18
Examination of witnesses
Professor Esther Rodriguez-Villegas, Professor Daniel Lasserson and Dr Pritesh Mistry.
Q83 The Chair: Welcome to this meeting of the House of Lords special inquiry into public and community care. Three of our members are participating online: Lady Redfern, Lady Armstrong and Lady Shephard. We have apologies from Lady Barker.
We are delighted to have three such excellent witnesses with us this afternoon: Professor Esther Rodriguez-Villegas, professor of low power electronics at the Department of Electrical and Electronic Engineering at Imperial College London; Professor Daniel Lasserson, president of the UK Hospital at Home Society; and Dr Pritesh Mistry, digital technologies fellow at the King’s Fund.
As you know, we will take it in turns to ask you questions. We need to get through quite a lot in a limited time, so we ask you to be quite precise in answering. I will ask the first question. What recent innovations have there been in health technology, and how can primary and community care—it is important that we focus on both—benefit from them?
Professor Esther Rodriguez-Villegas: There have been many innovations, but the one that I would focus on, because it is the one that I am most familiar with, is wearable technologies: intelligent devices that are able to do things that could not be done before. Before, we relied on medical devices for which doctors and patients needed to be trained for their use in secondary care, requiring also a lot of time from the point of view of interpretation, diagnosis and management. They were not deployable. Suddenly, we are starting to come up with devices that are so easy to use that patients themselves can do it. The devices have “intelligence”—they can interpret biomarkers—and this allows the management and diagnosis of conditions in a way that was not possible before. In some cases these devices are powered by artificial intelligence; in other cases they are not.
The Chair: Yes. We will ask you about artificial intelligence, so perhaps we will come on to that.
Professor Daniel Lasserson: I would like to move the focus on to diagnostics, rather than monitoring. I do a lot of work in patients’ homes and care homes, delivering acute hospital-level care. Although my clinical base is in an acute hospital and geriatric medicine department, my clinical environment is the home and care home. The biggest innovation that has helped us to do that is the availability of point-of-care diagnostic technology. It is replacing the tests that find out what is wrong, typically with an older adult who has acute confusion, is unable to walk or has become newly incontinent, for example.
We use blood tests, which can give results within a couple of minutes—it would normally take 30 or 40 minutes in a hospital laboratory—and, in particular, point-of-care ultrasound, where we can look at a number of organs in the body, particularly the lungs and the abdomen in patients with heart failure or gastric chest problems, or use echocardiography to look at the heart. The fact that we can share images through a cloud means that I can look at someone’s heart in their bedroom in a tower block and instantly get advice from a cardiologist working with me. We are trying to reimagine the future hospital, as it were, by seeing how much of what goes on there can be done in the home and care home, if that is where patients wish to be treated.
Dr Pritesh Mistry: I will go through a few different examples, some of which are market ready and we see being deployed now, and some of which are more at the research stage.
We are seeing the miniaturisation of technologies: hand-held diagnostics such as point-of-care ultrasound. You can imagine how something very small and held in your hand that plugs into your smartphone could come into the home environment. Miniature MRI scanners are being trialled by King’s Health Partners in London; the massive room that you see in the hospital may no longer be needed in about five or 10 years’ time. There are e-stethoscopes, and mobile phone microphones are being used as a stethoscope, so we no longer need to rely on someone’s ears but can configure information into something that you can see, send into the cloud, as was just mentioned, and analyse. With AI, we are seeing the digitalisation and quantification of things that are largely qualitative. Things like wound care no longer need to be visually assessed but can be assessed by your smartphone camera and measured and quantified over time.
Eye health is of particular interest. We are seeing a lot of interesting things in diabetic retinopathy, which can move eye screening into the community, for example. Some very early-stage research shows that things like AI can be applied to imaging the back of the eye and can give you detection of kidney disease, Alzheimer’s disease and liver disease, and predict risk of stroke and heart attack. There is lots of potential in this research.
