Winds of Change for the NHS?
by John Symon, SVP, International Markets
Next year in July the National Health Service in the UK will turn 70. With a staff of 1.7m doctors, nurses and associated care givers, the NHS is the 5th largest employer worldwide. Despite all the doom and gloom and growing political & financial pressures faced by such government funded health organisations, the NHS is still the most remarkable institution that provides free healthcare “at the point of delivery”, irrespective of the individual’s ability to pay.
The Current Challenges
A growing, ageing population, an increase of acute medical diseases, a dramatic rise in mental health issues, increased costs, workforce shortages, as well as management & infrastructure challenges are all factors resulting in increased pressures on healthcare bodies worldwide.
In a January 2017 report, spending watchdog, the Office of Budget Responsibility (OBR), estimated that publicly funded healthcare is currently costing Britain 7.3 % of GDP and that by 2066-67 it will have hit 12.6 per cent. The OBR is far from alone in making such warnings, with a recent paper in Lancet Public Health reporting the number of elderly people needing long-term care will rise by a quarter between 2015 and 2025. Today, in the UK, some 30p out of every £1 spent on all public services goes on health.
A recent report by the UK’s Care Quality Commission (CQC) highlighted:
- Staffing shortages, with vacancy rates in the NHS, rose by 16% over the last two years, despite an increase in staff of 4%
- Bed shortages in hospitals with occupancy levels being consistently above recommended levels since April 2012
- Falling numbers of nursing home beds – down by 4,000 in two years at a time when more are needed
- Rising numbers of people not getting support for their social care needs, with the numbers hitting 1.2m - up 18% in a year
- Number of detentions under the Mental Health Act up by a fifth in two years to more than 63,000 last year.
Further, in a report by the King's Fund on physical and mental health provision, “professionals should take a ‘whole person’ perspective, and have the skills to do so. The high rates of mental health issues among people with long-term physical health problems, along with the poor management of ‘medically unexplained symptoms’, cost the NHS more than £11 billion a year in England alone”, says the report. Integrating both physical and mental health care could both improve outcomes and save money.
There is a recognised, urgent need to join up primary, secondary and social care services.
The NHS’s Five Year Forward View proposes a series of measures to bring about the ‘triple integration’ of primary and specialist hospital care, of physical and mental health services, and of health and social care.
The Need to Deploy the Latest Healthcare IT solutions
It is now widely recognised that there is an increasing need for an integrated approach for healthcare services and that this can only be achieved by the deployment of the latest technologies to minimise operational costs, while greatly enhancing the quality of patient care.
The UK government announcement in February 2016, confirmed that they will be investing £4.2 billion in NHS technology over the next five years, including £1.8 billion for achieving a paperless NHS by 2020.
The opportunities to digitally enhance the NHS are now widely recognised, but it appears still to be highly regulated, highly layered, slow to move and culturally resistant to external influence.
Four particular technology-related areas are increasingly addressing the afore-mentioned challenges:
- Electronic Healthcare Records (EHR) - Electronic health records are digital records of a patient’s health and care.
- At present, patients may have several paper and electronic records stored in various settings. NHS England’s goal is to connect electronic health records across primary, secondary and social care by 2020.
- This system would allow people to monitor their own health and could improve patient safety and outcomes. Electronic record keeping would also aid the collection of data for research, and inform the commissioning of health and care.
- There is a range of technological and organisational challenges to implementation, such as interoperability, staff training and maintaining the privacy of patient data
Previous attempts to introduce comprehensive electronic health records under the National Programme for IT (2002-11) failed. Originally budgeted for £6bn, the NPfIT ultimately cost closer to £12bn. This was an apparent top down, one-size fits all, centralised approach, that was hugely ambitious, costly and difficult to implement and was allocated to just a limited number of multi-national suppliers to deliver.
- e-Procurement and Payment Processes - involving better solutions for the reduction of revenue leakage, cost recovery & medical asset tracking
Inefficiencies in the procurement and supply chain process for products being purchased and used by the NHS has produced significant wastage and revenue leakage. Systems to track medical supplies, drugs and equipment, together with better allocation of staffing, can now produce significant cost savings. The NHS has a challenge to deliver £22 billion in savings by the end of the financial year 2020/2021, including £700m from improving procurement processes. In addition, correct patient coding can drive further cost recovery benefits. It has been estimated that the overall underpayment value across the NHS costs in the region of £600-700M per year.
- Data Analytics enhancing diagnostics, aiding medical research & holistic patient view
The ability to analyse all relevant information from various data sources, and having access to it at the right time, enables early intervention to prevent adverse developments affecting patients' health.
