Written evidence submitted by Group 2 (Event 1) (DHS0046)

Transcript of roundtable event with members of the health care workforce held on Thursday 22nd September 2022 for the Health and Social Care Expert Panel

Group 2

Robert Francis: Fantastic. So we’ve got to work quite hard because we've been given 10 questions to answer, which means that there's just over 5 minutes per question. But there's a little bit of slack in that. So without further ado, let me start. We're talking here about the care of patients and service users basically as there are two commitments really we're considering there. But the first question really is in your experience of patients and service users using the NHS App, and if you think they are, do you think it affects the care they're accessing? And if not, why do you think they're not using it? Is there a particular problem around it? Who wants to have a start with that? Don’t be shy.

Participant A: I'm happy to have the first stab and I'm already off mute. I'll probably be fairly minimal on this one. Our experiences of the NHS App, particularly from the patient point of view, the feedback we get is that the experience is very variable. You can get two people stood in the same room next to each other, they come from different areas of the country and the functionality of that app varies depending on, you know, basically the back end of their GP system. We hear frustrations from that point of view, to achieve what they want to achieve. I don't know whether it's relevant, but from an industry perspective, there are concerns about the NHS App in terms of does it actually provide a block to innovation by basically being the total gateway to the NHS? And you know the questions of APIs have been able to link into that to bring your innovation to market as appropriate, which could happen again, could have an impact on patient access.

Robert Francis: Right. Thank you for that, Participant B.

Participant B: So my experience of the NHS App is as a user, in secondary care where I mainly work, although we do, I mean obviously, GPs do request imaging and so we do also work across both primary and secondary care. The NHS App does not work for us at all. I would really love patients to be able to book an imaging appointment online. That can't happen anywhere in the UK at the moment and I was told that maybe the NHS App would be the way forward, but, still we have a lot of people waiting to make an appointment. They ring up, they wait 45 minutes and we have armies of staff trying to do that so it doesn't work for us at all, or for patients, for us.

Robert Francis: Depressing. Participant C.

Participant C: From an optometry perspective. It's really quite limited interaction. It's not really integrated. The systems aren't on there, so we don't really have any use case for it at the moment and therefore patients can't access it either. So there's potential, but it doesn't really serve a purpose from our perspective at this point in time.

Robert Francis: And would the potential be the same as it would be if the GPs really, if you had it, which would be making appointments, maybe more than that?

Participant C: Making appointments potentially if it had access to information as well where we could, there's a huge connectivity challenge across the sector, so getting information to patients about what's happened to them within secondary care, if they could at least access it in that mechanism would be a huge help for patients and practitioners and eliminate onwards referrals. So there's a huge potential, but it's not realized at the moment.

Robert Francis: OK. Well, thank you for that. Overall, a mixed and somewhat depressing picture from your particular perspectives, at least. So I think we're still just the select group, and so we'll move on to the next question if we can, unless you've got more to say on that, which is how important is it to enable patients as...I'm sorry, Participant D. We haven't spoken yet. I'm really sorry. I'm miscounting.

Participant D: Not a problem at all. For the patients that use it in general practice, it is actually quite helpful, because it allows a lot of the transactional elements of their care, sort of checking their repeat prescriptions, ordering prescriptions, the ability to book appointments. But it's quite limited functionality at the moment. So those that are keen and tech savvy seem to like it, and want more from it. But then there's an equal number of people that haven't engaged with it at all. We found a lot of our patients started using it to get their COVID pass. So actually that's sort of introduced them and brought them on to the app. And as a consequence, had sort of raised awareness. So there's definitely space for more promotion of the app, for the basic functionality and then things like the ability to, when people are booking appointments, make it clever enough to be able to encompass sort of continuity. That would have additional benefits in terms of who they were booking appointments with. So again, as others have said, variable benefits at the moment, but there's definitely a role for it that could well be expanded we feel.

Robert Francis: And just to follow up on the question we've all been asked to think about, which is a bit more relevant to you at Participant D, which is, why do you think people are not using it and what could be done? You've mentioned promotion, but is there anything about the app itself which is sort of unfriendly or that people find unfriendly?

Participant D: I think the biggest issue that people have is that they just don't know it's there despite the fact that if you, from my practice, you go on to the website, it's the first thing that we promote on there and we're trying to direct patients through it for, as I say, the routine ordering of repeat medications and the like because it then turns it into a 24/7 service for them. There are cohort who just like to speak to the practice to do this because they want a more personal interaction and they don't want a digital interaction. But I think it's a lack of awareness that is the biggest block at the moment. I'd say the functionality is quite basic. So it seems to work for what it's meant to do, so I don't think it's functionality issue at the moment that is stopping people using it.

Robert Francis: Great. OK. Thanks very much. So now I think I can safely go on to the second question, which I'm afraid... I'm sorry. Do you want to come in?

Participant A: OK, I'll quickly come, it's really just what Participant D said made me think, I shouldn't just go for what can be done better and criticized. And I think I just want to pick up on the point Participant D made that I think, you know, there's really good functionality in things like repeat prescriptions and we can see from the data that is absolutely, you know, accelerating through the app. So yeah, we should call out the good things. And also the point about the COVID App, you know, if we go back to the early days of gaming consoles, the reason the console was so, was because of the killer app, you know the game that people wanted, and that was why the app took off because of the COVID pass. So it's trying to make sure that there's some really vital, important functionality within that app that drives people to use it.

