For our latest thought leadership HTN Now panel discussion, we focused on driving patient outcomes through health tech, featuring panellists Dr Penny Kechagioglou (chief clinical information officer and deputy chief medical officer at University Hospitals Coventry and Warwickshire); Chris Nortcliff (digital lead at Greater Manchester Primary Care Provider Board); and Lyndsey Reeves (director of operations at Livi UK).
Introducing herself, Penny explained how a lot of work into digital transformation is underway at UHCW including the introduction of a new EPR in June. “We are doing a lot of work around how technology can be used to engage patients whilst they are on a waiting list – how they can be empowered to understand where they are on the pathway,” she said. “There’s also a lot of work around data analytics and understanding where the bottlenecks are in processes so we can identify opportunities to improve flow.” In addition, the trust has established virtual wards, and is focusing on remote patient monitoring on a wider scale.
Lyndsey shared that Livi has been operational in Europe since 2015 and in the UK since 2018. “We’ve been on an exciting journey going from start-up to a consistent, longstanding partner to the NHS,” she said. Over the last two years, Livi’s work has included developing its clinical services to offer GP or ACP (advanced clinical practitioner) appointments as part of work around improved access and enhanced access contracts, and Livi is now working on “pulling all of our digital offer together”. In terms of her own background, Lyndsey started her career as a dentist and has worked in commissioning in addition to working as head of service at a GP federation.
In addition to his role as a digital lead for Greater Manchester Primary Care Provider Board, Chris works at a practice in central Manchester. He described the board as one of the “first primary care collaboratives of its kind, bringing together providers in general practice, community pharmacy, optometry and community dentistry” across the region. He is also the clinical lead for Greater Manchester Digital First Primary Care Programme, which focuses on a number of workstreams to promote digital in general practice including supporting digital access, upskilling the workforce and looking into projects such as automation and intelligence-driven primary care. “There’s a cross-cutting theme of digital inclusion throughout this work,” Chris said, “which is a real passion of mine.”
How can digital drive patient outcomes?
Penny raised the implementation of electronic patient records as a key element of this, along with interoperability with the shared care record, which she noted as particularly important in order to link with primary care and other clinical practices.
“We are seeing the benefit of electronic prescribing, for example, and how that has reduced errors compared to to writing a drug card where the handwriting might be eligible,” she said. “We’re also seeing the benefits of using barcodes to identify patients and give the right medication to the right patients; and benefits around electronic handovers too in terms of getting accurate information at the right time.”
These are the standard, day-to-day benefits, Penny noted, but interoperability is a key part of this too. “It’s about understanding what is happening in the community for patients. How can we discharge them to the appropriate place, more quickly? In that sense, we’re seeing interoperability through digital means improving flow through organisations and improving patient outcomes, because we know that longer length-of-stay leads to further de-conditioning.”
Then there is the aspect of diagnostics, using digital tools such as artificial intelligence and machine learning to understand data, make predictions, and support clinical decision-making.
On remote care, Penny said: “This transformed care in the pandemic and beyond. Being able to see patients in their own homes – and see their carers too – improves communication which helps decision-making, and this all optimised by digital technology.”
Lyndsey added a point here: “If you look at virtual wards and remote monitoring, there are huge benefits to patients in the sense that they can often really enjoy being able to access care in that way. These kind of digital method can be used in that preventative care space, which feels really positive.”
Chris agreed, and commented that remote monitoring allows clinicians to “work in partnership with patients”. Additionally, he commented, remote monitoring can be particularly useful in long-term condition monitoring by allowing patients to contribute readings or things like digital questionnaires that can be completed in their own time, rather than struggling to take time off work for appointments or facing similar challenges.
Penny moved on to raise the importance of patient empowerment and citizen engagement through digital. “This is extremely important, and we need to offer that agency to patients – from being able to track their appointments to being able to contact the clinical team, if there is a change in the condition. That’s what proactive care is about.”
She concluded by raising a point around use and adoption of digital technologies, stating that getting patients on board with tech and training the staff to use it properly “is a prerequisite to obtaining these benefits”.
