At this week’s HTN Now panel discussion on innovation in primary care, we were joined by Sam Hall, director of primary, community care and mental health digital services at Digital Health and Care Wales (DHCW); Liz Leggott, project manager for South Yorkshire Primary Care Workforce & Training Hub; and Bex Cottey, business manager for Conisbrough GPs.
Starting off with introductions, Sam shared how DHCW provides digital, data and technical support to the NHS organisations across Wales as well as supporting national transformation programmes across the country.
Liz explained that the hub exists to support PCNs and practices with their training needs, with funding from NHS England to run various pilots and programmes. When she joined around three years ago Liz identified a challenge around a lack of visibility for the training hub and sought to explore how technology could help with this, as well as helping with delivery of training.
Bex’s role focuses on moving the business forward to support service improvements for patients. “Over the past few years, we have largely been doing that through technology, implementing a lot of new technologies in-house and for patient access,” she said. “It’s about working smarter and not harder in providing best possible care.”
What does innovation in primary look like?
“We have embedded an approach to innovation in our work,” Sam said. “It’s not about asking what new technology we can buy, or what new systems are out there. It’s about asking how we can give clinicians back an hour of their day. That’s a fundamental point we start from. It’s not about looking for big shiny things that claim to solve all your problems, it’s about making small gains.”
Some of the key areas of focus for DHCW when it comes to innovation include how automation can be better leveraged, improving triage and reducing pressure on staff.
“Something that has come through really strongly, especially at our practice manager meetings, is the number of people who find their way into primary care because they don’t know where else to go,” Sam commented. “That is creating a lot of extra pressure. So a key focus needs to be better signposting to help people identify the care they need. We need to innovate to get people to the right care at the right time.”
Sam referenced Choose Pharmacy, a system in Wales designed to support community pharmacies to provide services and ultimately free up GP appointments. “That sees tens of thousands of patients every month who, when asked afterwards about where else they might have gone, reply to say they would have gone to their GP or to A&E. That’s where the extra pressure would have ended up if these people hadn’t been able to walk into their high street pharmacy and receive a service that meets their needs.”
She picked up on Bex’s point around innovating to work smarter, not harder. “I don’t think that our GP teams could possibly work harder,” she pointed out. “We need some of these tools around automation and triaging to help them. Within our systems we also need to iron out the speed bumps that slow things down; and some of those bumps are tools that we have previously provided because we have expected them to help. When you provide tools but you don’t necessarily understand how to get the most out of them, they can turn into an overhead instead of a help.”
As such, DHCW places focus on landing technologies with primary care clinicians “in a way that helps staff to consume the tools and use them in the best possible way. You can’t just give someone a car and expect them to drive it. There’s a lot of work to be done around getting the most out of what we have already got, and optimising that before we go out and buy something new and shiny.”
Bex agreed: “Everybody talks about capacity but the reality is that we have been beyond capacity for a long time now. People tend to frame the discussion around doctors and clinicians but we are beyond capacity with our admin staff too and our reception teams; everybody is working flat out. So what tools and systems do we already have, and how do we make those more efficient?”
When looking at new tools, Bex reflected that sometimes she has identified tools that are available but which would necessitate adaptions in working style. “You have to ask: is this the way we want to work? Does it make sense for us to adapt for the tool, or should the tool adapt for us?”
As practices are being asked to do more, she added, there is a need to keep looking into new opportunities, because “there are some great ideas and solutions out there. But you need to ask whether it is the right time to implement them.” Bex pointed out that her own GP practice has “implemented a lot in a relatively short period of time; but we wouldn’t maintain that level of implementation, because it would mean perpetual, high-speed change. That’s not good for us, our staff or our patients. You also have to let things bed in and start gelling together.”
On taking an innovative approach to training, Liz highlighted the need for healthcare teams to work alongside suppliers to develop tools and systems that work for the end users. She looked into how the existing training programmes worked for people, identified what people wanted to learn, and also explored existing gaps in training.
As an example of the hub’s work, Liz highlighted the use of body swap technology to help people practise their communication skills through a variety of different scenarios, such as navigating micro-aggressions and handling conflict. “By using bodyswap tech, we have been able to create a psychologically safe space for people to learn these skills, as opposed to sending them off into a real-life primary care setting to handle it for the first time. We identified a gap between people’s training experiences and the real world we were sending them into, and we used tech to help bridge that.”
Another example of the way in which the hub has used body swap tech is with international students in training, to help them practise communication and in particular the cultural and language norms they may not have been familiar with.
Liz also drew attention to the relationship between primary care organisations and suppliers. “I have had conversations with suppliers where they’ll ask me what I need to know about their system, but that can be tricky to answer because you don’t always have a starting point. It would be more helpful if they could take the lead in demonstrating the capabilities and letting me work out what the system could do for me and my organisation. Systems can be so vast and complex and we need to understand the depth of them. Coming into something from a fresh perspective, you are not in a position to tell the trainer what to train you on.”