Robert Francis: Great. Anything else on question one? Don't want to hurry. Fantastic, question 2, which has three parts, but the first is. How important is it to enable patients and service users to use digital tools to manage more of their care independently from home? What are the benefits? Are there any downsides? So, in that, can you tell us about any tools that have been enabled your patients or service users to self-monitor and/or manage their health? Thinking of your work over the last five years, how has technology affected your ability to provide patients and service users with the care they need? And thinking about different groups of patients and service users you care for, are there any groups that you think health technology is particularly useful for? And are there any groups for which technology doesn't help? So basically, what tools could help and what tools can't I suppose? Who wants to have a go at that? Why don’t we start with radiology?

Participant B: Yes, thank you. Do stop me if I go on. Because we are quite a tech heavy specialty, as you know. So, have digital tools enabled service users? No, in answer to the first one. But then I wouldn't expect that. So nothing to contribute.

Over the last five years, I mean things have changed tremendously. We now have a networked radiology system, so that's good. So I can look at images and report images from lots of different hospitals, which is good because I'm a kind of super specialist which improves patient care. And that is a big step forward and that's what we wanted. Having said that, actually it's very unstable. It's very, very difficult to use. It goes down all the time, not quite so much now as it did, but we quite often have a system, a situation where it crashes and nobody can see anything across the hospital. I'm in a hospital where we do 120 CT scans a night. It might be out all night and people can't see the results. Real patient safety issues. Really quite severe. The systems are complicated. So from a user point of view, I mean, I will ring up my IT support, and I say “it's not working” and they say, “well it you know it's not us, it's this person or it's not”, and there is that expression you want one throat to choke. And so you can end up being sort of moved around and there is a lack of, from our point of view, we feel there's a lack of understanding of the patient safety issues and just how difficult it is when they don't work. And actually there's the lap of IT support staff. I mean they do a marvellous job. There are so many heroes and heroines working in that field in the NHS, but there just aren't enough of them. And so many departments may have one PAX manager, every time something goes wrong. We ring him or her and, and you know? So it's on 24/7. So yes, so I think, I am concerned that we have these great big systems which are marvellous, but actually our infrastructure is probably a little bit too poor to support them, particularly in the older hospitals. And also we don't really have the workforce to help, you know? So what I really need is something like when my iPhone goes wrong, or I can't use it, you know, I can ring somebody up at any time and they'll talk me through and try not to patronize me. And that's what I would really like.

In terms of the last one, yes, health technology is absolutely invaluable in radiology. There are so many great tools we can use, both from the terms of online booking as I keep mentioning, which would free up whole swathes of staff for us. But also if, you want me to stop just sort of switch me off.

Robert Francis: Do carry on.

Participant B: But also from the other end. AI is really, really important for us. You could do all sorts of things, picking out patients that it thinks need to be reported 1st to take them out of the backlog, really improving both the quality of reporting and patient safety. Now I, as a clinical director tried to introduce some of these systems. I tried for two years. I couldn't get through a) the bureaucracy b) well, basically the bureaucracy and I haven't managed to do it. If you actually try to implement these solutions in a department, it is honestly impossible.

Robert Francis: Right. Well, thank you. I think you express loud and clear that it would be very useful for your patients. Yeah, great. Thank you, Participant A.

Participant A: Yeah, certainly everything Participant B said. But to take the first bit about how important it is that patients use digital tools, absolutely vital. I was in a discussion yesterday and I wish I could claim this quote for myself, I can't. And the quote was “patients are our next workforce”.

[Participant B makes thumbs up gesture in agreement.]

I think that is such a vital concept. You know if we look at retail, online retail, if we look at financial services, we're serving ourselves now, and with the pressures on the workforce, which is across, you know, European health systems, we must make use of all the resources available and patients themselves are going to be a vital part of that. Some of the tools that can really enable this? Yeah, we're seeing great results in terms of remote monitoring, be that for your long COVID, respiratory, etcetera. Those tools really seem to work well for patients, enabling them to take control, and, you know, working with the sort of patient initiated follow up regime which again reduces the demand on the system etcetera. I think that's some really important parts. It might be slightly out of context here but, when we're talking about these sorts of things as well, yeah, you know, AI and cloud and all that sort of thing is great. But the phone and text message are also really important elements of this to enable that sort of wider access when you haven't necessarily got all the technology because they can help as well as they did you in COVID.

Robert Francis: Excellent, fantastic. Yeah, Participant D.

Participant D: Thank you. So, just some quick thoughts to bullet point. I think any sort of digital tool that engages patients with their own care has got to be a good thing because an engaged patient who owns their healthcare tends to be more motivated and we get better outcomes. Some examples. So home blood pressure monitoring, home weights for people with heart failure, just being able to get that information on a daily basis rather than having to trips down to the surgery are good. The bit of technology that's transformed general practice has actually been set on my desk for 30 years, underused, and that is the telephone.

[Participant A makes thumbs up gesture in agreement.]

