NHS Commissioner: “Health apps won’t reach core NHS patients”

Health apps wont reach core NHS patients

Cassander Grey is the pseudonym of someone who works in NHS commissioning and writes about health policy and NHS management in the Guardian Professional. While nearly everything about this “Health apps won’t reach core NHS Patients” article is wrong it does highlight some very common misunderstandings about the mHealth market so I thought it might help to share some of my thoughts:

Health apps won’t reach core NHS patients… …Use of the health service is more common among older and less wealthy people and these groups are less likely to have smartphones

It’s critically important that we realise we’re all already using smartphones and it’s key that we accept that in only a few years easy to use inexpensive mobile phones will be as smart and capable as today’s super-smartphones (like the new Samsung Galaxy S4).

The idea that the “use of the health service is more common among older and less wealthy people” is just a nonsensical generalisation. Perhaps Cassandra means “frequent” use rather than more “common” use? The difference should be obvious when you realise the NHS has a cradle to the grave mandate eg. a 4 year old will on average use the NHS much more than a 98 year old. It is important that we all come to appreciate that the biggest health (and social) costs that the NHS needs to budget for will be spent on Patients who aren’t old yet.

The idea that the NHS is used by “less wealthy people” is also a common misunderstanding that a lot of affluent people make because they just don’t understand how the NHS and Private healthcare providers interact.

The idea that NHS Patients who use the most services are somehow incapable of using mobiles is also dismissing the fact that for most of these Patients their access to the NHS is not direct eg. they are supported by carers. With this understanding it should be clear that a statement like “Health apps won’t reach core NHS patients” is completely dismissive of the opportunity for carers to use these apps and is missing the point in the same way that you would if you argued that ‘the NHS doesn’t need ambulances because most Patients can’t drive them’.

I think it’s fundamental that healthcare industry commentators make themselves aware that more than 80% of all care in the UK is provided by unpaid, unqualified, volunteers/friends/family.

After a slow start, enthusiasm for health-themed apps is starting to permeate the NHS

Slow start? Across the globe mHealth apps for Smartphones have set new records for IT adoption rates amongst clinicians. Epocrates in the US has published figures on this but the UK actually leads this with BNF (which was being sold directly to Doctors and Hospitals by Medhand AB long before the iPhone was even launched and is now made available as a free app for NHS staff following a NICE initiative that realised it was nonsensical for clinicians to have to pay to have this clinical reference material on their always carried devices).

The NHS has been slower off the mark than other sectors, but enthusiasm for health-themed apps is starting to permeate the health service

Slow off the mark wouldn’t be how I would term the mHealth adoption by emergency call services eg. for over a decade the NHS has led the way with mHealth using Mobile Caller ID and location based tech to enhance emergency response services etc.

Frontline Healthcare Workers are no slouches either eg. the BlackBerry Digital Pen project at Portsmouth NHS Trust has seen midwives with Smartphones paired with digital pens for more than 5 years now.

NHS Choices has started a health app library, and there has been a proliferation of articles in the healthcare press about the potential role of apps in the future of medicine

I’m not sure about this. To say it has created a library is a big stretch of what it actually has done which is the compilation of a rating/recommendation website eg. You can’t borrow anything, you can’t download anything, etc, etc.

The most recent I came across was a piece by Ashley Bolser. Bolser’s article made some good points, in particular his argument for a process to ensure health apps contained accurate, reliable information. Furthermore, apps have a great deal of potential uses in the healthcare industry

This ‘there are no rules to this game’ response seems to be a typical conclusion made by commentators who are bamboozled by tech, don’t use app stores and have no idea how they work.

I am yet to be convinced, however, that this particular kind of technology is going to have a big impact on the NHS – at least in the short-to-medium term. The reason is very simple: NHS core customers are unlikely to have smartphones

You don’t have to have a mobile phone (never mind a smartphone!) to benefit from this tech. Swap out your diabetic patients Blood Glucose monitor for a CE marked Telcare device and there’s no new learning carers can instantaneously see that they’ve tested and see their accurate readings from anywhere at anytime. Call 999 with your basic Nokia mobile and you mobile phone will automatically roam onto any available mobile network and the call handler will be able to determine your location. Crash your BMW car and the mobile connected SOS system will instantaneously inform emergency services of your precise location, speed of the crash, number of occupants, etc, etc. Drop in on your Doctor and ask her for a look at the clinical resources they have access to at their fingertips to ensure they’re giving you the best care possible (note: it’s more than we had access to in the clinical library at our Medical School).

