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Will mobile phones save the NHS?

Published on 07/05/19 at 11:38am

The NHS is sick. According to politicians and NHS chiefs, the cure involves a strong dose of mHealth. Louis Goss asks to what extent mobile health apps can solve the problems of the increasingly strained health service.

Understaffed, underfunded and overstretched; Britain’s beloved National Health Service is under pressure like never before. As said succinctly in a parliamentary report from 2017: “Our NHS, our ‘national religion’, is in crisis and the adult social care system is on the brink of collapse.”

While demand for services is higher than ever, staff shortages and chronic underinvestment have pushed the NHS to breaking point. “Our conclusion could not be clearer. Is the NHS and adult social care system sustainable? Yes, it is. Is it sustainable as it is today? No, it is not. Things need to change.”

In response to the crisis, NHS England Chief Simon Stevens and Prime Minister Theresa May unveiled the ten-year-long NHS Long Term Plan, published on 7 January 2019, which sets out to revitalise the NHS through digital innovation and a focus on preventative care.

In pledging to inject an additional £20 billion into the NHS each year by 2023, the plan proposes a shift in focus away from hospitals towards community services and primary care. The Long Term Plan also vows to transform the way in which care is delivered, as it sets out a strategy for the digitalisation of the NHS. 

Much of this digitalisation will be focused on mobile health, or mHealth. As explained in the Ten Year Plan: “People will be empowered, and their experience of health and care will be transformed, by the ability to access, manage and contribute to digital tools, information and services.” This will involve the rolling out of a number of apps, which, it is hoped, will save money, save time, and improve care in the NHS.

The patient

The NHS was the first universal healthcare system to be established anywhere in the world. Founded in 1948, the National Health Service was set up with three core principles in mind: that it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.

As explained in a leaflet sent to every household in Britain in 1948: “The NHS will provide you with all medical, dental and nursing care. Everyone – rich or poor; man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a ‘charity’. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.”

The NHS has grown significantly in the 71 years since 1948, and this growth has in turn meant bigger budgets and more staff. In 1948, the NHS employed 144,000 members of staff. Today, the NHS is the biggest employer in Europe, employing roughly 1.5 million workers in the UK. The NHS is also more than ten times more expensive than it was in 1948. It is, however, worth noting that the NHS today continues to go underfunded and understaffed.

The diagnosis

Greg Fell, Director of Public Health for NHS England in Sheffield, explained: “First of all, it’s underinvested.  There’s plenty of evidence from lots and lots of different sources to say that the NHS is chronically underinvested. This has been the case for a good while now.”

While the NHS Long Term Plan does offer a 3.4% increase in real spending over the next five years, the boost is still 0.3% less than the average annual increase of 3.7% since 1948. According to a report from the Institute of Fiscal Studies (IFS), the NHS requires spending “increases averaging around 4% a year over the next five years to maintain provision at current levels and address the backlog of funding problems.”  A boost of 3.4% will, at best, maintain the status quo.    

“The further investment in the Long Term Plan is clearly welcomed, no doubts there,” Fell said. “It’s probably not enough investment to catch up with the backlog of underinvestment over the years, but the investment is welcome.

“The second problem is workforce,” Fell continued. “There’s certainly not enough of the right kind of workforce to address the problems – the demand problems – which are ultimately the problems coming from poorly people who are seeking healthcare.”

Despite the fact the NHS is one of the biggest employers in the world – in fifth place behind the US Army, the Chinese Army, Walmart and McDonalds – the UK has fewer doctors and nurses per head than nearly any other country in the Western world. Only Poland has fewer doctors and nurses per person than the United Kingdom of Britain and Northern Ireland.

The NHS was, at the end of 2018, short of around 100,000 staff, and this figure could reach 250,000 by 2030. Britain’s exit from the European Union will likely make things worse. However, the problem requires much greater focus on training and retaining staff. This means making the NHS a better place to work.

“The third major issue is that the NHS, for the last sixty years, has grossly underinvested in a preventative model,” Fell said. “We can’t treat our way out of the demand problems the NHS has. The only way is the preventive model.”

Spending on primary care has, in real terms, fallen since 2010. The number of GPs per capita has also fallen in recent years. The pattern reflects a long-term shift in focus away from primary care.