We couldn't have provided primary care services through the pandemic without the use of the telephone. Video consulting does have a space as well, but remote consulting generally using any technology acknowledges time pressures on patients. Those who work on sort of 0 hour contracts and don't get paid if they take time off work to access their healthcare. It's good from a travel miles and a sort of planetary sustainability point of view. We've got continuous blood pressure monitoring for diabetes, leading to reduction in admissions and better outcomes. And the fact that we can carry the medical record around with us, sort of we when we’re out visiting, I've got an iPad which gives me the full medical record. So I'm much better clued up when I go into the patient’s home, both my own patients, but more importantly, if I'm working in out of hours covering other people's patients, we do ward rounds using technology iPads. And for care homes, now we can sort of do a ward round remotely, utilizing the nursing staff in the home. And just to extend what Participant A was saying about self-care, the other problem we have is we don't have enough beds in the NHS. Everybody has a bed at home. So if we can keep them at home in their own bed and use technology to monitor them for that lower acuity illness, then that's massively important in saving acute beds. And for me as a GP, sort of those intermediate care beds where they need a little bit more care but not necessarily those of a specialist in a hospital. And it also empowers families and friends to look after people in their own home because they've got quicker access to information and remote healthcare. Particular groups we're finding it useful for is the homeless. So those are socially excluded. The fact that we can provide a digital health hub where people go in and they can join through a sort of remote connection from a place that they're happy to attend if they won't go into a health setting. And also we're finding with the fact that extended families are geographically spread now, you can have sort of three-way consultations. A patient can be in their home, the consultant can be at their trust and the son or daughter can be 300 miles away, and yet all talk together. So it's connecting people at a very basic level that makes a massive difference to the care they get.

Robert Francis: Fantastic, Participant C.

Participant C: I'll keep it really brief, so virtual consults have been brilliant for triaging out some of the patients that come in. I think the main challenge we have is the demographic of patients that we see. So most of the patients we have with eye conditions are at the older spectrum and because of that, they've then got an eye condition and potentially less familiar with technology. And those two things in combination make it quite a challenge to use sort of self-monitoring virtual technology or small screens such as smartphones, if they even have them. So that's quite difficult. It's not really in scope of this, but we've got the challenge of the advice and guidance from hospitals of actually getting data from primary care optometry into hospitals where we could really save patients having to travel. Because things like macular degeneration for follow up scans, whether they need more injections, we can't actually have that connection at the moment, which would be really helpful for patients, but it just doesn't exist.

Robert Francis: OK. Thank you. Just before we leave this question, we've had a little bit just now from about the downsides and the people like me in the older generation who can't look at a small screen and so on. But what are the downsides are there that you can think of? In terms of use by patients or tools? I mean, you've mentioned AI and some of it, and are there any sort of diagnostic tracks and that sort of thing? So what do you think? Participant B.

Participant B: So I would say I would just agree with Participant C's point. I think some of the downsides are connectivity between different systems. So from the patient’s point of view, it's very frustrating, and, you know, you would have heard this, patients want to tell their story only once. Well, we have all the information. Some people in clinic will be opening 9 different systems. And so the information is not in the same place, so that is a safety risk. Other downside I would just say would be stability really.

Robert Francis: Yeah.

Participant B: And also there is, certainly in terms of technologies developing so quickly that there is a little bit of concern around regulation, and understanding about data sharing and being able to explain, you know, what the risks are? For myself, for our department, but also when patients are concerned about it, explaining what the risks are there. Understanding how products, we don't really have particularly well-developed systems for assessing these products at the moment. And I think there's work going on on that, but it's developing so quickly, we don't really quite understand that. I think it's difficult to negotiate.

Robert Francis: OK. Thank you. Participant D, your hand’s up.

Participant D: Yes, I just quickly, if you become reliant on these for delivery of care and then they fail, there's often not a safety net in place, especially in small organizations like a general practice, and keeping both options available has cost pressures. And the other thing is, when I was training as GP sort of a couple of decades ago, we were taught that the doctor is the most powerful drug, and that personal connection of being in a room with someone, being able to lay a reassuring hand on a shoulder when you're telling, you know, providing reassurance, and the reason they don't need medication. That can be harder to convey through a digital medium. So we just need to be aware of that and it's not for a huge number of patients, but for some that actual personal interaction and breaking their isolation is a really important part of their therapeutic journey.

Robert Francis: Yeah, an emoji doesn't do it, does it? Participant C?

Participant C: Very briefly. So one of the pieces of technology we use often in optometry is optical coherence tomography. So we scan for things like macular degeneration and the normative databases within that are quite limited in scope. And if we're using the data of the patients who currently self-fund scans to build those databases further, we could potentially end up with this risk where it tells you that white middle class people because they can afford to buy and pay for the scans are more at risk of eye disease because the patients that are actually more tired risk of eye disease aren't actually making it into the databases, so that's inherent bias in the in the databases that we build and just a caution around that from me.

Robert Francis: Interesting. Well, thank you. We’re behind time now. So we move on to question three, which may be quicker, which is about virtual ward and getting care at home. Do you have any experience in these and if so, really which groups benefit most from it? Any experience of them?

Participant D: Through COVID with the respiratory patients and monitoring oxygen levels post discharge. That was probably the most successful example and then the people, tends to be the frail elderly, something like a urinary tract infection, just enough to knock them off-legs a little bit. So they need a higher level of monitoring and care. That's been quite successful as well. But it's the infancy of virtual wards still at the moment.

Robert Francis: Yeah, I doubt optometry has much to say about that? Participant B?

Participant B: Not really, actually. If somebody comes, we need patients to be in hospital to image them, and to be honest, it's much more efficient to image them while they're there, not necessarily hospital, but to be somewhere to image them. And it's much better to report it sorted out while they're there than any other time.

Robert Francis: Yeah.

Participant A: Yeah, just a quick comment really. I think to the point, it is very early days. So they're only really being set up in the priority areas that have been flagged nationally. So we don't really have a clear view of where else they might be beneficial. But in the respiratory areas, cardiovascular areas, you know, they do seem to be working well, from obviously, from the industry side.