Such data can help identify individuals who are at risk of serious health problems and minimise the need for retrospective treatment. The ability to use big data to identify waste in the healthcare system can also lower the cost of healthcare across the board.
- Tele & Mobile Health solutions –
Technologies are emerging and maturing that promise to disrupt how patient care is delivered – wearables, precision medicine, preventative measures, medical research, self-service and remote monitoring of health care services for patients or the elderly, both at home and in residential care facilities.
New Opportunities for Technology Innovation
NHS England is currently supporting selected, digitally advanced mental health and acute trusts as “Global Digital Exemplars”. A Global Digital Exemplar is an internationally recognised NHS provider, delivering exceptional care, efficiently, through the use of world-class, digital technology and information. Exemplars will share their learning, experiences & best practice to enable other trusts to follow in their footsteps as quickly and effectively as possible.
Over the past 3-4 years a more decentralised approach appears to have been embraced by the NHS, particularly to allow local, acute healthcare trusts more autonomy with their choice of suppliers and to achieve practical, clinician driven, solutions that deliver better and more timely healthcare for their patients.
This represents significant opportunities for a wide range of software & solution vendors, especially if they are able to demonstrate measurable ROI benefits, increased operational efficiencies and innovation that will enhance the quality of patient healthcare.
John Symon, SVP International Markets for Boss Equity, recently met up with Roger Wallhouse, CEO of Healthsys, an independent consultancy that provides strategic and marketing advice to the global Healthcare Informatics Industry. Roger is also non-executive director of 3 UK-based Healthcare software companies and has several decades of experience with the application and implementation of IT solutions within the Healthcare sector.
Some 5 years ago Roger undertook a study within the NHS in Scotland and later, across England & Wales, which quantified and exposed the extent of waste and revenue leakage, especially in the procurement & supply chain process, within the NHS.
Roger provides some insights into how the application of the right technologies can provide a paradigm shift within the NHS to drive down costs, improve efficiencies and instigate better health services across the patient care pathway. He also offers some pragmatic advice to IT Healthcare software and service vendors as to how they can leverage the value of their offerings.
Welcome to Boss Insights, Roger. Perhaps we could start with a brief background of your career within the Healthcare IT sector?
JS: I understand that you were a pioneer of one of the earliest Electronic Health Records solutions in the UK? How has the adoption of EHR systems progressed and changed over the past 5-6 years and how achievable do you consider the goal to achieve full conversion to EHR by 2020?
RW: A pioneer perhaps, but, certainly a veteran! My involvement with NHS IT began in 1978 through a joint venture with the US EPR vendor Shared Medical Systems (SMS) to introduce their products to the UK market. In those days our main competition came from mainly hardware companies now long forgotten – NCR, Burroughs, Univac and Dec. By the early/mid 1980s the then NHS Regions embarked on mainly Patient Administration System (PAS) procurements spurred on by the adoption of a DH drive to implement Korner data sets to analyse hospital activity.
Despite several centralised DH attempts to achieve widespread use of EHRs culminating with NPfIT the NHS continues to rely, to a great extent, on PAS with some additional clinical applications often at a specialty or department level. However, it would unfair to suggest no progress has been made as there have been an important take up of EHRs across some Trusts. The progress to full scale deployment in the Trusts is often limited by funding and the recognition that implementing an EHR across an organisation of many thousands of users is a marathon and not a sprint. For this reason, the NHS remains a long way from achieving full EHR usage. 2020 will be a target met by some, but I suspect it will be 2025 at least for some.
JS: What were the headline results of your findings regarding the apparent waste and revenue leakage caused by inefficiencies in the procurement & supply chain process within the healthcare sector? Is it possible to quantify the savings to be made with the application of the right technologies?
RW: The NHS in England spends circa £22 billion on non-direct patient care supplies, contract labour and estates etc, much of which is procured at a local level without exploiting the potential purchasing power of the NHS. Direct experience with Trusts over several years exposed the lack of supplies management with a high degree of reliance on paper based systems and little control over stocks and ordering. The report produced by Lord Carter highlighted the unwarranted variation across the NHS and concluded that “£5 billion” of efficiency savings could be achieved if the various matters highlighted in the report were systematically addressed.
Not all the wastage can be addressed by improved IT, but other analyses have shown that at least £2 billion could be made by eliminating the paper systems in supply purchasing, invoice validation and stock management which is woefully behind that which exists in large retail organisations.
JS: What are some of the latest key initiatives being taken by NHS England and other government healthcare bodies to accelerate the adoption of digital health solutions?
