what the manifestos missed (Wired UK)


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The NHS needs more money. By NHS England’s own estimation, it needs an extra £30 billion a year by 2020 just to avoid total collapse. That’s the bad news.

The good news is that every political party has pledged to deliver at least some of that (and it is no coincidence that half of all Britons class the NHS and healthcare as their top concern when it comes to how they plan to vote on 7 May). Those promises equate to £8bn from the Conservatives and the Liberal Democrats, £2.5bn from Labour, £3bn from UKIP, £9.5bn from the SNP and £12bn from the Green party. The rest of the money, all £22bn of it, is slated to come from “efficiencies” — which means cuts.

Where this simple equation gets complicated, as ever, is the point at which promises turn into reality, or not. Funding pledges are, as ever, widely ambiguous, and the NHS is not expected to meet its predicted £22bn savings. Hospitals are in the red because they can’t pay the staff they already have, but every party is promising thousands of additional frontline staff — staff whose salaries make up around 60 percent of the total NHS budget.

The NHS needs to invent a new solution to this problem — and that is where technology comes in. A report by think tank Reform estimates that the NHS could save £2bn by 2020 by using technology to get people more involved in their own healthcare. It talks about just one facet of facilitating efficiencies not through more cuts, but through technology — there are many more besides, from using algorithms to automate diagnoses, to simulations that can reorganise ambulance fleets based on predicted demand.


Ed Miliband 'saving the NHS'
Ed Miliband ‘saving the NHS’Christopher Furlong / Getty Images News


Tech isn’t a solution to all ills, says Victoria Betton, mHealth Habitat programme director for Leeds & York Partnership NHS Foundation Trust & Leeds Community Healthcare NHS Trust, but it’s a good place to start. Betton’s organisation is coordinating smallscale technology trials from eating disorder apps to digital speech and language therapy tools. “We believe digital technology will be key to improving services, but only as an enabler rather than as an end in itself,” she tells WIRED.co.uk. “We’d be keen for a real commitment to supporting the digital maturity of health and care staff and the digital inclusion of people who could most benefit from digital tools. This is the way that investments in digital can be truly leveraged.”

The point is, the NHS has heard the promise of tech, and it’s on board. Tony Young, NHS England clinical director for innovation and WIRED Health 2015 speaker, points out that NHS England’s own Five Year Forward View — which estimated we need an additional £30bn by 2020 — says “how important innovation is and that new technology will play a key role in delivering change”.

For that reason, investment in technology in the NHS should be written all over the face of the major party manifestos. Right?

Nope. As is the nature of political campaigns, top-line numbers driven by populist demand are favoured over explanations for how we are going to get there. 

So what are the major parties doing about this? Or perhaps more importantly, what should the next government be doing?

The good and the bad of the NHS manifestos

Conservatives

As with most things in the party’s manifesto, the Conservatives’ NHS rhetoric comes down to the economy. The party is going to make it “strong”. So no worries there. Specific pledges range from guaranteeing same-day access to GPs for over-75s — with an ever-ageing population the Nuffield Trust estimates will account for 40 percent of growth in healthcare spending by 2021, surely a good thing — and access to a GP on evenings and weekends for everyone by 2020.

The problem, as with many populist promises, is that the latter step is aimed at a demographic not responsible for clogging up A&E (the entire reason behind the pledge). “It’s about understanding what the issue is,” Baird tells WIRED.co.uk. “A lot of their promises are aimed at working-age population, while most people that use GPs are the elderly with complicated health conditions. There are odd promises coming out that are less than helpful.” The party is promising an extra 5,000 GPs by 2020 — but it takes five years and a lot of money to train a GP, “and a lot are already leaving because they can’t cope with the workload,” says Baird.


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The Conservatives have also publicly patted themselves on their collective back for achieving “billions of pounds in efficiency savings”, the result being “fewer managers and thousands more doctors and nurses”. Sounds great. But as Baird points out, sometimes we do in fact need managers. “The NHS is under managed compared to some industries — yes it’s over-administrated, but leadership is important. It’s just popular to talk about more nurses and less managers.”

The Conservatives also promise to “finally abandon paper records” — finally, being the operative word. That doesn’t mean the NHS will be online-only under a Conservative government, just that we won’t be creating yet more unnecessary hard copies to join the mountains already in existence. The good news is Cameron’s camp has committed to integrating services and care and increasing access to psychological therapy.

Labour

The party paints itself as the saviour of an existentially threatened NHS, focusing largely on a cash injection of £2.5bn (which it recently promised was just a “downpayment”), more doctors (8,000) and nurses and a halt to the perceived privatisation of the NHS provided by a repeal of the Health and Social Care Act. The party is also promising more integrated care, focuses on speedier GP appointments and access to psychological therapy. There is a top line promise that “reforms will focus on prevention and early intervention, and joining up services from home to hospital”. This would all be great in a connected healthcare, at-home testing and wearable monitoring sense of the words “join up” and “prevention”. But there’s nothing to suggest that’s on the cards or will be allocated investment.

