Could the NHS be on the Cusp of a Tech Revolution?

Imagine a healthcare system where making appointments digitally was the norm. Imagine if, no matter how many departments you visited, every doctor understood your condition and you never had to repeat an unnecessary test. Imagine that doctors could use AI to predict illnesses within your local population and preemptively intervene.

In the context of our overburdened NHS, this vision of 21st century healthcare might seem like a pipe dream.

But the NHS has already proved its ability to embrace this future. Take video consultations for instance. Once the preserve of private primary care providers, it’s now becoming standard practice in GP surgeries across the country. And the NHS app, launched just over three years ago, now has more than 22 million users. It was the most downloaded free app in the UK last year, finishing ahead of WhatsApp, TikTok, Instagram and YouTube.

As the health service now embarks on its most ambitious systemic overhaul to date – streamlining over two hundred NHS Trusts and thousands of GP practices into 42 Integrated Care Systems – the question is: how can it seize this moment to transform digitally as well?

To help answer this question, WIRED Consulting, in collaboration with Microsoft, convened an array of specialists – from frontline GPs and NHS digital leaders to senior consultants and health tech developers – to consider the complexities and discuss how they might be overcome.

Why has digital integration been so challenging?

The barriers to implementing new technology should not be underestimated. Myra Malik, consultant anesthetist at Hillingdon Hospitals NHS Foundation Trust, is inspired by the prospect of a data-driven, smarter NHS, but it strikes her as being a long way off, “it feels so abstract what the future is, or could potentially look like, it almost seems like a dream.”

Partly that’s because historical investment in digital infrastructure has been patchy across the country – meaning Trusts haven't been able to implement technology consistently. Katherine Church, chief digital officer at Surrey Heartlands Integrated Care System, puts it starkly: “Lots of people are talking about artificial intelligence. But there are areas that don't have Wi-Fi. We've got ambulance drivers that need to register with six or seven different Wi-Fi systems to conduct a handover. They’re handing over patients from ambulances into Trusts using paper.”

The NHS is still heavily reliant on analogue systems. Pre-operative assessments, for example, are typically paper-based, and appointments are often managed over the phone. As a digital health technology advisor and lead GP at Numan, Luke Pratsides has first-hand experience of the downsides, “in the NHS, if an outpatient wants to change their appointment, there are only specific windows of time when they can get through to someone. This causes so many non-attendances and comes at a huge cost to the system.”

Where technology has been introduced, it is sometimes not fit for purpose. For instance, as Ryan Kerstein, consultant plastic surgeon and associate medical director for innovation at Buckinghamshire Healthcare NHS Trust, notes, “in Trusts that I’ve worked in, the electronic patient records are accessed on a PDF storage system which has no searchability, and no kind of optical character recognition.” In other words, if you’re confronted with a patient with 40 years of records, and you want to see if they have had a particular condition in the past, you have to read all of the PDFs.

There is no shortage of ideas that emerge from within the NHS. “We have so many very, very innovative frontline staff,” says Kelly Lin, deputy director for commercial delivery in the NHS Transformation Directorate. “But giving their projects teeth, making them happen, scaling them up – all of that is a challenge”. This is, in no small part, down to the sheer size and complexity of the health service.

The NHS in England employs 1.3 million people, consists of over two hundred Trusts, and serves a population of 67 million people. Amid so many moving parts, knowing who the right stakeholders are – and knowing how to get them on board to navigate the approval process efficiently – is not obvious. Yet without buy-in from the right people at the outset, proving efficacy and safety is challenging in early-stage development. As Anna Dijkstra, innovation director at Microsoft says, "New innovators to the NHS think they are selling to one entity, but they're frequently shocked - and frustrated - to discover they are really selling to hundreds of separate organisations." Given the regulatory hurdles, these problems can spell the end for promising initiatives before they have a chance to shine.

As a result of being such a complex system, it is not always clear, even to those within the NHS, how to get innovations approved. Felix Greaves, director for science, evidence and analytics at the National Institute for Health and Care Excellence, says that “it's not clear who pays for what”. Until those kinds of ambiguities are ironed out, it will be hard to enact digital transformation in a strategic, methodical fashion.

