Available via license: CC BY-NC 4.0
Content may be subject to copyright.
INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL
34 35
INTRODUCTION: WHAT CHANGE
IS NEEDED IN THE NATIONAL
HEALTH SERVICE?
This is a question that has been asked hundreds
of times and has hundreds, if not thousands,
of truly valid answers. While some of these are
more nebulous and conceptual than concrete and
measurable, ultimately where we must look is to
policy change that has come from service-wide
consultation and information gathering.
In January of 2015, National Health Service (NHS)
England announced a new programme, the New
Models of Care Programme, to focus on the design
and implementation of new models of care in
health and wellbeing.1 It set itself the task under
Samantha Jones, Director of the New Models
of Care Programme, UK, of achieving the rapid
change that was recognised as necessary in the
NHS Five Year Forward View.2 While the Five Year
Forward View set out a clear view on what change
should look like in the NHS, it is ‘on the ground’
implementation processes that will drive this view
to be realised.
The head of NHS England, Mr Simon Stevens,
outlined the progress to date at the recent Liverpool
NHS Annual Conference but also highlighted
the need for further progress in urgent care:
“We need to redesign the way our urgent care
system works. The current system is confusing the
public. We have to do a better job of joining it up.
We need to simplify the urgent care spaghetti so
we can manage the demands being placed on us.”
Mr Stevens urged parts of the country to step
forward as urgent care vanguards. Organisations
and partnerships were asked to come forward
and help the NHS to innovate, and 50 were
chosen as part of a rigorous process of selection.
Each vanguard is taking a lead on developing new
care models as a blueprint for the NHS moving
forwards.3 Many are in Primary Care, because
evidence shows that healthcare systems with a
greater focus on Primary Care help to keep people
healthier for longer.3
While vanguards are a fantastic step in the right
direction, their setup process prevents the smaller
scale innovators from getting involved. Thankfully,
vanguards are not the only solution being proposed
and championed; there is a multi-pronged approach
to the change that needs to occur to relieve
pressure on our urgent care system. The following
is a non-exhaustive list of current avenues:
Academic Health Science Networks
The goal of Academic Health Science Networks
(AHSNs) is to translate research into practice,
NEW MODELS OF HEALTH
*Chris Whittle
NHS England Clinical Entrepreneur Fellow, London, UK.
*Correspondence to chris.whittle@mymedhealthcare.com
Disclosure: Chris Whittle is a director at MyMed, a company making online primary care both on demand
and free to access.
Received: 06.09.16 Accepted: 23.11.16
Citation: EMJ Innov. 2017;1[1]:35-38.
ABSTRACT
Last year in England alone there were approximately 57 million failed attempts to book general
practitioner appointments. The following article outlines the spectrum of solutions being proposed and
championed by National Health Service (NHS) organisations with a view to providing new models of care
in a cost-eective fashion. The intricacies and peculiarities of technology as an enabler in healthcare are
explored, with reference in particular to agile iteration as a key methodology in this space.
Keywords: Tech, National Health Service (NHS), MedTech, healthcare, NHS Digital, new models of care, Five
Year Forward View, telemedicine.
INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL
36 37
through the alignment of innovation, training and
education, clinical research, and healthcare delivery.
Billed as ‘systems integrators’, AHSNs have been
established as small autonomous enterprises
with a specific 5-year NHS England commitment.
Where they dier from traditional delivery vehicles
is their focus on return on investment, in keeping
with lean economic principles described later in
this article.
NICE Implementation Collaborative
The National Institute for Clinical Excellence
(NICE) Implementation Collaborative (NIC) is a
partnership between NICE, the NHS, and multiple
key health organisations and patient bodies.
The goal is to drive improved access to NICE-
approved medicines and technologies, and the
key element is that it does this in a timely fashion.
Having multiple large organisations increases
friction and decreases agility; the NIC plays an
important role in ‘redrawing the landscape’ by
identifying barriers and allowing the right people
to collaborate on practical solutions.
Innovation Connect and Portal
Anyone who has worked at any modern tech giant
will tell you that opening up access to innovation
support to everyone is a vital part of gathering an
adequate spectrum of ideas. Innovation Connect
supports innovators with ideas that have a clearly
defined need and clinical support, while the
Innovation Portal allows anyone to share ideas
and meet other people with similar interests and
experience. This comes down to scientific principles;
the higher the ‘N’ value for a particular experiment,
the more likely you are to get a statistically
significant result.
Funding: Challenge Prizes and the
Small Business Research Initiative
Arguably one of the world’s most successful
innovators, Elon Musk, whose founded companies
include PayPal, Tesla Motors, and SpaceX, cites
the basic psychology that has led to his success:
“people respond to precedence, incentives,
and superlatives.” The NHS England Innovation
Challenge Prize provides financial incentives to
encourage, recognise, and reward key frontline
ideas. The Small Business Research Initiative
(SBRI), championed by the aforementioned AHSNs,
provides another route of competition to address
unmet health needs.