Digital and patient access
“We’ve been a total triage practice for years now, but prior to the pandemic we were telephone total triage,” Bex explained. “Calls would come in, we collect patient information, and then our triage team would contact patients for more information and decide who it was most appropriate for the patient to see.” Following the pandemic, with the tools available, the practice moved to transitioning everything through its digital system. “It cuts out the in-between telephone call where you are trying to gather more information, because it puts the onus on the patient to identify the information they need to give us in the first instance. If they don’t provide enough information, you can quickly send them a text asking for more; and you can expect that these patients are digitally savvy enough to respond because they have come through the digital route already. If this happens it also means that the patient learns that they need to supply more information to get a better service for themselves.”
Everything goes through the digital system, Bex continued; patients can still call the practice or attend in person if they wish to, but the information collected still goes through the system in a standardised format so that everything is in one place.
“We have a lot of templates available – there’s the text template if a patient hasn’t given enough information, and another example is the ability to ask for a photograph if someone has got in touch with an injury, rash or bite, for example, that we can look at and assess. By doing that, we can then signpost that person on; it may be that a pharmacy can help them. We can look for opportunities to reduce pressure on the practice in this way.”
Bex also noted how the practice has saved time and supported access for patients by utilising the NHS’s ‘register with a GP’ system which links into the practice homepage, rather than requiring new patients to visit the practice. “It’s in the early stages, but it’s saved us a huge amount of time,” Bex stated. “Although we have to copy and paste the information into our clinical system at present, that’s all you’re doing. You’re not having to gather paper forms and type it all out. We were considering paying for an outsourced solution to tackle our registrations, so this service has saved us money as we haven’t had to do that. Plans for the future include integrating the service directly into practice systems, so we look forward to that.”
From the Welsh perspective, Sam shared that there is a lot of investment in the NHS Wales App. “It’s still in public beta at present. We’re building the plane as we are flying the plane; we’re developing it with user feedback. It will be the front door to lots of services so that patients can find information and results, but there’s also focus on how it can support self-care and maintenance of health and wellbeing.”
Sam shared her belief that this will “bring great benefits for the future, especially as our upcoming generations are digital-first and actively looking for a digital solution when they need help. We have to address that by giving them the tools.” She also highlighted the aspect of trust that comes with the NHS, pointing out that whilst people turn to Google to find information on symptoms or conditions, they don’t always trust what they find. “The NHS badge, by contrast, comes with a lot of trust.”
What does primary care need to innovate, and what are the barriers?
Liz drew focus to the NHS Long-Term Workforce Plan and said: “We need to get more trainees through the door, but how do we do that? On a practical level, we know that there are massive pressures on the NHS estate; so we need to think differently about getting trainees in and getting placements. This is where we at the hub have rethought our approach. We still offer the ‘traditional’ training like nursing placements, but we’ve also started to work with universities and suppliers to explore what training could be replaced with digital options, in a way that is safe and fit-for-purpose. What does that look like?”
She continued: “Of course, we could immediately say that we need technologies like generative AI, but they’re not the only options. We’re working with 360 degree videos at the moment to create nursing scenarios – the company we are working with offers scenarios freely to people with NHS or university emails. Their simulations do look like wards; but they looked like secondary wards, so we needed to work with them to figure out how we could make it work for us in primary care.”
Liz acknowledged the barriers around technology, its quality and capabilities. “As Bex said earlier – there may be a tool, but it may not be what you need and you may have to work out how it fits and whether it delivers the same benefit. I’d definitely recommend getting in there early with suppliers to talk to them about their tools and the design. We’ve saved a lot of money and time by communicating with the 360 video tech company, and we’ve ended up with a product that is fit-for-purpose for our students in primary care. We need to place ourselves as partners to suppliers.”
There is also the potential of enquiring about recompense if a supplier starts making money off the back of a tool developed alongside a healthcare organisation, Liz noted. “Perhaps we need to start thinking in an innovative way about how we run as a business and how we bring funding in, so that we can be a bit more self-sufficient. In that case, the barrier is our own limited imagination.”
Bex highlighted that one of the greatest challenges is the flow of information between secondary and primary care, with a lack of interoperability and standardised methods of communicating. When she goes out looking for solutions to tackle this, this is a “building block” for companies, she said. ‘They will suggest to me that the organisations should look to standardise their information, department to department, and that would be a start for them in terms of building a solution. Take discharge notes for example; we need clear, formatted information in bulletpoints that can be easily read and ingested by the software. The standardised format will pick up on the name, date of birth, date, NHS number and so on. Having this approach would help our staff even before the technology came into play; and then the technology could ingest it very quickly, code it and workflow it, and ultimately save endless hours of time.”
