For a HTN Now panel discussion on the topic of digital integrated care we were joined by experts from across the health sector, who discussed topics including approaches to tackling challenges from an ICS perspective; new models of care and pathway transformation; the role of technology in supporting the move from reactive to proactive care; and how a system approach can accelerate preventative care.
For the panel we welcomed Deborah El-Sayed, director of transformation and CDIO at Bristol, North Somerset and South Gloucestershire ICB (BNSSG); Dan Bunstone, clinical director at Warrington ICB; Stephen Bromhall, interim chief officer for digital and data at South East Coast Ambulance Service (SEC); and Laura Thompson, director of marketing at The Access Group.
Introductions and key projects
Deborah began by noting the significance of her role as chief transformation officer and CDIO. “Those two things go hand in hand, because we’re in 2024 and there is no transformation without some element of digital and data,” she emphasised, “and when approaching digital solutions, it’s important to understand the need to transform behaviours to get the value and the benefits.”
One of the biggest challenges from Deborah’s perspective is the fact that most systems across the health tech sector have been designed around organisational boundaries. In BNSSG, she shared, the focus has been on place-based partnerships “which gives us the opportunity to think about our population and the care and support they need”, as well as on shared care records.
From her perspective working with The Access Group, Laura highlighted her team’s work to deliver around four million electronic patient records, working with 200 local authorities and many community organisations, ICBs, and care locations. “We’re spanning the whole remit of health and care,” she said. “It’s important that as you go on this journey with technology, you look at how you can really deliver difference going forward.”
To achieve that focus of person-centred care, Laura continued, there is a need to support a joined-up, preventative approach that supports people to live independent and fulfilling lives. Organisations across the system “need to come together with multidisciplinary services to deliver on making the move from hospital to community; reactive to preventative; and ultimately analogue to digital. But it is about more than technology, because it’s also about people being able to work in a joined-up way, having the information they need, and being able to act on that information.”
At SEC, Stephen shared how in caring for the service’s five million patients, focus is placed on providing “the right place-based care, whether that means the technology and the datasets that support our frontline or a triage-based approach”. They are moving towards the hub model, he shared, which will see multidisciplinary teams across multiple ICS partners working to bring all of the data and digital together around clinicians and patients.
Dan told us how in his role as clinical director at Warrington Innovation Network, a lot of the focus is around trying to empower patients to use their own data and engage in self-management. “We’re creating a hub across the GP surgeries covering access, triage, pharmacy, to align our back-end processes and open up our capacity and availability,” he said, “and I think there’s a real opportunity for the GP system, the electronic patient record, and all of the data that exists there – there’s a huge repository of information there we can use to better plan for the future.”
The role of technology in supporting and accelerating the move from reactive to proactive care
On the preventative care agenda, Laura said: “When it comes to things like social prescribing, we shouldn’t have to keep proving that some of these things work. Wes Streeting at the Labour Conference made the comment that the NHS has more pilots than the RAF, because we keep testing things and trying things; but actually there are many preventative solutions and approaches that are already within systems and regions.”
Rather than continually looking for new things, she suggested that the NHS should “look at how we can deliver those existing solutions to get tangible results” and should also focus on taking a holistic view of the whole person. “If someone has poor quality housing, rising debt, or other personal challenges, that can impact their physical health. Also, it can lead to patients presenting at multiple places which can add to the burden on the health system.”
Laura also raised how siloed solutions bring their own challenges, like multiple logins and disparate systems. “We need to look at how we bring that view together, so it’s not just a case of taking existing analogue processes and making them digital; but looking at the processes, change management, and how people actually understand and use those solutions going forward.”
From an ambulance service perspective, Stephen said that SEC has been spending a lot of time working with partners and citizens to understand what the future operating model needs to look like to support their needs, with digital as a key component. Thinking about the delivery model at a regional level helps ensure that “we don’t cause any kind of health inequality with anything we do from a digital perspective,” he went on, “and part of that is making sure that the tried and trusted methodologies people expect from the 999 ambulance service continues.”
If there is an opportunity to use digital and data to help that augmentation process down that digital pathway, however, the trust remains committed to doing that, he added. That might be around 999 or 111 call handling, triage, or in frontline processes, giving staff the right data to do their jobs.
