For our recent panel discussion on digital primary care, we were joined by Nikki Mallinder (director of primary care at Surrey Heartlands ICS); Dr Paul Wright, (GP, deputy clinical director/IT clinical lead at NHS Greater Manchester and CCIO at Manchester and Trafford Local Care Organisation); Jamie Innes (product director at Inhealthcare); and Dr Osman Bhatti (GP and CCIO at North East London ICB).
Nikki, Paul, Jamie and Osman shared their experiences in digital primary care, with focus on managing access and demand; the management of long-term conditions; supporting the workforce digitally; and their hopes for the future.
Introductions
Nikki: I am the director of primary care in Surrey Heartlands ICS. I’ve got quite a broad portfolio in Surrey. I not only do the commissioning part of general practice, but I also do development; all the teams for GP IT, Digital First and primary care report to me. Recently we’ve taken on pharmacy, optometry and dentistry, so I work with a remit of about 1.1 million population, 104 practices, and 25 primary care networks.
Osman: I’m a GP in North East London, and the CCIO for North East London ICB which covers about 2.3 million patients, across 268 practices. One of the key things that we’ve been looking at as we come to the end of the Digital First five-year programme is how we can move on with making primary care digital, to continue the good work we’ve done and to look at new possibilities going forward – particularly in terms of taking advantage of the ICB, to work more closely with our colleagues within other trusts.
Paul: I’m a GP in South Manchester and the deputy medical director and IT clinical lead for Manchester locality, which is part of the Greater Manchester ICB. I also work for the Manchester and Trafford local care organisation, as their CCIO. At the moment I’m spending my time working in the interfaces – working around the systems and processes that sit between patients, practice, primary care, secondary care.
Jamie: I’m the product director at Inhealthcare. I work with our customers and partners on developing new digital technologies, and with our development team on the roadmap for our digital platform. At Inhealthcare, we work with NHS organisations on developing new digital and remote monitoring technologies that support transformation agendas, and we allow NHS organisations to work in different ways. Over the past decade, we’ve developed over 100 different clinical pathways with our customers and have had over 3 million patients using our services.
In-roads into primary care and the role of digital in managing access and demand
We asked our panel for examples of projects they have been working on, and for insight into what is working well in each of their areas in terms of digital when it comes to managing access and demand.
Nikki: Managing demand is key because general practice is under such a huge amount of pressure; but at the same time, we’re trying to balance that with patient experience.
In Surrey we’ve been going through a bit of a process to think about our websites across our 104 practices. They all have the same look, it’s very ‘NHS look and feel’, which we hope will help patients in navigating them. We’re just been through a procurement process for an online tool which is now embedded within the NHS App, so our patients can use it on mobile devices as well as desktop.
Another area that stands out for me in terms of managing access is cloud-based telephony. It’s been a game changer for us in terms of being able to think about the way demand comes in and where we place it.
Osman: With the digital-first programme, we had 14 different work streams that we were looking at. Some of the things we focused on that really helped with our foundations were things around care homes and social prescribing.
We tried lots of different things with care homes, but one of the biggest things that we needed to do is get the foundations right with the Data Security and Protection toolkit. We worked with all of our care homes so that virtually every single care home has now been through that process and understands what the needs are for their service. Then they can build on connecting with other systems to access clinical records, for example.
One of the things we wanted to do is spread the way that we do social prescribing, so we’ve done a lot of work around trying to get some of the basics right; how are all of our social prescribers coding and writing, for example? Historically, North East London had one online consultation provider, and with consultation with our practices, we soon discovered that one size doesn’t fit all. We opted for an approach where practices had the choice of one of three different online consultation providers, which has increased the uptake. I compare online consultations as opening an extra tap into the overflowing bathtub – before you do that, you need to make sure that the other taps have been turned down, so that you’re not just doing your face-to-face telephone consultations and then introducing long-term constraints on top.
