Ockham Healthcare: Supporting innovation in General Practice

Technology: Opportunity or Threat for General Practice?

The world is changing. We know it. We read books on a Kindle, download films, order just about everything online. Everyone has, and is permanently attached to, a smartphone. The NHS and healthcare has so far remained relatively unscathed, unlike many other industries. But that is starting to change. What will the impact of technology be on general practice?

A number of new reports have come out recently, heralding the changes. One of these, The Promise of Healthtech by Public, describes the rising impact of digital innovators and technology on healthcare.

The report identifies 9 trends where there is significant growth in technological innovation, the areas the report describes as “low hanging fruit”: procurement and productivity; recruitment and training; prevention; winter pressures and supported self-care; Artificial Intelligence (AI) in pathology and radiology; patient safety; mental health; social care; and research. It then maps the growing number of tech start-ups against each of these trends

You may think the report is overstating the pace of change, in its desire to encourage more tech start-ups to follow suit. But I don’t think so, because at the same time the big technology firms, like Apple, Amazon, Google and Facebook, are all moving into healthcare. According to this article published in March in Vox, “The most proven, forward-thinking, and, dare I say, disruptive companies in our country have decided health care should be their next big move.”  So whether it is the healthcare equivalent of Uber or Fitbit, or one (or more) of the more established tech companies, the current (relative) status quo is not going to last long.

Early stirrings are starting to have tremors through primary care. The GP at Hand service led to (mainly young) patients deregistering from their practice to sign up in London. Echo enables online ordering and delivery of prescriptions.

The Public report identifies numerous barriers that have slowed the introduction of technology: lack of clarity about the evidence; fast evolving regulation of digital health products; slow procurement; partial interoperability; unclear data security standards; and limited change management and digital skills. A quick reflection on the reaction to the introduction of GP at Hand within general practice and the size of these barriers becomes apparent.

I don’t think, however, these barriers will stop the tide of digital health development (disruption?) from coming in. Instead, overcoming them may well be the catalyst for greater and quicker advances. The use of blockchain looks set to empower individuals to control their own clinical records, as it can guarantee single ownership without requiring a central trusted authority, which in turn will start to shift power from the NHS as an institution into the hands of patients. The benefits of bringing together health and social media data, of enabling professional and community resources to interact effectively, is at the heart of the argument that is persuading Facebook to enter the health space.

General practice, sitting at the cusp between individuals managing their own health and accessing healthcare when they need it, is ripe for technological disruption. A recent Harvard Business Review article entitled, Virtual Healthcare Could Save the US Billions Each Year outlined it was changes to primary care that could deliver these savings. It says, “Without expanding the primary care workforce, virtual health technologies can augment human activity, expand clinical capacity, and improve efficiency by ushering in a new health care model where machines and patients join doctors in the care delivery team.

The independent contractor status of general practice means the barriers to entry are not as great as those that exist in the statutory NHS sector. Changes can happen rapidly in a small area and grow, without the need for national decision making. General practice has always prided itself on its ability to respond and act quickly.

The crisis engulfing general practice means the willingness to take risks is much higher than ever before. The incentive for a hospital within the NHS to take a risk on a new “carebnb” discharge option is simply not as great (given the potential for backlash) as for a practice facing financial hardship to try something new, however controversial.

Technology can help general practice become more efficient, but more importantly it can enable much stronger links between practices, their patients, and their local community. Shifting the demand curve is key to general practice emerging from its current predicament. The Public report, describing the trend for the development of technology in the area of prevention, states, “the need for digital solutions for wellness, supported self-care for patients with chronic conditions, AI driven behaviour change models and personalized patient education solutions is only going to increase.”

There is now an opportunity for general practice, given its current crisis, to reinvent itself as the supporter of communities and individuals to actively manage their own health, to act as a guide through the new environment as it evolves, and in doing so to make its own workload more manageable. The paternalistic “gatekeeper” role is unlikely to survive the changes that are coming, but the need for the expert generalist to empower, encourage and enable individuals and their decision making will be greater than ever.

The threat technological innovation presents is to the existing model of general practice. But given it is widely accepted that the current model of general practice is no longer sustainable, and in the absence of any meaningful investment in general practice, the opportunity technological innovation provides for general practice to reinvent itself seems to far outweigh the threat.