National Innovation Accelerator
The National Innovation Accelerator (NIA) is
focussed on prevention, early intervention, and
long-term condition management. Through support
of Fellows to take innovations to NHS providers
and commissioners, the NIA aims to deliver the
commitments of the NHS Five Year Forward View.
Test Beds
Set up to help pioneer the use of interconnected
devices for monitoring and data analysis, NHS test
beds are allowing early evaluation of technologies
in areas such as home monitoring, which many
see as a key area for future development and
potential cost-saving. The Internet of Things (IoT)
element of this is particularly interesting; while
the small agile nature of a test bed setup allows
iteration on processes at the point of delivery,
the NHS as a whole represents a key opportunity
for scale where eective solutions are found.
Clinical Entrepreneur Programme
Involvement of frontline clinicians has long been
seen as a key component to allowing the kind of
problem-orientated solution testing that is needed.
But, while allowing free rein on ideas and concepts
for change allows a fast narrowing down of options,
the true eect of each pain point is dicult to
evaluate without a deep knowledge and experience
of the multitude of processes involved. Doctors,
who work in parallel process lines across specialties
and rotate between trusts more frequently than
many multidisciplinary team colleagues, see
system after system and problem after problem.
Recognising their role in problem identification
is important but where the Clinical Entrepreneur
Programme (CEnt) will make the biggest impact
will be supporting doctors to implement and
iterate their solutions to the wider health service.
HOW BIG IS THE PROBLEM?
In 2015 there were 57 million failed attempts to
book general practitioner (GP) appointments in
England alone.4 The majority of these, on analysis
of patient survey data, failed because of a lack
of appointments on the day wanted and at the
time requested.
Mr Stevens speaks of the “demands being placed
on us”; his words echoed by the same patient
survey data, which is the result of questions asked
of nearly 1 million people each year showing a clear
INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL
36 37
rise in expectation of appointment immediacy
year-on-year.4 But even aside from the level of
patient expectation, it is an objectively measurable
numeric demand (more patients and more
appointments per patient) that is increasing.
The issue becomes more complicated when you
look at factors such as administrative change and
workforce alteration nationally.5 But the eects of
an overall increase in demand on GPs is clear to
see, it was reported recently by the British Medical
Association (BMA), relating particularly to the
shortening appointment lengths as GPs try to cope
with demand.6 The BMA stated in no uncertain
terms that the average 10 minutes per appointment
that has become the norm is putting many
complex patients in the UK at risk.7
HOW CAN TECHNOLOGY HELP?
Any communication system that still regularly
uses faxes, in 2016, could benefit from today’s
technology. Unfortunately, this applies in both
primary and secondary care settings across the
country. And yet it is the fault of no individual
when parts of a large organisation fall behind
other industries in technology uptake; rather it is
a function of in-agility and often resource focus in
other areas. Healthcare, where the NHS has been
at the forefront of increasing standards of clinical
care inexorably since its inception, has its own
‘unknown unknowns’ such as new infectious
disease outbreaks and avenues of costly treatment
research. This is the reason management
consultants have been called in to help manage
trust-wide issues with MBA-style modelling.
But more than simple hardware upgrades,
technology in this decade has brought with it a
wave of logical thinking; where system design
is widespread and iterations of architecture and
protocol are commonplace. The agility of start-ups
in the world-leading London tech scene is nothing
new (after all, large corporations all generally
began as small nimble companies) but their
popularity and subsequent success is a testament
to the ‘lean’ process that they nearly universally
undergo to achieve success.
All of the above listed NHS England avenues for
aiding urgent care point to lean processes as the
optimum methodology. It is exactly for this reason
that NHS England’s Innovation team have set up
the CEnt Fellowship, supporting front-line clinicians
to take their ideas for innovation forwards, and
iterate them to fit a marketplace that badly needs
eciency. Soon this fellowship will be extended
to Allied Health Professionals, and ultimately to
patients themselves. To paraphrase Sir Bruce
Keogh, Medical Director of the NHS, at the CEnt
opening event: in what other context would
you make it dicult for your most involved and
intelligent organisation members to innovate and
lead change?
WHY THE UBER MODEL DOES
NOT WORK FOR HEALTHCARE
As people see the ‘uberification’ of various
industries, those on the fringes of healthcare
begin to rub their hands and dream of the kinds of
figures that healthcare generates in revenue.
The next big tech unicorn, it is speculated, will
come from digital health. Deloitte predicts 35%
compound annual growth rate in what it calls
‘mHealth’ in the UK, while other industry onlookers
predict even higher expansion. “What is not to
like?” they ask. “Doctors on demand, to your door,
whenever you need. How can it be a bad thing?”
There is of course much to be said for increased
patient autonomy and using technology as an
enabler for that is inherently a good thing for
healthcare and patient empowerment. But when
it comes down to extension of another industry’s
model, medicine is not the simple carriage of a
person from one place to another, and doctors are
not constantly circulating and simply in need of
ecient redirection by a consumer-based service.
