In his latest column for Digital Health News, Dr Neil Paul talks about the struggle of introducing innovation to primary care, and whether we’re doing enough to remove the obstacles.
I’m passionate that technology is part of the solution to the NHS’s problems. This is because I believe that technology is one of the real ways of doing more with less. A lot of new treatments and advances in the medical world increase demand, or increase workload or cost. Few actually reduce them.
We are seeing several, real game-changing technologies at the moment and it is interesting to think about how their application – done right – might reduce our workload.
The smartphone is one such technology – a personal computer that can connect to a range of medical devices and sensors via the internet, to myriad monitoring or support system. It has the potential to call for help a hundred times a day, and if used right it has the potential to remotely and intelligently support people to self-manage their own health.
Importance of good data
Artificial Intelligence (AI) is another ground-breaking technology. We’ve known for years that most of the trick to doing medicine is pattern-spotting, and you get good with experience. To be good, AIs need as much of our data as they can get. But we need to be careful to code things right and record useful data.
There is a saying: “garbage in, garbage out”. If we record bad data, how will algorithms learn what is good? Also, what data do they use? I watch the way a patient walks into the room, sits down, stands up, I watch their facial expressions, on occasion I even interpret the way they smell. Me coding “looks unwell” on the computer isn’t much help for an AI to learn as I do. In which case, do we need to think about equipping patients or examination rooms with as many sensors as we can, in order to feed in ever richer data?
Rather than replacing me, AI has the power to help me be more efficient through diagnosis support. As a GP, I spend a lot of my life seeing trivial and common self-limiting stuff. My role is partly to sift out the few symptoms or signs that might indicate that something more complex is happening that needs a specialist. AI can help me watch for these and flag up really rare ailments, or patterns I may have not seen, thereby reducing time to diagnosis, reducing errors and reducing complaints.
Changing the scene
Another game-changing technology that is perhaps less obvious is remote working.
Remote working started out as outsourcing radiologists to the other side of the world for the reporting of digital X-rays. Now, it’s surgeons controlling robots from miles away, or GPs watching through VR goggles while a paramedic examines someone in their own home.
In primary care, we are starting to think about splitting the front-end clinical team from the back-end admin, clerical and support teams, centralising them perhaps in one master location, partly to give more resilience and more productivity while standardising and harmonising the quality.
As well freeing up space by taking admin out of the surgery, perhaps the space needs to change. We might have video rooms set up in surgeries to enable remote consultations. I’ve no doubt this happens already in remote parts of the world, but I’m talking about it happening in big cities, on the high street.
I spoke to a company that provides remote exam cubicles to pharmacies. The patient enters the cubicle and speaks to a remote online GP who can issue a prescription via the pharmacy. There is kit in the cubicle to examine the patient, and it’s remarkable how much information can be gathered remotely without any assistance, with a minimally trained HCA present.
I’m sure that could be improved on significantly. This service was being offered privately; however, I’ve also spoken to an online company who provide remote GP locums.
If there are no locums in your area, why not have one of them log in remotely and speak to your patients? It even brings in the concept of “on-demand” locums. Rather than booking a person for a session or half-day, this company is offering by-the-hour. They have access to the patient’s home record, but don’t currently have the examination tools – although that might be coming.
Similarly, when I want secondary care expert advice, why can’t I press a button and immediately see an online consultant, who could advice and perhaps even send a prescription? High-quality video links, a common system and high-quality cameras capable of being moved around to show rashes and lesions are what’s needed.
Looking at the smaller picture
Moving away from huge game-changers to perhaps just minor innovations, recently we have seen quite a few in primary care.
A lot of fuss has been made over trying to divert people away from GPs using IT front-ends to our appointment systems. A lot of money appears to have be spent on it, although I’m not convinced anyone is shouting that it’s worked. We have seen systems interrogate the patient trying to take a history, so that this is already done prior to coming. Again, I’m not hearing a lot of success on this one. Signposting patients to other non-NHS services, where appropriate, is linked to this.
We have apps and online lifestyle coaches advising people on healthy lifestyles. Other forums support people with poor mental health, or offer computerised CBT (cognitive behavioural therapy). Is any of this helping? If it is, most of the GPs I’ve spoken to haven’t noticed: they say they are still drowning in demand.
The big questions
Which begs the question: do we have the right products? Are we implementing them well? Do we have enough innovators or innovations? Despite the innovations listed above, I think there are a lot more ideas out there struggling to be heard.
Some struggle as they have an idea without a real problem to fix. Some are well-meaning, just don’t get it. I’ve met lots of companies from abroad who just don’t understand NHS, but are convinced they can fix it simply with a business tool with an NHS logo on it.
Money, money, money
One of the biggest issues is understanding the money flows in the NHS. I spent two hours in a meeting the other day being shown a product by a major UK company. It took me about an hour of explaining the money situation for them to realise their pitch wasn’t going to work. They said I’d put forward their thinking by a year. Why did this company get as far in their thinking without understanding this?
Some innovators need money to help them get off the ground. Some need access to programmers or hardware people. Some need help with the UI or interacting with the clinical systems, and some need help getting in front of users for case studies to prove their worth. Sometimes, clinicians with ideas need access to innovators.
Although I’ve written iPhone apps myself for a hobby, I wouldn’t call myself a professional programmer. A lot of successful ideas come from people who can program themselves. I recently worked with an individual who had a great idea; he raised some money but choosing a programming company and commissioning them to write his app was very daunting. It is easy to spend money and not get anything.
I know there are agencies like the AHSNs – I’m developing a good relationship with my local one – and I know there are hack days. I just wonder if there needs to be a radical change.
Do we have enough panels of every day users willing to try stuff? Do we have IT support on the ground if something goes wrong? Do we have project managers willing to write up a project? Do we have people who can explain the money?
I have at least three great ideas that could help the NHS. In Dragon’s Den, they give up a percentage for support – the more support, the bigger the percentage. I’d give up a big percentage for NHS support. It’s a big ask for me to develop something on my own. I might have to give up the day job, raise money, hire help, and do a lot of marketing. Again, lots of companies I speak to are fed up with traipsing up and down the country doing presentation after presentation to NHS managers who ultimately can’t say yes to a product.
I may be wrong, but I think universities are much better at creating spin-off companies and supporting them while retaining some IP. Are we doing enough of that? I look forward to comments telling me we are, but I haven’t heard of it and none of the people that contact me have. Perhaps it needs a bigger push.