You have no idea of the changes which are coming
By @edent
· covid19 future health nhs · 11 comments · 900 words · read ~771 times.
I wrote this before the pandemic. I chickened out of publishing it because I was working for NHSX at the time. Some of these things have come to pass. Some are yet to come.
I'll never forget the look of horror on my professor's face when I told him I didn't think his university course was good value for money.
I was in the first cohort of UK students paying tuition fees. A massive £1,000 per year. A group of us had gathered to complain about the poor quality teaching materials on a specific course, the lack of contact hours, and decrepit facilities.
Value for money and - by extension - user choice, was an alien concept in undergraduate education. We weren't humbled by wise old men - we were paying a significant sum of money for a resource.
I went back to my old university a few years ago. The crappy computer labs have been upgraded, lecturers seem more engaged with students - rather than treating them as a distraction from research, and the students are more confident in demanding what they need.
A large part of this is because prospective students aren't choosing a course based on which campus has the cheapest beer any more. They're on social media talking to existing students, they're looking up the salaries of graduates, they're investigating the ratings of professors. If you were paying £9k, wouldn't you do the same?
That conversation was 20 years ago. Fuck. I'm old.
But the same conversation has been and gone with swapping energy providers. I was bemused when we moved into our new house to discover that the previous owners were stuck on the most expensive tariff from a company which took 30 minutes to answer the phone. Sure, not everyone cares about switching to the best deal, but within 15 minutes I saved £100s and swapped to somewhere with better customer service.
Like millions of people in the last few years, I've fired my phone provider. I recently told my bank to improve their services or I'd switch to one of those fancy app-only banks.
Nearly every service in the UK has undergone a radical transformation due to digital disruption. Users' expectations have been raised for quality and value for money.
Now the same transformation is coming for healthcare.
My local village pharmacy was crap. They were slow, inefficient, never answered the phone, and were downright rude. OK, their prices for an NHS prescription were identical to every other pharmacy - but I didn't feel like their service represented value for money.
I could have taken a bus to the nearest town and got my drugs from there - I'm lucky to have the mobility and money to do so. Instead, I swapped to an app-only pharmacy.
Echo post out my meds with no delivery charge. They send me reminders when they reckon I'm running low. If I'm away from home, they'll deliver to me. They don't shout out in a crowded shop "MR EDEN? YOUR EMBARRASSING OINTMENT IS READY!"
All I needed was a smartphone and an Internet connection.
I appreciate not everyone has these things. And not everyone trusts online services. That's fine. But most adults do. And there will suddenly be a tectonic shift when people realise that there is a better way of doing things.
The same is true of a regular GP visit. Do I want to sit on an uncomfortable chair, surrounded by ill people, waiting for hours because the previous appointments have been delayed? I might not be able to physically reach a different practice - even if their chairs are comfier - but I can swap to an online GP.
OK, a video chat isn't going to take my blood-pressure or hear my heartbeat - but it is great for a whole range of appointments. And if I don't want to look a doctor in the eye - due to anxiety, embarrassment, or even just time constraints - I can text chat.
I think every GP should have the best equipment, the fanciest chairs, the politest and least-stressed staff, super-fast computers, and plentiful appointments. They should all have amazing pharmacists who are discreet and caring.
But I'd still switch to something which was more convenient to me, better met my needs, and gave me an experience which I thought was higher quality. I suspect many people would.
This is the change that's coming. And it reveals some interesting questions:
- What happens to a GP surgery when the built-in pharmacy doesn't have enough customers to stay profitable?
- If "simple" consultations are replaced with video-chat / triage, does that leave more resources for others?
- Do certain GPs want to work in an area with low / no digital take-up?
- How many patients care about seeing the same doctor each time? Is that easier or harder via digital technologies?
- We used to have doctors which made house-calls. Now they can do so virtually, what new skills do they need?
And, the big one:
What user needs are unfulfilled?
Ten years ago, no one wanted an app-only bank. The world has changed. And that change is coming for you!
Interesting take @edent Your 2nd bullet point I think is really on point. If we can't solve digital exclusion overnight, the freeing of resources is at least a near star for us. Also, does it matter if my remote GP is in Mumbai or Manchester? It might, for Indias health service?
David Durant says:
Interesting - I had a look into this a few months ago. It seemed that all the sites I investigated would allow you to do a text submission in the first place but then routed you to s video call. I didn't see any that provided an option of a text-only service.
I'd expect physical therapy to benefit from having a complete view of the patient, which might be a bit tricky over the webcam. Some folk I see on yoga sessions have it completely sorted, but some don't (and perhaps don't have the kit). For simpler chats or requesting medicine I'd expect it to be much more convenient, assuming a doctor can legally dispense medicine or advice without ever "seeing" the patient.
Not having a smartphone, I'm more aware of the changes brought about by COVID that assumes everyone has one (that's fairly recent, and that's on a data plan or can access local Wi-Fi). My local bus stop no longer posts times, instead having a QR code / NFC which presumably sends you to a website with the times. This is going to be more certain to be accurate -- I expect they're changing them more frequently due to lower use -- and can be enhanced with the standard "when will the bus get here" approximations which are common online or on the text screens in more central bus stops.
Apps for ordering in pubs and restaurants are also common. These have been a mixed bag -- it's nice to see the full selection + prices at a pub when you normally wouldn't get that, and it's nice to order immediately without waiting for a server, but ordering at Pizza Hut took about 10 minutes longer than normal, and we had to redo it because "salad" and "salad + bacon bits" were inexplicably two different options, not immediately obvious from the scrolling. A human server could just adjust this manually. You can say this is an app fault and I'd agree, but as we move away from human contact this is the sort of thing to not get fixed, I'd imagine, as soon as it's good enough.
The NHS contact tracing app requires a phone newer than the one either of my parents have. This is likely for good reason, and I think there's a non-phone alternative.
Before the pandemic, I had an issue in certain workplaces (e.g. NHSD) that required you to be able to access the internet to download the drivers you needed to access their network. Not a problem if you've got a smartphone and can turn it into a hotspot (I asked a colleague), but otherwise a bit of a catch-22! I hit this one afterwards at a different office, when somebody offered to email me the Wi-Fi password.
Really interesting set of questions. Whether aGP is inUK or elsewhere – would matter2Patients :because their pathway would be different depending on what hospital #policy would be in place when GP needs 2refer them.& patient timeline would have different variables i.e #NHSRTT
3 years ago The Doctor took my blood pressure.
2 years ago any nurse took blood pressure.
This year the machine in the lobby can be operated by a receptionist.
Slower than in the real world but they are getting there
I think the problem remains that you are able to use all of these things because of particular sets of priveleges. Each of the services you talk about is a hack around bad services, not something that adds infrastructure back into the public sphere.
Rachel Clarke says:
I would be perfectly happy doing initial triage for symptoms via video. I already order travel drugs online. If i needed to go regulary however, i'd prefer to see the same doctor, or nurse. My practice nurse has been doing my vaccinations, holiday checks and womens health stuff (smears). Its good to be able to go in and have a chat about stuff, because she remembers.
I do think there's a set of illnesses that will not come across via video, and that's when the doctor moves beyond what is talked about. That is the skill and instinct, so we need to be careful not to lose that
Let's not stop with GPs. Hospital consultant appointments at hospitals are often just a chat, but require driving/queuing/parking etc just to bring us to a single person for 10 mins
A Omron blood pressure monitor, same as a GPs use, is available for less than £50. Heart rate & variability, VO2 max, blood oxygen can be monitored by the apple watch/other smart watches. There smart scales. Surely if you could submit all that, it would cut down on trips in?
We talked to one of the digital health providers in this podcast recorded a couple of weeks ago. The thing I took away from it was that a better service means more engagement, more access, making health management something we do naturally and regularly, not just when bits fall off. https://wb40podcast.com/2020/09/07/161-future-health/
Whilst, I think there is a lot to agree with in this post, I'm troubled by much of it. My background is working in digital (some of it with the NHS) but I also am a patient with a long-term condition.
IMHO too much digital healthcare is designed around the "otherwise well" - healthy people who occasionally need to access healthcare because of a temporary problem. And yes, that is a large proportion of the population, but they make up quite a small proportion of the usage of the health system (a classic 20/80 split). So whilst there is value in designing services that support them, extrapolating those services to the majority of healthcare users is problematic.
The main concerns I have with the argument for non-geographic GP services is that (a) it reduces the notion of healthcare to a series of transactions, (b) it ignores the importance of place that speaks to a large part of the population and (c) it silos GPs as standalone from the plethera of primary/community health services that support individuals and population health management.
If we take "care" to mean "someone else is bothered by my predicament" (my favourite defintion), then no algorithm can replace human interaction. Moreover, being put in a front of someone because they have the right qualifications is secondary to being put in front of someone you trust and value the relationship that you have with them. That trust comes from regular contact; but it also comes from shared experience: we're in this together. If I'm after an oinment for a rash, then maybe that's not an issue, but if my cancer has returned and I'm worried how I'm going to cope financially and mentally with caring for my disabled son whilst going through another round of chemo, then do I want to be shouting down a Zoom call in the kitchen hoping the kids don't come in? I probably want that conversation with the person (or at least team) who has also seen me through my pregnancies, helped me learn about what my son can and won't be able to do etc etc. And I build that trust through the regular oinment for rash type appointments; in the same way the fallacy of automation works: I can only deal with an exceptional event because I've had the hours of learning from dealing with the regular.
And this is where the value of place comes in. Taking the David Goodhart definition of the "anywheres" vs the "somewheres", too much digital health is designed around the "anywheres" (case in point: the priority put on designing a find a GP service, when ~50% of the population live within 2 miles of where they grew-up). The team at my GP surgery know the school/nurseries that my kids use, they know the street I live on (in our case one of the locums actually lives on it), they understand the pattern of my life. When we've taken our kid to the out-of-hours we've seen a doctor who also locums at our surgery (we haven't yet been followed up by the same doc who saw us in OOO, but it could happen). They know the services they can refer us to, and quite possibly use them too. Similarly our pharmacist knows me well enough to know I need a flu jab, even if I don't look like someone who should automatically get one. That stuff matters, and the intel gathered is hugely valuable for population health management.
The closest parallel I can make is the argument that we could make libraries more efficient by just giving everyone an e-Reader and offering temporary downloads via a web catalogue. Yes, the transaction might be more efficient but you completely miss the true value of a library.
So remote appointments with a random GP will work for some people; but they are a small subset of the work of the health service. Design these services to complement not replace what exists already, and work out how to transistion between them (what happens when your 20-something becomes pregnant and needs access to a range of pre-natal services etc) and how the funding will match the demand rather than a simple headcount formula.