Bex pointed out the need to “think very carefully about what we are building on – are our foundations solid, or are we building on sand? Sometimes even our most basic IT needs are so far behind already. We are wanting to implement very demanding, high-energy hardware with intensive processing needs, and I think we will run into problems if we are not taking a good look at our foundations.”
Sam agreed on the standardisation point and said that Wales experiences the same problem. “Even agreeing on the same language and terminology to describe something proves really difficult,” she said. “That’s not just between health board to health board; it’s between hospitals within a single health board, and then into primary care.”
Standardised methods would help accelerate automation, she pointed out, and she also raised the risk of “losing people between the cracks, between primary, secondary, community and mental health care”.
For Sam, the “holy grail of healthcare” would be a “complete shared care record – a person-centred record that goes everywhere with them. Patients think we already have this in place.”
Ultimately, Sam said, “Digital is not going to support you with regards to innovation in primary care, or any care, if you are putting bad processes online. The first thing we’ve got to do is look at our processes offline and really kick the tyres on them all. Do we absolutely need to do these things? Is this process efficient? Does this definitely need signing by these people, who can check this document if this individual isn’t available? We can’t increase our capacity solely by expanding the workforce, because in truth we would just end up with more patients. The only way we can create time within our systems is by properly looking at what we do and how we do it. Then we can fit the digital tools around our work. But we have to be honest about it.”
What “good” looks like in primary care, and future plans
As the session drew to a close, we asked our panellists to share with us their thoughts on what “good” looks like in primary care, and some of their plans for the next 12 months in this space.
Sam offered us what she considered to be “a glib answer” on what good looks like, saying that “good would be people being able to access the healthcare they need in the way they need it, which for those of us with a certain vintage is kind of the “martini model” of healthcare, making that capacity for face-to-face for those who really need it, and for those who want digital access making sure that’s as simple and consumable as possible”.
Patient’s expectations of digital in primary care “are increasing all the time”, she added, “and why shouldn’t access in healthcare information and tools be as simple as ordering something on Amazon? That is the bar we’re competing with.”
For the next 12 months, Sam’s focus will be on the “real push” around “nailing the shared care record across Wales”, which Sam highlights as “a building block for such seismic changes in how we care for people”, as well as “big programmes of technology changes in mental health, primary care and social care”. Another major development expected is the move to one primary care system for Wales, which Sam says will be interesting when it comes to “seeing how much we can leverage from that, from working really closely with our partners”.
Bex focused on “good” in primary care looking like a better understanding for patients of “what is actually going on in primary care”, and how patients can access care when they need it. “There is a higher and higher expectation from patients,” she said, “and there’s a mismatch between that and what we can actually provide”. Sharing with patients any innovations happening, and maintaining those communications to try and manage those expectations is important, she continued, “as innovation for me is about taking patients on the journey, and what good looks like is patients coming with you wherever you want to guide them”.
Liz shared her perspective on what “good” looks like, starting out by noting the technical challenges she herself has experienced when delivering training, including difficulties in establishing “a good solid connection” to WIFI, which forced her to source her own WIFI solution which she now takes with her everywhere she goes. “The infrastructure within the primary care estate needs to be upgraded,” she said, “so it can support all these new digital products that are coming in”.
Looking ahead, Liz highlighted the need for her team to continue to “look at what the gaps in training are, because they continue to change, and funding for research and development into what that training looks like needs to be a consistent thing”. On a personal level, she spoke of her hopes that “the tech I’m using now in training will rub off on primary care staff, so any tech that comes to practice will be less scary to adopt”, and that another goal is completing a blueprint with the NHS Blueprinting team on the use of tech, “so if another organisation wants to replicate it they can”.
Some final projects Liz mentioned for the coming months were a tool being developed offering a 360-degree video from a nurse’s point of view on how to take a smear sample, a fully-immersive VR activity allowing this activity to be practiced, and some work around creating “generative AI patients that will act like patients, learn to respond like patients, so we can get that better, smoother ability to practice before actually seeing real-life patients”.
Final thoughts on innovation in primary care
Sharing some final thoughts on innovation in primary care, Sam shared her “surprise” at how few primary care system suppliers there are in the market, “and yet it’s a captive audience, so I’m wondering if that’s because we make it really hard to do something well, or the rise of cyber as a threat that’s putting off some innovators. You can see why it’s a difficult world to get into at the moment.”
Bex echoed this, but highlighted that “there’s a lot of innovation in primary care, and I think it’s the perfect place for innovation, because we’re independent businesses who can make our own decisions and react much quicker than a trust or department can, and embrace it.”
We’d like to thank all of our panellists for joining us for this session, and for sharing their insights on innovation in primary care with us.
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