Another view on: Implementing innovation
- 16 July 2019
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.
12 Comments
Mark, I gather you’re in the NHS so I don’t expect you to endorse specific products. However I can assure you that there IS genuine innovation out there, and NOT all products are the same or even similar. When you find one deliberately forging a different path from that prescribed by politicians and the NHS it might give you pause to consider. Why are they doing that, when surely the funding would go alongside compliance with policy? Is that not innovative, and if they have evidence that it works, wouldn’t that be valuable? One of your comments for example on 16/7 was that the next generation want video consults. Well, we didn’t know, so we tested it, and found it’s fewer than 1 in 1000, even though we offer fully integrated video at no extra charge. It’s not happening. Yet simply attaching a photo to a message is 30 to 50 times more popular. Have you seen a policy on that?
“Crossing the Chasm” (Geoffrey Moore I think) is indeed one of my favourites, along with Eric Ries “Lean Startup”. Every company has its own context and story, and very few have a straight path. For every Google there are thousands across the spectrum of success, survival and failure. The point is as entrepreneurs we have skin in the game, this matters, and we can’t say oh, marketing is not my bag, let’s just leave that to hopefulness. But now is the best time in history. Everyone in the world can see our service on the web. Boom.
Get what you are saying (there is a good book called crossing the chasm that you may have come across.) and I appreciate the “standards” thing but I still think its too hard for the average practice to find out about innovation – perhaps PCNs or GP feds can help here… and I think its too hard for people with an idea to take the risk of spending the time/effort in creating/delivering it.
Neil, a number of issues here. If only it were as simple as describing the amazing product, and showing the evidence, then every CCG would be recommending it. Adoption of innovation, even the very best, doesn’t work like that. It goes through stages of innovators, early adopters etc. But the NHS GP market is skewed, and screwed, by a number of drag factors. Yes, there are lists of NHS approved products and apps, and we’re on them all, but getting on them means conforming to specifications which we and many others do. However, I’m sure you know that “conforming to spec” is completely different from “works in practice, and provides value” – indeed, the two are often incompatible. Our approach is evidence based rather than compliance based and this is very unpopular with “the authorities”. But it’s very popular with actual users, and if you look at our website you’ll see a number of them. Follow @askmygp on Twitter and you’ll see other users talking about it. Ring some of them up and see what they say, eg one in Manchester. Others starting in Cheshire soon. Yes, we’re growing steadily and to those who say, “Why not faster?” I say “Investigate for yourself.” If you realise that it makes money for you now, don’t wait and hope that someone else, ie the taxpayer, will fund it. Buy it yourself, then you have skin in the game.
@harry – happy to look at your askmyGP – after my hols. i guess your story is part of what i was writing about. if your product is so amazing – why isnt every CCG/CSU promoting it an option for practices? Is MedCity helping promote it in their area? Does the NHS need a list of approved/recommended products? A lot of small companies I speak to have a sales/marketing problem..convincing 8000 GP practices to take up their offer can be hard and needs a lot of effort. Take AccuRx – i think its great (i have no interest) – its free and yes they are spreading virally but i still come across practices that havent heard of their offer. We have a app store aimed at patients – perhaps we should have a product/service store aimed at practices?
Harry, the framework is there to ensure standards and interoperability. While I won’t make opinionated comments regarding specific products, there are currently many products that are all very similar. There is no true innovation here, the market is flooded with similar products based on the same principles and technology. The winner will be the one that truly innovates and gives us something we cant live without. That is a major reason why products from smaller companies find it difficult to make an impact in a flooded market. Its no different to any market outside of the health industry. Give us something we cant live without.
Best of luck.
DOI alert: if you haven’t seen things working yet Neil, and making a difference both for patients and practices, perhaps you haven’t looked at askmyGP yet? Our practices average 58% of demand arriving online, and they complete the episode in average 117 minutes. 23,000 episodes per week in 50 practices. So take a very close look.
Valuable perspective Neil. MedCity was set up in 2014 to support growth in the regional life sciences sector and one of our key focus areas is helping innovations commercialise and get into the NHS. We have a dedicated programme for innovators looking to access financing and advice, Angels in MedCity, and also have worked closely with the NHS clinical entrepreneurs programme. Do get in touch if you think we could support you.
Thanks for your comments. I agree with you and didn’t really mention in the article the time to spread innovation can be years and what can we do to speed that? Its not just IT; Im involved in several pilots of things that have been proven to work elsewhere. One I’ve been talking about since I saw the evaluation published about 10 years ago. Its taken all that time to even try it locally (on another pilot just because we aren’t sure it will work here….)
Glad to say that using video links for outpatient clinics is beginning to happen in Dundee and Tayside via the Near Me programme. No GPs in Dundee using it yet but I hope that will come relatively soon. My role is to encourage people to take up new ideas and everything seems to take a while … but as soon people understand what they can usefully do with new technology, suddenly change happens. Enjoyed your article.
Hi Dr Paul, I’m a Senior Business Analyst, and as well as other work in the NHS I support CCG’s rolling out some of the tech you describe in the smaller picture to GP’s. I do not disagree with your interpretation, but it is my experience that these technologies we are beginning to implement, we will not see the great benefit for 5-10 years when the so called digital generation start their working lives. I see it now, this is the generation who don’t want to waste time in a GP surgery, they want video consultations, electronic consultation, digital pathways, any short cut that is available. However the majority of GP users are 40 years old plus. This is where we have a mixed economy of digital and none digital users as well as the ” I have the right to see my GP” generation, I mean no offence to anyone, however the latter is a definite factor in GP demand currently. I also agree that we have innovation and not innovators and the world of primary care seems frightened to innovate. That’s GP’s, clinicians and patients as a whole, they don’t like change. The tech that is being currently delivered will show benefit in time, patients and education is the key here, big bang would be a disaster.
The generation coming through want everything instantly, they have no tolerance to wait, this is when the benefits will be realised. I also agree that implementation is an issue. Most implementation is done through IT and Admin staff, with little input from GP’s through no fault of theirs. Its time restrictive. To find a way to include more education to the GP’s without being a burden would be a huge benefit to the programme, and that is the solution to me. Find the time for GP’s to be more inclusive without being a burden, with more education and support to patients. Yes this will come down to money in the long run, and that where suppliers come in. I’ve seen many products that are not fit for purpose, but managed to be purchased, boggles my mind at times. More openness from suppliers should be demanded and better product screening and testing from us before we commit to purchase. Time is money so they say, but a little bit of time spent on due diligence and testing could save ££££££££. Great article.
Great article. In terms of implementing AI, you’re absolutely right that the quality of the data going in is crucial. At the moment, there are many areas where records are not coded, not standardised, not accurate, and sometimes not even digitised. We have a long way to go!
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