Lyndsey agreed: “Being able to give patients autonomy over their care and being able to enable them to make good choices about their healthcare is really key.” She noted that Livi’s messaging platform Mjog has the ability to bulk message patients and send out appointment reminders, which she said “draws together prevention and access via a digital tool. Also on this note, patients can access our clinical services through many different means – for example through our app, from partners sending patients to us directly from practice using a digital tool, or through 111. It’s not about creating new digital ways to access care, necessarily, but about dovetailing digital into existing pathways.”
On specific patient outcomes, Lyndsey shared that Livi has done a lot of work, especially in European markets, around preventative care, with pathways including obesity and asthma care.
Lyndsey also commented on the role of technology given the current workforce challenges in healthcare. “How do we make sure that we are connecting patients to the clinician that they need to see, in the moment that they need to see them? Using digital platforms means you can connect staff to patients all over the country. This particularly helpful with some population demographics where access may be more challenging, or if you are in rural areas where you are struggling to recruit, for example. It can also provide flexibility for staff and support them in tailoring their work-life balance.”
“I think one of the main things to consider here is the fact that we have a capacity and demand mismatch in general practice at the moment,” Chris said. “Digital can really help to address that.”
It all comes back to getting the right patient to the right person at the right time, he continued, and there are an increasing number of digital tools supporting online consultations, many of which will be on the pathways framework from NHS England. “Some of the triage, AI and large language models within that really help identify who needs seeing now, who can wait a couple of days, who can be signposted. This helps us to make the most of the workforce we have.”
Chris also mentioned the NHS App, saying that it could be a “real positive” for general practice. “There’s lots of opportunity for it to be used better, and I’d like to really encourage people to turn on things like push messaging within the NHS App, because that is a really potent way of conversing with patients.” As well as allowing access, supporting prescriptions and potentially reducing medication waste, Chris emphasised that the app “creates a sense of agency for patients” and encourages them to take ownership of their care.
He also noted the “numerous examples of decision support tools which integrate into GP records”, highlighting one tool he uses for acute cancer care which “pops up when I am consulting to remind me to think about potentially missed opportunities to make early diagnoses. I think that’s a very strong way to drive patient outcomes.”
How can we accelerate patient benefits and outcomes?
Lyndsey pointed out that the pandemic necessitated a change in healthcare delivery which included fast deployment of tools that would potentially have taken a long time to adopt in other circumstances. “It demonstrates that the NHS is able to move at pace,” she said.
The General Practice Forward View from April 2016 included “five years of funding, some of which was dedicated to digital – that gave practice, partners and providers time to test out tools, to figure out how to use them, to work out how the tools could be meaningful to them in their everyday practice. I think having longer term funding streams like this helps people embed digital, so it doesn’t just become an add-on, it becomes integrated into the everyday.”
Looking at how some of those integration challenges is key, Lyndsey suggested, along with exploring how this can be done at scale. “Then you get all the benefits of resilience and economy too.”
Penny said: “We need to set a vision for digital-first as an approach; that digital is be part of the whole enablement to continuously improve in healthcare. Digital should be part of our innovation plans.”
Engagement is also important, Penny added, including engaging with all stakeholders from clinicians to data analysts. “We need to look at how we are using data in our everyday practice to understand common problems and how to solve them, as well as how technology could help us do this.”
That includes patient involvement, Penny continued. “Often, we try to feed technologies into pathways, but they are not actually serving a purpose or they do not add value to the patient pathway. We need to better understand how we incorporate technologies and use design thinking with patients to understand how tech can actually make pathways better, make the service itself better, and improve patient outcomes.”
Chris reflected that the NHS can sometimes have a tendency to impose how people access their care. “I don’t think we are always all that good with patient involvement,” he acknowledged, “but the way to get digital tools embedded and adopted is to make them a great experience to use. People use things that work well. If they have a bad experience, why would they use it rather than reverting back to what they did before? I think it’s really key that we work with patients to make digital tools something that they would choose, rather than feeling that the tools are imposed upon them.”
