From managing long-term conditions and preparing for operations to supporting discharge and facilitating admin tasks, the potential for digital health technologies to transform acute healthcare across the UK and Europe is vast. Helena Beer speaks to digital health expert Liz Ashall-Payne about the current picture and how she sees health systems overcoming the remaining barriers.
Despite all the problems facing the NHS and health systems across Europe, ‘throwing technology at something isn’t the answer’, according to Liz Ashall-Payne. And it’s a surprising statement coming from someone who has dedicated the best part of her 25-year career to digital health.
But the chief executive of the Organisation for the Review of Care and Health Apps (ORCHA) is resolute in her belief that a measured, whole-system approach is needed, with technology at its core, and she’s nothing if not determined to facilitate progress.
Ms Ashall-Payne’s digital health journey was born out of a ‘frustration and a passion in equal measure’. The frustration centred on the fact that as a clinician working in complex paediatric care, she was limited to only seeing – only helping – one patient at a time. And that’s where the passion came in. As with most clinicians, the ability to help people is what got her out of bed in the morning.
Driving efficiencies, making change
After coming across the concepts of lean methodology and Six Sigma – systematic approaches to identifying and eliminating waste in processes to improve performance and deliver more value – Ms Ashall-Payne was able to make fundamental changes in her organisation to release more time for patient care.
‘In a three-month period, we went from 21 months waiting for assessments to 11 weeks. It was amazing just how much we were able to do,’ she says. ‘But, of course, you do get to a point where you realise you can only drive so many efficiencies, you can only run so fast, you are still challenged by the fact that you can only see one patient at a time.’
By this point, however, technology had started to emerge as an enabler to achieving more access to healthcare and Ms Ashall-Payne championed it from the start. She took up a role leading on digital health for the newly established Academic Health Science Networks. These were founded in England in 2013 to drive the adoption of technology and innovation in the NHS to benefit patients and support the NHS itself as well as the economy.
While entering discussions with individual hospitals was all well and good, it soon became clear that a whole-system approach was needed to achieve the breadth of adoption required to make a real and sustained difference.
‘The obvious thing to look at is the distribution of drugs,’ says Ms Ashall-Payne. ‘So, in that analogy you have testing and evaluation – in the UK that’s MHRA and NICE – it then enters the curriculum and the British National Formulary. There’s then a prescription infrastructure that allows for safe distribution of the right drug to a patient, and that also supports reimbursement flow. And I thought, that’s what we need for digital health; we need a way of assessing and evaluating technologies.’
The big difference, however, is that this process would have to be done repeatedly because ‘drugs don’t change, technologies do’. And this is what Ms Ashall-Payne and her consultancy ORCHA are striving to achieve: providing core infrastructure across the UK and Europe to overcome barriers and introduce quality-assured digital health safely and effectively.
In a report published in spring 2023, ORCHA revealed that using simple evidence-based digital health technologies to encourage patients to manage their own care better at home, the NHS could save 5.9m GP appointments, 120,000 ambulance journeys, 600,000 A&E admissions and 127,000 unplanned admissions annually.
Applying a similar analysis to data from Denmark, Norway, Sweden, Finland, and Iceland, an estimated £38m of financial savings could be achieved within 12 months through the adoption of digital health technologies. And that’s from long-term conditions alone.
These projections suggest the potential is huge, and Ms Ashall-Payne remains positive that widespread adoption is possible. But there’s undoubtedly a long way to go.
Just how important are digital health products in the modern age of medicine and healthcare?
The reality is that we’ve never had enough capacity in healthcare systems globally to deal with the demand. And, of course, what that’s meant is that everybody’s seeking a preventative support mechanism to try and limit that demand.
The prevention agenda is far greater than just preventing illness. It’s also about preventing crisis and supporting efficiencies in long-term conditions. It’s about making sure that people stay as healthy as possible so people don’t turn up at an acute door.