Book Review – Perspectives by Judith Harvey

In his latest blog Ben reviews GP Judith Harvey’s latest book “Perspectives: A GP reflects on medical practice and, well, just about everything…”

There are not many non-autobiographical books where you feel like you get to know the author, but Perspectives by Judith Harvey is definitely one.   There is something compelling about getting inside the mind of a doctor, not just as a doctor but as a person, and getting a sense of how they see the world.

Judith Harvey is a GP, a patient, a charity founder, and a unique individual. She is also a very talented writer. “Perspectives” is a collection of articles she has written over a 10 year period. Her articles have been published each week in the National Association of Sessional GPs newsletter, as well as other GP publications. While they were written primarily for GPs, I am not a GP and I still found them highly accessible, as well as insightful, stimulating and challenging at the same time.

Her writing is characterised by her honesty. In “It’s a knockout!” she describes her own experience of having concussion, of how it impacted her ability to think clearly, to work effectively and to sleep properly. In “Sleeping with the patient” we find out why she spent the night sharing a bed with one of her patients. In “Giving up… or stopping?” she shares what the prospect of retiring from clinical practice is like in real time.

As the book progresses you start to sense her underlying frustration with the system, borne out of a deep concern about health inequalities. In many ways, Judith was always ahead of her time: a proud portfolio GP when the voice was not as loud as it is today; writing about the impact of employment on health as a medical student and being summoned to the Dean to be reminded she wasn’t training to become a social worker; to advocating walking (for staff and patients) as a route into cutting the NHS budget back in 2009, well before the social prescribers had moved into town. Her passion for learning from others systems is clear (Judith founded Cuba Medical Link, a registered charity which enabled medical students to travel to Cuba for their electives), as is her frustration that we are not learning more from the system that exports doctors and achieves some of the best outcomes at a fraction of the cost of systems we frequently refer to.

When it comes to dealing with difficult issues, no stone is left unturned. She tackles self-prescribing by doctors (an issue rarely considered by non-clinicians), whether placebos can (and should) be morally prescribed, and the impact discussing an elderly patient’s driving ability can have on the doctor-patient relationship. She talks about the problems of evidence based medicine, about the social pressure put on potential organ donors, and questions whether it is ethical to provide a new face to a healthy person whose face is damaged when the price is premature death.

Ultimately, what I enjoyed most was the sense I was starting to get to know Judith as a person, as someone who loves travel and film festivals and the paintings of Goya, as someone who embraces all of life, rather than choosing to be defined by her profession or one particular aspect of it, and as someone prepared to share some of her innermost thoughts so that we, the readers, can better understand the points she is making, simply because she cares.

Maybe the book would have been even better if it had included more of a biography at the beginning or end. The only thing missing for me was a more direct insight into Judith’s life, into where she has been and what she has done, as a canvas to enrich the colour of the articles.

That said, this book is much more than “a GP reflecting on medical practice and, well, just about everything” as it says on the front cover, which hopelessly undersells it. It is a rare insight into what the world looks like through the lens of someone who is both a GP and a fascinating individual, and as someone who had never previously read any of her articles, I found it captivating.

Judith’s book can be purchased via Amazon here. We will be talking to Judith about her life and career in a future episode of the General Practice Podcast

I am a Consumer of Health, and Why this Matters

Are patients consumers? It is a question that has vexed those trying to introduce a market into healthcare for many years, and I think it is fair to say the consensus view is captured in Dr Jordan Shlain’s article, “There are no consumers in healthcare, get over it”.

He summarises that this is a consumer:

  1. They have freedom to make choices based on their resources and their numerous options
  2. They can decide not to make a choice
  3. They add something to their lives (material or experience) after a purchase
  4. They have a trust psychology based on being excited, not anxious
  5. Consumers get immediate or near immediate benefit from their purchase

And this is a patient:

  1. They often do not have freedom to make a choice and the options are limited
  2. They must make a choice
  3. They are trying to get rid of something (pain, nausea) and have no idea of the cost
  4. They have a psychology based on anxiety
  5. Patients often have no line of sight into whether they get a benefit or not

According to Wikipedia, a patient is “any recipient of health care services”. But how does prevention fit in to this? If a GP surgery undertakes preventative activity with its local population, is it doing that with them as patients or as consumers? When I as an individual decide to go for a run to improve my health, am I a patient or a consumer?

