings in years to come, is a tough sell in such a market.
For its part the Government’s new national board responsible for the day-to-day management of the NHS, NHS England, is putting in place the frameworks and system architecture which should help drive the uptake of new technologies and services.
This includes the use of financial incentives to encourage providers to use new technologies to improve care, commitments to improve how the NHS engages with suppliers and open forums to allow trusts to share good practice in the use of new technologies and services. It also includes the creation of an integrated customer platform to replace NHS Choices with moves to improve the application programming interface (API) allowing suppliers to link to it more easily.
The example from the approach of London Underground in opening up their IT platforms to the market has been a successful one, spawning numerous new apps and consumer friendly tools.
Ultimately though, if real change is to be delivered in the new system it will need to be locally driven with clinical leadership and a strong business case at its heart.
There are emerging signs that areas of the NHS are better prepared and more willing to invest in new services where they can see a clear return on investment either in improved care quality and/or financial benefits. Some hospital trusts have installed new wireless networks – not an easy task given the parameters of the estate they are often working with – to enable clinical staff to access patient information more conveniently.
One example is the oncology day unit at Weston General Hospital which has adopted a wireless system to enable it to carry out efficient electronic prescribing for patients receiving chemotherapy. The network allows clinical staff to access patient records while they are undertaking patient consultations, reducing errors and improving care.
However, there is no doubt that the road to the new world will be bumpy. As I write this, East Riding Clinical Commissioning Group has said it will axe its telehealth service by the end of the year, because it is not cost effective. For service providers such moves show the continuing challenges that exist when engaging with the new NHS market.