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HTN at HETT: a day of digital transformation

Last week HTN took a trip to London to attend The HETT Show: Healthcare Excellence Through Technology.

With stands, speakers, panels and more on everything to do with digital health from apps to analytics to case studies, there was plenty to learn from. In this two part feature, we’ll share some of our highlights.

Infrastructure and data architecture

James Austin, Director of Data Strategy and Policy for NHS Digital, on the ‘Data Saves Lives’ strategy

When asked about the overarching aims for the data analytics capability across the NHS, James pointed out that it is important to recognise some of the potential that already exists and the initiatives that are already in place, but are not always leveraged to their full capability.

“The touchstone for us all, across the system, has to be the Data Saves Lives strategy,” he said. “I think there’s great virtue in having that system-level strategy because it very clearly set out what the opportunity is and provides a bit of a roadmap in terms of how we are going to get there.”

He noted that the strategy wanted to pull out key areas that could make a real difference to people working in the NHS. One such area is the role of data for health and care professionals providing direct care, making sure that they have the information they need to make accurate diagnoses, keep people safe and offer truly personalised care. Another key area in the strategy is importance of information governance to facilitate data sharing, and the need to make shared care records universally available to a common standard.

James highlighted the role of the decision-maker. “We need them to be able to make decisions about healthcare in full light of facts and data,” he said. “That means providing them with the information that they need to make smart choices around population health, enabling colleagues to be able to commission smartly, and at a national level being understand trends, manage risks and understand the type of interventions that may need to be facilitated at a national level.

“A big part of that is around better interoperability…. we’re never going to mandate that everyone has to use this platform or that platform, that’s not realistic, but what we can do is make sure that they all speak to each other and they are interoperable.”

The third key area is about “boosting data and analytics capacity and capability,” James continued. “There’s lots of capability, both at a national level and a regional level, but how we can join that up? How can we think about proper career paths, how can we use some of the learning and the practice that we have for other staff cohorts and apply it to data and analytics workers?”

Finally, James highlighted the “huge role” research plays in the UK. “We are ripe for innovation in this space,” he commented. “There’s a big focus on making sure that researchers can safely and easily access the types of data that they need in order to do their work. We’ve made some progress there already, but we need to look at making real the idea of secure data environments for access to that data.”

Andi Orlowski (President of the Association of Professional Healthcare Analysts, AphA) on supporting the data and analytics workforce

Andi picked up James’s point around boosting capability in the analytics workforce. He highlighted that there have been nine data and analytics strategies in the last financial year alone.

“You can understand the importance that the NHS has put on data and analytics as part of that,” he said. “It’s a key part of what we do. It’s the future and we need this focus in order to be and become the analytical powerhouse that we want to be.” However, he pointed out, “the analysts we have today do not have access to the continued professional development that they need and deserve.”

He shared how AphA ran a survey a month after the publication of Data Saves Lives, asking analysts how they felt about being prepared for the future, their development and access to that development. 83 percent of band five analysts reported no or little access, and only 21 percent said that their organisation support them in getting their access. Higher bands reported that they have access but have to pay for it themselves, do it in their own time and on their own initiative. Andi commented that strategies such as Data Saves Lives, therefore, must recognise the importance of supporting the workers as well as the data.

Andi encouraged people in the room to think about ways in which their organisations can support the analytical workforce. He raised a need for more centralised support and “clear commitment” from across the NHS to support analysts, from giving them more time to potentially funding professional development. As an example, Andi highlighted the Midlands Decision Support Network, a partnership of 11 ICSs working together to pay for training for analysts throughout the ICSs.

“For you system leaders in the room – do you know your analysts?” Andi asked. “If you don’t know your analytical team, please go and meet them, speak to them. I promise you, it will be a rewarding, fun and enthusiastic conversation.”

David Walliker (Oxford University Hospitals’ Chief Digital and Partnership Officer) on the national approach at trust-level

Next, David was asked how the national approach works in practice at a trust-level.

“I’ve been in the NHS now for 18 years,” David said, “and I’ve heard a lot of the same things said over and over again. But I do think that we are on the cusp of something now. I think it has been driven by requirement. Demand is continuing to increase, the money has to increase or else it flatlines and becomes a political football. But fundamentally, if we don’t tap into this data to enable us to transform our services or research, we’re never going to bridge that gap.

“I do think that the next few years will be tremendous because we’re now in a position, certainly in Oxford, where we will be able to collect and curate very rich clinical data. But we’ve got to hold a mirror up to ourselves and acknowledge that we’re starting in a tricky position. We’ve got this wrong a few times before, and we got it wrong because we failed to communicate effectively.

“I think the Goldacre report really helped with that – the report laid out what a secure data environment is and answered tricky questions around trust and the environment that you need to enable this work to take place. But we’ve really got to get that public engagement right, and professional engagement too.

“If we crack that, we’re going to be able to answer the aggregate questions – how many patients are coming in, what are they coming in with, when are they going? We can really start looking at population health then and find the insights in the data. It’s there, we just need the skills, the people, the infrastructure and the trust to find them. It’s all coming together with the strategies, and I think they’re good. You can get behind them. Policy-wise, we’re on the right track.”

