For our latest HTN Now webinar on new models of care and pathway transformation, we were joined by a panel including James Driver, digital innovation manager at BOB ICB; Kalle Conneryd Lundgren, chief operating officer for Livi; and Lyndsey Reeves, UK operations director for Livi.
The panel discussed some of their current projects and initiatives representing new models of care and pathway transformation, along with how transformation programmes can be scaled, patient pathways and experiences, and some challenges and approaches in this space.
Our panellists began with a brief introduction to themselves and their role or organisation. Kalle shared that he started out on a career pathway in theoretical physics, before becoming a clinician and then a senior consultant reconstructive surgeon. He joined Kry (known as Livi in the UK and France), a couple of years ago, to oversee operations across markets in Sweden, Norway, France and the UK.
Lyndsey told us how she had originally worked at a GP federation in South East England that had commissioned Livi for services and at Surrey Heartlands CCG, “working through the GP forward view and a lot of the precursors to ICB models”. Lyndsey shared that it has been “really interesting” to move from commissioning into a provider role, and added that she has been working for the last couple of years at Livi on delivering operational models and clinical services.
Finally, James gave us some insight into his role at BOB ICB, where he focuses on primary care and population health, looking for solutions to help support demand and capacity around the ICB’s services and exploring opportunities for technologies such as robotic process automation (RPA).
Examples of pathway transformation and new models of care
Our panel moved on to discuss some of their recent projects and initiatives around pathway transformation and new models of care.
Kalle stated that at Kry, they believe that there is “no such thing as digital or physical care any more” with every patient within healthcare experiencing digital interactions and physical interactions. He explained that he and his team work to try and lessen the strain on physical care by “handling as much as we can of patient’s needs digitally”.
If the “right sort of visit” can be provided through the right channel, Kalle continued, “we can help to overcome our biggest challenge, which is that our common resources are being eaten up by the healthcare system on a national level, taking about 20 to 25 percent of GDP. Where we can offload up to 50 and 60 percent of that to digital, we can utilise our physical infrastructure much more efficiently, as is the case in the Nordics and France. This is what we are working towards in the UK.”
From a UK perspective, Lyndsey shared that her favourite project to date has been an urgent care partnership in the South East, which involved taking patients from four different trusts that did not need to be seen physically, and using Livi to provide them with digital services. This meant that doctors from those trusts could then concentrate on patients who did need to be seen in a physical care setting.
“It was really interesting to see how that works in terms of using a hub-based EMR, so that all of the providers were working in one space, including ourselves. They could filter out patients to go to Livi, and patients to go to the providers. If we decided a patient needed to be seen face-to-face, we could send them to the provider closest to them, and we could do that from the same EMR, which made it extremely streamlined.”
From a commissioning perspective Lyndsey added: “You’re reducing your A&E attendances, and you are creating a pathway that’s going to be fundamentally cheaper than sending all of those patients into either urgent care or to a physical appointment with a primary care agent.”
James offered his regional perspective, talking about the challenge of the 8am rush and the difficulties in offering “effective digital access”, sharing that at BOB ICB certain practices have seen “significant success” in tackling this using digital triage and cloud-based telephony.
“I think it’s important that GPs and networks have these conversations, and part of my role is distributing that good practice, communicating that, and getting that at-scale. BOB is a big place, and to get things to work at a very large system level can be quite expensive, so sometimes it’s difficult to get a strategic view of that. But it’s a continuous process and where it has worked it has been very effective.”
Overcoming challenges
Our panel turned their attention to a question from our live audience regarding how challenges, including blockages in trust’s processes and culture with clinicians, can be tackled.
Kalle said that from a clinician’s point of view, there has been a “radical shift over the last few years – whereas prior to that it was quite difficult to convince clinicians that we could really solve the problem.”
Livi, Kalle added, has “about a 90 to 92 percent case resolution rate” and this runs across all of the company’s markets. This means that the majority of cases are resolved without requiring a physical visit. He also highlighted that he sees movement in the future toward a system whereby clinicians can work more flexibly from home offering this type of digital service.
“In terms of how to scale, I would say that the UK has come a long way in understanding and accepting that we need new ways to handle shortage of access. But there are still a lot of issues when it comes to contracting the agreements and figuring out how to work with partners, so there’s more work to be done there. It’s about having high competence in accessing primary care to avoid referrals into secondary care; but we typically look at primary and secondary care in isolation, and I think that’s a big challenge for most healthcare systems.”
