The Bigger Picture
We are now all well versed at reciting how well digital health has done in supporting the system in its response to COVID and how well the system has done in adopting new technologies for remote support and monitoring.
And all that is true, deserves recognition and needs to be embedded for the future.
But we need to take these lessons created from a unique point in recent history and see how it transposes into an NHS that is an integrated care system, not a COVID response service.
We don’t know at present when, indeed if ever, we will be free from COVID, but the direction is clear we need to get the system back to treating all patients, not just COVID patients. Although, I must admit to my surprise, the latest letter from NHSE states that even during the peak of the pandemic “hospitals were still able to look after two non-COVID inpatients for every one COVID inpatient”…it didn’t seem that way.
When we talk about the impact of COVID we generally think of the direct management of COVID positive patients in the ICU environment. But many of the changes we saw in the system happened in the community and primary care services that wrap around acute care - particularly remote monitoring, virtual clinics and virtual GP appointments. Everyone is now convinced of the role in technology in getting the service both back to normal and in transforming the way we deliver services in the future.
For so long 'out of hospital care' has been a buzz phrase, but no more than that. People felt reassured going to hospital with specialist doctors, lots of nurses, machines that go beep, it's where you went for the important stuff.
Has all that changed? We know, at least during the pandemic and still today, that there is a reticence about interacting with the health system and particularly hospitals. People have seen how much easier it is to have a phone (let’s not think it’s all about ‘digital’) or video consultation with their GP, how use of symptom tracking apps can help then get the health services they want.
So it’s about having the same care in a different setting? Yes, but, that again is not the whole picture, it's also about better care in a different setting. But that again is not the whole picture. It’s about self-care, managing long-term conditions and prevention. This of course takes us into a different realm, away from healthcare and towards lifestyle, nudge theory and public health.
These are also some of the other big lessons coming out of the COVID crisis, not that, again, these are particularly new, but people with long-term health conditions are at higher risk of serious illness and death from the virus. We have also seen higher numbers of deaths from COVID-19 among black and minority ethnic communities and people living in socioeconomically deprived areas, than in the general population.[1]
Now, before I get too carried away with how Digital Health technologies can take us to a utopian future, there still remain questions of trust and inequalities. We will still be reliant on a flow of data, whilst during COVID the rules enabled a much freer sharing of data, this is unlikely to be a sustainable regime long-term, despite the more permissive and positive views of citizens engendered during the pandemic. Our social health system is based on equality, and a rush into a digital first approach risks disadvantaging some groups. Social exclusion correlates closely with digital exclusion – of the 4.1 million people who are offline in the UK, 71 per cent have no more than a secondary level education, nearly half are from low-income households, and 80 per cent are aged 50+[2]. We need to build accessibility to services so everyone can easily access the care they need.
So this is our challenge in digital health, to breakdown boundaries between health, care and lifestyle and deliver services that support all citizens before they become patients, that encourages self-care and supports the patient irrespective of care setting. This isn’t technology for its own sake, it’s about delivering the right services at the right time to the right patient…that can be via an (old fashioned?) phone or the latest AI algorithm.
The NHS may soon have responsibility for social care, and be structured to deliver services through integrated care systems with payment mechanisms that support patient pathways - two points strongly hinted at in the phase three letter.
This opens up new possibilities. We have the technology to do this, the NHS has the data to do this, patients and professionals have shown they are ready. We need to get organised and build on what I hope is another enduring legacy from the COVID response, the desire, indeed need, for the NHS to collaborate systematically with industry.
[1] https://www.health.org.uk/news-and-comment/blogs/inequalities-and-deaths-involving-covid-19
[2] https://www.hsj.co.uk/technology-and-innovation/inclusion-crucial-for-a-digital-first-health-service/7027443.article