Jamie: One of the case studies I’d like to highlight is in the North East of England where we worked with Newcastle and Gateshead to introduce a musculoskeletal self-referral programme back in October 2018. Patients go online, fill out online forms that are validated against NHS Spine, and then information is triaged. It helps to avoid unnecessary primary care appointments. Approximately there are 1,500 patients that go through that every month; over 50,000 referrals have occurred to date. This is now being replicated across other services and it’s introducing different ways of access for patients that provides them with other options.
Paul: One of the things that is worth celebrating is the quality improvement scheme that we’ve had as part of the clinical standards scheme in Manchester for several years. We use that as a platform to support practices to have some investment surrounding quality improvement for digital-based projects, and to give them some choice around what they could do – for example, within the NHS App, with long-term condition management, or working with specific patient cohorts. Alongside that, there was equality impact analysis training, looking at the associated risk of discrimination coming in through digital channels. We’ve rolled that through to this year, into working on the NHSE website audit. The majority of our practices have opted to do a quality improvement project around that; so we’ve got our 83 practices which have all engaged, submitting information around that. We’ll be using that to speak with system suppliers and practices will be encouraged to take action on that to improve accessibility using the website audit tool.
Digital tools for managing long-term conditions
Our panel moved on to talk about using digital tools for managing long-term conditions, what they have found works, and the impact of this approach in their experience.
Paul: I’m going to go back to the quality improvement scheme. As part of that, there are clinical standards and the way that we’ve delivered that has been a team effort – we have a data quality team as part of the NHS GM infrastructure, so we have tools and resources developed to help us support particular activity. There’s been activity over the past few years in terms of inclusion and multi-morbidity, and looking at recovery post-COVID; and those tools are supported by guidance, support and training to practices.
We’ve also got really strong business intelligence infrastructure, so we’ve been an accredited safe haven for some time. That has meant that over the years, we’ve been able to build a platform that supports practices to have really good informatics around what’s happening with their populations, to help them understand who the key target groups are. It’s supported us, as a city, to be able to have a really connected approach with regards to specific target areas.
Nikki: There’s the at-home model from NHS England, using the Inhealthcare platform to automate changes to patients’ positions. I think that is the most powerful piece that we’ve got. It’s worth highlighting the impact on patients; for example, we’ve got a patient who has been through our blood pressure at home model, and their feedback is all about how they didn’t really realise how much they could do for themselves until this point, until they started to measure themselves and start to contribute to their healthcare journey.
In general practice, I think we see the same people for the same condition for the same amount of time; but actually we need to highlight those who are going through something slightly different or have changed or have moved into certain spheres. So I think the work that we’ve done on bringing all the data into one digital platform is really significant. How we reach out to populations for long-term conditions is really important, because some people are really good at giving you the information that you need upfront. But some people aren’t as good at it; we need to start remembering that actually we could start to respond to different cohorts of patients in different ways.
Osman: Coming together as an ICB, there are a lot of practices in historically different CCGs doing things differently. How do we standardise that? We’re blessed with a good clinical effectiveness group in North East London and they’ve helped us to do the basics, looking at what practices need to do for long-term conditions, not just reactively but proactively.
Over the last two of three years I’ve been seeing patients who haven’t had their blood pressure or weight checked and it’s changed dramatically. Historically, monitoring of those that now have long-term conditions hasn’t been as good. The clinical effectiveness group has helped us to standardise the data going in – as long as everybody’s got the same standardised way of entering all of the data and we’re coding everything well, then we can see the dashboard correctly. We can output to practices and build protocols, searches and bespoke pathways. It means that practices can say, ‘Here’s a cohort of diabetics that haven’t been reviewed’, and it’s stratified that risk.
Jamie: We’ve been working with Surrey Heartlands on the blood pressure at home programme that Nikki mentioned. I think it’s being used by approximately two thirds of Surrey Heartlands currently; I believe there have been over 3,500 patients through the pathway, and initial evidence showed that just over 50 percent moved from a high to a normal blood pressure within six months of being on the programme. Half of that’s due to diet and lifestyle changes, as Nicky mentioned, and patients feeling empowered to make changes.