Let’s apply Dr Shlain’s criteria for consumers to my choice to go for a run:

  1. I can choose whether or not I go for a run
  2. I can decide to stay at home watching TV on the sofa instead
  3. I feel more healthy (as well as slightly smug and self-satisfied) after I have been on a run
  4. I am excited to lose weight, improve my fitness, and to (feel like I) look better
  5. I feel great as soon as I have completed my run. My phone tells me how far I have run, at what speed, and how long it took. I can share it on social media and gain feedback from my own network.

So while there may not be consumers in healthcare, there are certainly consumers of health. Why does this distinction matter? It matters for two reason. First, if general practice is serious about changing the pattern of demand, of shifting the focus from healthcare for the sick to wellness for all (as described by Dr Amit Bhargava in our recent podcast), then the nature of the interactions need to be consumer-focussed rather than patient-focussed. We will need something very different from our current system of patient participation groups, something more along the lines of the “Beat the Street” initiative described by Dr William Bird.

Second, the big technology companies (e.g. Amazon, Apple etc) already understand that individuals are consumers of health. Their moves into healthcare are predicated on being able to reduce total expenditure by empowering individuals to manage their own health.

Apple, Google, and Amazon are trying to lower the cost of health care for their employees by steering them toward outpatient clinics and wellness programs that they own or control…There is a potential convergence going on now. Electronic medical records, mobile phones, and wearables have achieved widespread adoption, creating new opportunities.

Technology can make a real difference to us as consumers of health. But the opportunities for Apple, Amazon and Google are also opportunities for general practice. The risk is if general practice does not take them, it might be superseded by the technology companies who do.

Dr Shlain may be right that there are no consumers of healthcare, but there are consumers of health. The aging population and the rapid advancement of technology mean this distinction is more important than ever before, and its impact upon primary care is likely to be huge.

What does GP at Hand mean for General Practice?

The world is changing. The days of popping down to Toys ‘R’ Us for a present for the kids are over. Last week Toys ‘R’ Us announced it was closing all of its stores. According to toy industry analyst Jim Silver, “They lost online and they didn’t adapt.”

It is not just the toy industry that is changing. It is everywhere. Earlier this month Countrywide estate agents reported significant ongoing financial difficulties. In a statement they acknowledged they had not yet learned how to deal with the challenge from digital property services (such as Purple Bricks).

General practice is not immune to these changes. Lillie Road Medical Centre practice in Fulham, which last year started to offer the GP at Hand video consultation service to anyone outside its area living or working in London, has seen startling growth. Taking up the service requires patients to leave their existing practice and register as an out of area patient. The list size of the practice has grown from 5,000 to almost 25,000 in 4 months, and 85% of registrations have been patients aged 20-39.

The GP at Hand experience means the digital threat to general practice has just become real. The capitated payment system of reimbursement for general practice means losing the younger, healthier patients on the list, and being left with patients who are older with more complex health needs; and could result in income not matching costs. It could well be the final straw for many practices already experiencing financial pressure.

Should these changes be resisted? Are video consultations a “good thing”? In a paper published in the Journal of the Royal Society of Medicine, the team from the Department of Primary Care and Public Health at Imperial College London said that while there is evidence that video consulting is acceptable to patients and offers many potential benefits, at least to those of younger age, its safety and efficacy in primary care currently remains largely untested. It raises concerns that while online consultations may help practices manage demand more easily, it may conversely increase pressure through supply-induced demand, or defensive practices.

In our new society, video consultations are more about allowing patients to access services in the way they want to, and less about reducing workload for GPs. Increasingly, it is patients who are going to set the pace for changes like this. The early results from GP at Hand demonstrate for some there is an impatience to see these changes now. Our recent technology panel ultimately felt the profession would not be able to keep control of the use of technology, and it would be driven by patients, if not now then certainly at some point in the future.

We are only at the start of the “digital journey” in general practice. Technology is evolving all the time. Jim Forrer on the technology panel talked about an app currently in development that can monitor blood pressure, pulse rate, oxygen saturations and respiratory rate through the camera function on a smartphone. Technology will change the doctor patient interaction and the way patients manage their own health. Google and Amazon are entering the health space, using global cloud-based health platforms and data, and this is going to have an impact on general practice.