Lastly, there is a lot of focus on clinical applications. We must not lose sight of operational, admin and managerial opportunities for technology too—things like supporting managers, admin and operational functions, which are essential for smooth running and for the auditability and accountability of the healthcare system. You may have seen the Hewitt review, which talks a lot about workforce shortages, especially in competition with other sectors such as data analysts and so on. This kind of technology could help those scarce resources to go much further.
The Chair: Thank you very much for starting us off so well.
Q84 Baroness Armstrong of Hill Top: How can health technologies help integration both between primary and community care and in the wider health system?
Professor Daniel Lasserson: Probably the simplest way in which you can deliver integration is through the sharing of information. Very often, there are issues of duplication in healthcare, where teams can be in the same environment—the home is a nice example, as there can be multiple teams who see patients in the home—but if they do not know what has happened, they are quite likely to repeat assessments and tests. Every clinician who sees a patient needs to be sure about what is wrong and that they understand how best they can help the individual to get better.
There are a number of issues around how that integration can happen, such as data protection and how different providers can access each other’s information. There are some beacons of hope—Leeds, for example, where primary and secondary care use the same electronic health record, so both can read and write and understand. Wherever the patient is in their journey from home to hospital or back again, everyone understands what is happening. I work in a very fractured environment in Oxford where it is hard to know what everyone has done, so duplication happens as a result. One of the simplest things to do would be to focus on that chain of information and reducing duplication.
Dr Pritesh Mistry: There is already very mature technology that we could use that is not being leveraged—for example, asynchronous messaging. Newer technology, as my colleague just mentioned, is about the sharing of medical information, especially the ability to capture medical information and natural language processing, put that information into records and share it.
It is not just about capturing information. How do we make sense of the information that is captured in a way that is timely and helpful for clinicians and patients? There is an opportunity for AI at the other end too. We do not want people to drown in data; it is about being able to use the data. We need to be able to do the really simple things intelligently, such as co-ordinating appointments and having actual, multidisciplinary teams around a patient.
Underneath it all, there is an opportunity to combine video connectivity and flexible working to really bring care around the individual. In the example I gave of wound care, you can imagine a community nurse or a district nurse coming into someone’s home and being able to help them, give them care, assess their wounds, contact a clinician, have clinical supervision and perhaps prescribe something. In the Isle of Wight, they are delivering medications with drones.
You can see how this all starts cobbling together, but it needs connectivity, a flexible workforce and the ability to work together. That is one of the things that we found in our research in September: even if you have good technology, it does not guarantee people working together. You need good relationships between those people as well.
Professor Esther Rodriguez-Villegas: I do not want to replicate what my colleagues said, which are the main, core points, but I will say that we should not forget that new technologies enable new pathways. Part of the issue that we have with healthcare in this country and in many countries—not just here—is that the pathways are suboptimal. We stick to them because changing pathways is complicated. I always say as an example that it is like trying to put plasters on haemorrhages. We have the ability to do some disruptive things now. We are opening the doors for that, so it is very important that we embrace it and instead of asking, “How can we put these two things together in a more efficient way?”, we ask, “Can we think out of the box and create something new?”
Q85 Baroness Armstrong of Hill Top: When you are creating new pathways or trying to use new technology, or you know that new technology is available that would be useful, are the funding streams adequate to enable that level of change?
The Chair: Thank you. At the same time, we will take Baroness Tyler’s question about funding.
Q86 Baroness Tyler of Enfield: My question is primarily for Professor Lasserson. As it is relevant to my question, I declare that my mother is a long-term resident in a nursing home.
I was very interested and encouraged to hear the things that could be done, either in the home or in care homes, in terms of diagnostics and treatment. It has been a real problem for me over the years when they have needed my mother to go into hospital to have tests done but she is too frail and fragile to get there. In the world that you are describing, what skills and capacity would be needed in the care home for the social care staff and the nursing staff to be able to assist with diagnostics, treatments and follow-up?
