In January 2019 NHS England published the much-anticipated NHS Long Term Plan (NHS England, 2019).
This ambitious plan, which is designed to sustain the NHS over the next decade, places emphasis on disease prevention, the eradication of health inequalities and on offering ‘digital first’ care where appropriate. The plan is configured in seven sections. Section five details the Government's commitment to upgrade technology and digitally enabled care across the NHS.
Background
The use of technology to manage care is as old as the use of the telephone itself. In fact, the first recorded use of telephone technology in health care occurred in 1879 when a doctor was able to reassure a parent and discount a diagnosis of croup by listening to a sick child's breathing over the telephone, reported in a letter to the Lancet (Aronson, 1977). However, diagnosing patients and imparting healthcare information over the telephone could be thought of as analogous to providing care with your eyes closed and your hands tied behind your back (Glasper, 1993).
The development of NHS Direct and its successor NHS 111 was still predicated on the telephone and although call handlers use specially designed decision-support software, supported by clinical advisers who are usually trained nurses, they cannot actually see the patient. However, new digital innovations such as Skype are a solution to this problem. Skype is one of a number of telecommunications application software products that allow users to see and hear through a video link between computers, tablets and mobile devices.
Some hospitals in the UK are using wearable communication devices, such as Vocera Smartbadges (https://tinyurl.com/y9mckwao), which enable health professionals to receive and read information about patients—such as bed position, personal data and physiological status, including current early warning signs scores.
In 2016 the then Secretary of State for Health, Jeremy Hunt, awarded substantial funding to several NHS trusts to help them develop digital technology for the improvement of patient care (Department of Health (DH) and Hunt, 2016).
Much of this interest in the application of digital technology to the NHS came about following the findings of the Wachter review of NHS technology (Wachter, 2016) for the DH. Professor Robert Wachter is internationally renowned for his application of technology to medical care. His report has influenced the current plan to embrace digital technology to improve health care.
The NHS app
A key feature in rolling out enhanced digital technology is the NHS app, which has been designed to provide a simple and secure way for patients to access a range of NHS services via their smartphones or tablets (https://digital.nhs.uk/services/nhs-app).
The NHS app was piloted in 2018 by GP surgeries from 16 clinical commissioning groups, involving more than 3000 patients. The app is now freely available and the features are being incorporated into many GP surgeries. The majority of surgeries will have embedded the app and its features by the early summer of 2019. The NHS app will allow patients to check their symptoms, get information on what to do if they need more urgent help, book and manage their GP appointments, and order repeat prescriptions.
Tomorrow's patients, in addition to having face-to-face contact with a health professional, will be able to access virtual services via their home computer or smart phone. The Government is keen to move away from mechanistic medicine and to embrace preventive medicine, which will be predicated on high-quality, up-to-date health information, as featured on the NHS website (https://www.nhs.uk/).
Much of this information will be accessible via the NHS Apps Library; currently 70 such apps are available which have been kitemarked and approved for use in the UK (https://apps.beta.nhs.uk/).
The Active 10 walking tracker app, for example, has been designed to tackle the rising levels of obesity in society and promotes brisk 10-minute walking exercises. The app is personalised and allows people to record their progress in achieving their exercise goals and providing positive feedback to users.
Providing digitally enabled primary and outpatient care
The NHS Long Term Plan has underscored the findings of the 2018 Royal College of Physicians (RCP) report on outpatient care. The RCP believes that the traditional model of outpatient care is no longer sustainable in terms of cost and contemporary lifestyle. It states that clinicians are overwhelmed by the sheer volume of outpatient waiting lists and overbooked clinics. And it is believed that some 90 million outpatient consultations each year do not actually require a hospital visit.
One of the primary assertions of the RCP report is that outpatient consultations of the future should better utilise technology such as communications software.
The RCP report cites a number of innovative outpatient case studies such as the introduction of an inflammatory bowel disease service, where extended waiting times and patients disruption were addressed through the development of a web-based patient management portal service. This portal allows patients to record their symptoms and to communicate with their care team remotely, thus avoiding unnecessary outpatient visits. In embracing Skype, apps and online tools (such as teleradiology tools) the RCP believes that significant numbers of patients will not have to suffer the inconvenience of an outpatient visit and this will simultaneously reduce NHS expenditure (RCP, 2018).
Some NHS trusts are already embracing digital technology to support patient care delivery. For example clinical staff working at the South Devon NHS Foundation Trust are offering Skype consultations with home-based patients via a patient-controlled records system, ‘Patients Know Best’ (https://www.patientsknowbest.com/) (Al-Ubaydli, 2011).
The role of NHS Digital
NHS Digital is the national information and technology partner to the health and social care system. The NHS Long Term Plan (NHS England, 2019) depends on NHS Digital to develop digital technology to transform and make possible the changes envisaged.
In providing national technology for health and care services, NHS Digital already facilitates innovative ways of providing and enhancing care, especially for vulnerable groups. For example, it has enabled homeless people in Hastings to access medical treatment through a digital outreach programme (NHS Digital, 2019).
By gaining access to online health and medicines information on the NHS website, homeless service users have been enabled to better comply with taking medication for long-term conditions and managing their side effects.
This has been made possible through the use of computers that facilitate access by homeless people to a health-information website. Support workers are available to assist clients in accessing the digital health information devices.
Will digital access disadvantage certain client groups?
Newspaper reports have pointed out that a number of GPs have concerns about digital patient access because they believe that some patients' signs and symptoms of illness can only be verified by direct contact. Additionally, there have been concerns raised about the computer literacy of some older people (Borland and Martin, 2019).
Despite fears that older people might be disadvantaged, a 2017 study of older people's use of tablet computers shows that participants in the focus group were keen to learn, although none of the participants had any previous experience of that particular technology. However, members of the study group expressed feelings of apprehension about lack of instructions and guidance in using the machines (Vaportzis et al, 2017).
Adapting to a digital future
It is clear that embracing a digital future will mean staff and organisations must adapt. In a study of neonatal post-discharge management using telemedicine support Robinson et al (2016) showed that the use of a dedicated web page and video calls reduced the number of emergency hospital visits by families. The study also found that, although the nurses were in favour of using telemedicine for the management of discharged neonates in the community, their schedules and work routines prevented its optimal use. The researchers stated that organisational adaptations would be necessary to make the best use of telemedicine.
Conclusion
The NHS Long Term Plan (NHS England, 2019) advocates the use of digital technology to reduce costs, improve the efficiency of the NHS and help health staff optimise both their time and skills. The plan aspires to make digital appointments with NHS professionals the norm over the next few years. Reducing the number of unnecessary face-to-face contacts will ensure that patients who really need to be seen in person will get a better quality and less hurried consultation. Additionally, it will be possible to remotely monitor people with long-term conditions through wearable physiological devices, thus allowing them to better manage their own health and avoid hospital admission.
However, this drive to embrace healthcare technology will depend on how successful the Government is in increasing the number of nurses in the NHS. The Government is supportive of increasing the number of undergraduate nurses in training and in reducing attrition from training with improved retention, with a specific aim of improving the nursing vacancy rate to 5% by 2028 (NHS England, 2019: 79).