Robert Francis: Yeah. I mean, maybe we if we haven't got that experience and it is new, do you have views as to, what groups would be? I think we mentioned some it would be likely to be impactful for. Sounds they're probably not be radiology as you’d do it all at once?

Participant D: I was just going to say I think one group where it could prove useful, say with sort of cognitive decline, early dementia, where moving them into a hospital environment to deal with a minor problem, actually destabilizes them quite significantly. And if you can keep them in their normal environment and get them treated, then that would be beneficial. And it tends to be very low-level medical problems, just enough to break a normal routine or a normal caring situation. If a partner goes off-legs with something then the other person living in the household, that might just tip them over. So I think there's some benefits there.

Robert Francis: Right. OK. Shall we move on to Participant A?

Participant A: Similar vein, that sort of dimension, frailty, those sorts of areas, beneficial. I think there's probably a lot more to come, not necessarily to the virtual wards as such, but in terms of monitoring and managing mental health.

Robert Francis: OK, well, good stuff, OK. Integrated care records. First of all, are they rolled out in your area? If so, how well does it/do they work? I should imagine this is, we'll start with Participant D.

Participant D: I'm very lucky because general practice records tend to be the best records within the system because they've been kept over a long time and lots of people feed into them. There's some movement being made in my locality to incorporate sort of more hospital data and social care data. But again, it's very superficial. But it would potentially be a game changer if we were all reading and writing into the same record.

Robert Francis: Any other experiences with it in action?

Participant B: Well, I mean my experience is that we have a lot of different ones. We do have an electronic patient record (EPR), but at the moment it's a lot of written notes scanned in, which is actually the worst of all worlds, and you never find anything. But I agree the GP records work really well and our systems integrate with the GP records as well, which is great. And I know that there are some places, I think in Cambridge they've got a very good EPR which works really well and can integrate Great Ormond St. So there are really good products out there. I think the implementation is often very painful, but good, really good and potential.

Robert Francis: So Participant B you’ve answered the question about how easy this is to find information amongst bad doctor's handwriting.

Participant B: And scanned in upside down.

Robert Francis: Yeah, and in the wrong order. So any other comments on that?

Participant A: Yeah, I would just say, GP side is really good. You’ve got very good coverage and you've got a limited number of systems inter-playing with those systems. It is easy because you know what you're dealing with. It's not the exact opposite, but very different in the acute sector, you've got lots of different types of systems and secondary care that coverage is somewhat less as well, and the ability to interface with them is highly variable. So a stark difference. GP or acute.

Robert Francis: Yeah, I'm sure that's right, Participant C.

Participant C: A recurring theme. The poor relations in optometry, I'm afraid, for connectivity. There are 8,000,000 outpatient appointments in ophthalmology per year. It's one of the busiest outpatient specialities. And most of those patients are seen in optometric practice, but you can never tell if they've been seen. If they're awaiting follow up, if they've been lost to follow up and all the rest of you can imagine the potential and the risks that sit around that because of that lack of connectivity.

Robert Francis: Enough said. Thank you. OK, let's move on. So basically what we're saying is it's a really good thing when it works. It needs to be more intelligently applied perhaps in some places as we've scanned records.

Participant D: Can I just highlight a challenge? Sorry to interrupt you. When patients have access to an integrated care record as well, they're privy to a huge volume of information. And I actually work in the Cambridge area, Participant B, and it it's very helpful. But often the patients have the results and reports before I do. And then we've got them on the phone saying, you know, my results have come. I had blood taken this morning and a scan at lunchtime. I've had these results, it's now teatime. What do they mean? And, I at that stage don't know why they've had them done, what the results are or what it has shown. So it needs to be managed across the system. Sometimes I think that it can get too quick and clever for the system that's wrapped around it.

Robert Francis: Good point.

Participant B: That's a good point, Participant D. Thank you.

Robert Francis: And challenging to sort out I imagine. OK. So that's commitment one. Only got three to go, health of the population the next one. What benefits do you think research has had on the area in which you work? Because the commitment, you recall, is about research program and £200 million to transform access to and linkage to of health and genomic data. Any comments? And also about the other point is more about patients and healthcare providers having reservations about the use of their data for secondary purposes such as research.

Participant D: The only factor I place on here is how important it is that patients trust what's happening with their data and their health record, even when it's anonymized or pseudonymized. There's a high level of cynicism amongst patients as to what we want data for. I think if they understand that it's for research and planning of services, they seem quite happy with it and wonder why doesn't the NHS do that anyway? It's just assumed that we would use it for sensible purposes. But there are growing concerns around it being used for sort of commercial organizations getting the data. And I think that would be my only comment. And research around all of the use of these technologies and impacts on different groups of the population is absolutely key from an impact assessment point of view.

Robert Francis: Yeah. Participant A, what would you say about that?

Participant A: Yeah, just a comment on that bit about, sort of, industry access to data because this is a big topic for us. Certainly when you ask the question, do you want your data to be shared with commercial companies, the answer is no. When you scratch below the surface of that, it's a bit more nuanced in terms of, well, what type of company and what type of use. You know, they don't want to share with insurance companies with marketing companies for marketing purposes. When you start talking about, well, the sharing, the data will deliver new interventions that will support the NHS, we'll support better patient outcomes in your particular peer group of people have X disease, then they are much more open to sharing data. I think this is very much a communication exercise…

Participant B: I agree.

Participant A: Why data needs to be shared and used, but to Participant D's point you know, some of it is already assumed that it's happening.

