Episode #3: Shaping the future of UK healthcare: Breid O’Brien in conversation with Karen Taylor

Talking Public Sector

In the third episode of Talking Public Sector, we discuss our latest healthcare report; “Shaping the future of UK healthcare – Closing the digital gap” with Breid O’Brien, Director of Digital Transformation at the Health Innovation Network and Karen Taylor, Lead for the Deloitte Centre for Health Solutions.

Breid O’Brien is the Director of Digital Transformation at the Health Innovation Network which is one of fifteen Academic Health Science Networks (AHSNs) across England. AHSNs operate as the key innovation arm of the NHS. Breid has an extensive healthcare background spanning the NHS, the UK private sector and the Australian healthcare system. With a background as a Registered Nurse specialising in Emergency care, she has since held senior operational management roles in acute healthcare organisations, before moving to system level roles for the NHS in London in both strategy and healthcare informatics.

Karen Taylor leads Deloitte’s Centre for Health Solutions. Karen supports the Healthcare and Life Sciences practice by driving independent and objective business research and analysis into key industry challenges and associated solutions; generating evidence based insights and points of view on issues from pharmaceuticals and technology innovation to healthcare management and reform. Karen also produces a weekly blog on topical issues facing the healthcare and life science industries.

During this episode, Breid and Karen discuss the challenges facing the healthcare system in realising the policy ambition of a digital first NHS, and some of the solutions to overcome them.

Karen Taylor
UK Centre for Health Solutions Director

Karen is the Research Director of the Centre for Health Solutions. She supports the Healthcare and Life Sciences practice by driving independent and objective business research and analysis into key industry challenges and associated solutions; generating evidence based insights and points of view on issues from pharmaceuticals and technology innovation to healthcare management and reform.

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Karen Taylor (00:00:03): Welcome to Talking Public Sector, Deloitte’s podcast on government and public services. This series features conversations and insights on the big issues facing the UK public sector. My name is Karen Taylor and I lead the Deloitte Centre for Health Solutions and I’m joined today by Breid O’Brien, who I’m going to ask to introduce herself.

Breid O’Brien (00:00:22): Hi, I’m Breid O'Brien, Director of Digital Transformation at Health Innovation network which is the academic health science network for South London and my background is I’m a nurse very long time ago and I have moved through many roles in operational management, technology and improvement science in the NHS.

Karen Taylor (00:00:40): Thanks for joining me today Breid. Today we are going to discuss our latest report, shaping the future of UK healthcare, closing the digital gap. In the report, we examine the current challenges facing the healthcare system in realising the policy ambition for a digital first NHS and some of the solutions to overcome them. We also look at the potential of digital and information technologies to tackle some of healthcare’s most intractable challenges, of which there are many. The NHS long term plan and the fact that amongst other things, it does provide an increasing funding to help the NHS realise it’s ambition to be more digitally enabled and support staff to a different need. As part of our methodology for the report, we interviewed some 1500 staff across the UK and interviewed about 65 leaders in the digital industries as well as the NHS and academia across the working with NHS. So, on the basic of those interviews and the survey, we had a lot of interesting insights as to what’s really happening today in the NHS as well as what the ambitions in the long-term plan are and looked at whether or not those ambitions are realisable. One thing that we start with is the fact that most industries today that are customer facing have transformed themselves and are almost unrecognizable in the way that they deal with customers, the way customers can self-help and navigate those services themselves. But healthcare is lagging behind. What would you say to that point?

Breid O’Brien (00:02:23): I don't disagree in principle, but we have a long way to go. But actually I am heartened by the fact that there are parts of the NHS where there are some really exciting things happening. I think about the Health Innovation Network where we support the digital health London accelerator programme and we've got lots of innovators that we work with who are doing some amazing things to bring what I think of as modern easy to use technology to the NHS. We do have a long way to go though and we've got to get the right constructs in place for that. And I think some of those are picked up in your report and I am quite heartened by what I hear from centre and NHS experts about trying to solve some of those problems that perhaps are getting in the way of our progress.