Professor Daniel Lasserson: I am sorry to hear that you have had that experience in the care home, Baroness Tyler. You are absolutely right that many of the tests that would make a meaningful difference to medical management, to prescribing or not prescribing for conditions, or giving information to patients and their families about prognosis and what may happen next, can now be done in the home. The point-of-care imaging that we use and the MRI from King’s are nice examples of that.
The advantage of the technology is that the individual doing the test does not need to have the expert interpretation. I support my nurses who go out and deliver ultrasound in the homes, as well as doing it myself. We have a model where we work in collaboration with care home staff. For example, I have a patient I am supporting in a care home. We are delivering intravenous treatment. The nurses come in, and we monitor that with our own tests as well. We are working in parallel with the registered nurses in the care home as well as the care home staff.
We work with those in the care home who want to learn a new skill or practise an existing skill from when they were nurses in hospital. They may take down bags of fluid that we put up or give subcutaneous injections that we prescribe. I still hold the medical responsibility for the patient. The processes of care are a mix between the team I work with and those in the care home who wish to take part. None of them has to if they do not want to. We find that a lot of them are willing partners and want to do things. They are never given anything to do that puts them at risk or is an issue for the care home staff.
We find that there is real interest among care home staff in upskilling to deliver more of that acute care. Our wish is that every patient in the country who has a crisis for which there is an out-of-hospital alternative should be offered it and have the choice. Patients I see are never denied hospital treatment if that is where they wish to be, but when I lay out the choices, they always prefer to stay at home or in the care home. My job is to support them in their choice.
In my experience, funding is much less of a barrier than culture. A lot of things that I have done have not required lots of money, but there is a culture among the perhaps more conservative elements of my profession—medicine—of seeing only risks rather than potential benefits, or focusing on risk mitigation rather than saying, “Actually, there are some significant benefits here”. Any change has risk and benefit; it is about finding a managerial or organisational culture that allows governed innovation. We do not want anyone being a wild maverick, but, equally, we do not want to fossilise either.
This is about finding a way of practice where clinically led models can innovate and change but also evidence their own insight and data awareness, so that we can check that we are having the effect that we think we are having and give some reassurance to more risk-averse members of the managerial team around us that we are not just making things up; we are doing things right. The technology and money are there, but culture has been the bigger block.
The Chair: Do you agree with that, Professor?
Professor Esther Rodriguez-Villegas: I have two hats: I am a university professor and the founder of a medical devices company. Unfortunately, funding is an issue. I agree that the issue of culture is massive, but the situation with funding is this: to create a new pathway, that new pathway needs to be demonstrated; that is the first thing. NICE will be up for recommending something new, but we need to provide clinical evidence, health evidence, economic evidence—all of that.
The question is: how does one gather that evidence? There are many different stakeholders when it comes to healthcare, and each has a completely different incentive. I am going to say something that will sound very strong, but it is the truth. Things are not done for the benefit of the patient only. More than 50% of the time, different stakeholders do things because it benefits them.
On the one hand, we are talking about research, so academic institutions want a piece of the pie, as do the NHS Trusts’ research departments. And there are many different ones, so who will be the payers? What are the outcomes for the patients? The funding is not only about money but about how we create a process that speeds up the evaluations and penalises those who basically delay that process, because it can take for ever to .
Dr Pritesh Mistry: Culture is a bigger barrier than funding. From what we have seen and, anecdotally, from conversations I have had in the system, the funding tends to be very specific, which prevents full-scale digital transformation in a part of the healthcare system. Also, we tend to transform by organisation, which means that you continue to build silos into your digital infrastructure, instead of thinking, “How do we transform and integrate around the patient?”, for example. Funding is definitely an issue, but there are other issues that are just as much of a barrier.
Q87 Baroness Finlay of Llandaff: You have started to answer my question; I wanted to ask you about the challenges that are preventing wider adoption. You have laid out five things: money; culture; lack of evidence in evaluation; stakeholder selfishness, if you like—doing what they want to do; and reinforcement of silo working. Is there also the problem of multiple comorbidities and therefore difficulties about where responsibility lies? Do you have other things to add to that list? Importantly, how do we change things to overcome the challenges? It is fine to list the problems, but we must have solutions.