Participant B: Totally, totally agree with that. And so research; great. There are amazing products out there for use in imaging and radiology and workflow and all those things. So it's fantastic, but I've already mentioned the problems with implementing. I think there's often a mistrust of industry and commercial companies from within the NHS. And one of the things that I have seen is people working on products which actually aren't going to be that useful. And maybe what I think we need to do is to improve our improve our input. Say this is actually what we need - can you build me one like that? And that sort of that doesn't happen a lot.

Robert Francis: Yeah. That may be relevant for the next commitment area. Unless anyone has anything more to say on that, we might move on to contracting methods. This is the cost and efficiency of care. Some of this is already covered, but in terms of procurement, how easy or difficult is it for you to access software or devices to use?

Participant B: You've already heard me on this one.

Robert Francis: I’ve heard you on that one. Answer: difficult. And really, you're saying you don't have the channels through which to sort of specify what it is you need, or would be good in your field?

Participant B: So, I mean, people approach me as a clinical director of a large X-ray Department and also with input into a big network. So that would be good. So these products are being tested. We know they work, but the question is, what difference do they make to patients? And that is the question which needs to be answered in practice. And we'd be happy to test that, and do that. But we can't put them in and implement them because our procurement department, just to give you this example says well, even if they're giving it to you for free and you're testing it, they might have a market advantage. When you come to the end of that bit, which is true. But what am I meant to do about that? I want to try it because I think that patients might benefit, and we just don't really have an answer to that. It's two years we've been trying to put one of these in.

Robert Francis: And you can't try all the competition at the same time really?

Participant B: No, and maybe we have to then have a procurement exercise. But do I do that? You know, how does that happen?

Robert Francis: Yeah. OK. Participant C.

Participant C: I’m mindful I’m starting to sound like a broken record, but as for a number of the contractor professions, so not just optometry, dentistry, pharmacy and GPs as well to a large extent, a lot of this equipment is self-funded. So the technology is self-funded. So the decision on what piece of equipment to purchase, it comes down to a cold business decision in many instances. That doesn't necessarily work well with what it needs to connect to at the other end. And without something that joins up that way of thinking or leverages a supply chain for the contractor professions as well with the economies of scale, that makes it very difficult to purchase what may work best with other systems, rather than just taking a, you know, a balance sheet decision.

Robert Francis: Yeah, Participant A.

Participant A: First of all, Participant B, I think your procurement department need to look at some of the more innovative procurement routes, because things are available that should overcome your problem there. But to the bigger point about leveraging NHS buying power to buy centrally, that sort of thing, that sounds right in principle. However, the NHS doesn't act as a single NHS, so they can't buy as a single NHS. They can only leverage the buying power if you can commit to delivering the volumes that buying power suggests, and in a lot of cases, most cases, they are unable to do that. So it's a good theory, but practically doesn't seem to work.

Robert Francis: And would there be commercial resistance to doing that anyway because it would start competition?

Participant A: Yeah, absolutely. Yeah. Currently actually digital technologies procurement is better than certain traditional medical devices etcetera, it’s a much more dynamic system in terms of frameworks. And I think that's really important for what is a still a very nascent market to ensure that there is that competition and innovation to drive things forward.

Robert Francis: Thank you, Participant B?

Participant B: So this will sound very naïve I'm sure to you, Participant A. But I feel as if what I would like is, a systems designer, you know, a sort of somebody who will come and sit with us and work with us and say, you know actually this is what you need, somebody who knows about it. And I mean we do have a great IT department in my hospital but actually they're too busy dealing with me ringing up because I've forgotten my password, of the many nine systems. Do you see what I mean? It's like I need a designer. Who will understand what can be done and how we could improve it.

Robert Francis: Yeah, Participant D.

Participant D: A lot of GP equipment is supplied, it was by the clinical commissioning groups, but it's now through the ICSs. So, the actual purchasing is fairly simple, because someone else does that. The issue is keeping it up to date. And certainly with software and the like, it's not understanding the problem you're trying to fix, or not foreseeing the new problem you create two steps down the line by fixing the block that you have at the moment. And so it's getting the expertise into systems to work out well, if we fix this bit, what do we break? Because inevitably it will break something else. And how do we fix that at the same time? So we don't just move the problem elsewhere and we're using technology to streamline stuff rather than just to move one block and put it elsewhere.

Robert Francis: Yeah. Do any of you get involved in negotiating pilots and contracts?

Participant A: I don't directly, but our members do, so I have some insight into that.

Robert Francis: The question prompted to ask you is how supportive people feel when doing that and that must be from a healthcare providers point of view. I'm sure the providers of the IT are well supported in negotiation but I wonder if it's the other way around? Nobody knows? OK. What about funding for trying innovative solutions? So, Participant B, you're really saying you don't know what the solutions might be for each campaign for the funding really.

Participant B: Well, I mean, a lot of them are self-funded. There are so many companies that really want to get into healthcare. You know, I don't normally have to pay for anything.

Robert Francis: Yeah.

Participant B: But, well not the new ones anyway. But that also appears to be a problem. I didn't think it was going to be a problem, but it does.

Robert Francis: Participant A, let’s have a solution for it.

Participant A: I think the funding regime for trials is pretty good actually. We look at NIHR and innovate UK, SPRI, AI labs, you know there there's a number of different initiatives you can tap into at any given point. I think it's one of the things we do fairly well in the NHS, or the UK anyway.

Robert Francis: OK, that's good news. So apart from getting the thing, how good are we measuring at the value added in the innovations? And whether they’re worth having? After having tried them, obviously.