Karen Taylor (00:03:12): Yeah and of course healthcare as is in the news all the time has got some really intractable problems not least the increasing demand at the time of staff shortages. So we'll come back to some of those points later. Just back to the survey that we did – we asked survey respondents what three words came to mind when they were thinking about UK Health Care's journey towards digitalization and by far the most mentioned words were: slow, expensive, efficient, challenging. Most of the responses at that point in our survey were negative but there were some positives – improvements in accessibility, efficiency and also the fact that it was exciting. In your opinion do those responses reflect what you're yourself seeing in your world?

Breid O’Brien (00:04:05): Yes, I think I hear for example the word efficiency mentioned on both sides of the argument, that actually in some cases the technology is really helping people be more efficient and reduce duplication; in others I hear people say actually the technology is making us less efficient because the user interface, all the time it takes to interact with it, takes longer. But I think what I do get a sense of is the excitement – people do feel actually that technology can make a difference. And on a good day I think that keeps people going but without a doubt, people do get change fatigue and you know the NHS is probably more challenged than it's ever been. There’re 40000 nursing vacancies. You know, we're trying to move ahead at a time when there are so many other things that perhaps are getting in the way.

Karen Taylor (00:04:55): I mean that's an interesting point because part of the reason for us doing this report was last year we had a report called ‘Time To Care’ looking at the sustainability of the hospital workforce, identifying the challenges of these increasing numbers of vacancies and the fact that staff are just so beleaguered that the chance to think about how they could do things differently is very hard for them to do. And the need for something to happen and we identify technology in that as being one way of bridging this gap between demand and supply. Have you seen any examples where this is happening at pace?

Breid O’Brien (00:05:34): I think one of the interesting ones recently is the work from Moorfields (Eye Hospital NHS Foundation) on AI and where we know that the radiology workforce is really challenged, as in demand far exceeds and capacity in terms of number of radiologists available and the work they've done has shown that actually using AI, they can triage people to make sure that they see those people who are most at risk from macular degeneration, the most common cause of blindness in the UK and Europe and make sure they're prioritized. So that actually is driving efficiency but more importantly driving patient outcomes because early treatment really impacts.

Karen Taylor (00:06:14): Actually, that's one of our case studies in the report so I'm glad you picked that one up. Again, back to our survey. We asked survey respondents what the top three challenges their organisations were facing in implementing digital technology and the responses by a large margin was the cost of the technology followed by finding the right technologies and the complexity of technology. We asked that same question to our interviewees and they identified funding as the biggest priority and the biggest challenge followed by leadership and interoperability. Again, it would be interesting to get your take home on those findings.

Breid O’Brien (00:06:52): Well only funding leadership interoperability I can't disagree with any of those. And perhaps they sort of interact anyhow. Interoperability for me is one of the key things if we're going to maximize the benefit that technology brings. I hear all the time from patients or frontline clinicians that duplication of data entry or that for patients, they want to see records, they can see them in an organizational view but that's not their story. I see one organization here or someone else there. Yesterday I heard about somebody who with their child who had learning disabilities was interacting with 14 different consultants – getting 14 different views of your single information – interoperability for me is huge. But actually to deliver that we need strong leadership and I think we need brave leadership because not everything has a strong evidence base. So as long as we're not compromising patient safety I think the willingness to scale some proven innovation is something we really need to grasp. But it all comes back to funding a lot of the time and that's particularly relevant if you're an organization that is financially challenged and digitally immature. How do you get on that on that journey? How do you even start?

Karen Taylor (00:08:11): Good points. And if you go back to the long-term plan, there is an on offer of £20.5 billion additional funding over the next five years. But in return it does expect that all providers and commissioners will both become digitally mature and become part of an integrated care system and redesigning services around public health with a key role for primary care in that digital transformation. There’re some targets for primary care that all clinicians will be able to access patient records wherever they are, and every patient will have access to online GP consultations by 2021. What's your take on being able to access GP consultations remotely or virtually and what is the difference between virtual consultations and digital consultations?

