For HTN Now: Digital Social Care and Mental Health, we were joined by a team from Apira consisting of Alan Brown, Director of Professional Services; Iain Borland, Managing Consultant and Head of Deployment; and Director Geoff Broome. The talk focused on challenges to the managed convergence agenda in mental health.
Starting off the session, Alan shared some information and background on Apira: “Between us we have about 60 plus years of experience in mental health… we actually celebrated our silver anniversary this year, 25 years old! We’ve worked across the NHS, across every care setting, but tech has been a running theme throughout the organisation over time. We de-risk our customers’ digital journeys and assist with their clinical and other systems.”
Apira’s pathway “takes customers on a journey from the justification and business case right through to the adoption of that clinical system and the realisation of benefits.” In a mental health capacity, Apira have worked with a number of trusts including the Leeds and York Partnership, One South West, Sheffield Health and Social Care, Hertfordshire Partnership University, and more.
The journey to today
“Before we talk about where we are with the market, I just want to take a step back and look at how we got here,” said Geoff.
Looking back to the nineties, Geoff shared how there was an open market. “There was a document called Information for Health which talked about ‘a thousand flowers blooming’ – there was a lot of encouragement of new players,” he noted. Along with the new players, there were a lot of failures, especially in terms of local solutions falling by the wayside.
“In the wider sphere, we had a period where data standards started to emerge,” Geoff continued. “In this period it was quite creative and innovative.”
In the noughties, there was a lot of development in mental health and EPRs with RiO deployed in many trusts. Geoff said: “We noticed in this period that mental health trusts did benefit, because the systems they got in the national programme were materially better for a lot of them. In other areas it was more challenging, such as the deployment experience in acute settings.”
After that development ended, Geoff highlighted how they had learned about the scale of the challenges in deploying these systems, and the importance of making sure that they “had a good commercial set up with suppliers that was based on a win-win relationship.”
Markets
Iain explained how markets work in the mental health industry, with many examples via pie charts and graphs to show the work at a glance. These can be viewed from 9:05 on the video below.
Iain stated that there are two main companies dominating in this industry which is a “really difficult scenario for somebody to try and come into.” He posed important questions to consider: “Who can move into this market? What’s going to drive new entrants to come in? What’s going to drive the existing people in there into expanding what they have?”
He added: “A perfect market in the real world needs lots of suppliers, lots of buyers and perfect information. Do we have that in mental health? Not really.”
Challenges
Picking up on the above point when discussing the challenges in mental health, Geoff explained that for a long time there have been “no new significant entrants”, despite ownership changes.
Alongside this, churn is also a challenge as “a lack of churn causes stagnation.” He noted that there is also evidence of “cash cowing”, as “income is fixed and new business pipelines are not really sufficiently robust to justify investment.” He added: “That’s true for some suppliers but not all. There is certainly a risk of that if the market is not active.”
A lack of focus on integration is another challenge Apira have found, but it has begun to improve. “There has been progress here on the need to integrate inside and outside the trust, partly because of the commercial model and better understanding around the shared care model, to do more here. Suppliers have been engaging. But there have been problems around commercial incentives to encourage that integration.”
The last challenge expressed was the use of add-ons and apps. “Trusts also tend to use add-ons and apps to drive innovation and service user engagement,” Geoff commented, “as opposed to trying to get the application in the EPR itself to do that.”
Opportunities
Talking about the opportunities that are presented in the industry, Geoff said, “I’m always interested in trying to facilitate the market and play a role in driving innovation. The ICB level initiative does present some opportunity because there is potential for a wider scope, for a single solution standing across acute and mental health.”
Extending primary care solutions, as has been seen with TPP as an example. “Could this drive new activity?” Geoff asked. “It’s possible. I think one challenge I’ve found within mental health is that, as there are 42 ICBs and 48 mental health trusts, they’re not coterminous meaning most mental health trusts are in more than one ICB.”
Iain added: “There’s also potentially the opportunity from the social care market coming into mental health. They’re very closely linked, so a lot of the solutions involved in social care could be extended.”
Barriers to entry
Geoff described how the mental health system in England provides a barrier in terms of looking to get into the market. “There is an awful lot of investment needed to get into banks and camps and nowadays you need such a track record to stand a chance of winning,” he said.
“There is a bit of a chicken and an egg problem for people looking in from the outside world,” he continued. “This is partly due to bigger players in the acute sectors from overseas not building mental health solutions. At the moment, there isn’t that much international competition.”
Another barrier is transition costs when deploying systems: “From the experiences we have had in the last few decades, procurement itself – the expenses, the time it consumes, and deployment – is challenging people, especially if they think there is no meaningful functional gain.”
Solutions
For solutions, there needs to be better usability in getting these applications “to a point where they’re for the staff, potentially patients and carers too – to a consumer-level functional usage.” Geoff added: “I still think there is a little bit further to go on that road, and that again discourages people from changing the system.”
Co-production functionality is said to be another factor to consider: “I think this is going to become important and some good things have been done, but the uptake is still a little weak. So, carers and service users need to be able to support and contribute to their own care, and use their own devices and input.
“What has actually been deployed and used is still relatively weak and we feel that there are missed tricks which are still a problem…that’s just part of the challenges we face in making this a vibrant market that supports innovations, challenges suppliers, but also gives them a market to go for.”
De-risking
The next topic of conversation was about de-risking your journey and how Apira “takes trusts through this digital journey”.
Geoff highlighted how the first part of the journey, from justification through to specification and purchasing, is “quite nice in a way, as it can be defined as a process.”
He added that “there is a lot of good practice in there, but I think we need to challenge ourselves as a community to see if this side of the equation can prepare us a little bit better for what comes after we sign the contract. We often say to colleagues who are buying systems, ‘You need to think – what happens the morning after we sign?’ If we don’t know that, if we aren’t super clear about how the relationship will proceed through deployment and adoption, we need to take a step back and rethink. That doesn’t mean make it super complex – it just means make it clear, make the incentives clear, make what happens known. I think sometimes people have balked at moving through the first half because of their awareness of the challenges in the second.”
The second half of the journey is from deployment onwards, covering deployment, adoption and realisation of benefits. “We need to watch the optimism bias that can happen in business cases,” Geoff commented; trusts need to be prepared for the “cold realities” that they will face in change management. Additionally, staff shortages can make it particularly difficult to move through the deployment stage, as “it is such a challenge to get people released from the frontline to come and work with the team to deploy it.”
The future
Looking towards the future, “it’s likely that the pluralism of these applications is going to be done by apps and facilitating more incremental, iterative approaches.”
For Apira, this is the reality in a lot of trusts they work for. They would “still like to find ways to get international acute EPR vendors into this space in the UK”, as it will create more incentives for players to innovate and “leverage things in the EPR solutions that require a certain amount of configuration for mental health,” said Geoff.
He explained that to create a market, you need a lot of suppliers and sellers with a level of churn that encourages investments and agility. “I think we need at least three or four processes per annum to make that a market. That’s a tough call from the one or two we have got at the moment and this might require different incentives for trusts beyond regular funding streams because they are facing the challenge of the deploy, adopt, disruption and the cost.”
After this, the team answered questions from viewers which you can watch from 35:26 on the video.
Many thanks to Alan, Geoff and Iain from Apira for joining us.
You can watch the webinar in full here:
