Paul Burstow: Putting people first

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Paul Burstow, President of Telecare Services Association (TSA), discusses the work of TSA to support integration of health and social care services through technology.

This presentation was recorded at our Digital Health and Care Congress 2017 on 11 July 2017.

Transcript

Thank you very much Linda.  As you just said, I’m not here wearing my hat as chair of the Tavistock & Portman NHS Trust, that is what my badge, that’s what it was going to say on the programme.  I’m actually here today speaking on behalf of the TSA.  TSA is the body that represents commissions, providers, suppliers of technology enabled care.  So, it covers the sector from a variety of perspectives and we’re going to talk a bit about some of the work that we’re doing at the moment and might be of interest to you and I’m going to particularly talk about some of the upcoming work we’re doing around the switch that we will be all racing over the next few years from an analogue world to a digital world and some of the implications that will have as well.  

So I just thought I’d start to reflecting on something that Rob Shaw was saying this morning about how we shouldn’t really try too often to predict the future, especially when it comes to things like general elections where as we know recently it was a bit of a mugs game to do that, but Bill Gates said this a few years ago and Rob I think put it very powerfully when he talked about David Cameron coming into office in 2010 and how the first five months of his premiership we didn’t have iPads, we didn’t have tablets, these things hadn’t yet come into general usage.  That’s so recent that you can almost touch that, it’s so close, but things do change and technology has and it will continue to remake our world.  Most of us have within our pockets or our purses, Smartphones that have the power and capability well in excess of that which was necessary to land a man on the moon, so things do change quite rapidly. 

But in some senses, they don’t always.  I last spoke at this congress back in 2011 and I’ll explain a bit why I was doing that then, but these subjects have been on the agenda in one way or another both in the popular media and in science fiction and in science fact and speculation for a very long time, going back to the 1920s and there was talk about medical consultations using the radio or look at the first ideas around tele cardiograms going back to the early part of the 20th century.  So there’s been talk about these things for a very long time and the thing that was striking today was how technology can remake and get us to think differently about the bricks and mortar in which our healthcare is delivered and indeed whether bricks and mortar are relevant and I came across this particular project that’s taking place over in the United State, perhaps the world’s first virtual healthcare centre, where there are no beds but they are monitoring large numbers of people and delivering healthcare in an anticipatory predictive way in that part of the world. 

I think for the TSA perspective, what we’re seeing is a really interesting convergence taking place, and that convergence is between cloud computing, mobile revolution, sort of the ubiquity of those Smartphones I was mentioning just now, the internet of things and theme of today, the power of data analytically used to give deep insight to predict, to be actionable in one way or another and we’ve seen how this has led to a transformation in many other sectors of our economy, think about banking and think about the nature of banking in the 1950s where we would have been going to the bank to deal with our transactions, today we will pull out phone in many cases and do it all on the phone.  That is what is also happening increasingly in care and in healthcare as well. 

I just thought I’d put a couple more quotes up just to sort of illustrate why it’s always dodgy to predict the future and these were just a couple that stood out for me, just the final one was this.  An estimate a few years ago was that was all we would need, and again, just think how much a memory just one of our phones has today and even the brightest and even the smartest can get these things wrong, and Bill Gates was predicting that back in 1981.  So, Linda said I was going to give some context as to why change is inevitable, why change is good, why change is necessary, and I want to just give some context and I think it’s in that way, one begins to see the value and the context of the changes we’re talking about. 

Just last week, Care Quality Commission, they published another report in which they said we really are getting very near to the tipping point when it comes to our health and care system and Joe Sutcliffe said the risk of adult social care approaching that tipping point is still real the year before David Behan the Chief Executive had said the system was very fragile and the evidence suggested that we were approaching a tipping point.  Now, I meet many people who say when does the tipping point tip and when has it in fact tipped, and many would say that it already has and certainly that the pressures are there around the system.  The obsession with delayed transfers of care is an obsession with a symptom of many of these tipping point issues that are well documented by our regulator and they have given rise to government responses, additional £2 billion announced in the budget.  The Council Tax pre-set and so on.  

But, a focus on the money doesn’t tell us all of the story and certainly isn’t all of the case for change because we also have work that’s being done by Skills for Care which shows that the demand for care workers, and this is a workforce that is larger than the National Health Service workforce, is outpacing domestic supply. Supply in the United Kingdom and that by 2025 we will need about 1.8 million care workers, an 18% increase.  Now that’s good and it’s good from the point of view of a job and work creation, but we need to under what the pressures are in terms of shortages and some work has been done by the International Longevity Centre an independent age, looking at the trends, looking at O&S data and other data to project forward what the likely numbers of available workers will be, and what they found in a report they published earlier this year, last year now, was that there’s a workforce shortage with a range of between one million to 400,000 depending on how attractive the sector is seen by the people who work in it.  The less attractive it is, that will lead to an even greater shorter, the more attractive it is, that will close that gap but there will still be a gap if business as usual is what we accept and what is available, and that seems a long way away 2037, so lets’ go a bit nearer because the same research also found that by 2020, that’s the sort of shortfall.  