Breid O’Brien (00:09:04): That's a really interesting point because digital or virtual consultations mean different things to different people. So I think of it as meaning anything from an email to a high-tech video consultation where perhaps you can even listen to some of these tests and those exist. I think we've got to be really careful that we don't go for the shiny new thing, that we actually use the approach that's right for the patient and something I've read recently from the US is of a group of patients who have been identified as not requiring face to face treatment or appointments (and) of that cohort only 2 per cent opted to have video consultations. Most people wanted email that's asynchronous, it's not about them having an appointment time – they just email and interact that way while they have a telephone call. So, I think we need to be really careful that we don't go for what seems as the shiniest thing, that we actually moderate and use what's the most appropriate. And again that comes back as well to patients’ ability to interact with technology, we know there's a variation in our population in terms of how willing or able people are to interact with digital products. So actually making sure we use the simplest tech for the individual patient is key for me.

Karen Taylor (00:10:29): Yeah, I think we picked up in our report that it's not just a variation in the state of digitalization across the NHS but there's a real variation in how patients want to access that their clinicians, the services and an almost a need to segment the patient population. That's not easy to do but population health management is part of that approach.

I'll go back to the actual infrastructure, the IT infrastructure across the NHS and the fact that we found such a wide maturity gap both within different countries, within different sectors, within the secondary sector within community and mental health services and also between that the sectors and between the countries. In England we've had a digital maturity assessment both in 2016 and 2018 and admittedly they are self- assessed although there was some validation of the 2018 assessments, but they did show that that whilst there's been improvements there was still this wide gap and, in a score, out of 100, the range was from as low of 18 to a high of 93. So that ambition to bring all providers and commissioners up to a level of maturity, how achievable is that in the next four five years?

Breid O’Brien (00:11:49): I think it brings us back to the funding question ultimately because obviously what the GDE (Global Digital Exemplar) program has shown (is) that if you invest, you can actually drive maturity. I know there's varying opinions about that because obviously some people rightly say it has increased disparity, there's the haves and the have nots. However, from what I've seen, it is driving using the GDE the fast follower the production of blueprints so that actually were not all continuing to make the same errors and is actually very powerful, but I think the question which is obviously being debated at the moment is how do we fund the people who are less mature because often they will be the financially challenged trusts so they don't have easy access to capital. I think there’re conversations that are happening at a higher level in terms of how that can be supported. But yes, and we need to find a way of bringing everybody to the same level because otherwise we're not going to get the patient benefits because patients often, certainly in London, don’t move between multiple organizations so it's very strange for a patient to be able to get one thing in one organization and not in another.

Karen Taylor (00:13:07): We've seen the same issue before for clinicians and particularly junior doctors who might start off training in a digital mature hospital will have access to all the latest technology and kit and then find themselves in a in a in one of the lower mature hospitals. And the frustration of not being able to do the things that they've become accustomed to doing. So I think it's a problem for both patients and staff.

Lord Hill (00:22:22): The first thing I’d like to say – I had never worked in the European system before, so off I went, and it wasn’t a job that I had sought – I had no particular history in European politics –

Breid O’Brien (00:13:32): I had a conversation on that with the junior doctor recently who recounted having worked in a trust with EPMA (electronic prescribing) and then going to work somewhere where they didn't. And actually simple things like they forget that they have to rewrite the paper drug charts because actually you're alerted, and you don't have to do that in an electronic system. So at night time sometimes people realize at midnight that the drug chart has finished and actually you’re calling the night person to do it which is not an acceptable way of doing things because that's when you've got less staff and you're increasing the burden. So it's a really interesting reflection that when you get used to using technology you forget some of the paper systems and the extra load they put on.

Karen Taylor (00:14:16): Absolutely. That brings me to one of the other questions we asked in the survey which was about the staff's familiarity with the different types of, what we termed basic technologies, which would help classify that organization as a digitally mature organization. And they range from – the sort of basic ones were electronic health records, e-prescribing, point of care diagnostics, e-rostering and some forms of patient apps and then we also asked about their familiarity and belief in the use of things like voice recognition, robotics, virtual reality and artificial intelligence. Unsurprisingly, the technology that got the most recognition was electronic health records with the 90 percentile responses, that's what people were familiar with and we're using; e-prescribing dropdown to less than 50 percent. And then when you got down to the virtual reality and artificial intelligence you were down at less than 3 percent. So, these things are with us today – the technology is here. But we have yet to get even those basics right that are top of my list. Where would you sort of prioritize if it was up to you?