Professor Esther Rodriguez-Villegas: I will start with the practical thing: money. Of course, there needs to be funding and it needs to be allocated to prove evidence in new pathways. Technologies are starting to appear; we are still a long way from having what are almost panaceas, but they are starting to be there. We need funding allocated to that, but, as I said, funding with accountability for the different stakeholders, and with timelines. It cannot take three years from the moment the funding is announced to the moment when an evaluation starts. From my experience, I came to the conclusion that it was better to do all the evaluations somewhere other than in the UK, despite the UK having some of the best doctors, the best researchers and the best guidelines body—NICE. Why? Because it took too long.
In the same way that the Health Research Authority centralises the process, somehow something needs to be done to prevent the bottlenecks that exist at NHS Trusts level. Prior to the Trusts allowing something to go to the Health Research Authority it can be stuck on administrators’ desks for years. Red tape is the biggest issue that we have at the moment.
Professor Daniel Lasserson: I will take the multimorbidity point first, because it is really important. All my patients are multimorbid; that is one of the joys of geriatric medicine. There is a tension between whether it is a generalist service or a specialist service. I have found that what works well is a generalist service leading innovations, so there is a platform for generalist care, and having specialist expertise that integrates as and when it is needed in real time.
That is how we practise in our system. Obviously, that changes the portfolio of diagnostic tests that you need, because you would be looking at needing blood tests for multiple systems and diagnostics that can work on multiple systems as well. The patient with multimorbidities should be the aim; they are the key individual around whom we need to understand how to integrate care. A generalist platform is best for doing that, because the training is thinking of those multiple things at once.
On solutions, the point was extremely well made about the delays as you come to market when you have an innovation—how quickly it comes to market and is used in the NHS. NIHR has put some effort behind that with its Medtech and IVD co-operatives—research centres designed to speed up that process and generate some of the evidence. They were probably not big enough or well-funded enough. That is changing; new funding for health research technology centres is being bid for now, as we speak. They are bigger in ambition, there are more of them and they are better funded by NIHR. That may add something in terms of speed and trying to improve the process. Theoretically, NIHR is on it; it is just not doing it as well as I think we would all like.
Solutions come from patients, the public and our accountability systems. What helps me to do something for the first time is the patient effectively creating an innovation space. Often when I see people and we have worked out that there is something going on that requires quite a high-level intervention to treat, the patient says, “I want to stay here. I don’t want to go to hospital any more”, and gives their reasons, and we, the team, are invited into the space—an innovation space, if you like—that the patient creates. It is a gift they are giving to the health system, for us to understand how we can change our practice around them.
By analogy, the drive for speed and change around the patient should come from the patient and the public themselves. We have not yet worked out how to release the power of the patients and the public in this space and whether ICBs could have much stronger accountability for speed, innovation and patient-centred outcomes than they do at the moment.
Baroness Finlay of Llandaff: Is that because data systems do not transfer the data adequately, or does it go back to silo working by professions?
Professor Daniel Lasserson: It is a mix of silo working and the fact that, apart from the ballot box, we have not yet worked out locally with our health systems how we say that we are meeting the needs of our patients. They say things in individual consultations about whether things are working, but that sense of broader power is not there.
Dr Pritesh Mistry: Specifically on the subject of this inquiry and committee, there is a lot of focus on the digitalisation of trusts. A significant amount of money is going into the vision and digitalisation of trusts. PODAC is the phrase used in NHS England—pharmacy, optometry, dentistry, ambulance and community services. As far as I am aware, the strategy for digitalisation in those areas links to the data of trusts and GP practices. If there is a vision for digitalised community services in primary care, it is currently not really seen or observable.
I will run through a few of the barriers. There is an overfocus on new technology and the deployment of technology. We measure how much technology is there, but less so how it is being optimised, the impact that it is having and how it is being used. Having technology there is not good enough to have an impact, as you may be aware. There are some basic infrastructure issues that people struggle with: 8% of GP time is lost on IT issues; about 50% of GPs say that they do not have good enough wi-fi or laptops; 20% of doctors say that IT systems are not fit for purpose; and 74% of district nurses struggle with larger laptops running out of battery. There are a lot of really basic infrastructure issues that need to be dealt with.