Dominic Cushnan (Director of AI, Imaging and Deployment for NHS England Transformation Directorate) on how artificial intelligence can be moved from research to deployment in the NHS

In this session, Dominic presented an overarching question: “How can artificial intelligence help and improve healthcare services?”

Firstly, Dominic highlighted some of the widely-known benefits of AI in healthcare, including stratification and forecasting, the ability to read and make sense of unstructured notes, and computer vision when it comes to medical imaging and diagnostics.

He noted some of the concerns that people have with using AI in research, such as the fear of clinicians being left out of the loop if AI takes over specific tasks, or whether diagnoses and decisions made by AI can be trusted. “We are having these conversations, not just as policy level but at deployment level too,” Dominic said.

He noted that AI has a lifecycle, and at the deployment stage it is particularly important to discuss how you will monitor the AI through its lifecycle.

Dominic provided information about the NHS AI Lab, a programme of work that began in 2019 and aims to provide support for the development and deployment of AI in primary and secondary care.

He outlined the AI Lab’s key goals, starting with the aim to  create the right conditions for development and deployment by creating policy, optimising the regulatory pathway and convening key stakeholders. This means ensuring ethical access to health and care data that is reliable and of sufficient quality to enable development and validation of technologies, supporting the robustness and optimisation of the regulatory process, and addressing barriers to the adoption of AI by collaborating with stakeholders and designing policy solutions.

The second goal is to ensure that AI works for all. Dominic shared how this includes mitigating the potential negative impact on health inequalities that developing AI could have, with a focus on addressing racial bias. In addition, this means improving confidence in using AI through auditing and assurance practices, and by ensuring staff have access to appropriate training.

The final goal, to enable deployment based on evidence, is achieved through ensuring that AI deployed in the NHS has robust evidence for effectiveness, efficacy and safety in order to meet demand management, elective recovery, and accuracy of diagnostics and treatment. This also means working to ensure that NHS organisations and healthcare professionals understand when AI use is appropriate to address a problem or need.

In terms of how the Lab is supporting the evaluation of AI products, Dominic shared that they are working on impact assessments and ways to support the robustness of the organisation.

“We also want to work out how we can improve the trustworthiness of AI,” Dominic said, moving on to discuss the AI Lab’s Ethics Initiative, which seeks to embed ethical approaches to AI in health and care. On this, Dominic highlighted the importance of making sure that bias is not introduced to datasets and products, and shared some of the AI Lab’s key programmes of work in this area, such as their work with Health Education England to build clinical confidence in the use of AI and their in-house science and technology team who work with various people and organisations to test ideas and concepts.

Dominic emphasised the role of education here, commenting on the work that goes into finding “how we coordinate the integration system and how we can support staff to really understand the opportunities available, and also what we really mean by artificial intelligence.”

Summarising the top tips he would give on factors to consider when deploying AI models in the real world, Dominic highlighted the importance of medical device regulation; monitoring; training of staff; model validation; algorithmic impact assessment; and data infrastructure and governance.

Digitally empowered patients

Majid Kazmi (Consultant at Guy’s and St Thomas’ NHS Foundation Trust) and Paul Landau (CEO for Careology) on empowering patients and driving clinical efficiencies with digital cancer care.

Majid explained how the collaboration between Guy’s and St Thomas (GSTT) and Careology came about. “We’re at a turning point where things are changing and we need to change the way we treat patients and the way the system is geared,” he said. “For me, what we really need to ask is how we can change our services to to be genuinely patient-centred, genuinely clinically-led, and genuinely research-drive using the latest information to drive decision-making. That’s why we had the initial conversation with Careology. Hopefully, this collaboration will allow us to realise some real tangible differences that we can make to how we look after our patients.”

Paul explained how his wife Lucy was diagnosed with cancer and underwent treatment. With his experience in the software industry, he observed that there was “so much that the patient has to do for themselves, there was such a steep learning curve. There are so many tasks that are actually quite clinical, involving clinical judgement, that patients are making when they are at home.”

The product is built with a user interface for patients and caregivers, Paul said; originally it was provided through the Careology app but has now been expanded and made available online for accessibility reasons.

“Working with GSTT, the idea is that we will co-develop and take the platform to the next level,” he said. “We’ve made enormous strides over the last three years working with a small passionate team and a clinical advisory group who have helped us get to this point. Now, as the business is scaling, you can sense the appetite for this technology.

In terms of what he would like to see as a result of the collaboration, Majid said, “For me one of the early wins will be around patient experience.” He noted that in the national patient feedback survey, a key piece of feedback for GSTT was that patients don’t feel that they are given enough information about their disease. “If you’d asked staff, they would have said that they give a lot of information,” Majid commented. “There’s clearly a disconnect between what we think we’re giving and what patients think they are receiving.” He noted that patients would often be given printed information sheets but acknowledged that in a changing world, “We don’t just read from cover to cover, we like bitesize chunks of information when we need it. We’re hoping that by working with Careology, we can start to improve the quality of the care that we give.”