Breid O’Brien (00:15:33): Interestingly, one of the CCIOs that was interviewed last week by Matthew Gould at Expo talked about AI and said she doesn't have her clinical colleagues coming and asking her for more AI. What she's got them coming asking her for is, “I don't want it to queue. I want to log on and I want it to happen quickly”, and she gave the example of that every minute she spends logging on, and if he takes 10 minutes to log on, is a distraction from her interaction time with her patient. And if you think, that's a 10-20-minute consultation – that's very significant. So, for me, I think the AI is really important and we should keep doing it. But actually we need to get the basics right. And it's not an either- or it's actually we need to plan for the future while sorting out the present if that makes sense?

Karen Taylor (00:16:19): It definitely does, and I think also in the way we weren't surprised by the responses on AI because many of the technologies are AI-enabled and staff won't even know that. So you can physically see whether you can log onto a patient record whereas you can't see what's happening behind the scenes.

Breid O’Brien (00:16:39): Again, conversation at Expo was that eventually AI needs to get to where it's like electricity. We don't actually think about the fact that electricity is doing everything it's doing but when it first came about everybody was really aware of it. So once AI is established and it's just something that happens in the background I believe it'll bring huge benefit, but we're just in the early stages aren't we.

Karen Taylor (00:17:03): We are! You talked about when we were sort of introducing ourselves to each other, about Maureen. I think that would be something interesting to share with our listeners.

Breid O’Brien (00:17:18): I am a strong supporter of the IHI model, and they have an international conference every year. And I think it's about eight years ago. Maureen Bisognano who was the president, spoke about this interaction she'd had with a young diabetic patient whose name was Trevor, and where he had talked about as a patient. As a type 1 diabetic, he spent most of his time caring for his condition and his interaction with the healthcare providers was minimal, but it needed to be a really positive interaction. So he's he was the manager of his condition really. And he talked about using the model that comes from I think basketball and education in the US of us healthcare providers needing to move away from the paternalistic model. So, moving from being the “sage on the stage” i.e. “we know everything about everything”, to be the guide on the side – a really proper partnership with patients with long term conditions. And for me, that's the really exciting thing about digital because it does allow that constant connection, knowing that you've got access when you need it but actually yourself managing and when everything's well, you don't want to be reminded that you've got a long-term condition. I've heard that very strongly from patients when we talk about apps and reminders. Actually, when I'm well I don't want something constantly reminding me, but I want to know that when I need to interact with a healthcare professional I can. And I think you’ve mentioned (this) in your report, the IBD study from Surrey in Sussex. And that's a really good example of where patients are, that they're being guided rather than – they're managing their condition and actually 77 per cent said that they felt more confident in self-care. And that's really quite important.

Karen Taylor (00:19:12): Yeah. And that's a good example just for anybody listening – Irritable Bowel Syndrome.

Breid O’Brien (00:19:18): Yes. Sorry. Yes acronyms. Which is we have a lot of in the NHS.

Karen Taylor (00:19:20): We identified five key steps that we think need to be taken to bridge that digital gap. Three of them were around liberating the data and we hear a lot about data but being able to collect, analyze, use data in ways that we haven't in the past – there’s so much data. Will it lead to new innovation, to new treatments and better patient outcomes? So, the infrastructure, the need for open electronic health records so that people can access them wherever they are and the interoperability we've talked about. The other two features are under something we've identified as called changing the mindset on creating that culture, a different culture and attitude towards technology and the two steps in that are both governance and leadership. Would you say something about leadership? I know you've already mentioned it but something a little bit more about what you're seeing and how you feel we are moving in the direction of creating digital leaders.

Breid O’Brien (00:20:30): I think there's been lots of really good progress in terms of developing digital leaders. We've got the Digital Academy, there's lots of fellowships, so there's a really strong move to supporting people. When I first started working in healthcare technology, medical directors had responsibility for digital alongside the day job. We now have Clinical Chief Information Officers, the same for nursing, we now have Chief Nursing Information Officers. So, I think the clinical leadership is really evolving, and these people are having an impact. I think in terms of leadership elsewhere, I think we've got a mixed bag because in a system that's so pressurized, people don't always have the time, the thinking time because some of this is very complex and actually I think creating opportunities for leaders to explore digital more would be a really good way forward. I haven't met anyone who doesn't think the digital revolution for health care is a good thing. So I don't think it's that people don't want to do this. I genuinely think it's the operational pressures of the day. Sometimes digital feels nice to have against any target or the fact that you know you've got patients waiting for beds, that you’ve cancer patients that you can't get in – they are the real day to day problems for leaders in healthcare, so I think that just trying to create that time for people is one of the biggest issues.