There are the issues of fragmentation and siloed technology. I mentioned the potential for imaging the back of your eye. Unfortunately, cameras are all siloed in the community, and the data is too: we cannot link to the optometrists and ophthalmologists who are the experts. The potential may exist in research and technology, but the basics are fragmented technology that cannot be overcome, in many ways. The technology is clunky and poorly designed. District nurses are putting information on paper, duplicated in electronic records or across two records because of the problems I have just mentioned. Data sharing and standards lag procurement, and sometimes across organisations they are not symbiotic; they might match one organisation’s needs and another organisation’s needs, but not together.
Lastly, we are struggling to bring the public with us so that we can transform the NHS. We can do it rapidly, as we saw during Covid, but if we do not bring people with us, there is an elasticity, so it goes back to where it may have been before. It is key to bring them with us and to make sure that the technology works for them as well.
Baroness Wyld: I was going to ask about the public, and perhaps you will pick this up when you come to Lord Kakkar’s question, which is next. You talked about cultural barriers in the profession, but I wonder about cultural barriers in the patient community. So far, we have talked as though everybody wants this technology, but there are a huge number of innovations that presumably happened quite quickly after Covid that patients do not like; telephone triage is an obvious example. I do not know whether Lord Kakkar wants to come in, but can you comment on that? Is it a case of forcing people, or are there things that you can recommend?
The Chair: Let us go on to Lord Kakkar’s question and deal with those together.
Q88 Lord Kakkar: What evidence do we have that the new technologies that we are all so enthusiastic about will empower citizens, patients and their relatives to take responsibility for the management of their own health and, indeed, drive improvements more broadly in the long-term chronic management of comorbidities that we have discussed? Is there enthusiasm among patients to adopt all this technology? What kind of resource will be required to ensure that we can train our patients to be able to take advantage of all of it? Have technologies been developed that are predominantly patient facing in their utilisation, rather than an adjunct to clinical practice?
Given the composition of the panel, I remind noble Lords that I am chairman of the King’s Fund.
Dr Pritesh Mistry: A couple of months ago we released some research. We spoke to the public to try to understand their experiences and expectations of digital health technologies. Broadly, people are very positive, but their expectations are not matched by the services that they find in the system. Generally, there are people who want to have digital technologies and there are people who are not willing to have them. One person we spoke to did not want to use digital technologies at all. She was faced with digital-only services and, as a result, she avoided health services and found herself in hospital a number of times. She avoided them until she could not do so any more. There are opportunities, but we need to make sure that the technologies are there and the choice is there: it is technology, with people’s choices.
A lot of taking responsibility and being able to self-care has relied in the past and currently relies on giving people access to information. That might be the NHS website, access to test results, which we continue to try to push towards, or access to records, for example. I do not think that goes far enough, to be absolutely honest with you. Giving people information does not necessarily empower them. The concept of democratising information is great, but it does not necessarily mean that people are able or empowered to do anything with it.
We need to go further, and there needs to be more research into how we can do that, including using AI to convert test results into an image, video, audio or different means so that people can use them better. The same goes for NHS website information. There is a lot that we can do to coach people and improve their health knowledge, but, again, it all remains for people to go to it, as opposed to it coming to them. We are much more used to that now. There are a lot of opportunities to do things like that to support people to manage their own healthcare.
Professor Daniel Lasserson: It is interesting. A lot of the evidence on the use of terminology is often observational in nature rather than from large-scale trials. The strongest trial I have seen for remote technology was immediately after people had been to hospital for heart failure. We are looking at how to use remote monitoring, with some degree of physician and nurse oversight, after that. There is incredibly strong evidence from randomised trials that those patients will live longer and be happier and healthier outside hospital.
