By Feedback Medical CEO, Dr Tom Oakley
This week an amazing policy paper from the Tony Blair Institute (TBI) was published outlining a bold vision for the future IT infrastructure and operating model of the NHS – Preparing the NHS for the AI Era: A Digital Health Record for Every Citizen. As a contributor to the TBI paper I wanted to highlight some key elements of the vision and why I believe they will be transformational to the NHS and its patients.
Before doing so, it is worth briefly outlining the current landscape of the NHS in order to demonstrate just how transformational the proposals are.
The current NHS landscape
The NHS exists not as a single system but as hundreds of disparate care providers, each running their own IT estate. Despite patients moving between these providers, the data held by each provider is not readily shared across their care journey. As a patient you have to repeat yourself and your medical history each and every time you interact with a new service. Whilst inconvenient, this belies a much deeper problem.
Having limited access to your information limits the ability of a service provider to deliver safe, effective care to you. It often means that they have to repeat tests unnecessarily and can potentially lead to avoidable harm with the unsafe prescription of medications to patients with unknown allergies or drug interactions. The difficulties in accessing necessary information also result in huge inefficiencies for staff, contributing to staff burn out and lost clinical hours.
There are many reasons why this problem exists. It reflects the funding and political flow within the system, which are largely directed to acute hospital providers who commission technology based on their individual needs as a provider, without consideration for how these interact with wider services.
This is in part a protective mechanism, as by locking in the data and investing in certain system capabilities these acute trusts become the only provider capable of delivering services which could be delivered by others and reenforces their regional monopoly position on care delivery. This restriction of care provision is fundamentally what limits capacity in the system and results in the waitlists that currently plague the country.
It is for this reason that new Secretary of State for Health Wes Streeting has called for a redistribution of funding, power and care delivery back into the hands of community providers through a programme that he calls the Neighbourhood Health Service.
However, if this vision is to be realised it must be facilitated by a dramatic change to the digital landscape of the NHS, away from siloed provision to communal provision around the patient; making the patient the focus of data rather than the providers treating them.
A digital health record for every citizen
The digital health record (DHR) called for in the TBI paper is the enabler of this transformation and the transition towards a Neighbourhood Health Service focused on the patient. By centralising data around the patient the system ensures that the information is available to each care setting that interacts with the patient as they all have a common view, through a single operating system.
This reduces the training burden on staff, improves safety owing to the fact that all service providers have all the relevant information, and mitigates the risk of data driven errors such as the prescription errors outlined above. A prime example would be an ambulance service call out where the ambulance team could see the GP record and communicate with the GP and hospital doctors simultaneously to reduce an unnecessary admission and manage the patient effectively in their home with community support – a neighbourhood care model.
It also means that any service provider can use the record to deliver care meaning that services such as diagnostics, which previously were the purview of the hospital providers can now be delivered in broader settings, such as community pharmacy, closer to the patient. All of which improves care for the patient and transforms their experience of the system.
An additional benefit of the DHR is that if opened to private providers it enables them to deliver NHS care more effectively, helping to bring additional capacity to assist with care delivery and, in the short term, the elective care recovery. When delivered at the same NHS tariff, this model presents the most effective lever for reducing the waitlists and has already been championed by the Secretary of State as an essential element of the NHS recovery plan. The DHR ensures that it is done safely and in a connected manner.
The article describes four ways in which the DHR could be delivered. In my view there is only one viable route, certainly if one is to attempt its creation within one political term and within the current financial envelope available to the NHS, and that is to start from primary care and build the DHR around it.
Building a DHR from the primary care record
The primary care record is the closest thing to the core record of the patient in today’s NHS. It is updated after most provider interactions, though often manually based on the receipt of letters or emails from those providers, however it contains the richest longitudinal record for the patient. It also has most of the core functionality required by most care settings, certainly if augmented with capabilities such as diagnostics and collaboration features.
The limitation on the use of the primary care record for this purpose has so far been the restricted access to this record for the patient’s GP. If broader system access were granted, underwritten by the right security and data governance protocols, then the primary care system would be the best foundation for the DHR. The other advantage is that the current primary care landscape is a duopoly between two companies, EMIS and TPP.
This greatly reduces the number of commercial parties that need to be involved in its formation and opens the potential for a national system that could be delivered under license from one or other provider nationally, under the direct control of the Department of Health as a state-owned asset and would already be available to approximately half of the NHS with the remaining half able to switch to it in short order.
Secondary care and other models for the DHR
In contrast, the information held in secondary care settings is episodic and provides little longitudinal capability. There are hundreds of providers, each running different EPR systems and at different stages of digital maturity, making it nearly impossible to build out a viable DHR from this provider setting. Attempts to connect secondary care providers, such as the Federated Data Platform programme, could support or interface with the DHR but they will not result in the formation of the DHR in and of themselves and certainly not without the inclusion of the primary care record.
The other two options outlined, scaling up existing models of shared care records (SCR) and building a DHR from scratch, are both potentially viable, however there are difficulties with each. In terms of SCRs these have broadly been developed regionally and bespoked to local needs which, although arguably supports local service variation (something that the system at large is trying to remove from the operating model), makes them a difficult model to replicate and scale.
Each region has developed their SCR differently and it is highly unlikely that one region would drop their approach and adopt the approach developed by another, especially where time and resources have been committed. Most SCRs are also limited in scope and do not contain all of the information needed to realise the vision of the DHR outlined in the TBI paper. Lastly, although building a DHR from scratch may sound appealing and give the most tailored product the time and cost involved, in doing so makes it an impractical approach, especially if it needs to be delivered from a standing start within one term of government.
The best thing about delivering this from primary care is that the solution is already here.
A ready-made solution for the DHR
Our platform Bleepa® has already bridged the divide between primary care, diagnostic facilities and secondary care, unlocking the potential for rapid service redesign that has already demonstrated some of the impact outlined in the TBI paper. Over the course of two years of our pathway pilot with Queen Victoria Hospital in Sussex, we have demonstrated a 63% reduction in wait times and an 88% reduction in outpatient appointment requirement.
By combining the Bleepa® technology with the primary care record and making it available to all care settings we can deliver on the vision of the DHR, including the ability to bring in and view diagnostic information, multistakeholder collaboration and cross-provider pathway capabilities. Using the existing footprint of primary care providers this DHR could be deployed nationally in days, with allied provider settings onboarded in a matter of months. The ensuing service redesign and the ability to leverage private provider capacity could facilitate the clearance of the entire NHS waitlist within five years.
This is the shortest and most robust way of achieving the DHR at pace and, I would argue, the only viable route to doing so within the financial envelope available and within one parliamentary term.
If you’d like to know more about how we can support the delivery of the DHR vision, contact us here.