Karen Taylor (00:22:00): Yeah. I'm a non-executive director on a hospital board and we've identified all people who’ve volunteered. Three senior clinicians-to-be, Chief Clinical Information Officers and the energy that comes with that and the support within the hospital is tangible. You can see a real sea change in their approach to how we can just innovate do things differently, work better for patients and patients are always the you know at the end. That's what the aim is to improve outcomes.

Breid O’Brien (00:22:30): And I think what I am talking to colleagues and talking to people together where you've got the Chief Clinical Information Officer, the Chief Nursing Information Officer, the CIO working as a really strong triumvirate, you can achieve amazing things providing the executive team are supporting, helping make this the DNA of the organization. So, if they create a construct in which those three people can operate then I think it's fabulous to watch.

Karen Taylor (00:23:05): Yes. We, because we are the center of health solutions we had to look at some solutions, identified some characteristics of digital solutions that we think will help improve adoption and we gave it an acronym because people like acronyms and we called it SMART. SMART is Straightforward, Measurable, Agile and Affordable, Reliant on working collaboratively and Tailored to the needs of clinicians and patients. We've got examples, case examples, for all of those separate characteristics and then some which cover all of them. For you what is what is the most important or one that stands out to you. Because I think they are all important.

Breid O’Brien (00:23:50): Absolutely I think they're all important and I could tell stories about why each of them is important. But I guess the one that feels the most important for me at the moment is “straightforward” and “easy to use”, because I hear from so many people, and it comes back to my point about logging in and how long it takes clinicians to do things and we have a phenomenal effort in the NHS when they go live with new systems on training you know there's a training schedule that would make your eyes water. But actually nobody gets trained on how to use you know apps on iPhones and things like that because they're intuitive. So I think for me straightforward and easy to use is probably the key both from healthcare professionals and for patients because we really want patients to interact. It has to be simple and doesn't take time doesn't take effort. So actually they do it naturally.

Karen Taylor (00:24:42): And that's particularly true I think for people with long term conditions who like your diabetes example live with their condition day in day out, but manage it in a way that they don't even know they're managing it but when they do need to bail to you to get that support and understand how their health is changing being able to use technology to give them that information that otherwise they'd have to go to a doctor to get is really important. So you mentioned again when we were talking earlier about a particular app and I don't know whether there's one that stands out for you.

Breid O’Brien (00:25:20): Well I mean there's lots, but I think from recent conversations, the Freestyle Libra for type 1 diabetes – I think it's more as a product rather than just an app, but it means that you know people can live a life where they don't have to constantly prick their finger. They're you know getting so many more data points on their blood sugars that actually helps them manage and know what impacts it. So for me that's one that I think has a huge impact and having recently gone on their website and looking at the patient testimonials they are so powerful about how people, you know our colleague who corrected me from saying diabetic patients, she very rightly said I'm a person living with diabetes. And actually that for me, the Freestyle Libra and some of the work around diabetes app (there's lots more apps and products) is really exciting because that's one long term condition where technology is making a real difference.

Karen Taylor (00:26:24): You know one of the examples we pick out in the report is cognitive behavior therapy and the ability to be able to receive that more remotely to be able to interact on a more regular basis with you with your clinicians. And it's in the report it's silver cloud and the way that that's being adopted across the NHS. Have you seen other ones that are getting that much traction?