There are small pockets of very good, high-quality evidence, but I hope we all agree that there is not a large amount of evidence from a typical randomised trial paradigm for remote monitoring across a range of conditions versus not having remote monitoring. That is absent at the moment. Notwithstanding that, NHS England has obviously put a lot of money into a virtual ward programme, which is predominantly about remote monitoring in its technology.
There is a lot of catch-up for the academic community to do, to understand how this technology is best applied, for whom and under what circumstances. Particularly in the case of heart failure, there is clearly a key vulnerable period just after discharge from a hospital admission with heart failure exacerbation, and it has huge amounts of value to a patient coming into the system at that point.
On the point that people vary in what works for them, they have different sets of values and different perceptions based on their current illness and environment, and I think technology allows us to personalise and tailor. From where I work, that is more about how clinicians change what they do with technology rather than putting the onus to innovate and change on to the patient. The onus is on us to change our practice and deliver our care outside hospital in a way that means that the patient does not need to interact with any technology at all. I often deal with patients who are very frail, and have delirium and acute confusion with their illness.
We have to find ways to care for them safely and well so that they get better quicker at home, without them necessarily needing to have a degree of performance or functional status to be partners in their care. Yes, some people may be able to do more tests on themselves—the younger and less acutely unwell—but for it to work in our population, we need systems where they do not need to be active participants in care because of their functional status and acuity of illness.
Professor Esther Rodriguez Villegas: I think there is the danger of averaging and generalisation in this question and in these kinds of studies. You would not say that your experience of two phones, or two headphones, or any other piece of technology is the same. When it comes to technologies in healthcare, it depends on the technology. It depends on who has that kind of technology and whether they have the end-user in mind.
Ultimately, that is one issue that we face. With the vast majority of these technologies, who designs them? It is engineers or, in many cases, academics. That is where I come from. Academics tend to be in their own bubble. It is not necessarily about going into the real world and having the experience that clinicians have. It is completely different. The thing is that we will get there. There are terrible technologies from the user point of view, mostly when it comes to vulnerable populations. Those will get terrible reviews and you will not get the patients to adhere to their use. Then there are technologies that are wonderful. Why? Because they kept their user in mind.
We are in a transitional period. Our use of technology, throughout all our lives, has been completely different from the use of technology, by, for example, my kids, who are now in primary and secondary school. They were born with technology in their lives. We need to maximise the adoption now of what is coming for those of us who are already adults of a certain age. Then, one generation from now, people will be completely used to it, but we need to start the process now, because we can improve the lives of all of us by adopting technology.
Lord Kakkar: Thank you. I have just one other point. We heard earlier about the problem that manifests itself in redesigning pathways of care to ensure that the technology we have available to us can be appropriately incorporated and have the impact that we would anticipate. Are funds available from NIHR or any other funding body that allow for the design or redesign of those pathways as new technologies become available for incorporation?
Professor Esther Rodriguez Villegas: There are funding bodies and funding calls. There might not necessarily be a call for a specific pathway, but you can use it to gather evidence that can help you to say to NICE, “I have this evidence”, and then it can recommend something else.
The issue I see is that there is a bit of conflict of interest in the way those funds are managed. Unfortunately, they are very geared towards academia in many cases. Even in cases where they are not geared towards academia, they require companies to work with academic institutions to get access to funds, which are needed anyway, because these things are expensive. But the incentives for academic institutions are completely different to the incentives for SMEs, which ultimately are the ones that create innovation more quickly. Trying to mix the two when it comes to allocating funds is what leads to things not being quite so optimum for generating evidence.
Professor Daniel Lasserson: It is a great question. I have been caught out when designing diagnostic studies that have changed what hospitals and others needed to do. The issue comes with trying out who is going to pay for which bit. The research funder will say, “This is a change in healthcare provision, so the NHS should pay that”, and the NHS will say, “Well, hang on a minute, we’ve got to change what we do, so this is an academic question, and the researcher should buy it”. You have to navigate a fine line about who is going to pay for the different bits of the new pathway that you want. People can agree that it is a good idea to trial it, but apportioning who is going to pay for what is not straightforward. Even if you agree it, hospitals can refuse and say, “Well, actually, we can’t cover that cost, so we can’t take part in the research”.