“My sense is that we’ve underinvested in generalist care and we’ve overinvested in high tech super specialist care. High-tech super specialist care is exceptionally important if you’ve got a high-tech super specialist problem, but many people have got generalist problems or 14 different things that are wrong with them all at once – multi-morbidity. High-tech super specialist care is useless, or next to useless, in the context of multi-morbidity, hence the shift to a generalist-oriented model,” Fell said.

The medicine

According to some, mHealth apps are a cost-effective solution to the troubles of the NHS. Advocates for the tech say that mHealth could allow patients the ability to better manage their conditions, while limiting avoidable service use through better preventative care. It has been argued that mHealth technology could cut out a lot of paperwork and bureaucracy, while others hope the mobile tech could help to improve access, especially for those with mobility problems who struggle to access primary care.

Research from the Now Healthcare Group, a healthcare technology company based in Salford, found that telehealth consultations removed the need for a GP appointment in 56% of cases. Meanwhile, ‘adherence technology’ was found to increase adherence to medicine regimens by 41%.  The paper argues that if these technologies were rolled out across the entire population, mHealth apps could save the NHS £7.5 billion each year.

Greg Fell was sceptical: “Will mHealth solve the problems of the NHS? No it won’t! It will go nowhere near it! There’s precious little evidence that mHealth apps can replace what skilled humans can do. We have skilled humans for a reason, because skilled, well-trained humans are pretty good at making judgements, and often mHealth apps aren’t good at making judgements.

“My sense is – and I will be challenged on this – that lots of different stakeholders oversell the effectiveness of mHealth apps of a whole range of different types and flavours. The manufacturers will oversell the benefits because they want to sell the app! Other people will oversell the benefits of mHealth apps because they believe that mHealth apps are a cheap and efficient alternative to things that skilled humans can do, and other people oversell mHealth apps because they misunderstand or misconstrue the nature of evidence of effectiveness. There’s a whole bunch of stakeholders in the mix that will tell you different things about evidence.”

Fell did however concede that some mHealth apps could be useful in certain situations. “There are some exceptions,” he explained. “We’ve seen the rise of computerised cognitive behavioural therapy (CBT). There’s reasonably good evidence that computerised CBT is pretty good. Is it better than what humans can do? We don’t know! But it can achieve bigger reach than we would ever be able to have with the appropriate number of CBT therapists.

“The upsides are the potential ability to provide greater reach and greater coverage and to get to populations and provide healthcare to people that would never receive it,” Fell said. However, he was clear in stating: “I’m still not convinced that mHealth, tech, gadgets and gizmos of various types and flavours are the answer to the NHS and social care problems that we’ve currently got.

“I can see the intuitive draw of being able to get access to a medical professional really quickly and easily,” he added. “But there are downsides to it, and the downside is that it moves money away from the model of primary care that has been with us for quite a long time now and which has stood the test of time, and has changed through that time. I personally would be loath to do too much change to the model of primary care delivery and comprehensive registration of a whole population birth-to-death care. I think we’d be foolish to mess with that too much.”

The Apple ECG

In March, Apple announced the UK launch of their electrocardiogram (ECG) app for the Apple Watch. According to Apple, the free app “will help users identify signs of AFib (Atrial fibrillation).” British tabloid The Sun was quick to report that “A man’s life may have been saved by taking an Apple Watch ECG just days after the feature launched in Europe.”

However, Dr Venk Murthy, a cardiologist and associate professor at the University of Michigan, was not convinced. Dr Murthy pointed out two major issues with Apple’s ECG app: firstly, the app alerts users to false positives; secondly, “we still have very little idea of how much atrial fibrillation the app misses.” While false positive could unnecessarily use up doctors’ and nurses’ time, false negatives could lull patients into a false sense of security, which could be dangerous for their health.

Nevertheless, there is also the problem of how we treat those who have been correctly identified as having atrial fibrillation by the Apple Watch ECG app. As said by Murthy, “We still do not know whether treatments for asymptomatic atrial fibrillation are worse than the disease. Does giving anticoagulant blood thinners to patients with small amounts of atrial fibrillation lead to those people living longer, healthier lives? We don’t know the answer to that. So, without knowing the answer to that impact question, I personally think that we, as a medical profession, do not have enough evidence to say that the Apple ECG app is a good idea for patients. ”

Greg Fell commented: “The false negative/ false positive thing is probably always a risk. Looking at the data it seems like there’s a really high false positive rate. So if we are relying on those kinds of things to do our screening we may well be sorely disappointed.”