If you take something as simple as hip and knee operations, we know that 7.4 million people are waiting for a hip replacement. Nearly half a million people have waited over two years and those people are waiting in pain, those people are not mobile. They may be putting on weight or turning to alcohol or cigarettes, they might not be sleeping. What does that mean? Well, it means is there’s a revolving door to primary care, but in the acute environment, 20% of all operations are not filled because that patient isn’t fit for that operation. It’s about preventing loss of capacity and we’re back to the capacity and demand challenge.
If you take something like mental health and the numbers of people who are turning up at points of crisis in an emergency situation with self-harm or suicide. If you look at the challenges around discharge and supporting people to get back into the community.
All these things start to level up into even bigger macro challenges around the economy. People are off work while they’re waiting for elective recovery or while they’re struggling with their mental health waiting for intervention. And that means that people can’t get back to work so the problems are exacerbated.
We’ve done research which found that digital health is more effective in the prevention of type 2 diabetes than metformin – and it’s cheaper. And this is big because digital health changes behaviour, whereas giving somebody metformin doesn’t change behaviour. So, we’re starting to see the evidence base that sits underneath.
Digital health is our future medicine. I 100% believe that digital health will be prescribed as frequently as a drug. This is important for the for the NHS, but it’s important for us as populations as well. And every part of society, actually.
To what extent are apps currently being adopted in primary and secondary care?
Every single day, five million health apps are downloaded. That’s the global number. That increased from about four million a day from a pre-Covid perspective. So, people are actively wanting to use digital health. However, our research has found that only 20% of the technologies out there are safe and effective.
What we also know is that the people who are going to download these technologies are not the people we really need to target. The people who really need to target don’t even know these technologies exist. People living with COPD, people with schizophrenia, eating disorders, people who could hit crisis.
And so how do we get them to engage in these technologies? Well, the best way to do that is through a trusted healthcare professional. Over 90% of healthcare professionals believe that technologies could help their patients and they want to engage with it, they just don’t know what to do. There isn’t an actual system in place so tracking the number of technologies being recommended is really tricky.
What we are definitely seeing is healthcare systems procuring more digital health apps. Continuous glucose monitoring is being commissioned in the NHS, for example, and there’s a route to market and reimbursement with evidence of return on investment (ROI). And that is what’s ultimately missing in a lot of these instances so there isn’t wholesale adoption.
If you take somewhere like Germany, they’ve got the DiGA process. They’ve passed a law that says if a DiGA-compliant product is recommended by a doctor then the health insurer pays for it. That sounds brilliant – they’ve cracked it. Well, they haven’t cracked it. If you think back to the drug distribution process of evaluating to distributing and reimbursing, they’ve got the evaluation and the reimbursement but, for that distribution element, they have no training or prescription infrastructure for digital health. After two years, the DiGA is not doing what they’d hoped it would do because of those missing segments.
What do you see as the other barriers to adoption?
There are five big barriers. The first is awareness. People, patients, healthcare professionals, healthcare systems and commissioners don’t even know these technologies exist. Why? Because they’re not trained in them. If you’re doing your training now to become a doctor, you might if you’re lucky get seminar on digital health, but you’re certainly not trained in them. So, awareness is really low and wholesale awareness in our population is low as a consequence.
The next problem is access. There are 350,000 health apps and of those 21,000 are mental health products, for example. Where are you going to get even a long list from? As a clinician, you want to know the right products for the person you’re trying to support based on their personal challenges, personal preferences and needs.
If we both want an anxiety product, but you’ve got hearing impairment, and I’ve got a visual impairment, we’re going to want something different. And if you’re 15 and I’m 82, we’re going to need a different product. So, you start to think about the nuances and well as the big picture. And if you think about this in a drug analogy, there isn’t one antibiotic, there’s not one insulin, and that’s because we know that different drugs help different people in different ways.
Once you’ve accessed a product, the next challenge is trust. Can I trust it? Is it safe? Is it effective? Is it going to share my data? Is it secure? Has it met all these standards? And of course, it’s a challenge because, even if you’re a clinician, you don’t know whether you can work out whether it’s safe or effective.