Deborah shared that BNSSG is currently looking at CHC, or continuing healthcare. “That’s one of the things people don’t realise; that there are people on a caseload where local authorities and ICBs share responsibility for ensuring they have the right care packages. There are millions of pounds spent collectively on that, and we need to make sure that we support it.”
The other thing her team is working on is secondary prevention. “We’ve been using our PHM data to understand the cohort of patients who haven’t been using their prescribed medication and have gone on to have a secondary cardiac event. We’ve then used that data for our insights and behavioural teams to go and have a look, and have found some very simple things that need to change, such as patients not realising they need to return to their GP for a second round. From that, we understood that we needed to put some mechanisms in place to communicate better with those patients. She highlighted the importance of data in driving that kind of work forward, commenting: “We need to look at where we can use our data to understand patterns in our population, so we can achieve prevention for the individual, the family, and the community in a way that will lead to population improvement.”
In Warrington, Dan shared some details of a hypertension project underway utilising remote care pathways, focusing on better patient management. “It takes longer to look at lifestyle than it does to just give patients medication,” he said, “but the impact is huge – we’ve managed to treat about 80 percent of the patients we’ve treated to target either with improved compliance or lifestyle advice. From the patient perspective side, they absolutely love being approached rather than having to come and see someone when they have a problem. We’ve had some really amazing feedback.”
With these kinds of projects, Dan added, you need a “brave” ICB to think, invest, and plan for the future. “It’s hard to invest in five years’ time when A&E is on fire.”
Dan also noted the benefits of having a completely remote team of nurses working on the app. “Even though there’s a recruitment problem, you’re fishing from a much bigger pool,” he pointed out, and you’re enabling work from home and work-life balance. This project is getting to a point where it’s achieving a 14 to 15 times return on investment – and I think you’d be crazy to not do it.”
Tackling challenges from a regional perspective
One of the most difficult things about changing ways of working is getting away from “doing things that are organisation-centric and looking at performance targets,” Deborah said. “It is hard to put new ways of working in – it’s like changing a wheel on a moving car, and we are going to have to think differently.”
It doesn’t tend to be the exciting work, she reflected, but it makes sure that the foundation and architecture is in place. “For example, our nurses and midwives work in every GP practice – not having this in place creates a lot of friction when looking at integrated care, so we’re trying to make sure we’re putting our foundations in place so people can work anywhere.”
Starting to engage with the person and leaning in to opportunities offered by things like the NHS App is also integral to advancing conversations around prevention, Deborah considered. “It’s important for people to start to feel like they are in control and part of that shared decision making, and there are many opportunities out there we can look at when we start connecting data.”
Laura agreed: “Allowing people to be more involved in their own care is definitely important, whether that’s using patient engagement portals, social prescribing, self-referral or remote monitoring. Technology-enabled care is an untapped resource at the moment and we’re seeing opportunities where patterns can be recognised and technologies like AI can be used.”
It might be something as simple as picking up on a change in patterns of behaviour, Laura continued. “For example, maybe someone isn’t as mobile, or they’re not drinking as much water, and that could be an indication that we need to intervene.” She also reiterated Dan’s earlier comments around virtual hubs and different ways of working to do more with less. “It’s not just about throwing everything out and starting again; it’s reviewing the current tech stack and understanding what is already working, what the gaps are, and how it could be better.”
Dan reflected: “We have to be brave – now is now, so we have to deal with that, but we also have to look at five years’ time, because otherwise we’ll be back here in five years probably and the situation will be worse. That’s a global problem; we need to crush the amount of frailty and ill health, and that point between ages 65 and 85 where we’re not at our peak health and we start to become ill. If we could reduce that time by 12 months, the world would save $40 trillion per year.”
Putting the right care around the patient and focusing on delivering what they need in the most effective way, so “we’re not pushing them into that acute medicine space” is essential, said Stephen. “That’s where using technology can support things like remote care – perhaps how we transform the pieces of this conversation we’ve had is looking at what we’ve already got and using that more effectively to create a multiplying effect, without spending more money.”