It is there on paper, but I have found that doing it in practice has been quite difficult when I have wanted to change how we diagnose sepsis, or other things.
Dr Pritesh Mistry: We have real positive activity, for example, with virtual wards when leaders across organisations and ICSs are working in partnership. The money might come into one organisation, but they are sharing out some of that money. A recent survey showed that 10% of district nurses feel that their workload has increased because of virtual wards, but the money is going into acute. Where it works well is when some of the money, resources and responsibility are shared out and there is working in partnership. Yes, there is a question about where the money flows, but it is also about the culture and how people work together to be able to reconfigure the services.
The Chair: Thank you very much indeed for those most interesting and wide-ranging answers.
Q89 Baroness Osamor: My question is to do with accessibility and inclusion. How can the health sector ensure that the health technology used in the community is inclusive and accessible for patients and staff?
The Chair: I think this is a continuation of how we get patients involved.
Professor Esther Rodriguez Villegas: There are several things. In order to get any technology to market this needs to go through a regulatory process. As part of the regulatory process, usability needs to be proven. In this case we are talking mostly about usability in a home environment.
What manufacturers do not need to prove so convincingly is inclusivity—the point you mentioned—and how usability applies to vulnerable populations. One could argue that we could ask manufacturers to prove that prior to putting a device on the market. But that is a very dangerous thing to do. Again, sometimes there will be technologies that might work fairly well for one particular population—for physiological reasons, let us say—and not work so well for others, in which case this could be delaying the route to market for all of them.
However, what might be a good idea is to include this as part of post-market surveillance and as part of the manufacturer’s plan to increase accessibility and inclusion. Does that make sense? In other words, saying, “What are you going to do from the moment you put it into the market? In the next three years, how are you going to prove that everybody can access this?”
Professor Daniel Lasserson: I think the problem is with partnership working. Healthcare institutions have perhaps not been the most rapid in undertaking evaluations or understanding the impact on a particular patient population. A particular strength of partnership working with third-sector organisations like the King’s Fund, for example, is that they will do evaluations and provide support. Agencies that partner with healthcare providers have much more literacy and understanding of disadvantaged populations, so that health inequalities are narrowed rather than worsened by the introduction of technology. Again, the King’s Fund is probably a good example. That leads to you nicely, Dr Mistry, but I think it is true.
Dr Pritesh Mistry: Thank you so much. There is a tendency to assume that tech is exclusionary. That is not unique to tech; physical services can be exclusionary as well, but sometimes we ignore that fact. We need to move towards bringing them both together around what the community needs and what we can provide, linked to patient choice. I mentioned that we published research a couple of months ago. It shows that digital exclusion is dynamic and not static. It changes, depending on personal situation as well as your health. People may be digitally included at one point, but if they are less mobile and less able to use their hands, for example, they may find themselves digitally excluded. It changes, so we need to be able to provide both types of services.
From our research, we basically found that there are underpinning factors that you may have come across: devices, data, digital skills and privacy. Without those, you have no access to digital public services. We find it working really well where healthcare system providers work with charities, the voluntary sector and local authorities to go out and talk to people and understand what they need, and they can source donated devices from industry and give those to people who do not have them, with data and volunteers to support people to learn how to use them—to get email addresses and learn how to log on and become familiar with them. Partnering is really important, as was just mentioned. That then leads to the co-development of services and you can co-develop more inclusive services that work for different communities and different people and build trust into them. That helps to create services that are more inclusive.
However, as I mentioned, some people just do not want to use digital tools. We talked to the Roxton practice, which has basically created three levels of digitalisation for all its services. It said, “We’re going to have our traditional non-technology service, and we’re going to have a mid-level digitalisation”, where it has assets in the community such as pharmacies in community centres and libraries with staff and volunteers there to help them. Then there is the high-tech level, which is basically tech at home. People can choose which service they use. They are starting to try to help people transition to more digitally advanced services, where possible.
