Recent technological progress has revolutionised clinical practice and has enabled an unprecedented increase in public engagement in managing one’s own health. Digital health apps, systems and solutions have enormous potential to reduce the time, effort and cost of managing personal health as well as improving health outcomes to a significant degree. However, the successful design, integration and deployment of digital solutions into existing health systems require a radical shift away from traditional clinical workflow and changes to core mechanisms of reimbursement are also needed. The NHS is actively taking steps to encourage, assess and scale digital innovation within its system. The NHS Innovation Accelerator (NIA) has been established to identify and support digital innovation and a tool is currently being created to assess digital maturity across Sustainability and Transformation Plans (STPs). However, the practical barriers to commercialisation and integration across the NHS abound.
Let’s look at the commercialisation challenge first. While the tariff system for digital health is beginning to be addressed by the NHS, these are very early stages. The current system is characterised by great uncertainty in coverage and insurance codes, making reimbursement within the NHS ambiguous, complicated and often unavailable. There seems to be no straightforward way to select the right digital health solution for patients with a particular health problem.
The NHS Innovation Accelerator (NIA) provides a reimbursement route for digital health solutions that focus on any of the three key challenges, based on population health needs: prevention, early intervention and long-term condition management. However, I am convinced that proving value to the NHS is only viable for the long-term condition management category. One reason for this is simple maths; the management of long-term conditions (mostly for an aging population) is a disproportionally large drain on NHS funds and a prominent pain point for a large market segment. Any cost-optimisation for this greatest expense category is likely to have the most impact on the overall cost and yield a convincing business case. Another reason is a budget system where commissioners are responsible for allocating budgets on annual bases. In such a scenario, there is no motivation for commissioners to look at the medium to long-term perspective which is essential in order to demonstrate results in the prevention and early intervention categories.
For these reasons, the route to commercialisation of digital health solutions is in the area of long- term condition management and through providing evidence that the solution is saving time, saving money and improving outcomes within a timescale of one-two years.
Another challenge in the digital health industry is the misalignment of agile digital culture and NHS bureaucratic processes. Like any government system, the NHS is highly hierarchical and formalised with a wide range of stakeholders, users and service suppliers – doctors, commissioners, practice managers, nursing staff, patients and payers (including insurance companies). Creating digital solutions that will become part of the overall NHS system means investing the time – early in the process – to develop an accurate stakeholder map and uncover every single stakeholder. Time invested should include answering the ‘What’s in it for me?’ question in relation to each one. Involving these stakeholders in co-designing solutions will take time – it may easily take six months just to present the concept to NHS stakeholders.
The future of integration
The introduction of digital health systems int the NHS adds a new level of complexity which the current system is not set up to accommodate. Getting clinicians to change their workflow and involving IT departments in deciding on appropriate medical procedures (previously decided by infection control, nursing staff and procurement) is not a quick or simple task. The integration of digital health products into the NHS system also means dealing with the complexity of integrating Electronic Medical Records (EMRs) with digital solutions interfaces. EMRs display little ability to interface and often do not communicate well with other EMR systems, let alone telemedicine or digital health systems. Moreover, remote sensor data cannot be easily integrated and accessed on the EMR.
Furthermore, digital innovation is unlikely to be the top priority for doctors, medical directors, CIOs or CFOs and the new level of complexity is likely to be an annoyance in an environment focused on providing immediate assistance to patients who are ill. It is important to invest the time to understand the inner workings of the NHS, build relationships with key stakeholders and focus on metrics that can demonstrate real benefits of time/cost savings and improved health outcomes. I believe that demonstrating undeniable benefits and clear implementation routes will help offset initial resistance.
Getting to know stakeholders
The NHS has developed policies to incorporate digital technologies focused on delivering cost and time savings as well as better outcomes for patients. However, the gap from policy to practice is evident; there is still no clear system or reimbursement environment that would welcome digital services yet understanding these systemic shortcomings and current NHS priorities allows one to develop solutions that can break through the bureaucratic labyrinth and prove value.
Before digital health companies start developing services they have to get to know the relevant stakeholders in the NHS and design solutions with their needs in mind. The NHS should also focus on the operational side of integrating their solutions with the various systems currently available. Finally, and most importantly, the huge costs related to the ageing population have created an enormous opportunity for digital health companies focused on long-term care. It is only a question of time before the NHS will make extensive investments in this area, sparking a vigorous innovation ecosystem.