In addition to patient outcomes, there have been significant savings for primary care in terms of time and appointments. Initial pilot feedback across four practices showed that it saved approximately 80 GP days compared to previous ways of working, which is tremendous once you start to scale up these digital initiatives and make them ICB-wide programmes.
We’re working with National Services Scotland on a similar type of model, and they’re looking at replicating a lot of the learnings and the evaluation that have come out of Surrey. There are aims to make this into the largest blood pressure programme in Europe with 40,000 concurrent patients involved. That’s where scale and economies of scale for digital technologies result in significant improvements and changes across primary care.
Lessons learned and scaling-up in remote monitoring and care at home
We asked our panel for their insight on remote monitoring, care at home, and the scaling-up of these models.
Nikki: General practice needs the time and the space to think about how to change its pathways and to think differently about things.
The NHS App was mentioned earlier; I think sometimes we underplay some of the things that are in front of us and we don’t utilise them to the best they could be. I think the information is out there, but patients need to know where to go and how to access the right thing. It’s about time and sharing learning. In Surrey, we’re trying to get a little bit more of a consistent offering across the practices. Through all of the insight work that we’ve done with patients, something that often comes up is the inconsistency of how they get dealt with as they come into the system.
Jamie: I think one of the key elements is what Osman mentioned earlier in terms of one size doesn’t fit all. You need to keep things really simple and easy for patients to use. A lot of it is about inclusivity and accessibility for the patients, providing them with choices and options.
One of the other key lessons that we’ve seen working with Scotland, as an example, is they’ve worked really hard to create standardised solutions across entire regions and across the national perspective, making it simple and easy for everybody. The aim is that regardless of where they live, which GP practice they access, patients all get the same standardised level of care and access to services. They’ve brought together clinical leads to develop these digital solutions, tried them out in areas, gathered feedback, then made the national pathways; if that approach was taken in ICBs, I think it would work really well. You end up with consolidation of activities, and that’s where you benefit from digital scale and economies of scale across the entire piece.
Paul: I share the same passion for clarity, especially with regards to coding and definition of pathways and flows. I think getting the basics right and keeping it simple are the underpinning principles. There’s always space to think about what the barriers are, what’s the problem that we’re trying to solve; it’s crucial to think about these things at inception. If we go off without that sort of critical thinking at the start, the risk is that we don’t get that sustained change that we want to achieve.
Osman: I think the main point is: if it’s not working, then change something. Try something different. A good example is the NHS App. Rolling out the NHS App, we were wondering why we weren’t getting traction – it should just be a case of picking up your smartphone and it being intuitive. But we found that staff didn’t really know about the NHS App, so how could they inform patients? We got staff to use it for themselves, to see how it works, and then it’s much easier for them to explain to other people how to use it. Sometimes, we just need to stop and think if things aren’t working, rather than pushing the agenda forwards at all costs.
Engaging patients and staff to use digital tools
Paul: We’re really lucky through the digital-first primary care programme to have some excellent digital facilitators as part of our locality team; they’ve been supporting projects and engaging in local community. We’ve got forums like the Manchester disability collaborative, which are great in terms of patient engagement. Trying to follow the spirit of co-design, with patient engagement through the process from the start, is key in terms of defining new pathways or new processes.
Osman: It’s something that we want to try and build. When we’ve looked at how to develop clinical leads, we’ve soon found that it doesn’t actually have to be a clinician; you can have a digital leader rather than a clinical digital leader. In my role at North East London, I’ve asked every PCN to nominate a digital person that can liaise with me; so rather than dealing with 260 practices, I’m dealing with 42 PCNs. You just need an enthusiastic conduit – it could be an enthusiastic receptionist who leads on digital in the practice and can then disseminate things across the PCN. It’s really working well for us in terms of getting that information back and forth.
Challenges with technology in primary care
Jamie: I think as a technology provider, one of the key challenges that we face is integration into some of these primary care systems. Having a single set of standards and integration APIs would allow for more digital solutions to be taken forward with patients – using the information that is within their records, and also streamlining the process for healthcare professionals. I’m aware that in primary care especially, there’s still lots of manual activity that takes up valuable clinical time. Anything that can allow clinicians to spend more time with their patients is a benefit.