Liberal Democrats

Not much change here — mo’ money, no problems. A recent release from the Lib Dems says the £8bn a year it’s committing by 2020 equates to 38,000 more GPs than Labour. By what decade we can expect to see those 38,000 doctors, considering the five-year training time, expense, and total lack of incentive for many young people to sign up, is unclear. The party’s pledges again fall into similar camps to the other two main parties’ in England, with integrated care a priority and easier access to GPs. It is, however, the only party to mention technology specifically. A release promises it will “fund NHS digital revolution”. “Liberal Democrats will set aside £250m from the profits of the sale of redundant NHS assets to fund new technologies in the health service.” Sounds exciting. What “new” means in reality is online doctor appointments and repeat prescriptions (already available, just not everywhere) and “encouraging” patients to contact their doctors by Skype.


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How technology can help save the NHS

Learn from the startup sector

We should be looking to technology applications that have worked in the mainstream, for answers. In the context of telehealth, that means asking why networking in a social context works so well online, as with Facebook, but not in health trials.

“People are already using everyday technologies like Facebook and Twitter and blogs to manage their health and connect for peer support,” Betton says. Young predicts we will see more products like PatientsLikeMe, a forum in the US where 100,000 people are sharing their health records online to seek out solutions for themselves. “These things are going to spring up more as patients want to inform themselves and take back control of their health care. Right now everything’s organised round what’s convenient for the medical system, but when you look at surveys convenience for the patient routinely tops the list of what people want.”

Think tank Reform said these types of innovations are already outstripping the NHS in terms of empowering the public to take charge of their health and deploy cost-saving preventative measures. The report states: “It is quite possible the technology enabled ‘expert patient’ will emerge more quickly outside the NHS than from within.” The private sector, the report states, continues to pick up the torch — “insurers and employers are also seeking to provide greater access to online and remote healthcare that is not typically offered by the NHS” — referring to virtual GP service Babylon.


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Invest in innovation

Naturally, if we are to look to the startup world for inspiration, the UK healthcare system should also start reaping the benefits of that innovation by supporting it. Young has cofounded the £500m Anglia Ruskin MedTech Campus for just that reason, bringing together industry and academia to create “the leading medical health innovation space on the planet”. “We want to help provide the infrastructure to make your idea happen — to turn it into a global product or care pathway rather than being ideas in someone’s head that don’t go anywhere.” It’s on its way to creating 12,500 new jobs in Essex, and longterm he wants to see the UK capitalise on its expertise in the sciences to make money from products and services for the country. It’s the same idea behind the boosting of Silicon Roundabout, and Young says the GVA (gross value added) to the economy of MedTech is slated to be £6 for every pound spent. “We have a history in our country of invention and early testing and trialling. The CT scanner was invented in Britain, but commercialised abroad. We have the largest, longest healthcare system in the world and the second largest university base on the planet. Can we build on that and develop something? Absolutely.”

Our data is (part of) the answer

Connecting the massive medical datasets we have at our disposal in the UK could provide huge leaps in efficiencies, better diagnoses and much more. The Clinical Practice Research Datalink, funded by the NHS National Institute for Health Research (NIHR) and the Medicines and Healthcare products Regulatory Agency (MHRA), already provides anonymised NHS clinical data to help researchers. But there’s so much more we could be doing.

The debacle of Care.data, NHS England’s initiative to synch up GP and hospital records, has no doubt slowed that progress, particularly after it was revealed the department had sold data from medical records to a trade body for actuaries, which help set pricing for insurance premiums.

Naturally, all the major parties have fallen silent on Care.data. Baird from the King’s Fund insists as long as there are “more safeguards” that are made clearer, it will be as effective and successful as predicted. And there is no question that it will ultimately go ahead once these issues are resolved. Young predicts these datasets, and more incoming, will be revolutionary for the NHS. “There are such rich datasets in this country, going back many years.” With the 100,000 Genome Project, he points out, we are able to look back at volunteers’ records from 25 years ago to understand why they are today suffering from specific disorders today.

When wearables and at-home monitoring devices become ubiquitous, that data pool will explode and Young predicts the focus will not just be on randomised controlled trials, as is the gold standard in the sciences, but on live data. “We can’t do randomised controlled trials, because tech moves so fast. We need evidence to show where to have most impact.”


mHealth Habitat workshop
mHealth Habitat workshop


NHS innovations today

Our mHealth Habitat Discovery DaymHealth Habitat

Technology might not be front and centre in the manifestos, but the story from those working within the NHS today, and in the private sector, is much more promising. Trials focussing on just the kind of efficiencies Reform recommends are well underway, and more besides. Here are just a few:

  • The newly launched NHS Innovation Accelerator (NIA) programme aims to attract and support healthcare innovators from across the globe, to the UK. Applications opened in January and sought 20 “cutting-edge innovations”, and NIA fellows will benefit from a startup-style accelerator course that will speed up development of products and technologies, to be deployed to help improve care and reduce costs in the UK.
  • Picking up a recommendation from the NHS Five Year Forward View, NHS England has launched a test bed programme designed to evaluate the real world impact of technologies that could improve the NHS. Applicants wanting to take part have until 29 May to flag up their interest, and innovations will be put to work in five test beds within the NHS.
  • mHealth Habitat is supporting the development and testing of apps and other digital tools focussing on, “goal setting, adherence to treatment plans and self-monitoring progress in between appointments,” Betton tells us. “The digital tools are supporting the efficacy of the clinical intervention rather than to be used entirely independently.” The initiative has been up and running for a year and the first products are due to launch this summer. The group is also launching the People Driven Digital unAwards (applications close 24 May) that encourages innovators in the health tech space. One of the latest mHealth workshops focussed on using Minecraft in a health context for, among other things, social story telling for learning disabled children, recreating hospital environments so kids can worry less about what it will be like, a tool for mental health therapy, an art therapy tool or a public health tool for recreating the body in Minecraft. “There is a great appetite from practitioners to engage with the platforms that people are already using and harness them for health purposes,” says Betton. Some of the best Minecraft experiments will be tested in practice.
  • Young says at-home sensors are being trialled across the UK, and the NHS is already supporting some of these. The aptly named SENSOR app on iOS, which automatically uploads 42 clinical measurements everyday from parent company Aseptika’s sensors, is funded through a Phase 3 NHS England Small Business Research Initiative Healthcare. A clinical trial of 30 patients is underway. The space is ripe for trials. “There’s a digital plaster, new ear sensors that carry 3GB of data,” says Young. “It’s designed to measure heart rate and blood oxygen, but it won’t be a step too far to do blood pressure, all while the wearer listens to their favourite tune. It’s about how we use these to bring benefit for the population.”
  • The NHS already has its own apps library, which features therapy tools and diet trackers. As more work is done around verifying the best use of remote sensing technology, more patient data will be shared with the NHS in this way in the future. The key obstacle, the Health Foundation’s Steventon suggests, will be what data we are processing and how we interpret it. “Often we are looking at vague shadows of people’s lives — not the rich complexities like social support, economics situations, housing, environment. All these interact to affect people’s health.” But just as the likes of Amazon garner data to improve services, Steventon believes we can do so in healthcare. “It’s about closing the data gap, and understanding those data shadows so our understanding is more like people’s reality. That’s the vision and it’s quite a long way off, but there’s still a whole bunch of technical questions about the apps we need to research over the next few years. They are, however, likely to contribute to finical savings in the short term.”

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When is technology not the answer?

While technology can certainly help us achieve a lot in terms of cost-saving and preventative healthcare, it is as far from a magic pill as the top line promises of the main parties. It’s about looking at where the technology we already understand and have at our disposal, can make the most impact.

“It’s not about splitting atoms,” Young tells WIRED.co.uk. “We want to make a difference and impact patients tomorrow… Technology has a really key role but it is not the solution on its own.” Young gives the example of “the largest telehealth trial” ever done. Everything looked encouraging, until the trial-leaders dug deeper. “Tech was leading to people being more socially isolated, so didn’t fulfil its aim because people want human contact.”

Adam Steventon, Head of Data Analytics at the Health Foundation, worked on a telehealth trial featuring one billion rows of data, but found “some very ambiguous evidence” that at-home blood sugar monitoring or auto-relaying weight readings (a helpful indicator for heart failure) to physicians reduced hospital admissions. Steventon says this was likely because of strict clinical models that expected already overworked nurses to monitor blood sugar readings. “This is why the discussion is always so difficult, because technology by itself is only one piece of the puzzle — it’s how people use it.”

Someone already well aware of that, NHS mHealth’s Betton, adds: “I think we need to have a lot more focus on building the digital literacy and confidence of health practitioners. By engaging and involving them we can truly realise the benefits of digital and they can use digital tools in their day-to-day practice, hopefully helping more patients get online. There is a current mismatch between the people most likely to be using digital tools and the people who would most benefit from them (i.e. people most likely to use the health services).”

What’s next?

There is at least a light at the end of the tunnel, even if the main parties try their best to ignore technology’s place in saving the NHS. There is most definitely a drive from patients to take charge of their own data and health plan — one survey showed 97 percent of consumers want access to their electronic health records — and the NHS is playing catchup with the startups already capitalising on that desire. A thought to leave you with, though, from King’s Fund’s Baird: 

“The NHS is still using fax machines,” he told WIRED. “So we have a way to go.”

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1 May 2015 | 4:46 pm – Source: wired.co.uk

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