Breid O’Brien (00:26:50): Well recently we had a guest speaker from Australia, a mental health clinical nurse consultant, and we had a roundtable with people and it was around virtual consultations. You can imagine in rural Australia getting acute mental health assessments. They were sending patients 200 kilometers or more to just be assessed and they were admitting about 80 per cent of those patients because they travelled 200 miles, not good if you’re in an acute mental health crisis. And actually now, they do virtual consultations. A lot of training, a lot of interaction but with the local team supporting and the specialist obviously on the other end and they've flipped that, now they're admitting about 20 per cent of their patients and more importantly, they're not sending these vulnerable pay patients 200 miles away from their care network. So they're actually keeping them closer to home. So, for me that's very relevant, and we had a really good discussion because although rural Australia is very different it's not that different when you think about providing care as in what you're trying to achieve in outcomes. So we have to move patients many miles and on regular basis, probably, for acute mental health beds at the moment. So this is something that you know, maybe we can learn something from.

Karen Taylor (00:28:00): Yeah absolutely. Excellent example and that point about learning from others. There’re many studies that I've done across healthcare and I always identify examples of good practices. There's no shortage of those examples, but seeing those examples being adopted by others and adopted at anything like scale has always seemed to be a big problem for the NHS. So getting that adoption at scale – what would you do to try and improve the adoption at scale?

Breid O’Brien (00:28:29): I think the power of storytelling is huge, patient stories, and they're not stories, they're real life. This has changed things for me. I think that we need to get better at. I think one of the challenges I said we have digital health accelerator and work with lots of small medium enterprise companies, who do great things. But we all struggle a little bit with the evidence because you have to have opportunities to try these things to get the robust evidence, so it's this “chicken and egg” thing. So I think I would probably say encourage people to be brave and try some of these things, but I say that completely understanding that it's against a backdrop of operational pressures. So sometimes, this new innovation just feels like a step too far. So having the right moment is key here. So, a strong storytelling, the evidence based as robust as you can. Funding obviously becomes the issue at that point but if you have the first two sometimes funding’s a bit easier.

Karen Taylor (00:29:29): Yeah and there are steps to improve that through things like the NHS app library but also NICE’s (National Institute for Health and Care Excellence) new portal to assess technologies. So I mean there are the things are starting, they are in place aren't they.

Breid O’Brien (00:29:44): Yeah I did read actually because we had the launch yesterday of our next cohort of SMEs on our accelerator program and there was a quote from somebody, an NHS staff member saying that actually what was great about the accelerator is somebody had vetted these companies upfront so they didn't have to go out to this big process, they could actually think well, these companies have gone through some process so as you've said some of the things you've mentioned also help with that.

Karen Taylor (00:30:12): Yeah definitely. So just to finish we asked our survey respondents what three words they would hope to use to describe the state of UK digitalization in five years’ time and they were predominantly positive responses: efficient, effective, reliable, safe and integrated. So there is a lot of positivity to take from people's attitude towards digitalization and our interviewees were slightly more cautiously optimistic. They talked about it being connected, easy access and cutting edge but they thought maybe five years was a little bit sooner to see that change at scale. What would you say you would hope to see?

Breid O’Brien (00:30:55): Coming back to something I keep mentioning, interconnected systems – as a patient, I want to be able to see my record as it works for me, not as it works for organizations and that’s really dependent on interoperability. I’d also, I guess, like to see this partnership that we’re really genuinely working, in partnership with their patients and I think that’s where digital, you know in terms of some of the work again with the SMEs where people are really working with users and clinicians to design the systems. So, actually they are really solving problems for people. I’m quite excited by the future, I think we are in a really interesting time for healthcare technology. I think there’s a real focus on the outcomes that it’s driving which rather than the tech where in the past was perhaps more about implementing tech, that is a sea change that has happened. It doesn’t mean we haven’t got change management challenges. I was excited recently using the NHS app because although I could get into my GP’s website, I could, on the move, order my repeat prescriptions and I’d just pick it up and go at a time that’s convenient for me. There’s no phone call, no having to sit at a desktop. I did it probably when I was on the bus. That actually might seem like a small thing, but that’s how I do everything else in my life. So, we need to think about how we do that for people who need to interact with healthcare – how does it just become part of something they do in their life, rather than this thing on the side. And that’s about staying healthy, as well as actually managing a long-term condition.

Karen Taylor (00:32:32): Thank you Breid. That was really interesting. And I hope our listeners agree. Thank you very much.

Breid O’Brien (00:32:40): Thank you!


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