Guy Wood-Gush, former neurosurgeon, ophthalmic surgeon and current CEO of Deontics, talks about a digital NHS and the Carter Review, highlighting the influence the Wachter Review could have on the future of digitised healthcare
The Carter Review promises good things for a digital NHS. Now the NHS and its Wachter Review need to reject its language of efficiency, and take a more open approach to see how technology can achieve the quality aspirations that should drive the future NHS
The Carter Review was, in some ways, good for health technology. It made a clear recommendation that NHS trusts should embrace key clinical systems such as electronic patient records (EPRs). It set a deadline and assigned responsibility. It gave scope for development under the use of the term ‘meaningful use’ of clinical data.
Carter has tried to set the foundations for a greater use of health technology. But there is the risk that this will end up delivering more of the same. Awareness of what health technology can offer is low.
As Henry Ford supposedly said, “if I had asked people what they wanted, they would have said faster horses”. The NHS now has the opportunity to set out a new direction of technology-enabled travel; the fear is that we will just see some faster horses.
In addition, the Review uses language that will surely decrease the clinical engagement that is vital to achieving the objectives of the report.
Telling a clinical workforce that variation is unwarranted is a red rag to a bull; their imperative is to treat the patient in front of them to the best of their knowledge and ability to ensure the best possible outcome. Never mind efficiency; these are people’s lives.
However quality and efficiency can co-exist and, as a recent King’s Fund report in improving quality noted, the need to embrace quality as the driving force for transformational change is essential. This language makes sense to clinicians. It can also have efficiency benefits.
In the US there is a driving need for quality and efficiency from the insurers who pay for people’s care. In oncology for example, the cost of drugs is high and patients need to be treated in ways that minimise the chance of readmission. The payers follow the costs on every patient and maximise efficiency throughout.
To support this, payers such as Anthem are incentivising the use of evidence-based clinical pathways to the tune of several thousands of dollars per patient. This would not be happening if there was not a return on investment.
The use of such pathways is in its infancy in the UK. However a system that is looking to drive efficiency should be looking at how these can be implemented and new generation clinical decision support systems (CDSS) are vital in combining good practice with the needs of an individual patient, and ensuring the delivery of cost-efficient, quality care.
Unfortunately, because of a lack of understanding of what is possible with new generation CDSS, in both the UK and the US, CDSS are some way off being seen as an essential part of the drive for quality and efficiency. They are seen as if they might be important but are not well understood. So if a trust is choosing an EPR, choosing one that ‘delivers decision support’ is a desirable but not an essential feature.
Many EPRs do basic decision support; but most I hope, would admit that they are not exploiting decision support to its full potential. Sending alerts and enabling computerised physician order entry are good and can have benefits.
However new generation CDSS go well beyond that. They can apply the most up to date guidance for an individual patient’s condition and present that to the clinician at the point of care. They can learn and adapt so that personalised care with its multiplicity of variations can be delivered with confidence and at scale. They can monitor variations in clinical practice and compliance with the evidence base in real time, allowing both clinicians and patients to choose the appropriate care in line with best practice.
Individual clinicians are empowered with tools that help them improve the quality of their care, which also happens to be the most efficient. They can compare their outcomes against their peers, and the culture of continual improvement that the King’s Fund report recommended can become real. This is meaningful use of health technology.
However awareness of such potential is low and it is no surprise that they are only discreetly referenced in the Carter Review recommendations.
It is now up to the Wachter Review to show that it has its eyes open to the potential for health technology that can be perceived as empowering clinical staff to deliver quality, rather than forcing them to prioritise efficiency.
The US has declared the ‘Meaningful Use’ programme dead. This has been due in part to its intentions for its new direction for travel being met with a pushback for ‘faster horses’ from existing technology suppliers. Change can happen and products developed, but this can take time.
As we often say, you can buy the most powerful sports car in the world. But without the right tyres or the right fuel you can only ever expect standard performance, even when there is much more to offer.
Let us hope the select group of individuals that form the Wachter Review are open in their thinking to what technology can offer the healthcare workforce, and see how its use needs to be part of the Amazon-style approach that puts the user – be they clinician or patient – first.