RW: Following the publication of the Five Year Forward View and its subsequent update NHS England instigated a review of the state of EHR in hospitals across the service by the US Professor Robert Wachter. Arising from this is a new national EHR strategy based on the establishment of Global Digital Exemplars. This GDE programme aims at accelerating the adoption of EHR systems across the NHS. Under the programme a non GDE Trust, known as a follower, will partner with a nominated GDE to adopt the same system and benefit from the GDE approach.
In parallel the DH initiated the Scan for Safety programme funding six hospital Trusts to adopt GS1 bar coding systems for supplies management and usage. One aim of the programme is to demonstrate to the NHS at large the benefits in cost, supplies management and patient safety by the adherence to a bar coding approach such as that achieved at Derby Hospitals, the first of the six pilots to meet the full programme requirements.
There are numerous more local or regional initiatives to facilitate the better use of IT of which the Great North Care Record is but one example. Here the strategy is to link all relevant care providers in the North East such that the data for individual patients stored across numerous systems can be brought together to provide a unified view.
JS: What do you consider are the biggest barriers to such a transformation?
RW: Transformation, whether it’s the NHS or in a commercial business, can only occur if there exists the leadership to drive through and communicate the direction, a recognition of the need and a willingness to change, and the funding to support a transition that cannot be achieved out of normal operating finances. It is to be hoped that the STPs will ultimately drive integration of health and social care services and in so doing create a sustained stimulus for IT adoption across the NHS and social care landscape. Meanwhile, the funding provided for the GDE programme and Scan for Safety will give impetus to a minority of Trusts with the potential for more to come in time. But, leadership at the grassroots level remains a real barrier. At board level IT projects are more feared than welcomed. There are few Trusts where the CIO is a permanent board member and, yet Trusts are completely dependent on IT to operate.
The pressures on resources play a key role too in the adoption of IT. With critical clinical staff in constant demand slack does not exist in the system to support the necessary commitment or will to change. Having said that clinicians recognise that IT can make their working lives and the care they deliver to patients far better but are held back by a lack of willingness to invest in change at the local level.
JS: Which do you consider are the top 2-3 technology areas that will drive the greatest ROI for the Healthcare sector and enhance the quality of healthcare.
RW: AI has the potential, over time, to make a real and very significant contribution to how care will be delivered, and diseases diagnosed. Although there are numerous well publicised projects adoption will come as clinical and patient trust is established and medical evidence is robust. One aspect of AI development that needs greater focus is that of data quality. The more that reliance is placed on the output from AI based products the greater is the need to be 100% sure the input is quality assured.
Perhaps the second area where considerable potential exists is that of ‘open’ technology solutions built around accepted and emerging standards. The work of InterOPEN, IHE-UK and openEHR all point towards are less proprietary approach to healthcare applications. The NHS in England move towards a closer working between health and social care demands the integration of patient data across the health continuum. Supplier success will eventually depend on the extent to which they can show adherence to an open strategy. Healthcare is too fragmented and complex for any one solution to meet all needs and so integration and data sharing is paramount to the NHS and good patient care.
JS: How well adopted is the application of Cloud based solutions within the Healthcare sector and which specific application areas do you consider will drive the greatest benefits?
RW: If one was to consider all of the systems currently in use across the NHS then Cloud based solutions probably account for a very small percentage. In part this is because many of the systems in use have been there for a long time and/or were never conceived with Cloud in mind. So, the growth in cloud based systems will come as a result of a replacement strategy combined with net new applications designed to exploit the benefits of cloud.
Naturally cost and the size of the potential user population will tend to dictate the suitability for cloud. Large scale systems designed to support the sharing the data across a population of providers should allow the benefits of cloud to be maximised. EHRs and the increasing adoption of integrated care records are two examples of where the power of cloud can be exploited.
JS: What advice would you give to vendors of Healthcare Software & Service solutions to leverage the value of their offerings in this sector?
RW: Given the financial constraints and the everyday pressures at the ‘coalface’ the NHS is a tough market in which to do business but full of opportunities. The first and most important point to remember is that the NHS is NOT one customer; it is a market of hundreds, if not thousands of separate ‘business’ units. Increasingly, NHS organisations are recognising that IT solutions are more of a must have than a nicety although such views are not yet endemic. For any supplier, irrespective of size, persistence and playing the long game is vital. It is not a market for those wanting to make a rapid entry and ‘quick profit’.
Success will ultimately occur with the establishment of proven use cases where a demonstrable RoI is established. Whatever apparent benefits may be attributable to the solution the final test will be its affordability and, in this respect, it is well to remember that price, cost and payment are different and need to be aligned to each solution according to local NHS needs. Alignment of who pays and who will see the financial benefit can often determine whether a deal will succeed or not. In the confusing landscape that is the NHS this is not always clear.