We may think in a tax funded system based on needs not wants that market forces won’t apply. But the reality (as demonstrated by GP at Hand) is they will, because people will not accept what they perceive to be a second class service when it comes to their health, and will demand that health services evolve in the same way as every other aspect of the world. Resisting the implementation of technology will, at best, be a short term strategy. The risk of that approach is that others will move in to fill the void and the opportunity to respond positively may be lost.

If we can’t stop the march of technology, and given the significant potential financial impact, can general practice survive the changes that are coming? Well, established players in other industries (unlike Toys ‘R’ Us and Countrywide) have. Take the experience of the supermarkets. Online grocery shopping is the fastest growing area in the sector, but it is the major supermarkets who understood the change was coming and set up their own services. While new entrants have come into the market, Sainsbury’s, Asda, Morrison’s and Tesco are the major players. Morrison’s are now building partnerships with those with better distribution networks such as Amazon and Ocado to further cement their place.

The world is changing. GP at Hand is simply the indicator that general practice is not immune to these changes. Right now the onus is on general practice to respond, to respond quickly and to respond positively. Part of the opportunity of the move to scale in general practice is precisely for this, as it enables practices to invest in technology or partner with technology firms, to test and develop its usage and to evolve the model of care. By working together, practices can meet this challenge. The other option, to resist the changes, to pass motions that “more needs to be done” by commissioners and policy makers to preserve the status quo has the whiff of King Canute on the beach, and may leave current GP practice businesses in a position like Countrywide or Toys ‘R’ Us, rather than evolving with the changes like the supermarkets.

Where is general practice going?

We all know what general practice is trying to move away from (a crisis), but where is it going?

Anger, irritation, fear, or frustration with the current situation can be a great motivator to get change started, and provide an initial impetus to motivate a practice to take action. But if your only motivation is ‘away-from’ the current crisis, then your attention is consistently drawn to the negatives in your experience, filtering out the positives in the process.

It is also not sufficient motivation for sustainable change. For example, if a GP’s goal is ‘not to be in crisis’ (by their own definition of the term), then they have achieved this goal when they reach the level they decree to mean ‘not being in crisis’. They then lose a significant portion of their motivation so run the risk of dropping back down to a point at which they become motivated by their ‘moving away from being in crisis’ goal again. ‘Moving away-from’ goals produce inconsistent motivation levels which are rarely satisfying at any stage.

Sustainable change requires an element of ‘towards’ motivation as well; a vision of where you want to get to. Creating a vision based on aspirations and positivity and not on barriers or avoidance is both empowering and inspiring.

Where is the vision for the future of general practice? I don’t think it really exists. The GP Forward View seems to be more a public acknowledgement of the challenges general practice is facing while ploughing on with extending access, rather than the development of an inspiring picture of what is to come. So here at Ockham Healthcare (with help from whoever will give it!) we aim to put that right. We want to help build excitement and anticipation about the future of general practice, and to shift the focus from the crisis around and behind us, to an inspiring and attractive future ahead.

To kick this off we are holding a series of interactive sessions with some of the leading thinkers and practitioners in general practice. We are exploring with them some of the key changes they believe will impact the future of general practice. We will distil the key lessons, and capture the learning as a resource to enable GPs and practices to prepare for what lies ahead.

We are going to consider four questions:

  1. How will technology shape the future of general practice?
  2. What will the infrastructure of general practice look like in 5 years’ time?
  3. How will the new models of care change general practice?
  4. What do GPs (of the future) want?

We recently held the first of these panels, to discuss the technology question. You can listen to the first part of the discussion here. We will publish the second part in a few weeks’ time.

What is already clear from our first panel is there are huge changes on the horizon. There is an opportunity for general practice to embrace these changes and use them to create a future that will enable a greater focus on prevention, on building patient ownership and control of their health and their illness, on a new partnership between doctors and patients, and on new treatment opportunities (e.g. the use of virtual reality in pain management).

Finding a way out of crisis is not a plan for general practice. It is the start of the journey, but to ensure it doesn’t peter out there needs to be a vision, a future, a picture of what it will be like. Our aim, starting with these panels, is to help paint that picture.

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