DGT0019

Written evidence submitted by the Royal College of Physicians (RCP)
 

The Royal College of Physicians (RCP) welcomes the opportunity to submit evidence on how the NHS needs to make better use of digital technology and data to improve services for patients. Representing over 37,000 members and fellows worldwide, the RCP plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence.

We have been encouraged by the more innovative use of data and technology that COIVD-19 has precipitated. The pandemic has meant rapid and long overdue changes to outpatient services and more joined up access to patient records. These changes now need to be embedded, but in a way that directly addresses the challenges the move to “digital first” presents in terms of the risk of widening health inequalities and clinicians being able to deliver the best care.

To ensure positive changes are embedded in the long term, the RCP recommends:

1. Resetting outpatient services to be “digital first”, subject to a rigorous evaluation process to establish the best approach to implementation. This would see remote care offered as the first choice unless the clinical issue or patient access requires a face-to-face interaction.
    
2. Extending the Control of Patient Information (COPI) notice to make better use of data to deliver more integrated care.

As part of a longer term plan to transform patient services through better use of data, it will also be imperative to prioritise:

3. Embedding genomic medicine in the NHS through investment in workforce education and capacity.
    

Resetting outpatient services to be digital first

It has been clear for some time that the traditional model of outpatient care did not work well for patients and needed to change. Our 2018 report Outpatients: The future – adding value through sustainability described how one in five appointments in England and one in four in Wales were cancelled or reported as did not attend, with the majority of cancellations by hospitals. The environmental impact of traveling to in-person outpatient appointment is also significant. NHS-related traffic accounts for 5% of all road traffic in England alone, with outpatient appointments likely to make up a significant amount of that.

In a July 2020 survey of RCP members, we found that 73% were now conducting remote consultations in light of the pandemic – a transformative shift. Some basic IT issues remain that are hampering the ability to conduct effective remote consultations however. Almost a third (32%) of respondents to this survey said they did not have access to the right equipment (most commonly webcams). Progress must continue to be made on this as a targeted solution to improve access for clinicians and enable effective remote consultations and the best patient care.

Many physicians are reporting also that remote consultations are taking longer and involve more administration than face-to-face appointments. They also express concern that unless there is increased investment in remote monitoring and diagnostics, a wholesale move away from face-to-face appointments could increase the risk of missed diagnoses.

The move to a digital first approach needs to be implemented in a sensible way which tackles these downsides. In terms of patient access, a key risk is that commissioning digital first services risks widening health inequalities if we do not take account of the digital literacy of the patient population. This is because those who are already most difficult to engage in the health system are often those with the least digital literacy too. Communicating information to patients via phone and video can also be more difficult, and decisions about how patients are contacted will require the consideration of senior triage.

In short, there needs to be a rigorous evaluation process to establish the best approach to delivering digital first services, which encompasses supporting and training the workforce and co-designing pathways of treatment with patients and clinicians.

We have worked with the Royal College of General Practitioners to produce a set of principles and recommendations for how this digital first model of outpatients should work. These include:
 

• Remote care should be offered as the first choice for patients unless the clinical issue requires face to-face interaction
• There must be alternative arrangements available for patients and carers who can’t access or use the required technology
• Integrated care systems must co-design new clinical processes to take account of beneficial new technology. Appropriate safeguards must be built in to protect privacy and confidentiality
• Integrated care systems must ensure that all organisations have what they need to deliver remote consultation safely and effectively. Organisations should establish a system to assess whether patients and carers have access to technology and are able to use it. Organisations must meet patient and carer needs in line with the Accessible Information Standard
• The NHS should introduce a blended payment model for the outpatient system. It should combine a fixed payment based on the likely needs of the population with a payment based on outcomes. Those outcomes should include patient-reported quality of communication and experience.

Extending the Control of Patient Information (COPI) notice to make better use of data

The response to COVID-19 has meant that clinical staff across primary, secondary and social care have been better able to access the same patient data. This is because the government introduced the COPI notice in March 2020, which required NHS organisations to share data as part of the COVID-19 response.

To take one practical example, in Greater Manchester the COPI notice has allowed the introduction of the Greater Manchester Health Care Record across the entire region. Now clinicians can access vital patient records across all 10 localities in Greater Manchester, where previously they could only access patient records from their own area. This makes clinical decision making much simpler, with up-to-date information on test results, care plans, medications and social care support.

The COPI notice has been extended until the end of March 2021, and the government should further extend this notice, while considering how it can permanently embed changes to make safe sharing of patient data across health systems standard practice.
 

Embedding genomic medicine in the NHS

As outlined in the March 2019 statement by the Academy of Medical Royal Colleges, the data derived from genomic sequencing enables ‘more accurate diagnosis in rare disease, infectious disease and cancer…and develop tailored therapies’.

Effectively embedding genomic medicine across the NHS will require a genomic-literate workforce.
This not only includes clinicians but also scientific and nursing staff. Staff need to be well equipped to interpret and explain genomic findings to patients and support them in accurate decision making.

In order to create this genomic-literate workforce, the following actions are needed:
 

• Compulsory genomics education for all medical and nursing students, and ongoing education for already qualified staff. This will ensure that all staff will be well equipped to interpret genomic findings and support patients in accurate decision making.
   
• Strong investment in genetic epidemiology to establish the likelihood of disease-causing variants causing particular illnesses. A priority should be establishing in the UK Biobank and other large datasets the likelihood of disease-causing variants causing particular illnesses to better inform decisions for patients and their families. Without this it will not be possible to take advantage of genomic medicine to accurately personalise treatment for patient benefit.
   
• Research into the clinical benefit of using genomic data compared with standard care pathways to determine the clinical utility of genomic medicine.
   

For further information, please contact Jordan Marshall, RCP Policy Manager
(Jordan.marshall@rcplondon.ac.uk)