For NHS Trusts to become smarter, access to large volumes of high-quality data is critical. The NHS stores gargantuan quantities of information, from cleaning records and fridge temperatures to patient records and care outcomes. However, the information is often collected in different ways across disparate systems, leaving it unstructured and unconnected. It’s not just that immense value could be realised by integrating large data sets, but also that not doing so can negatively impact both clinicians and patients.

“I've worked in hospitals where the systems themselves don't talk,” says Kerstein. “You have to open up five or six different things to see notes, bloods, or theatre lists. And you can't even connect those dots within a single trust, let alone externally.” Church recently carried out research that shone a light on what this means for patients: “there are people who take whole carrier bags full of documentation to each appointment, so that they don't have tests repeated because we are not sharing data on interventions.”

As with the wider picture of technological sophistication within the NHS, there are likewise pockets of excellence in relation to data sharing. In maternity services, for instance, a clear, full record of everything about the patient and the course of their pregnancy is available to all. “But as soon as you have a baby,” says Dr Hiba Sher Khan, Obstetric Clinical Lead at NHSX and DCCIO and FemTech advisor at the Hillingdon Hospitals NHS Foundation Trust, “we go back to square one.”

Until data is integrated across the system, it will be impossible to realise the full potential of tools such as artificial intelligence. But we are getting closer. In the opinion of Greaves, “the English NHS is in a tantalising position of having almost all the data in almost all the right places.”

While there are many technical barriers to digital transformation – lack of tools, too much bureaucracy, unconnected data sets – the human factor is no less important. As Helena Painting, head of software development at Surrey and Borders Partnership NHS Foundation Trust, has observed, “with change there is often resistance. Frequently people will be keen to maintain their current local or manual systems – it’s as much about the ‘hearts and minds’ as it is about the technology”.

It’s vital to get buy-in not only from senior management but from frontline staff too. Or, as Rishi Das-Gupta, chief executive of the Health Innovation Network, sees it, “to make change happen consistently everywhere requires both leadership and followership.” The workforce needs to be actively encouraged to contribute to innovations themselves and be empowered to make a difference. When Malik was part of a quality improvement team at Imperial College Healthcare Trust, one of the most enabling things that happened was a simple conversation with her boss. “He sat me down and said, ‘you have permission to seek change.’ But how many of our frontline staff believe this to be true?”

As well as empowering their workforce, leaders also need to articulate the benefits that new technologies and ways of working will have, in order to bring their teams on board with new initiatives.

Key to a successful adoption of change initiatives is the provision of appropriate training. Vinay Shankar, clinical advisor in quality improvement to the NHS and founder of Once Daily, points to a recent report by Deloitte as evidence of how serious the lack of training is. “About 29 percent of GPs and 22 percent of primary care nurses have not had any training on digital tech. When you think about it, that is actually quite high, considering what our vision for the future is.”

Understandably, a further barrier to tech adoption is that clinicians have more urgent priorities. We all want to be talking about new tech, says Sher Khan, “but currently, I'm also trying to get enough doctors to staff a rota. We are just trying to find patients a bed. All of these clinical pressures trump technology conversations, and things get delayed.”

So what needs to change?

For Malik, the approach taken to deploying new technology is often back-to-front. “Are we being led by the need?”, she asks of the inadequate technologies that have come in, “or are we being led by a solution and trying to retrofit that solution into systems and processes that will not support it?”

But in such a complex system, which needs should be prioritised? The first step to determining which issues to optimize for is to look at the whole system through a user’s eyes, in order to understand various user journeys and their interactions with different parts of the system. “If you're in primary care, you have a very specific view of your relationship with a patient,” says Church. “Whereas if you're looking at that patient from the perspective of an acute hospital, you may have a relatively transactional relationship with that individual whilst they're in your care.”

We need to better understand the different kinds of patient journey, where the pain points exist, and where the inefficiencies are the greatest. Doing so will show us where user experiences can most readily be improved. This exercise requires looking through the lenses of the clinician, patient and manager.