Participant B: Me again. Sorry. I mean that is that is really difficult, actually. And no, I don't think we are very good. And actually we employed somebody in our department and he's still trying to work that out. So actually how do we work out what difference this makes to patients? That's the main thing. So you can say what it can measure a nodule that accurately and it can measure it again six months later and tell you whether it's got bigger. But what difference to outcomes does that make? I mean, we're pretty poor with that generally in medical research actually. But that's what we want to know and we need some sort of general way of doing this, I think an accepted way of doing it.

Robert Francis: So what about you, Participant D? You've much experience?

Participant D: Yeah, I think we're really poor at evaluation. I think it takes us so long to adopt stuff that once it's adopted, we just move on to adopting the next thing without really evaluating the last thing. Certainly with general practice, the different needs and requirements of individual patients are so broad and diverse, that it depends what you mean by value. And I imagine that's why it becomes then so difficult to evaluate. I mean often it's easy to say does the product do what you were promised it would do. But then that next bit that Participant B eluded to, “and so what?” is much harder to answer.

Robert Francis: Participant C, whenever I go to the optometrist there's always some new gizmo they seem to be trying out, usually for an extra charge. Do you have good systems for evaluating what value they add for the patient as well as for the bank account? Sorry, cynical question.

Participant C: So no I don’t think we do.  I think for certain things, going back to OCT retinal imaging, all those sort of things, because of the overlapping to ophthalmology, there are quite good mechanisms to say what things work and what value they add. But there's a number of fringe products that actually I think there's a huge amount of scepticism around because the only support is around manufacturer support and obviously that isn't necessarily as impartial as it could be in some instances. Some are very good, some less so. And that raises a challenge, but where it overlaps with ophthalmology, yes, because we can lean on the support from what they're doing to say, yes, we know this works.

Robert Francis: OK. Well, shall we move on to workforce literacy? That is a literacy in a digital sense and workforce. What we're after here is finding out about skills actually in the number of staff and the first question I imagine the answer is obvious. Are there enough staff with digital skills to operate technology where you work? And Participant B already said no.

Participant B: Well, I mean, I actually think that the staff, the general staff, in terms of the people that are using it are pretty good, you know, and they adopt things pretty quickly. You know people will say, oh, I need training on this particular thing. But actually they get the hang of it pretty soon. It's more the kind of design as I say that sort of higher level function I think.

Robert Francis: What about general practice?

Participant D: I mean, I think it's an important requirement that we do have time to learn to use the tools because I think we’ve probably got some very powerful digital tools. We’ve just scratched the surface of the benefits we could get from them. And sort of those change management programs to facilitate implementation right across the team in a practice. It's no good one or two of the team being able to use it. You need everybody to be using it. And then that sort of technical support because if my computer goes down for two hours, that's ruined my day because I've lost those two hours. I've got 2 hours worth of patients building up. So you need a very quick response to get stuff done. And I mean it's demonstrated, you know, if we have a power cut at the practice, I can't do anything. I can't access the records. I can't look at results. I don't know the patient’s phone number to phone out to them. I can't see their record and we are completely paralyzed. There's no point me being there. If when I press the button it doesn't turn on and work. So we have a very, very high reliance on them. And especially in terms of records, because patients will go “can't you go back to the written records?” and it's like, well, we've not written in those for 20 years, so they're rubbish as well now. And so once you become reliant on it, it has to work. It has to be efficient and part of that is getting the real basics right. You know, 50 odd percent of GPs in a survey we did reported that their Wi-Fi speed wasn't adequate. And so that slows everything down. And then if something's working slowly, you tend not to use it, you find a workaround and so there's a lot of getting the basic infrastructure right as well as the specific products.

Robert Francis: Participant A.

Participant A: Yeah, I mean there's a lot of information already out there from Health Education England on this. I'm sure secretariat can track that down, but if they can't feel free to drop me a line. But one of the key sort of areas is the specialist IT support and particularly things like cloud engineers, data analysts etcetera. They're in such short demand across the economy and can, you know, demand wages several times more than the NHS will pay them. So it really has to be about the desire to work for public service rather than the economics of wages. So yeah, it's a big issue certainly at that technical level.

Robert Francis: So am I right in thinking what you're saying is that there isn't a shortage of staff to fix Participant B’s forgotten password, but there aren't enough staff to deal with the strategic level, of in any organization, of what IT they need or could benefit from, and how it all fits together?

Participant A: Yeah, I wouldn’t necessarily like to say there’s enough for Participant B’s password. But, I know there’s a shortage of, not just the strategic, but the specialist technical areas. So not the general desktop support, but the systems architectural design.

Robert Francis: Yeah. The plumbing?

Participant A: Yeah, having the infrastructure, yeah.

Participant B: But are they all working fintech firms in earning an absolute?

Participant A: Yeah fintech and big tech. You know our industry suffers the same thing. We can't compete.

Robert Francis: And so is there, on the course of that, a reliance on consultants? You will obviously charge commensurate fees for us. Or don't? Or doesn't even that happen?

Participant A: I don't know the answer to that to be honest, Robert.

Robert Francis: OK. Sorry, Participant C. Yes, you've been very patient.