Lyndsey noted the need for traditional change management work around engaging with clinicians, particularly “making sure we have people on site with them, and taking that multidisciplinary team approach”. In one project, she explained, Livi placed teams in the waiting rooms so that they could demonstrate use of the app to patients and support clinicians in their triage.
With regards to working with the elderly or patients with less digital experience, Lyndsey also talked about her experience on a patient engagement project which saw Livi’s team visit a practice and help patients access the app. She noted feedback including that patients could be “very nervous” about using the app to begin with, making the support valued, with one elderly patient saying that use of digital removed the need to “struggle to leave the house”, which “made so much difference to her”.
Change management is always a challenge, Lyndsey acknowledged. “It’s about gently taking people on that journey and understanding how it can be beneficial to both patients and staff.”
From a regional perspective, James talked about funding being the biggest challenge, with this often preventing a move to scale up more innovation. He said that there is “also something about retaining a local primary care network’s place within ICBs, as ICBs have a big strategic overview in terms of funding, governance, population health, managing large-scale data, and so on.”
Place remains “very important in terms of establishing coherent integrated care systems and integration between services,” James continued, “and possibly even integration between data. I think perhaps there’s a tendency to try and scale up data at too great a level, which makes it less meaningful in terms of patient access. Essentially, it’s about maintaining consistency, which I think could be done more at local level. At ICB level, sometimes it’s difficult to know what is going on. That’s why this sort of discussion is important, to make sure that we know where good practice is happening, and people can make their own local models or pick up on ideas that are working effectively.”
On James’ point about funding, Lyndsey highlighted that often it is about “opening up those channels to use workforce at scale, and not having to fund extremely costly locum services, for example. We are looking at building resilience for practices, getting those benefits of scale, and building a national pool of clinicians so you’re able to dial-up that capacity.”
Patient pathways and the patient experience
Our panellists moved on to discuss patient pathways and the patient experience, looking at what improvements could be made for patients and how we can work to make improvements to patient pathways to help healthcare catch up with other industries.
James spoke of the importance of “always maintaining the balance between digital platforms and digital platforms which specifically look to enable access”, citing the NHS app, where there is ongoing work to increase functionality, as well as cloud-based telephony and patient record systems.
“As much as I’ve seen these used to enable patient access brilliantly, they have also occasionally resulted in a digital bottleneck, whereby a clinical organisation is using it to manage digital access, and that puts a squeeze on face to face care. It’s about ensuring that digital retains a balance with the physical patient; we don’t want to digitise them, or turn them into people that we manage virtually, and that is really critical.”
On catching up with other industries, James commented that meeting clinical requirements and “clearing hurdles” around information governance are often part of the process. “I think that’s something that we can be better at; so then you can get your systems implemented and the benefits that they deliver for those patients implemented more quickly. That’s why my role at BOB is about horizon scanning, knowing what’s on the market, and bringing that in to deliver those benefits to patients – capturing the innovation that is going on out there amongst private suppliers and also within the NHS more quickly.”
When looking towards Europe, Kalle agreed with James on the need to be careful about “trying to convert the patient into the digital patient”. He raised the need to keep patient experience in mind and think in terms of cohort of patients or whole regions, rather than the individual patient, as “the young and strong that are the early adopters of digital technology are usually first in line”.
A barrier to catching up with other industries, Kalle continued, is the “old school idea that when introducing digital into healthcare, some government or regional body of some kind should develop a big technology ‘thing’. Or there can be the idea that if we buy this fantastic EMR and then force everyone to use it, we’ve solved the problem, which is obviously the wrong solution. It ends up being super expensive and outdated in two years.”
Instead, he said, “we need to get the providers in every market to work together and enable the transfer of information from one to another – that’s driving innovation in other industries at a much higher pace, and is much less costly.”
Lyndsey talked about the importance of “removing that postcode lottery and making sure people have consistency across offers”. She elaborated: “In the last few years, there have been quite a lot of projects which come up for six months, and grant you access to this great piece of tech or pathway; and then it goes away again to be replaced by something else, after you have downloaded and learned how to use it. That just puts barriers to care in place for patients.”
Highlighting Livi’s offer, Lyndsey explained how practices using Livi’s booking tool see patients calling up and practices booking them in. “It’s just like another clinic to them, so the experience for the patient is much the same.” The provision for patient-led care also means patients can add themselves into an appointment through the app, circumventing the 8am rush.
“Then once you get to that care, we are fully integrated with those practices; so we have access to their records, we can see the correspondence, and we can send information back in real-time, so your practice can immediately see what our clinicians are doing. Patients still get the same access to pathways and onward care.”
Many thanks to our panellists for taking the time to join us.
