Evergreen Life – Written evidence (INQ0006)

1. About Evergreen Life

1.1              Evergreen Life https://www.evergreen-life.co.uk/ is a personal health record (PHR) app used free by over half a million people in the UK – and it’s the only provider to be connected to all three major GP systems in England, providing online patient-facing services on behalf of the NHS across the country. The app also allows people to monitor their health and fitness; record allergies, medications, and store medical documents and letters. By empowering people to own all their health information, they can make informed decisions about their own healthcare, and they can share this with anyone involved in their healthcare.

1.2              Overall, our goal is to help people feel better informed and more in control of their healthcare, their health, wellbeing and fitness. Our belief is that our ageing population can be helped to live longer, healthier lives if people have the ability to curate and share their own health records and are given the ability to work with their care network to co-design and deliver the care they need – underpinned by technology.

1.3                            In this regard we would like to offer feedback on your questionnaire under 4 themes:

1. (Goal Setting) Defining the goals for a strategy to address the challenges of an ageing society
2. (Extending Healthy Years) Using technology to compress the years that people live with morbidity and increase healthy years
3. (Treatment Technologies) Using technology to facilitate access to the right services in the right way at the right time
4. (Improving Well-Being) Addressing the “wellness” challenge

2. Goal Setting:

2.1              Public Health England and others have done great work to understand the profile of our population, but more can be done to understand how public services can engage people, so that they are partners in addressing the health and well-being challenges they face.

1. We need to agree a goal for our ageing population (although recognise that the life expectancy curve is flattening) that reflects a desire to live longer, healthier lives with fewer years of morbidity.
2. The goal could include a triangulation of citizen, community, government views which will need to be set into cascading indicators which direct and monitor government and citizen activity.
3. Getting 5 years back and removing inequalities is a blunt instrument compared with defining how well you can be and then charting a journey. We would recommend personalised goals, which can be aggregated for instance, everyone lives 5% longer than they were expected to live; everyone lives with 10% more healthy years than expected; working lives are extended without impacting quality of life and so increase tax-take.
4. Evergreen could help solve this issue. Our Personal Health Record linked with the GP record enables people to record key health progress and answer questions and become more engaged with their health.

3. Extending Healthy Years:

3.1              When people enter our care system with a health problem then they generally receive a good experience of the NHS. If they have multiple problems, even if the root cause is common, then the NHS can find it more difficult to provide great care because of the way it is organised so that individual specialties work well, without necessarily owning the patient as a whole. Of course, the GP owns the responsibility of supporting citizens and communities, as well as patient cohorts. However, helping people when they become sick is not the best way of enabling people to increase their healthy years. There are some issues we need to address in order to solve that problem.

1. We do not have the analytics that profile populations, society, trajectories and allows goal setting because we don’t invest in it. So, we live with outdated analytics based on incomplete data, which often isn’t linked, that is updated too slowly and is based on supporting outdated commissioning models and operating within austerity driven paradigms where the focus is on cost-reduction as an end and not a means to providing the affordable care that people want.
2. Let’s get value out of data and eliminate the wasteful practice of multiple organisations processing the same data sets for broadly similar purposes at the same time. For example, the secondary care activity data set known as SUS (Secondary Uses Service) consumes a disproportionate amount of the health budget in terms of the number of people working oin it, across the many organisations that use it. If some of the effort was diverted to building other and more relevant data sets then data could inform systems of engagement[1] with the elderly (and those of us who will hopefully be elderly) so we have a holistic and evidence-based approach to service design.
3. Key to solving the ageing crisis is shifting as much care and responsibility left, away from dependence on Acute Hospitals. What can be known and done at birth (via DNA), what can be done at school, how do we influence choices we make as we go through adolescence and into work etc. Technology can become a trusted coach through these phases of life, for people and for government as data is harvested and used to revisit strategy.
4. Evergreen is focussing on this sustained engagement between people and care systems, as well as focussing on well-being coaching for individuals. The practical impediment we face in UK is having a better relationship between government and people where everyone has a phone but only a small percentage of people are using the device to engage with each other and government on health and well-being management.
5. Every country has the problem of sustaining engagement between the right partners in care. People trust their GP and they trust their local A&E to help them if they have an urgent problem. If people knew about, and trusted, other services then they would use them. If their non-NHS support systems, such as their families for example, were enabled to provide them with the support then the surface area of the care system would widen to encompass more service points that could be used to provide higher quality, safer care in a more cost-effective way.
6. Improving self-care for people with Long Term Conditions (LTCs) is critical. If we can support people with LTCs to do more for themselves to keep as fit as possible, we could make a significant impact on healthy life years. People spend a few hours with health professionals a year - the rest of the time they are on their own.
   Apps are likely to have a big part to play. The evidence for app-stimulated health behaviour change is strong.
   An interactive app that combines your GP record with a PHR will enable personalised advice and guidance that supports and encourages people with hypertension to do more exercise, for instance; people with COPD to do pulmonary rehab; people with diabetes to alter their diet. It can be targeted to particular groups on GPs’ lists – changes can be fed back to the GP record. We would have seamless positive feedback for improvement.