He also raised the need to further train the healthcare workforce in foundational digital skills. “We don’t train people to use Microsoft Office, for example – we make an assumption that people know how to do it, but not everyone does. We state on job descriptions that people need to be competent in these tools, but do we ever support them to make sure that they are doing it right? It comes back to the workforce having confidence in the tools that they use.”
In Manchester, Chris shared, there is a push to get the primary care workforce to use the NHS App for themselves. “What better form of agency to get people to use the app than a personal recommendation from a real person who can properly share their experience?”
However, digital exclusion must be considered. “If we don’t take an inclusive approach, we will end up double running systems. I often hear that the argument for digital is: if we can get 80 percent of people to use it, then we have more time to deal with the 20 percent who can’t use the digital tools or may struggle with them. I don’t think we are anywhere near the 80/20 split in reality, and we need to do a lot in healthcare to really support people to address digital inclusion, which covers skills, confidence, connectivity and access.”
How can digital support self-help, engagement and activation?
On how the healthcare system can reach that 80/20 objective, Chris said: “It’s definitely a challenge, but I think it’s important to step back and realise what the benefit of digital is to people. In my clinic, I’ve realised that I am seeing more people struggling with problems in life, poor housing, poverty, isolation and so on; and some of those things can be positively affected by getting online. For example, evidence suggests that manual workers who are online will earn more in a year than they would if they were not on the internet. There are everyday examples too – I recently had my car MOT and I got a 10 percent discount for booking it online, that’s a saving made because I use digital tools.
“There’s also the case of digital improving isolation by helping to connect people to their friends and family, or helping them make new connections. In that sense, digital can be shown to improve people’s health just by being able to access tools. This helps when making a case for why healthcare providers should promote digital inclusion. It becomes fundamental for delivering proactive, preventative care.”
Penny raised the point that one size does not fit all, with a need to cater both for patients who are happy to access information and results online to take care of their health where they can, and those who require clinical support in order to do that.
“In terms of driving outcomes, I agree with Chris’s points. I think we have an opportunity with digital tech to educate patients; for example, what do your vital signs actually mean? How do you know that your diabetes is improving? What are you looking for and what do changes mean for you? If your blood pressure drops, does that mean you are feeling better, that you are spending more time doing the things you enjoy? It’s an opportunity to use nudge theory within digital; patients, when they see that they are gaining these real-life improvements, are often more likely to persevere and do more about it. Eventually, bad habits can turn into good habits.
“I think we have an opportunity as clinicians to co-design tools with patients to make them clear, simple and to make the most of other opportunities – for example, make them connectable to the wearables that a lot of people own nowadays, so we can use that data if it is there. This helps drive people to become accountable for their health. That then leads to bigger things – if we look after ourselves and our families, then the population gets healthier, and there is less disease and less burden.”
Lyndsey agreed that demonstrating value is key, at patient level but also at system level. Are digital tools helping to reduce unplanned care admissions, are they helping to relieve the burden on PCNs? “There is also the cost opportunity – if you are working on extending your access, opening longer hours at a physical site, your costs are going to increase in various ways, and that has a huge impact on systems. But if you are taking away facility costs and stock costs by implementing a digital tool, then that is a key benefit you can demonstrate at system level.”
Alleviating capacity and demand challenges
Chris posed a question: do we actually know what demand is in general practice? Before advanced telephony and online consultation routes, practices surmised that demand was whatever the capacity of a phone queue was.
“In order to manage demand and assign appropriate capacity to deal with it, we need to know what demand is. Some of the tools we have in advanced telephony for example include the ability to look into failure demand; how many people called back next day because they didn’t get through? How many people are signposted away because we have given them opportunities to self-manage?” Until we know the answer to these questions, Chris said, general practice cannot truly manage capacity.
With the various access routes now in place, he continued, there is a need to bring data together to form meaningful insights. “Then we can better match workforce to demand,” he said. “Where demand hits is not consistent over the course of a week. We need to look into every aspect and then plan around that.”
Chris also mentioned that some of the triage and digital pathway tools “really do help manage capacity and demand, in active signposting, supportive self-help, and prioritising people who need to be seen sooner. It’s about working with patients to work with demand, and find the right capacity for the right people.”