A vision of success for the future would make the product the go-to option for patients, Majid said. “It will be more than just another option of something that they can utilise, it will be something that they rely on because the benefits are so self-evident for them. It will also improve the staff experience – it will free up time so that highly-skilled staff can be deployed to do the tasks that they really need to do.”

Integration and interoperability

Charlotte Williams (Chief Strategy and Improvement Officer in Mid and South Essex NHS Foundation Trust), Matthew Taylor (CEO of NHS Confederation), Ian Smith (Chair-Designate of Surrey Heartlands ICS) and Matt Curtis (TTP Clinical Advisor), on integrated digital and data services across integrated care systems

A key topic of discussion in this session was the issue of controlling the number of applications and systems that are used across an ICS.

“It’s vital that what matters to a patient is the same thing or is aligned with what matters to the clinical teams and care teams looking after them,” Matt said. “And that needs to matter to the ICS too. Keeping the systems simple is vital too. We need simple, safe, easy-to-use and reliable systems with nationally agreed standards.”

Charlotte added: “For a long time we talked about how we integrate products into people, rather than thinking about products adapt to human factors and the way that we work. I think with integrated care systems, the opportunity is to understand what residents need and move away from thinking about patients as episodes who interface with different pathways… the industry and providers themselves have to think more about the bigger picture and their responsibilities, making sure that they are servicing the whole pathway. Otherwise investments are redundant, effectively.”

“I think one of the dangers with any organisation, but especially the NHS, is that we can be very divergent with lots of apps and lots of innovation. I think there are three core technologies that are very useful to us,” Ian said. The first, he said, is the NHS App, which needs to be a major portal for patients, and one which works for patients and provides the capabilities they seek most such as managing appointments and prescriptions.

The second, Ian continued, is triage. “Patients need to have a single point of access and then we do all the connecting behind that to put pathways in place, so unless they absolutely have to, they don’t end up at A&E.”

The third core technology is the shared care record: “Clinicians need to be able to see what other parts of the systems are doing. We currently have one that gives us visibility, but we need to get to the second level so that the records interact, and the third level where it does so in real-time.”

Matthew highlighted that Surrey Heartlands ICS is currently one of the most advanced ICSs. “There is a lot that other ICSs can learn, and it’s really important that they do learn from each other,” he said. “One of the things we are trying to do at the Confed is to have a model of change at the NHS that is more about lateral change, leader to leader and clinician to clinician, and less of a top down approach. I also think Ian’s take is interesting because from this you can see how ICSs can add value by looking at the gaps between institutions, how you can make the overall data ecology work more effectively.”

He added: “We talk about the issues with digital and data in the NHS, but I just want to say that our commercial partners have to bear some responsibility.” Over-promising can be an issue, he pointed out, along with the creation of monopolistic situations in which it is much harder than it should be for the NHS to innovate.

Mala Ubhi, GP and Clinical Advisor in Digital Productivity for NHS England and the Improvement Transformation Directorate, shares the benefits of the NHS electronic referral system.

“The electronic referral system or e-RS is used by 70,000 GPs every day to serve referrals to specialists,” Mala said. “So what are the benefits of having a digital advice and guidance platform? The main benefit is for quality improvements, for patients and for clinicians. As a GP, the most important thing for me is the value that I can add to a patient’s care, from a familiar person in a familiar place in a really timely manner.”

Mala commented on the current expansive NHS waiting list. “Using these digital conversations, I’m able to get advice and guidance from my specialist colleagues, sometimes within 38 hours and sometimes within a few weeks. I can add something to that patient’s care whilst they are on the waiting list, through that support from specialist colleagues.” She noted that in current times, with waiting lists sometimes spanning as much as two years, her practice sees a response rate of 95 percent within two weeks for advice and guidance requests through the system. “That makes a massive difference for patients.”

The benefits of gaining digital advice through referrals include “a better and more equitable patient experience,” she continued. Depending on where you are located, “you may not get the same service as somebody in a different area, depending on who your clinician knows, and depending on capacity and demand.” It also improves the visibility of the care journey. “This digital advice and guidance conversation can be put into the patient notes so that the patient can access it as well as you.”

It also helps with auditing, she added, as it provides one clear way in which advice and referrals can be served, replacing the need to use other, difficult-to-track methods such as phoning people or using online forms.

Additionally, e-RS support referrals moving between other NHS settings, which Mala noted is important as primary care networks grow.

“By having one standardised digital platform, it means that different regions are all doing the same thing. There’s also better equity, in that it provides the same offering to patients and to primary care clinicians in and out of hours, which is really useful for extended hours and locum work.

“It’s flexible, supporting teams to work remotely, and the biggest thing we have found is that it really enhances relationships between clinical teams. Often in medicine there are siloes between primary and secondary care, but this helps us to tackle those siloes, work collaboratively, and remember that the patient is at the heart of this journey.”