Participant C: No, that's OK. Thank you. So it's a little bit different for us because of the, sort of as you alluded to, the overlap into the retail space as well how we operate. Actually, that sort of support for the day-to-day running is built into the business running. So we're not as reliant on the NHS in that regard. We just buy in what we need to buy in, so we have an advantage there. From the actual users of technology, they sort of split into two categories though when things go wrong. The nerdy tech stuff that we all enjoy playing with, we get really good at. And the stuff that's a bit more, mechanics of, you know, fixing the password, fixing the network connectivity, that's the stuff we outsource to others because we're not interested in that because it's not fun. It's just necessary. But the OCTs and the scans and all the rest of it, that's quite good for them to play with so that the users are generally across the whole optometry workforce very engaged and sort of self-trained, and on any course they can get on to enhance their skills because it's an exciting way to practice for them.

Robert Francis: OK. Any plaudits for particular bits of training any of you have? You know something that's really good in terms of training? Be it good or gaps in the things that you needed training and you haven't had?

Participant B: I think in terms of training, it's about, you know, I've had a lot of training in different systems, often six weeks before the system is done. By which time I have absolutely no memory and I don't think I'm alone in that. It’s not really so much training, you need ongoing support. Most of us are pretty good at having a bash? But once you get a bit of ongoing support then people train each other in a big organization, anyway. I think it's maybe different in general practice but you know we've got a big department full of people and I'll be working alongside other people and I learn a huge amount from my colleagues. I say, how do you do that? I think it's about ongoing support. It's about having somebody there. Easily, easily accessible because the training I've had is honestly, it's not that it's not great training, but it's just not the right time and it's all at once. And I just forget it.

Robert Francis: OK. Well, I think that probably leads us on neatly to the final question and indeed the final five minutes, which is where do you think that digital or technological solutions would be especially important in meeting the needs of patients and services in the coming years? And as I'm sure the answer must be yes, is it your experience that the skilled staff are in place to make ourselves such solutions? I think it probably will make use of such solutions in other words, you know, in a developing field? Have we got the staff? And I think your answer is universally no, and largely because we can't afford the eye watering salaries that they get in the City or wherever else in big commercial organizations. Is that what you've been telling me?

Participant D: I mean I read the question slightly differently, in as much as, if you provide a load of solutions that we could use in general practice, is the general practice team and workforce trained to use them? So, from that reading of it, I think it's absolutely key because there's no point having it all if you don't know how to use it. Then equally, we need to be able to train patients to be able to use it as well, if they're going to be recipients of a different sort of care or a different mode of care. Otherwise, it's technology for technology’s sake. I think it's really important that we know what we're trying to fix, and once we found a fix, we know how to use it most effectively and efficiently. And it goes back to that really important, you know, we're still researching the benefits of remote consulting in general practice. And you know, we switched over the space of a weekend without any research base and we're sort of doing it the wrong way around this time, because of the pandemic. But I think they're the sort of things that are interesting. But absolutely if we become reliant on new technologies to provide new ways of working and new offers to patients, it's got to be robust because we’ll often dismantle the current services that are in place. And if therefore the new one isn't robust enough, and very reliant and user friendly, we end up in a worse position than we started.

Robert Francis: Participant B?

Participant B: Just want to tell a very quick story to say that I think that this is the group that we really need a staff. If I had to choose one group of staff that could give most to the health service it would be, kind of, IT designers, IT support. The ED lead went to every single emergency department in the country and put in the same script about a 70 year old woman with a twisted ankle. In some departments it took him less than two minutes, in other departments, more than 12. And what he worked out was if everybody was in the lower quartile, it would save 179 shifts in every type 1 ED in the country. So if you get this right, you are immediately giving yourself more staff. This I have to say, is our only hope. You know, I mean, you can tell, I feel strongly about it, but actually we've got to make the most use of our staff and this is the way to do it.

Robert Francis: Right. Thank you, Participant A.

Participant A: Yeah, I didn't raise my hand for this, but it's a great point, Participant B, about data collection, it's a part of the puzzle we often overlook. It really is being made effortless for the frontline staff. But why I raised my hand actually was about the issue of, sort of, the training and use by patients. And I think we need to have almost a new partnership between the NHS and industry. Industry need to be providing and enabled to give that support for their systems in use. And if we look at areas like diabetes, you know, the interaction between patients and the company providing the diabetic solutions has been great over the years. And yeah, that's the relationship. You know, a lot of cases rather than with the GP as such, at least ongoing on a day-to-day. We need to have more systems like that.

Robert Francis: Thank you. And sorry Participant C, I overlooked you. It's just that Participant A has the advantage of being at the top of my screen. So that's the problem.

Participant C: That's OK. That's absolutely fine. So, I think it's really to echo that to a large extent. I think in optometry the skills are in practice, but it is how patients use it, and who helps the patient to use the technology if that's the way we're going to go? Because if you're asking the practice to have the time to facilitate all the needs of the patient on how they interact with it, that's a big ask. But if there's another mechanism to help educate the patient, so that they are better at using the technology, then I think we're in a good place. It's just how we bridge that? Because if you went to, I'm going to Participant D or Participant B as well and said, OK, you've now got to coach each patient through how to use this technology every time. That's a ginormous ask for anybody and it's how we close that gap off. I think that's what we need to pay some attention to as well.

[Participant B makes thumbs up gesture in agreement.]

Robert Francis: Fantastic. Well, we just got to the end of that, but are there any further comments? Any general comments that anyone wants to make about any of these commitments? Which is you know, by the way, we haven't yet got authority from the Select Committee to say these are the commitments, but they usually agree with us. So we are assuming that that is going to be the case.

Participant B: Well, thanks for the opportunity to input. That's all I'd say.

Robert Francis: I mean, do you have anything to say about the commitments as a generality?

