Can digital innovation reduce healthcare inequalities?
Covid-19 overshadows all our lives. But just because we are battling the same storm does not mean we are all in the same boat. The people likely to be most exposed to coronavirus, and to suffer most from the resulting interventions, are disproportionally those already disadvantaged in society (the #ethnic-breakdown-of-deaths-by-age-and-sex">startling disparity between white and BAME outcomes is one tragic example).
This inequality predates the pandemic. Even in the NHS — the world’s most mature system of universal healthcare coverage — morbidity and mortality are strongly correlated with where a person lives and how much they earn.
If these dark clouds have a silver lining, it is that the pandemic has also highlighted the most effective tools to repair this imbalance: chief among them is digital innovation. Below are some key lessons that healthcare professionals, politicians and scientists should consider as they tackle discrimination in the digital age, and examples of what can be achieved in a variety of care settings when innovation (digital and otherwise) is applied with care.
Mobile tools for fairer access to consultations
It seems increasingly common to hear that the last ten months have seen ‘ten years of innovation’. But while services like video consultations have certainly become more widespread, start-ups like DrDoctor and Zesty had already developed a variety of remote care tools, from appointment management apps and text updates, to self-monitoring questionnaires and paperless referrals.
Solutions like these are convenient: improving patient choice, shortening waiting times, and significantly reducing overhead costs. But there is a risk, says Lloyd Price, Co-Founder of Zesty, that “technology always starts by benefitting the most affluent, educated, and digitally mature people in society” because “the focus tends to be on cutting edge platforms. Innovation can’t just be for the early adopters at the ‘top of the pyramid’; it needs to be for everyone. ”
By taking advantage of near-ubiquitous technology like mobile phones, we might finally see all sections of society able to effectively manage their own care. Shift workers could flexibly report on chronic conditions; those living with financial insecurity could consult a GP without incurring holiday or travel costs; and homeless people could receive timely diagnoses without needing to rely on a discriminatory paper-based approach.
Universal benefit does not require universal uptake. Those unwilling or unable to engage online still benefit by ‘delegating access’ to their carers or when automated booking systems free up clinic phone lines. Tom Whicher, Founder and CEO of DrDoctor, believes this combined approach is vital. “Digital transformation can help everyone by bridging gaps in health inequality. But the way to do it is not to force digital products on everybody and alienate them from their own health journey. New tools need to work with, rather than replace, existing behaviour. ”
Integrated analytics to improve planning of local services
Effective case management, while a perk for patients, is vital for healthcare organisations. This was the challenge faced by boroughs in North West London when they were hit hard by the first wave of the pandemic. Facing a critical incident, North West London Collaboration of Clinical Commissioning Groups (the local body responsible for planning and procuring clinical services) enlisted the support of analytics company TrueCue to help them combine, sort, and understand the vast array of information they were dealing with.
In only four weeks, TrueCue and NWL launched a reporting platform to integrate data from almost 20 source systems and display it in near-real-time using a variety of ‘dashboards’. Clinicians and managers are now using these reports to spot trends earlier, identify high risk groups, and plan interventions.
James Don-Carolis, Managing Director at TrueCue, emphasises the importance not only of combining inputs, but also sharing outputs widely. “Integrating disparate data sources is vital for holistic, evidence-based decision making. But you only see maximum value if the information can be accessed by teams in multiple care settings, including hospital staff, central leadership teams, and GPs. This collaboration is the only way of managing caseloads without losing a patient-centric view. ”
An online portal to help ageing patients access care
Other organisations like North of England Commissioning Support Unit(NECS) have made the opposite transition: taking existing innovations and re-purposing them to deal with Covid-19. In 2019, NECS — one of a handful of units providing business intelligence, consulting, and back-office support to other parts of the NHS — launched 'Capacity Tracker', an online portal to address the significant delays that exist when moving patients from hospital to a care setting.
There was historically no way of searching care homes and matching the requirements of individual patients, but Capacity Tracker allows social care teams to find and fill vacancies more easily, saving time and anxiety, and freeing up critical hospital beds. As well as working with more than 15,000 care homes, it is now being used across other settings such as community rehabilitation and drug and alcohol services.
Stephen Childs, Managing Director at NECS, believes this growth in uptake “is an example of how local innovation can be rapidly adopted at a national level without the high initial overheads of a top-down approach”. The UKGovernment has used it to support the national pandemic response (providing real-time insight on PPE, workforce requirements and flu immunisations) and it been adopted for the same reason by a primary health network in Australia.
Diversity works both ways
Just as technical innovations can support under-served populations, increasing diversity also improves technical innovation. One example is in genomics, where recent advances have opened vast new possibilities for the diagnosis and management of rare diseases.
The UK is a world leader, and NHS Trusts, private organisations, and Genomics England have begun partnering with other countries to share their expertise. However, most genomic studies focus on participants of white European ancestry, and this ethnicity bias is impeding the equitable sharing of clinical benefits and the advance of scientific knowledge.
Dr Saghira Malik Sharif, Principal Genetic Counsellor for Prenatal Genetics at Leeds Teaching Hospital, believes that the way to increase participation is through broader education. “The key issue,” she says, “is to develop researchers with cultural — as well as clinical — competencies. If we can identify the practical barriers to engagement, and address people’s concerns through effective communication, we will build a system able to embrace advances and improve health outcomes for all patients. ”
Education and engagement need to be driven by, as well as for, the groups in question. Katherine Mathieson, CEO of The British Science Association, has extensive experience working with minority communities. “I often hear calls for more ‘representation’, but that’s not the problem,” she says (indeed, the BAME population is actually #by-ethnicity">over-represented among the NHSworkforce). “Instead, we need to ask different questions; to be led by local communities as well as launching centrally funded ‘outreach’ programmes. ”
Be slow to be fast
So why not start immediately? First, because the health and care sectors are complex: strictly evidence-based, highly regulated, and often decentralised. The NHS, however coordinated it may be, is an ecosystem of hundreds of organisations. While transformations have historically suffered from rigid centralised planning and mass rollout, some preparation is needed.
Secondly, we are already in the midst of excessive change and the fatigue it brings with it. Even healthcare data, despite its value, can be hard to manageand even harder to build public trust in. Without firm foundations, any rush to innovate may lead to more problems than solutions.
There must be a period of reflection, where pockets of innovation (like accessibility and inclusive prescribing) can be expanded, and new ideas sifted. This is one aim of the ‘NHS Reset’ campaign being championed by NHS Confederation, The Health Foundation, and England’s Academic Health Science Networks.
As Richard Stubbs, CEO of the Yorkshire and Humber AHSN, and one of the Reset campaign leads explains, “We have seen rapid and fundamental changes in the way the health system functions. Now we have a time-limited opportunity to evaluate these changes and sustain the ones we expect to deliver value in the future before we slip back into previous ways of delivering care. ”
Cause for optimism?
Despite the clear and present challenges to health equality, there is cause for hope. Mobile approaches are widening access, reducing costs, and improving user experience. Clinical commissioning is being enhanced through real-time system integration and information sharing. Across health and care, innovators are working quickly, building locally before scaling nationally, and investing in essential education and community engagement.
If we are to see the dawn of truly universal healthcare coverage, leaders in the NHS and globally will need to take time to balance the trade-offs, learn from the past, and share those lessons with each other.
“I'm more optimistic than I've ever been," says Hassan Chaudhury, Digital Health and Care Lead at Healthcare UK in the Department for International Trade. “There is so much digital innovation in the UK, from NHS organisations to start-ups to well established private companies. If we harness it in the right way, we can revolutionise patient care forever. ”