Healthcare professionals as a whole already
function in a relatively economical way in the
community for face-to-face interactions; patients
attend their surgeries (when well enough to do
so) and the doctor sees far more patients this way
than if he or she were forced to do house calls
for all of those patients.
This is not to downplay the ineciencies of a
‘localised’ system (immobile resource scaling and
potential condition cross-contamination) where
aspects could be delocalised. The above taxi driving
analogy however would be more accurate if it were
extended so that each person who wanted a taxi
was unsure where they wanted to get it to,
was unsure of the urgency, and in fact could only
vaguely describe where they were presently located.
The solution, therefore, is not about shuttling
doctors to their patients, on demand. It is about
finding where it has been inecient for a relatively
fit and well patient to attend their GP, only to be
INNOVATIONS • January 2017 EMJ EUROPEAN MEDICAL JOURNAL
38
asked a few simple questions and sent on their way
(occasionally clutching a signed piece of paper
that will take a while to transform into treatment,
normally at another institution altogether).
It is about streamlining that interaction,
such that GPs’ time is opened up to dealing with
those who need extensive history taking and
examination; the elderly and those with chronic,
poorly controlled conditions.
The NHS New Models of Care is about exactly that;
the need for change has been recognised in the
Five Year Forward View, and the various approaches
outlined above are the lean methodologies for
speeding up the process. Rather than being
‘unfocussed’, a widespread lean approach allows
the kind of quantitative and qualitative testing and
hypothesis acceptance and rejection that clinicians
are very familiar with. The rapid iteration of these
results is the part that needs to be focussed upon
if we are to achieve significant change in such a
large organisation; we should test safely until
the optimum change is seen, and then provide
evidence of safe, eective impact at scale.
The peculiarities of medicine that have kept it
at a distance from innovators in the past are
beginning to melt away. A decade ago, streamlining
consultations based on likely clinical simplicity
may have been perceived as too disruptive to be a
working model. To extend the taxi analogy, it
would be akin to trying to predict which taxi hailer
is likely to want the shortest ride ahead of time.
Now however, we have the technology provided
by search engines and electronic patient records
that gives demographic information and allows
prediction to become a health-needs foresight.
CONCLUSION
In the ‘big data’ age, we are able to predict health
outcomes in ways not thought possible in the past.
The NHS New Models of Care, alongside complicit
bodies like the Information Commissioner’s Oce
(ICO) and the UK Department of Health, will allow
innovation that safely keeps patient data under
the watchful eye of appropriate informational
and clinical governance. The ‘crown jewel’ of the
welfare state has a unique standpoint on the
health of a nation, just as Twitter (San Francisco,
California, USA) has a unique standpoint of the
security situation at the Olympics as it unfolds.
The key is harnessing this in a safe and responsible
manner. Our NHS, in this sense, represents a key
opportunity to move human health forwards.
The recognition of the need for guidance and
directed strategy in this respect, from the very
upper echelons of the world’s fifth largest
employer, is the first step on the road to bringing
about the change that is needed. And in this
author’s humble opinion, it is just a matter of
time before healthcare has its own ‘Uber’ model.
1. NHS England. New Models of Care
Programme. 2015. Available at: https://
www.england.nhs.uk/2015/01/models-of-
care/. Last accessed: 22 November 2016.
2. NHS England. The NHS Five Year
Forward View – executive summary.
Available at: https://www.england.nhs.
uk/ourwork/futurenhs/nhs-five-year-
forward-view-web-version/5yfv-exec-
sum/. Last accessed: 22 November 2016.
3. NHS Report 2016. New Care Models:
Vanguards - developing a blueprint for
the future of NHS and care services.
Available at: https://www.england.nhs.
uk/wp-content/uploads/2015/11/new_
care_models.pdf. Last accessed: 22
November 2016.
4. Ipsos MORI. GP Patient Survey - National
summary report. 2015. Available at: http://
gp-survey-production.s3.amazonaws.
com/archive/2015/July/July%202015%20
National%20Summary%20Report.pdf.
Last accessed: 6 September 2016.
5. Curry N. Fact or fiction? Demand for
GP appointments is driving the ‘crisis’ in
general practice. 2015. Available at: http://
www.nuffieldtrust.org.uk/blog/fact-
or-fiction-demand-gp-appointments-
driving-crisis-general-practice. Last
accessed: 6 September 2016.
6. BMA. Locality hub model: Safe work-
ing in general practice. 2016. Available at:
https://www.bma.org.uk/collective-voice/
committees/general-practitioners-com-
mittee/gpc-current-issues/safe-working-
in-general-practice. Last accessed: 22
November 2016.
7. BBC Report. Patients at risk from
length of GP consultations. 2016.
Available at: http://www.bbc.co.uk/
news/health-37211590. Last accessed: 22
November 2016.
REFERENCES