Participant B: Only what I've said already really, that actually staffing is the biggest problem across the NHS, across everywhere. No matter how quickly we train people, we're not going to keep up with demand in our current way. So we've got to think of something different, and this is the biggest opportunity in my view.

Robert Francis: Everyone agreed?

Participant C: I think for me, a plea to make sure that all the contractor professions are engaged. And I sort of feel like I need to champion, not just optometry, but dentistry and pharmacy as well. Obviously, the new Health Secretary has been talking about making greater use of pharmacy in the Commons only this morning, and it's using those other professions to support where they can, but making sure they also have the connections and the technology and aren’t overlooked when we're planning, that will really help us tackle some of the challenges that we've got going forwards.

Robert Francis: Very good point.

Participant A: I’ll take this in a slightly different direction, in terms of these commitments, all fine and good. I look at it from a slightly different angle, I believe the other departments made other commitments through the Life Science Vision about how they can support the industry sector. And some of those don't seem to have come to fruition. Certainly around how we utilize the NHS data asset, and whether they’re going so well that that’s down to the NHS or not. But that asset really needs to be exploited, both for the benefit of industry and UK PLC's, but absolutely for the benefit of service design and patients.

Robert Francis: We haven’t really talked about, and I’m not sure where it does actually come in, I think through the integrated care record commitment. But is the challenge or conflict between either big systems or lots of local ones joined up? Because the experience I think I'm hearing is big systems tend to collapse more easily or don't work for everybody. But on the other hand, the small “we invented it here systems” never seemed to be compatible with anyone else. So what's the solution to that problem?

Participant A: Yeah, I think there's general agreement that you don't want to pool all the data into one place. That's not the way to go. It's about federated datasets. So enabling the interoperability between the data through better labelling, data quality, curation etcetera, you absolutely need. We have lots of data, it's siloed, just not interacting. I mean this might fall to Participant C's area, the ability to link image data with integrated care records etcetera. is very limited and not happening. Or Participant B's as well actually, we're sort of getting the PAC systems etcetera, risk systems to talk to other areas. Not saying take all the image data and put it somewhere else, but you need to make these things work properly.

[Participant B makes thumbs up gesture in agreement.]

Participant C: I’d absolutely agree with that. It's not where it's stored, it's how they talk to one another and mandating that they have to connect, rather than mandating where the data has to be, that would solve most of our challenges. It doesn't matter where it is, if you can get to it and you can link in an amount of it from various systems, that's the national steer that lets the local innovation then thrive in the way that it needs to.

Robert Francis: Fantastic. Participant D, I mean GPs, I suppose have always been at the front line of such integration, as we have or haven't had. But how do you see it? Do you see it as being in a better place now that we were a few years ago and has it ground to a halt or is progress continuing as far as you're concerned?

Participant D: No, I think there is progress on integrating the record. I think one of the challenges we have is as a healthcare sector is that we're often looking for solutions for the problems we've identified. We're not allowing those that develop the innovations and the tech to radically redesign the way we do things. So I think often there's a lack of ambition for the scale of innovation we want to bring in, and it's a bit like the iPhone, isn't it? 20 years ago, you'd never have dreamed of carrying a phone around that does all the things that it does, and the thing you use it for least is making phone calls. And so we'd have never asked for that product. And I do sometimes think that still holds us back in terms of how innovative we could be in the delivery of healthcare. We're looking for solutions to make the way we deliver things traditionally better and easier, rather than asking what's out there, what will we be doing in five or ten years time that we should be thinking about commissioning now that will radically change the way in which we provide health and offer care to patients.

Robert Francis: We have got a couple of minutes left. So I'll be self-indulgent and ask about something that's always a bugbear at Healthwatch, which is the digitally excluded, and those who don't benefit properly from it, or don't have a phone or whatever. How do you make sure that they don't get left behind?

Participant D: I think there's two schools of thoughts on this from a general practice perspective. If we can get 90% of our patients using the new technologies, which speeds things up and makes things more efficient then that, gives us more scope to help the group that are digitally excluded. And the other thing is I think there's a lot of misconceptions around anyone over the age of 60 won't be using the tech and I find my older patients are the ones that are most engaged with it. So I think we need to be really careful about stereotyping the people that we think will use it, and won't. There are certainly social groups, the homeless is an example on my patch where they were truly digitally excluded because they were excluded from most health other than emergency attendances in EDs. So by providing them with some of the digital solutions, we've managed to bring them into mainstream services. But yeah, it's just that risk of stereotyping people that we need to be mindful of, I think.

Participant C: So just on that very briefly, sorry. It's interesting about the generalization about age, which I think is the dangerous one, I agree. Our practice is in a very poor NHS area though, and they have mobile phones, but they don't have data plans that enable video calling and things like that. So they're digitally excluded even though they have the technology. They don't have the means to finance the contract, they need to access the technology that they possess and that's a slightly nuanced sort of approach. They have the tech, so it's how we go about how we go about solving that, I guess.

Robert Francis: Hmm. Yeah, very good point.

Participant A: Could be prescribing data plans where necessary?

Participant C: Well, funded potentially as a pay as you go card or something could be an option if it's the cost of providing £5 worth of data, as opposed to a face to face appointment. That may actually be a very cost-effective way to provide care for someone, or for £10 worth of data or whatever it is.

Robert Francis: For monitoring as opposed to visit hospital. Yeah, very good point. So I think we’re nearly out of time. Thank you very much. I've enjoyed the conversation.

Sept 2022