Professor Trisha Greenhalgh is Professor of Primary Care Health Sciences at the University of Oxford, a practising GP and a Founding Fellow of the Faculty. In this insightful blog, Trisha reflects on the role of government and technology within the NHS, challenges being faced, and offers her thoughts on how these issues might be tackled.
This blog isn’t about politics. But given the prevailing volatility in Westminster, it is not inconceivable that a snap general election will give us a change of government sooner rather than later. Love them or hate them, how would you advise an incoming Labour government on technology policy for the NHS? I recently gave this question some thought.
First and foremost, I would remind Labour that technologies are merely tools that allow us to achieve our goals. Arguably, Labour doesn’t need a health IT policy; it needs to ensure that its wider health policy is value-driven and optimally supported by IT. Labour values emphasise universal healthcare as a public good and a human right, the state’s moral duty towards vulnerable groups and a commitment to the eradication of poverty (a key social determinant of health). Questions about technology should follow from these values. For example, instead of asking, “should we try to maximise video consultations in the NHS?”, Labour might ask, “how might video technology help us to improve access to NHS services for people working in the gig economy, who cannot get paid time off work to attend their appointments?”.
Second, I would emphasise that technology-supported change in the NHS is inherently difficult, slow, costly, more or less unpredictable, and not easily scalable. Change is often emergent and nonlinear. Goals, milestones and budgets should take account of this reality.
Third, I would recognise that an incoming Labour government will inherit some existing policy commitments for technology-supported care models, notably from the recently-published NHS Long Term Plan. These include, for example, a promise to make online consultations (especially via video link) widely available. A Labour government – which should surely not declare itself anti-technology just because the current Conservative leadership is pro-technology – should use the opportunity to reframe this policy commitment in a way that reflects its own values and priorities.
Take the example of GP At Hand, an NHS-funded General Practice set up by Babylon Health (partly with venture capital funding), in partnership with an existing GP practice. Londoners have been invited to switch their GP practice registration to GP at Hand since November 2017. After one year, 37,000 patients (mostly young, healthy professionals) had done so. The model’s alleged success is based on satisfied patients and fast response times. Critics have accused the company of ‘cream-skimming’ (luring away healthier patients and leaving conventional GP practices with sicker ones) and setting up an overly complex service which generates high costs elsewhere in the system (e.g. because the host clinical commissioning group finds itself commissioning for patients far beyond its usual geographical footprint).
From a traditionally socialist perspective, it is not the technology that is the problem here but the risk of eroding and fragmenting the long-established system of locality-based GP practices who take all comers, provide comprehensive care (including preventive services) to an entire community and undertake place-based commissioning informed by population needs (in other words, they deliver the service as a public good). Arguably, models such as GP At Hand reflect neoliberal values (an individual, choice-based model of care and an assumption that competition and market forces will drive up quality) and downplays the social determinants of health and the community value of the local GP practice.
Whilst it could be argued that the current system drivers are perverse and could be changed (e.g. the Carr-Hill formula for varying GP capitation fees by age and deprivation status could be amended to make ‘cream-skimming’ less profitable; out-of-area patients could be banned or further disincentivised), the underlying neoliberal model would remain. A more enduring solution, reflective of Labour values, would be to fund local GP practices to develop their own digital-first model, perhaps in collaboration with neighbouring practices.
My fourth suggestion to an incoming Labour government would be to get a firm grip on data-driven technologies that process and learn from NHS patients’ data. This is a fast-moving field in which technical and commercial developments are complex and intertwined. Current regulation frameworks do not ensure that the value extracted from NHS data is returned to (or at least, shared with, the NHS). It may not sit well with Labour values, for example, that in exchange for a potential cross-subsidy from venture capitalists to provide access to a tiny proportion of NHS patients, a private company is able to gain a rich understanding of care processes, outcomes and data flows in general practice which it can then use to develop other potentially lucrative innovations such as a diagnostic chatbot.
Finally, I would remind Labour that the NHS has a key role as an employer, a contributor to national and local economies and a source of innovation and research. Yet our ability to measure value in the NHS, and to monitor technology-supported change, is currently weak because data sources are sometimes incomplete, inconsistently structured and of variable quality. Investment is needed to improve data quality, support data collection and undertake world-leading evaluation and research to build the evidence base on what works, for whom in what circumstances.
I thank a colleague who wished to remain anonymous for feedback on an earlier draft of this blog.