The revolving door

In January 2019, the government announced Nicola Blackwood would take over from Lord O’Shaughnessy as a junior minister for innovation, in the Department of Health and Social Care. Critics condemned the government after it was revealed that Blackwood would be joining the department from her role as Strategy and Governance Board Member at online medical consultation service, Push Doctor – a firm hoping to be contracted by the NHS.

Blackwood, who has since 2017 worked for Public (a firm which helps private sector companies get public sector contracts) after she lost her seat as Conservative MP for Oxford West and Abingdon the same year, would, in her new role, be responsible for rolling out digital technology in the NHS. She has in the past also worked for a number of private companies with interests in government policy and the NHS. These include lobbying firm Global Counsel (a company founded by New Labour mandarins Peter Mandelson and Benjamin Wegg-Prosser) and health data firm, Eagle Genomics.

David Miller, the Director of Spinwatch, an organisation focused on rooting out those undermining democracy in the UK, commented to Oxford University newspaper Cherwell: “This is the latest in a long line of revolving door appointments involving public servants who go on to work for private clients in the lobbying world. There is no effective regulation of this and it is simply unacceptable for lobbyists to be appointed as government ministers in this way.”

Meanwhile, Juliet Bauer, NHS England’s Chief Digital Officer (CDO), announced she would be leaving her position to join Swedish online GP consultation service, Livi. The same month, before the news of her new role at Livi had become widespread, Bauer wrote a piece for British newspaper The Times as “the Chief Digital Officer for NHS England” celebrating the company’s app. Meg Hillier, Chair of the House of Commons Public Accounts Committee, condemned the piece as “brazen” and “jaw-droppingly inappropriate.” Even David Cameron condemned the “far-too-cosy relationship between politics, government, business and money.”

Blackwood and Bauer’s stories are mirrored in the case of Paul Bate, former Executive Director of the Quality Care Commission, who in 2016 took on the role of Director of NHS Services at London-based mHealth firm Babylon Health. Health Secretary Matt Hancock was later criticised for repeatedly promoting Babylon. In one instance, Hancock was even featured in a paid-for advertorial for the company, which featured in the George Osbourne-edited daily London newspaper the Evening Standard.

Meanwhile a 2018 study published in The Lancet called into question  the safety and effectiveness of Babylon’s Chatbot, in suggesting the firm “does not offer convincing evidence that its Babylon Diagnostic and Triage System can perform better than doctors in any realistic situation, and there is a possibility that it might perform significantly worse… Further clinical evaluation is necessary to ensure confidence in patient safety.”

The “cosy relationship” between those in government and private firms hoping to win contracts in the NHS should be of concern. While the “revolving door” does not mean we should entirely disregard the legitimate benefits of mHealth apps, it is worth keeping in mind when assessing the value of new technologies in the NHS.

“Of course there are upsides to mHealth,” Fell said.  “No one’s debating the fact that there are upsides, but we need both sides in the debate, and we need measured assessment of the evidence, prospect by prospect. Sweeping assumptions that mHealth will be the thing that saves the healthcare system from certain doom – well, I think you’ve gathered by now that I don’t buy that notion by any stretch.”

The prognosis

As healthcare swallows up an ever-growing share of Britain’s GDP, intelligent, time-saving solutions are what is needed if, going forwards, we hope to create a sustainable NHS. As people live longer, and medicines become increasingly expensive, these problems are only going to get worse. At first glance, mHealth seems like one of these smart solutions to the problems plaguing the service.

However, it is important not to become overexuberant as to the virtues of mHealth; while it may bring with it some advantages, it is not a cure-all for the problems of the NHS. As recited in the Hippocratic Oath: “there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.” This will be where apps fall short. 

“I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick,” goes American Physician Louis Lasagna’s modern version of the oath.

While an app may help relieve some pressure on the healthcare system, mHealth cannot replace the various forms of comprehensive primary care that have been on offer for many, many years. Nevertheless, anything that genuinely improves the healthcare system should be welcomed, as we may genuinely have to rely on these solutions in years to come. Thus, it is crucial that we take a balanced approach towards mHealth, especially when it comes to the NHS. 

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