The fourth challenge, which most people don’t think about, is if I’m going to recommend a product or an intervention for my patient, who’s governing any future risk? The technology will change so who’s holding the liability for future change? And this is the difference in drugs versus technology.
And then the fifth challenge is who’s going to pay for it. So, particularly in the UK if you’re an NHS clinician, you don’t want to be suggesting a product that’s going to cost the patient £100. You want to make sure there’s equal access – it’s part of our ethos. For any clinician, who pays is really important.
Those are the big, big barriers to adoption. And I think in a lot of healthcare systems globally people are getting stuck on the trust bit.
What are the biggest benefits and downsides of digital health for acute care?
Working pan-system is really important. What we can do from an acute perspective is to know who the revolving door clients are. There will be a good percentage of people who are very well known to the acute environment and they clean them up and ship them out. But, actually, why don’t we provide them with an intervention to avoid future crisis?
If this is somebody who keeps having an COPD or asthma exacerbation, let’s give them something to manage that long-term condition. If this is somebody who’s struggling with a mental health condition and they’re waiting weeks for referral and keep turning up with a self-harm challenge, let’s give a product that supports them to access remote crisis intervention.
Then we get into the efficiencies. Digital health is massively supportive in that pre-op piece. Most acute environments will provide patients with a pre-op assessment six weeks before their operation. We need to be doing that way earlier. Because if somebody’s got to lose four stone, they’re not going to do that in a six-week period to be ready for that operation. So, let’s work further upstream and support people to be ready for their operation. These are low-complexity products with low risk for high volumes of patients.
There’s also a whole load of utility products that support with admin. Getting locums in, bookings, all those kinds of products. This is very much about supporting clinicians to have more time to care, so that you drive more efficiencies from an admin perspective.
And then, of course, a big area to support in acute is early supported discharge. And this is a really pragmatic example going back to the hip and knee operation point. After you’ve had surgery, you need some support around physiotherapy and occupational therapy. Quite often people experience that while they’re in an acute environment and then they go home and they sit down. Actually, there are amazing digital products that you could discharge people with to get them doing the physical interventions in their own home. It’s more sustainable and we’re able to release beds earlier for other patients coming through the system.
Single point solutions aren’t the answer. And, of course, prior to that A&E crisis turn up, you’ve got your ambulance visits, prior to that you’ve got your revolving door in primary care and so on. We need to look at whole pathways end to end and look at the ROI across the system.
The downside is the current way in which commissioning happens. In the UK, if you’re an acute provider you get paid for seeing patients. If you manage to prevent patients from needing your services, what does that mean? We absolutely need to have a different conversation about how we pay hospitals and reimburse hospitals and we need to incentivise them to support this whole pathway agenda. It’s reasonable for them to say this will take money away from the acute trust because they need to be as sustainable as everybody else.
Is the NHS ready for this digital transformation?
I think when we use the word technology it’s just really important to think through historically what we’ve meant by that. I remember when we had laptops put on our desks and going to be trained in how to send an email and I remember thinking it was magic. That was 20 years ago, maybe a little bit less than that. We then move into electronic health records and, again, I remember thinking I’ve got my paper notes, why do we need it to be electronic? We’re now over that hurdle, it’s just getting used to different types of technology.
The implementation of these technologies has previously been led by IT or technology teams. What we’re moving into is clinical interventions that are provided digitally. And that, of course, is a very different side of the equation.
This is why it’s really important that we have clinical leadership and medical leadership pushing these interventions. I don’t believe that the IT team will lead this. It isn’t about infrastructure; this is about supporting patients through clinical interventions.
So, do I think that the NHS is ready? Do I think globally we’re ready? No, I don’t because of all those barriers. If you ask a clinician what’s the best dementia product, they might not even know there was a product available. So no, we’re not ready.