Nikki: I think that’s absolutely right. When you’re working in the ICB or in a practice, one of the things that is quite challenging is the amount of providers in the landscape. I think the NHS England frameworks that they put forward are helpful, but we need to do more to make sure we are narrowing the pitch and getting to the right providers. Digital First comes to an end in 2024, and that’s a really difficult time for ICBs. We really need to think about how we move in order to ensure that we continue to progress all the things that we’re trying to do.
Osman: A lot of it is out of our hands; the funding coming into primary care needs to increase fundamentally, because that’s the need that is required. The promised 5000 GPs turning into a negative 2000 GPS hasn’t really helped either. We can throw all the digital tools at the workforce, but if there’s nobody there to use it, it’s not going to work. So it’s key that we look at workforce plans and go back to the basics; let’s get the fundamentals right, things like making sure that the machines switch on in the morning within 30 seconds and not 30 minutes.
Paul: I think Osman’s overflowing bathtub analogy around demand and supply is really significant. As we support the digital transformation process, the concerns are transformation fatigue, digital fatigue and the workload overload. It’s important that we recognise that there is a finite amount of work that can be done – if we could actually agree that it’s OK to say ‘we’re full’, that would be great.
From a system-specific perspective, I would love for there to be more integration around actually recognising the capacity of teams within the software, so that there’s a real recognition of workload management. I’d like to see something about more intuitive around the online console platforms, so staff don’t have to try and do complicated things with their rota to calculate what they can do on a specific day; I’d like to see the system do some of that management for them instead.
Future plans, and what does “good” look like in digital primary care in the next two to three years?
Nikki: In terms of the next 12 months, we’re focused on the GP development toolkit, rolling that out and showing people what they can do, and ensuring there’s consistency for patient’s sake. And as Paul has just touched upon – where can we automate? Where we have products that can do it for us, we should be stripping out some of that demand before it hits.
In terms of what good looks like, I think if we can just help general practice to respond to the increasing demand in the most simplistic way, that’s all that’s required.
Paul: We’ve talked about the Digital First programme – in Greater Manchester, there’s work ongoing around primary care blueprinting that is setting the scene. It would be great to see that we’re thinking about the communication, engagement and education as much as we’re thinking about the software-specific solutions; because ultimately it’s going to be the workforce that do this. Investing in workforce is equally, if not more important. Being able to support and build on the amazing digital facilitators and our digital champions coming through from practice is going to be key for next 12 months.
Jamie: From a technology provider perspective, over the next 12 months we’re focusing on integration with some of the national systems that are now opening their door – things like the NHS App, which are now available for technology providers to leverage and surface their content to patients through that interface.
In terms of what good looks like and what I’d like to see two to three years from now; I think regional scale and adoption of digital technology is really key. We’ve been doing some great work in areas to scale out programmes across an ICB area, and then expanding that into new areas. For example, we worked on Surrey Heartlands on hypertension, and that’s now moving into heart failure at home. It’s great to see how these programmes are evolving and taking on new conditions as they start to scale.
I think what I’d like to see in the future is some real focus on prevention; looking at using digital technologies to enable early screening and early assessment and identification of patients at risk.
Osman: If I look at the outcomes, we want the patients to be seen by the right person first time, in the right setting. That provides a lot of challenges for PCNs and ICBs. Digital tools are great for taking a cohort of patients, but we still need to make sure we’ve got the right telephony and the right avenues of face-to-face for those people who can’t use technology. So it’s about working on those pathways and again coming back to some of the basics around data. We need consistency across the whole patch, not only from primary care but also from secondary care; and we need to build on how we can influence, as an ICB, what happens in secondary care that will have an impact on primary care.
Some of that is around workload shifts and how we can use technology to better manage things like referral pathways and consent before operations. But it is also fundamentally about looking at infrastructure. One of the biggest challenges we’re now realising is that with the increased number of staff in our practices, our network switches can’t support so many extra desktop PCs. We need to look at how we manage infrastructure in this way – remote working, for example, is a potential solution.