As historic examples such as email have demonstrated, new innovations don’t necessarily reduce workloads. Take online triage services, which let patients seek advice from their GP without having to call. Juhi Tandon, GP, clinical director and co-founder of health tech startup Cognitant, says that it’s a double-edged sword. On the one hand, improving access to care is to be applauded. On the other, GPs are now expected to triage large numbers of completed forms, increasing their workload substantially. “We're having to deal with all the backlog from the hospitals unable to manage the waiting lists, but then we've got thousands of triages coming in and have to deal with that too. By enabling people to contact the surgery any time of the day via online forms we are seeing a surge in patient queries which wouldn’t normally have come our way – we need to encourage more self-management through better access to health information,” she says. “When we introduce new technologies, we have to ensure they can operate within the current system.”

It’s clear that it’s not a lack of new technology that is the problem, it’s making sure that the right tool is deployed in response to a need. There are dozens of external providers who are keen to provide new digital tools to the NHS but establishing the effectiveness of these products prior to rollout can be very difficult.

Therefore, the test, measure and learn phases are all essential as digital tools are rolled out, in order to rapidly assess their efficacy. For Greaves, it will be vital to make sure these assessments don’t stall progress. “At NICE, we will be looking at technologies as they come through, rather than just waiting for them to present themselves fully enabled with a great big bag of evidence to back them up.”

As England’s health service embarks on its journey of transformation, there are choices to be made about how high to aim. On the one hand, there is a need to get the basics right consistently. But there is also an opportunity to aim much higher. Shafi Ahmed, a consultant colorectal surgeon at the Royal London Hospital and chief medical officer at the AR/VR [augmented reality/virtual reality] medical training company Medical Realities and Nobel Peace Prize nominee, would agree with the need to think more boldly and to be unafraid of making decisive moves. “What I would do is think radical: let’s take radical solutions,” says Ahmed. “What about if we let existing contracts wind down? Let’s spend £100 million on our own EHR [electronic health records], so in three years’ time we have a perfect system that works, rather than trying to fix the one that we’ve got with backward integration.”

Bigger thinking could also be inspired by other countries’ healthcare systems. The NHS is unique – it’s the world's largest employer of highly skilled professionals – but the problems it faces are not. Other countries also have extensive healthcare systems that face a myriad of pressures and challenges. Couldn’t we learn more from them?

Ahmed thinks we would do well to look at countries such as China and India, because they are adept at serving large populations. “In Chengdu West China Hospital, they have 10,000 beds in the hospital, and 10,000 appointments in the morning for ophthalmology. How do they manage? Let’s go and see how they manage their healthcare system and make ours more efficient.”

In other parts of the world, we can see a working prototype of the very kind of transformation that NHS technologists hope to implement. Take, for example, the city of Helsinki in Finland. The authorities dealt with the basics first and ensured that their health systems worked and were connected. As a consequence, they’re able to innovate. They have a feature called Health Village, for instance, which automatically presents patients with information relevant to the severity of their conditions.

Looking at how other countries have upgraded their systems can test our own hypotheses by proxy. Consider Estonia. “The Estonian healthcare system is in some ways the most advanced in the world,” says Tandon. “Patients essentially have their health passport on them digitally – all their medication history, all their allergies – it travels with them wherever they are.'' This not only benefits the patient, but also the clinician treating them as they are less likely to make medication errors. Having the full patient record along with latest test results also means clinicians are more likely to make the correct diagnosis.

Where do we go from here?

Investing in digital skills, learning from other countries, simplifying procurement – these solutions will take time. But what can we do straight away to make meaningful change? Rather than focusing on the long-term vision, we might consider what could be achieved within a three-to six-month timeframe. Surrey and Borders Partnership NHS Foundation Trust’s Painting is doing just that by isolating paper processes that can be digitised and automated. “With the amount of contact we have with people using our services, there were bits of paper flying around with questionnaires and Word documents. We're now using a Microsoft solution. We are working on implementing Power portals, which will give us a secure platform to present web forms which are anonymously authenticated online, so users don’t need to enter a username or password.”

To expedite change, let’s also not forget to build on transformations that have already happened. “How can we start utilising some of the things that everybody's already got access to?” asks Microsoft’s chief clinical information officer, Umang Patel. “And how do we make it better for those who don’t have access, who aren’t able to interact in ways that we take for granted?”

If we manage to do that, we may have a greater chance not only of creating an intelligent healthcare system but, crucially, one whose technologies address real needs and are available to all.

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This article was originally published by WIRED UK