4. Treatment Technologies:

4.1              Quite rightly there is an increased focus on system integration (enabling IT systems to talk to each other), data integration (enabling date to be linked) and encouraging innovation within a standards framework.

1. Lots of technologies are available but there is a fragmented landscape and lack of alignment to a national strategy, which is equally fragmented and being developed by multiple government agencies. It is very difficult to get the technology which can easily be embedded in clinical workflow, which is appealing to people and which simplifies the way the NHS and people can engage using technology. Technology might help the elderly with issues like COPD, for example, but we do not have technology that is focussed on the ageing issue. NHSX is not the answer to this. Better embedding of technology in care system transformation is. But this requires the care system to embrace the disruptors.
2. The “quantified self[2]” trend is coming to the NHS. Technology vendors are developing tools that help people to monitor themselves, such as digital scales / apple watches / blood pressure cuffs / devices that can be added to spirometers so data can be collected and share, and the market is maturing quickly. However, the NHS will not benefit unless the data embedded in clinical and operational workflow so that clinicians and other can easily use it.
3. The questions about the home and open spaces are relevant but the questions of “where do I live, how and what do I do?” are quite different. Other countries have benefitted from not starting with technology as they look to address these questions. In rural Norway[3] the postman knocks on pensioners’ doors as they deliver the post, to make sure people are OK. Technology could be used, for example, to take a selfie and share it, so the family far away knows everyone is fine. The camera can read the face and perform health checks. It is this sort of reimagining of the visit from the postman that will see technology having an impact.

5. Improving Well-Being

5.1              To age well we need to invest more in our earlier lives, recognising the constraints that people live under and improving our opportunities to reduce the challenges of ageing.

1. Using genetic profiling can help us understand the issues we are born with and help design a response throughout our lives so that the impact is minimised as we age. Genetic profiling which focusses on giving us information that we can do something about will be most effective; diet, fitness, metabolism are all things we can influence.
2. Personalised guidance can help people to make informed decisions about how they live their lives so that they maximise the opportunity to be well and yet there is a paucity of support for this in UK public service where blanket content, in the wrong tone, using inaccessible channels that people don’t use is limiting people’s understanding of what could work for them.
3. Coaching and signposting can help encourage people to use resources that are available to help them. Often people don’t use public services which have been funded to support them, because they don’t know about them, don’t know how to use them or don’t see their relevance. The on-line retail industry has addressed this issue and knows that not treating people like customers and giving them a good experienced is the road to ruin. There is no reason why the NHS, for example, could not think the same. There is a myth that this degree of personalisation is prohibitively expensive and yet retail operating costs (using technology) have come down.
4. Using AI for operational improvement is already resulting in efficiency gains in the NHS[4]. Contrast this with the issues impacting the adoption of AI for clinical use (ethics, reliability, trust, cost, clinical engagement) and it is possible to suggest that prioritising investment and effort into making it easier for people to “do business” with the NHS may be the best way of achieving early gains. If the NHS can listen to threats to well-being and respond early, on-line, then the impact could be huge.

6. Summary:

6.1              Taking all these issues into account, we suggest there are four key messages from our submission. We would be delighted to discuss these with you further at any time:

1. The issue is complex, and we need more evidence to understand it and create policy
2. The technology landscape is fragmented and technology-led so misaligned to what people need
3. An increased focus on using technology to build engagement between people will be important
4. Technology can assist with personal coaching and be used to change behaviour

19 August 2019