He pointed out that the NHS has “a lot of great assets – let’s use what we’ve got across our systems and partners before we go and spend a lot more money going through yet another change programme. We’ve all got change fatigue and want to look at what we’re here for, which is putting the patient at the middle of all we do.”
“We can’t just think about new money,” Deborah agreed, “because that might not come – we need to be focusing on a few of these things and galvanising our resources around them.” Quoting a colleague from BNSSG, she said: “Data is only what we choose to write down about what happens in reality, and there are opportunities for us to collect data that we need to make these cases. We need to do this together, because at the moment we’re all doing bits of the jigsaw.”
The technology challenge in delivering integrated care
Responding to a question from a live audience member about whether there is a technology challenge when it comes to delivering integrated care, Stephen shared his view. “As an ambulance service we don’t have huge technology stacks; but as national chair of the Association of Ambulance Digital Leaders Group I do have a national view on this. We’ve found that the vendors and partners we work with are very open to sharing data with us in a way I didn’t see when I spent time in the acute sector.”
One of the major struggles, he added, is the lack of standardisation in the sector. “We’re late to the party with FHIR and HL7 integration, so that creates a lot of technical workarounds we have to do. That makes interoperability a lot harder. In our sector I would say that’s one of the biggest challenges in this space.”
Having systems and EPRs that have been in place for a lot of years is also a challenge, Deborah noted. “We’ve had APIs for a long time, but you still need to map data point to data point. We as the NHS have set data standards and have said to suppliers they need to be interoperable and have open APIs; but that doesn’t mean they know every use case where you want to integrate.”
Thinking about and developing those standard use cases would be one way towards resolving this, Deborah continued: “Although I know there’s a piece of work going on at the moment with NHS England, we haven’t designed any data standards for a very long time. Working on that together with suppliers is really important, because that has the potential to give us a solid foundation to get those elements of data to stack up without expecting suppliers to tend to 500 customers who want things to work 500 different ways.”
Deborah also mentioned the Urgent Health UK’s work with Warwick University, which asks health tech providers who have a component of the user journey to work together to design that in collaboration. “Some of this more modern design-in-collaboration mindset is something I’d like to see us embrace more,” she said, “rather than throwing requirements at suppliers and hoping they come up with a solution that works.”
Laura agreed with this need for increased collaboration. “As a technology partner we work alongside trusts and the system, but we also need to include local authorities, community services, and the voluntary sector, who are really key when it comes to prevention.” She shared details of The Access Group’s partner programme and how it is important that the company recognises it’s “not always best of breed”, because there are “fantastic partners who have a very niche part of that journey for specific use cases”.
Part of the Group’s work in understanding where to go next comes from “fostering those interactions to understand the bidirectional interfaces. We want to learn how we can bring these things together; and how we can continue to maintain security, inclusion and confidence, from a patient and family perspective as well as a frontline worker perspective.”
The future of digital integrated care
Contemplating what digital integrated care might look like in the future, Dan raised the need to aim for “appropriate” access to patient records “across the entire system”. He also noted that he would “love to get to a point where we’re using proper PHM data – so we know who’s going to become ill, we have a map of hotspots, and a clear view of the whole system that everyone can see, including bed space, bed access, care hubs and so on.”
Stephen agreed with the need to improve access, saying that for the ambulance service ensuring that everyone has access to the national record and connecting all local shared care records in one place would be a priority for the future of digital integrated care. “The other thing is connectivity for our mobile workforce. I hope in five years’ time our nurses aren’t having to stop in a lay-by to get a signal to check the patient record for someone they’re going to see.”
Deborah concluded: “It’s about all of the things we have discussed here today – we need to be brave, we need to manage our data better, we need to consider the challenges for our workforce, release time to care, make sure we are connecting the population, and actively step into a space where we make a commitment to use our data.” Curiosity is also important, she added. “We need to recognise these opportunities and what we can learn from each other and our populations.”
Laura pointed out that there is an assumption that your GP knows everything about you; that they hold information that they do not have access to in reality. “The next generation will have even higher expectations from growing up with technology,” she reflected. “As a parent, I want the future to be planned around my daughter not having to face some of the challenges we face today, when it comes to her health and care story.”
We’d like to thank our panellists for sharing their insight with us on this topic.