On a normal distribution curve, we’ve gone from email being at the innovative side to it being a very simple basic. And where we are at the minute is digital health being super innovative. Once we get over the hurdle, it becomes adopted by the masses and it will happen. We’ve already got history to show us that this will happen, it just takes time.
How far away from being a core part of prevention and healthcare is digital health?
It feels like we are at a bit of a critical juncture. The burning platform has never been brighter. If you look at the trajectory for our workforce and capacity, the problem is just getting bigger. Politically, there’s a huge amount of pressure. If you look at anything where the word transformation or innovation is discussed, digital is right front and centre. People are already wanting to use these technologies.
I think the challenge is that the same system that I’ve described as needing all of this change is running from one crisis to another and firefighting. They’re under huge amounts of pressure, they’ve just gone through a massive restructure in the NHS, we’ve just gone through Covid and people are recovering. I think it will absolutely happen, the challenge is scale and how fast it’s going to happen.
There’s case study after case study where we’ve got small pockets of amazing success where primary care and acute care have worked together on things like a whole mental health pathway or a public campaign on strep A. We have to get better at scaling faster. That scalability is about sharing knowledge and evidence. Clinicians, the NHS and healthcare systems globally want to see the evidence.
For us at ORCHA, what we’re obsessing about is not evidence and ROI of single point solutions, but evidence and ROI of a whole pathway transformation using digital health. Why? Because that’s where you’re going to get much greater impact.
If we only look at one part of the system – community care, social care, primary care, acute, mental health services, third sector – and RAG rate performance, if you’ve got a red area saying acute, what happens if you turn that green without thinking about everybody else? You’ve just moved the red, you’ve not actually made an improvement. We need to think whole system and make sure that an improvement is an improvement for the system, not just the movement of a problem.
Is Europe at a similar stage to the UK in this digital transformation?
I would describe this, in brief, as a jigsaw puzzle. Every country has got a few pieces of the jigsaw puzzle in their picture but nobody’s completed the picture yet. And it does feel a bit like there’s a race to complete the picture, which is good, because that means that somebody will get there. Along that journey, sometimes the wrong pieces of the wrong jigsaw puzzle get put on the page. Everybody really needs to learn from that.
So, there have been some challenges with the DiGA in Germany in terms of training. France is fast behind them with the PEC-AN – they’ve created an adaptive DiGA with a few more of the holes covered. What we’re also seeing is the European Commission thinking about this whole scale and pan-Europe.
If the biggest barriers to adoption are trust, awareness and access, how can we have a pan-European place for compliant technologies that are safe and effective and that people can access, procure and deploy?
People are getting a bit stuck in the standard setting, which is really important, but they’re not thinking through the practicalities of who’s processing, who’s deploying, who’s training, who’s paying. And we’ve got to shift.
Like I say, Germany and France are making progress. We’ve also seen smaller countries coming together and considering, for example, whether we can have a Nordic-wide offering so that the innovators and digital suppliers want to come. Creating a joint access point for the market means smaller countries can still use these products to have an impact on their patients.
I think what is quite interesting and exciting about Europe is that they’re setting out with the correct ambition and vision. I wish that we were further on, but we’ll see.
Has there been movement from policymakers in recent months, or any signs to suggest further progress?
I think that politically this is really high on the agenda because of the capacity and demand challenge, the resourcing challenge, the economic impact of all this. We saw digital health discussed in the UK budget for the first time and investment into digital health has been announced in the UK.
We’re also seeing other parts of the system involved. So, as ORCHA, we’re having conversations with the police. They’re looking at this because a significant number of people that they interact with have mental health issues and that’s often actually the underlying reason why the crime was committed.
Employers are also very interested in digital health and looking at how they can support their teams to be healthy, stay in work or get back to work. Educational environments are starting to think about this. It’s a top-down and bottom-up approach.
The pressure has mounted. What we now need to do is scale what is known and put some of the enabling infrastructure in place to allow that to happen at pace. Scale and pace are the two things that need to happen now.