In July 2019, the Government announced that the NHS was to collaborate with the US global technology company Amazon to provide reliable health information from the NHS website through Amazon's voice-assisted technology, Alexa (Department of Health and Social Care, 2019a). ‘Smart speakers’ with Alexa respond to voice commands and give appropriate answers. The female voice of the Alexa digital assistant is now commonplace in many homes and other companies such as Google and Apple offer similar voice-assisted technology platforms. Now, for the first time, voice-assisted technology is to be harnessed to NHS healthcare advice provision.
History
The importance of innovation in health care cannot be overestimated and, since the dawn of communication technology and the invention of the telephone, the healthcare industry has endeavoured to harness its potential. The first recorded use of the telephone for the purposes of a healthcare consultation occurred in 1879, only 3 years after its invention (Glasper and Wilkins, 1998).
The success of telephone consultations depends on a number of factors, including the capability and understanding of the patient. A number of nurse-led telephone triage services have been available for specific patient groups. The ‘sick kids hotline’ a province-wide telephone triage system for parents with concerns about their children hosted by the Hospital for Sick Children in Toronto, Canada, proved to be a success (Glasper and Wilkins, 1998). This may have influenced the Department of Health to consider developing a nurse-led telephone service in the guise of NHS Direct in 1998. This came about principally because of changes to the GP contract in England and an associated increase in out-of-hours calls to GP surgeries (Lattimer et al, 1996).
However, subsequent concerns related to the increasing numbers of patient being referred by NHS Direct to emergency departments led to its demise and its replacement with NHS 111 services. Developed in parallel to NHS Direct was NHS Direct Online, which allowed members of the public to seek advice via a computer. This service was similarly replaced with NHS 111 Online in 2017. It offers a fast and easy-to-use alternative to the current 111 telephone service where users can obtain health advice on self-care (https://111.nhs.uk/).
Lake et al (2017) have reviewed telephone triage and advice services and suggest that there are no major differences between those and traditional care in terms of patient safety. Hence the Government is committed to developing digital services to empower people to better manage their own health and care needs. In addition to the 111 services, the NHS now hosts a range of digital platforms such as the Health A to Z website (https://www.nhs.uk/conditions/), which allows people to access health information on a variety of subjects. NHS Inform offers information on common symptoms and guidance for self-help to people in Scotland (https://www.nhsinform.scot/symptoms-and-self-help). However, the deaths of 11 patients have been linked to problems with the pathway protocols used by the 111 service and most ambulance trusts (Donnelly and Johnson, 2019).
Harnessing digital technology
Significant recent developments in digital technology are driving change in the way health care is perceived and delivered. The dawn of the ‘smart home’, equipped with technology to monitor and initiate patient interventions, is an indication of what is to come in the near future. For example, in a systematic review of literature pertinent to smart homes, Demiris and Hensel (2008) identified a range of digital technologies currently being applied in homes. They defined a ‘smart home’ as a residence equipped with technology that can monitor the wellbeing and activities of the home residents not only to improve their overall quality of life, but also to increase independence and mitigate against potential emergencies. Physiological monitoring, functional monitoring and the promotion of social interaction can all be facilitated through smart home technology. Such technology can improve the overall quality of life for elderly people and help promote independence and expedite a rapid response to emergencies.
In the 2004 movie I Robot, elderly people in the year 2035 were being looked after by robots in their own homes. This may have seemed farfetched in 2004, but later that decade Broadbent et al (2009) were reviewing the ways in which robots could offer a way of helping people to stay healthy in their own homes. Robotic assistive devices, which combine computing facilities and advanced software housed within a mobile machine structure that can react rationally to the environment around it, offer the potential to bridge the gap between the increased needs of an ageing population and the supply of health and social care staff in an industry already facing crisis.
Undoubtedly Broadbent et al (2009) believed that the voice interface between the machine and the person offered great potential to alleviate some aspects of daily living for elderly and frail people. In the decade since their article was published, voice-operated digital assistants have evolved to the point where some of these visionary aspirations for the technology have come to fruition. Portet et al, writing in 2013, reported on an evaluation of a voice interface technology system by older people, which aimed to help them to live in their own homes for as long as possible.
To accelerate the utilisation of digital technology within health, the Government has launched NHSX (https://www.nhsx.nhs.uk/) an organisation to promote the use of digital technology in health. Launched in February 2019, the primary goal of this unit is to merge and expand digital technologies across the NHS in England, thus allowing service users and healthcare staff to benefit from the latest digital systems and technology (Department of Health and Social Care, 2019b).
The Government hopes that the benefits of modern technology can be disseminated to all and bring together the combined knowledge of the Government, the NHS and industry to facilitate earlier diagnosis, empower service users to better manage their own health and free up staff time by bringing together all the levers of policy implementation and change for the first time.
The NHS website and Alexa
The partnership with Amazon to harness the potential of Alexa is intended to be of particular use to the frail elderly, those with vision impairment, and those who find it difficult to get access to the internet via computer or mobile phone. They can quickly access professional, NHS-verified health information, through simple voice commands (Department of Health and Social Care, 2019a).
The NHS Long Term Plan sets out the Government's intention to fully harness digital technology to allow patients to access virtual services alongside face-to-face services via a computer or smartphone. The NHS will also continue to support the development of apps and online resources to support optimal mental health (NHS England and NHS Improvement, 2019).
Alexa will now be able to use information from the NHS website to provide answers to voice questions such as:
The Government hopes that this digital technology has the potential to reduce the pressure on the NHS and GPs in particular, by providing information for common illnesses. Voice searching the internet has been increasing rapidly and by 2020, half of all searches are expected to be made through voice-assisted technology (DHSC, 2019a). NHSX will continue to explore ways of making more NHS services available to patients through digital technology.
It is essential that the production of health information and care protocols are written and checked for accuracy by competent health professionals from across the multidisciplinary team.
It should be remembered that voice-assisted technology or contact with a patient through a telephone does not permit a visual assessment, which can be a problem in the case of atypical presentations of an illness, as can occur in infants with meningitis.
The key to patient empowerment is information giving and the success of nursing interventions, however they are carried out, depends on high-quality communication irrespective of whether that communication is via the written or spoken word. The information that will be used by digital assistants such as Alexa must be provided by human health professionals who know their subject, are aware of its purpose and, importantly, know their audience. The problem of low literacy levels in some sectors of the population, which prevents the optimum use of written information, may be mitigated by voice-assisted technology such as Amazon's Alexa.
Conclusion
The Secretary of State for Health, Matt Hancock, believes that the harnessing of this new voice-assisted technology will give people access to reliable health information, which in turn may reduce pressure on community health workers such as GPs and pharmacists (Department of Health and Social Care, 2019b). He is confident that NHSX will drive this new technology revolution for the benefit of the NHS as a whole.
However, it could be argued that voice-assisted technology such as Alexa could be a Trojan horse, with implications for data protection. This notwithstanding, the era of the smart health home is already with us and Alexa may only be the first of these new voice-assisted technologies to offer help to vulnerable groups in society—who can now obtain health-related advice from official NHS websites.