Increasingly this will be further extended as mobile (the newest mass media) is used to connect devices eg. Smoke/CO Alarms, Care Monitors, Blood Sugar Monitors, INR Monitors, weigh scales, ECGs, BP Monitors, etc.

Get some idea about these by checking out the slidedeck from my talk last week at the José de Mello Health Group‘s annual Healthcare Conference just outside Lisbon.

A report showing UK smartphone ownership by age band, as of March 2011, showed that ownership is lowest among older and less wealthy peole. Conversely, use of the NHS is more common among these same groups. Data for 2011-12 show that patients aged 65 and over accounted for almost 40% of finished consultant episodes in English NHS hospitals

Back to the point about carers that I made above. The use of these statistics really highlight the ignorance that this NHS commissioner has of the important role being played by carers. Healthcare costs in the NHS would explode if seniors weren’t being cared for by friends, family and volunteers and in many cases the use of mobile apps by these individuals can make their invaluable work possible.

The link between poverty and poor health is well established; see for instance Lord Darzi’s year of life expectancy lost with every stop heading east on the Jubilee Line

You’ll also find that there is also a rise in the percentage of mobile only households as you head into poorer regions of the UK.

This fits with what clinicians are seeing on the front line. Dr Jonathon Tomlinson, a GP in Hackney and a medical blogger, is probably far from atypical in his estimate that 10-20% of his practice’s patient list accounts for 80-90% of all appointments, and that the elderly, deprived and poorly-educated are disproportionately represented in this group

Is anyone actually surprised that we have a 80:20 rule for GP visits? Perhaps that’s because the NHS has been providing lots of other services for wealthier patients (e.g the premium rate NHS Direct line) or they have greater access to the internet (and the information available there) which would really help in the argument I’ve been making for years calling for mobile operators to be required to voluntarily provide free access to content on the .nhs domain.

If the NHS is going to cope with a future of static or negative funding growth, the big opportunities for cost savings are going to come from preventing these core customers from using as much healthcare as they currently do

This is a common misunderstanding of the healthcare challenge. It should be obvious that the big opportunity for cost increases lie squarely with the 80% of Patients who are currently not users making more demands of the heathcare system (perhaps after developing a chronic disease early as a result of obesity?).

It is easy to conflate novelty with usefulness, especialy where technology is concerned, and it isn’t hard to find NHS-specific examples of prioritising medium over message. Take Second Health that was once the future of healthcare communicationas an example. Early in 2007, online virtual world Second Life was approaching the zenith of its popularity. Imperial healthcare NHS trust spent an unspecified amount on purchasing electronic real estate and constructing a virtual community hospital and polyclinic

A fundamental misunderstanding of the opportunity here. Just because a idiotic strategy based around the PC/Internet (the last mass media) didn’t work doesn’t mean one that is based on leveraging the newest mass media (one that is personal, permanently carried, always on, available at the point of creative impulse, etc) will also fail.

Since 2007 there has been more than a doubling of the number of adults who accessed the internet every day but we’re still talking about a number that’s around the 50% mark – about the same proportion of citizens in the UK have a smartphone with them at all times (even when they’re accessing the internet, reading a paper, listening to the radio, watching the TV, etc). SMS penetration exceeds 100% (many people have more than 1 phone and many people who don’t even think they use SMS do still receive messages eg. from a friend and their mobile operator with service centre/voicemail notification messages).

Money, time and enthusiasm are all finite resources. The NHS needs to direct these resources to where they will have the greatest effect

In a NHS that still sends snail mail envelopes to Patients containing more Stamped Addressed Envelopes asking for feedback and outsources important Patient Information (to no-win-no-fee legal claim management firms) perhaps it’s time this NHS Commissioner asks who is the customer and what do they need?

Will Health apps reach core NHS patients or have they already? What do you think?

About David Doherty

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