The acute system, Lyndsey pointed out, has things like OPAL scores so clinicians know when there are challenges in the system; but primary care does not have this transparency in the same way. “At Livi we have been trying to design services whereby we can increase or decrease support depending on factors such as resilience position of the practice,” she shared. “We have services where it is an add-on, where a certain number of hours are there to be delivered as needed; or you can dial up that service when you need to. It would be amazing to do that at scale, because there is the scope to do that beyond the boundaries of a PCN.”
Lyndsey also noted the role of data. “In some of our practices where we can see a broader dataset, we can see when patients try to use the app, when they complete a symptom form, when they attempt to book an appointment, or whether they have attempted multiple times. We can then use all of those factors to design workforce around this.”
“How we can alleviate demand is an important question to ask,” Penny reflected, “and it encompasses emergency demand versus elective demand as well. A couple of years ago, we looked at some data from our organisation and we could see that a third of people coming into A&E didn’t need to, there were other services they could use such as primary care or social care. With that in mind, I think implementing tools that can direct patients to the appropriate service is really important. That requires consistency, having the appropriate tools there for patients to use, and having the other services in place.”
The other aspect is the management of elective demand, Penny continued. “It comes back to the opportunity to prioritise – how we can use tech to identify people with the highest risk of deterioration due to comorbidities. We also need to look at sociodemographic elements and social determinants of health. We’ve done some work in this area, looking at our waiting list and prioritising people in terms of the impact that waiting is likely to have on things like their job, the role they play in society.”
Penny also noted the benefits of virtual wards in keeping people out of hospital. “It’s about having the right criteria, selecting the right patients who can use the tools at home and having that safe pathway set up for them,” she said.
Learnings from outside the UK
“Some of the work that Livi has been doing in Europe has been really interesting, combining digital with physical,” Lyndsey said.
Livi has undertaken this work in Sweden and France, with Lyndsey sharing a particular example from Sweden. In this project, when patients register with the service – particularly if they have multiple conditions – Lyndsey said that they see “a peak of access in the first three months, and then it goes down. Whether the contacts they have with us are digital or physical, the number reduces after that period, because they’ve been able to access the care that they needed, as they needed it. That speaks volumes to me. I think often it’s a struggle to get data in the UK around the onward journey of patients because of the challenges around accessing data and integrating it with systems, so this project raises an interesting picture.”
Lyndsey also highlighted an obesity programme run in Sweden which takes a virtual multi-disciplinary approach, and described how Livi has utilised a virtual workforce for other areas of care such as women’s health. “Menopausal care is not addressed at primary care level, so we have brought in nurses and midwives specifically around women’s health to support more women to get access to the care they need. We also have sexual health clinics as well.”
Challenges to be tackled
Concluding the main part of our webinar, we asked our panellists for their views on the main challenges that need to be tackled in this area.
Penny highlighted change fatigue. “There are a lot of pilots and innovations coming in and out, which is great and exciting, but it’s important that we look after our staff and workforce because there can often be a lot of things happening at the same time as day-to-day work. We need to always come back to looking at what the problem is that we are trying to solve and how we can own it together and use technology to solve it, avoiding burnout.” She also raised education and digital literacy, for patients as well as staff.
Chris agreed. “I think the biggest challenge we need to tackle is digital exclusion. The health service is supposed to provide care for everyone and we need to be really cognizant of that. There are various ways to address it; it just takes a concerted universal approach.” He recommended that anyone interested in going further with this challenge could look into AbilityNet or The Good Things Foundation’s National Digital Inclusion Network.
Lyndsey picked up on the point around consistency. “There are lots of one-off pieces of funding around specific challenges, but that often means that you have a service for a while, patients get used to it, and then it’s gone. If you have services that are integrated and very much part of your experience, and it’s just what patients expect, then it is easier for them to learn how to access it.” Additionally, Lyndsey suggested that more needs to be done around linking in with other third-sector providers.
Many thanks to our panellists for joining us.