Sitting in there are questions about Brexit, but it’s not Brexit that’s the main driver here.  70,000 of our EU fellow citizens are working in this workforce, but that is not the sole driver, it is that whole issue of attitudes, behaviour and to the value that we attach to this.   

I said it’s a mugs game to predict, but you can always look back in the mirror and say two things about the election we’ve just had.  One is that the conservatives won, but somehow lost, and two, that Labour lost but somehow won and I think the question now is where do we go when it comes to social care.  I was speaking at this conference back in 2011, as a minister, a minister for care in a coalition government and we tried unsuccessfully, to address some of the fundamental questions around social care so our coalition was unable to fix it.  Majority governments have been unable to fix it and the question is, can a hung or balanced parliament fix social care?  

We had the 2010 general election fought over a death tax, and we had the 2017 election fought over a dementia tax.  The conclusion the politicians and speakers are sort of retired, or retiring politician is that this is a third rail issue, you touch it politically and you get fried.  And I think that’s the wrong conclusion.  It’s a dangerous conclusion, but I fear that that is the conclusion that many in political class have reached, and I think that actually, the only solution is genuine cross party dialogue and it’s just worth noting, I’m not going to quote you verbatim, but if you were to have taken the time to read the sections from each of these manifestos to find out your fate, in the unlikely or likelihood of one of them getting into power, you would have found actually a remarkable amount of common ground.  They all want to pool budgets, they all want more integration.  They all recognise there is a fundamental issue about funding of social care, they all think that there needs to be more done to integrate the system. 

And it’s not just about the money, and I’ve said that and I just want to sort of re-emphasise that because I think it is a key message that I think really plays into the debate about how technology can make a difference and I think there are three things I just wanted to highlight before I talk about some of the technology and the first was this; Care Act passed in 2014, established a proposition and remunerated that proposition which was the promotion of individual wellbeing should be the organising principal for adult social care.  In other words, the maintenance of social function, the ability to function well, to feel good, to be able to maintain connection, to be able to do the things that sum up what is to be aligned and I think that’s a pretty good organising principal for when it comes to addressing issues of the management and maintenance of people living with long term conditions.  It’s in essence what self-management is about in terms of empowering people to manage their conditions. 

But also, this conference and this particular session is about efficiencies and opportunities for health and social care through integration and the local government association just a few months ago published this piece of work from a piece of work they commissioned from an organisation called Newton Europe, I don’t work for them so I’m not particularly selling their product, but it’s worth having a look at this report and this was their top line, this was from a survey and detailed work they had done in eight local authorities around the country doing quite detailed data analytics and process analysis and what they found was this was potential efficiency savings and they identified a number of things which are very relevant to service redesign.  They found that one in four acute admissions could be avoided.  They found that one in four hospital discharges could result in a person going into a cheaper care package, yes cheaper, but actually better, in terms of the outcomes that it delivered for the individual and they found that up to 45% of the pathway decisions about where someone should go, what nature of package they should get could have been improved and there was huge variation sitting in the system between different decision makers leading to significant opportunity.  

Now this billion, if it were realisable in practice, doesn’t answer the whole question but it provides some of the reason that politicians often say well there are things that can be done beyond just putting more money into the system and I just put this chart up because of some work that was done by the building research establishment and it’s just a compelling fact I think for me, which was that they estimate that the first year treatment costs of the population living in the 15% of worst housing in this country costs the NHS this.  So, many of the solutions to our driver and demand ridden health and care system actually lie outside that system.  

So, technology.  Well the TSA message is a very simple message when it comes to technology.  It’s not about the kit, it’s about the end user, and it’s about how the service is enabled to be different to the traditional experience that people of services.  More interactive, more driven by the consumer and their preferences.  And we published a report, last October at our conference, looking at some of the experiences places like Hampshire, Sunderland, Liverpool and others who although much at the cutting edge of how we used digital technologies and we came up with a case for change, what good would look like, what the key enablers are and also the essential need to commission increasingly on the basis of outcomes and why did we say that?  Well we said that because very often it feels that we are doing the same things with an anticipation that we will get a different result because we’ve just tried harder and that in the end is the route to insanity. 

So, what did we say we needed to have coming out of this piece of work, what were the key ingredients from those authorities and CCGs and providers that we spoke to last year, as part of the preparation of this report? Well the first thing they said to us, was that what was an absolutely key component was really robust benefits realisation.  Really critical to getting commissioners on board and critical to convincing finance directors that there were both costs being avoided as a result of these interventions being put into the service but also costs could be reduced and places like Hampshire have those methodologies in place, the local authority and it is convincing their finance director to continue to commit investment because it is saving.  

Second point which came up into question to Rob this morning, absolute key, is the critical importance of involving service users and gaining insight from their experience in co-designing new services and that that requires us all to be curious, it requires us to be perhaps sometimes more empathetic than we necessarily are and it means that we have to be interested in the context in which healthcare consumption takes place.  And one of the things I’ve picked up really very strongly today, is the vital need for there to be partners across the system, really to deliver the integrated models that we all aspire to and not least around data sharing which has been a key theme and I’m not going to labour the point and I’ve seen on Twitter, various debates as to whether it is the oil in the system or whether it’s the road that we use or whatever, but nonetheless it is absolutely key and getting beyond some of these rather limiting debates about what information governance requires and doesn’t require is absolutely key. 