There are ways forward, but we need to try to achieve an omnichannel approach, to use marketing speak.
Q90 Baroness Wyld: There is really obvious innovation. I have all my healthcare on Patient Access on my smartphone, so I get all my test results there. Has anybody done any sort of study? It occurs to me as a layperson that there are great advantages to being able to go on that and get all my routine blood tests, but it relies on me knowing whether I need to do anything and ring the doctor. There is also a note saying that it is your responsibility to check your results.
It is empowering and quick, but there are two things. Has there been any study to say that it makes diagnostics better or worse? Presumably there are efficiencies. The receptionist does not have to talk to you and the doctor does not have to ring anybody, but if people look at their results, cannot interpret them and then end up panicking and phoning the doctor anyway, do we not have unintended consequences? Are there any studies of particular technologies—it does not have to be of that one—where the plan has not gone as intended?
Dr Pritesh Mistry: I think Amir Hannan has published a lot of information on access to records and test results. It takes a lot of work to get there, building trust with patients and helping and guiding them through the information needs. There is sometimes an increased workload in the healthcare system because of it. Ultimately, it empowers people and helps them to make healthcare decisions. The work that Partha Kar has been doing on type 1 diabetes and access to blood glucose measurements has empowered patients and taken work away from the healthcare system, and enabled people to manage their own care better. More research needs to be done.
The Chair: Do you think there is anything that would be useful to the committee? We would be very happy to have references to it.
Professor Esther Rodriguez Villegas: Yes.
The Chair: Thank you.
Professor Daniel Lasserson: Reflecting a particular point of time when people were much more vulnerable, some work was done in Middlesbrough looking at kidney patients post transplant, and patients doing their own renal function testing at home to ensure the health of their transplant. There was earlier flagging if they had problems that needed some sorting out rather than letting things get a bit worse, when it is much harder to come back.
There are times of particular vulnerability in any healthcare journey or life journey when that participation can add a lot more value for patients and improve outcomes. Another key element is when it is happening.
Q91 Baroness Redfern: What one change could the Government make in the area of health technology that will enable better integration of primary and community care?
The Chair: I emphasise that we want one change.
Baroness Redfern: Yes, it is a difficult question.
Dr Pritesh Mistry: This is such a difficult question. As the discussion has laid out, the scope and potential for technology is huge. I think people expect the system to be digitalised. There is a certain level of expectation around that from the public.
Fundamentally, it is important to prioritise getting the basics of digitalisation right. As I mentioned, it is very oriented around acute. My recommendation would be about having an aspiration or a vision, but having realistic timeframes to get the basics right. It is improving how technology works for people in the system.
Professor Esther Rodriguez Villegas: I completely agree with my colleague on getting the basics right. However, that can take an awful lot of time, and in the meantime we can lose something as well. Something that the Government could do is to incentivise the different NHS Trusts to adopt these technologies. Why? Because in the process of initial adoption, we will gather more data. We will know more. I do not mean personal data; I mean how the user reacts to it and what changes we need to make. Are we getting the basics right? Are they properly specified?
The Chair: What is your specific recommendation?
Professor Esther Rodriguez Villegas: My specific recommendation is to allocate funds for digital technologies. This will also facilitate quick adoption that will allow us to find things out.
Professor Daniel Lasserson: One thing would be incentivisation of partnership working. There is very adversarial working across a lot of healthcare. The quickest way to deliver that would be with technology, whether that is sharing with other things as well. You will be paid by how you work in partnership with the patient rather than paid for your activity. I think that would radically transform it. Tech would be the medium through which you would do that.
Baroness Redfern: By incentivise, do you mean more money?
Professor Daniel Lasserson: Whatever it takes.
The Chair: Thank you very much for your focused answers and, indeed, for all the evidence that you have given us today. I remind you that there will be a transcript of your evidence, which you will have the opportunity to look at. I repeat what I said about anything else that you think could be of use to the committee; we would be delighted to receive it. On behalf of all my colleagues, I thank you very much for coming today.