And then we talked about well what does digital leadership mean in all of this for this report.  And the first thing we said really was that digital leadership is not something that you put into a little silo, it’s not of the back cupboard into which you put a techie expert.  We really question whether or not it even should be seen as a separate thing at all, that in fact by doing it that way you risk that technology enabled care and digital health becomes delegated away from those that are responsible for commissioning the service itself, those that are responsible for thinking about how you redesign services and in the end, it winds up being bolted on, and if it’s bolted on, it’s less likely to be as effective as it could be. 

And what are the skills that are necessary?  Well you’ve been talking about this all day today, data analytics, advanced analytics and we’re moving up a hierarchy as we get better and better at pulling different datasets together, but then there are also soft skills around being able to listen to lived experience, to co-commission, to co-design, not just consult.  It is beyond consultation that is necessary, and not just with the service users but also the expertise and drive of staff of all sorts.  

We also say in this report from the experience of those that are doing things on the ground, that you need to be agnostic about the technology itself.  Optimistic but realistic, open minded but challenging and seeing the potential but not being dazzled by the individual bits of kit, and we think we need to have a different conversation about risks and rewards.  We think that innovation requires different forms of contracting to create a climate in which there is genuine risk sharing between the commissioner, the provider, and the supplier of the equipment and that that is a way of driving things forward, and therefore we do need more outcomes and population based approaches to contracting to share those risk across systems.  ACSs, ACOs, may well be one of the routes by which we realise that.  

We also need to be realistic about things as well.  We need to set realistic expectations about the pace and scale of transformation.  Again, one of the lessons and learning points from those that have done it and done it successfully, and the bandwidth within our systems because of the pressure of the day to day just keeping the show on the road, means that sometimes it’s absolutely key to be able to buddy up, to share the skillsets that are necessary to drive and deliver service change.

And I now talk very much from a social care perspective.  Social care because it is means tested.  There are large numbers of people who are never going to be funded by the state for their social care needs.  They’re self-funders, but they actually are people that local authorities have a role to play in making sure that they are informed about the opportunities and routes to getting access to the sort of technologies that can make a difference for them and also provide reassurance for their family, in other words, that self-funder market is important to be considered because of the knock on effects it has to the NHS, and when we said something about evidence and course we need a culture of evaluation and action, but because we’re talking about rapidly changing and moving circumstances, are randomised controlled trials always the mark because by the time the trial is published, the technology has moved on so far.  It’s a bit like waking before the Second World War for the Spitfire to arrive before you started mobilising and investing in any sort of air force and wonder why you’re then invaded by the Germans. 

Just having the evidence is important though and the last time I was here was in 2011 and I was talking then about dare I say it, the whole systems demonstrator.  Yeah, it does get that sort of reaction, doesn’t it?  It’s worth revisiting some of the learning from that, and indeed some of the revisiting has been going on recently because of some new work I’m just going to speak about now and one of the learnings was actually that it was a demonstrator of how not to do it because it was also about bolting things on and not necessarily redesigning services.  But since then, we’ve had Dallas and that’s been lots of learning from that.  We’ve had a lot of material that’s published on NHS England and just two weeks ago at Health Plus Care, and I’m not going to set out any of the details because I think they would shoot me if I did, the health innovation network for South London, on behalf of NHS England’s new model team started to set out some of the work they’ve done as part of a rapid review, building the case for techs insights from the evidence base, and all I’m going to say about that is really this; they’ve done a rapid review of the five key areas of focus, all pretty much the things that are out there well-established technologies and the report’s due out soon but what they concluded from this is, that we have a lot that we could max out on still when it comes to using existing technologies and we could do more of that. 

So, what is the TSA doing with its report? Well, we’re doing things like we’re doing today, we’re raising awareness of it.  We’re talking to the likes of ADAS working with the Care Quality Commission, talking to colleagues at NHS Digital, working with the new models team, talking to NHS 24 in Scotland.  We’re also launching a digital leaders network, a virtual network to try and bring these different expertise across local government housing and social care together to share experience.  

This is an incredibly busy slide, I’m not going to talk to it in great detail.  I did just want to point to that, that’s called the ood and the ood was a product that came out of a design call by the design council around dementia back in about 2011 and what it does is just sends sort of an aerosol smell into the air, generates a sort of sense of appetite, helps re-establish the rhythms around eating and I’m just going to point to this one, that’s a fridge, really high-tech pieces of technology.  This fridge has a camera in it which is great for me when I’m shopping because it means that when I’ve forgotten what I need to buy I can check to see what’s left in the fridge, and what it can also be used for is getting a sense of whether somebody’s eating well and so on.  So, it can be used as part of that internet of things in a smart way.  And why does this matter?  

Well, this is Vera she had a problem, she kept on getting up at night to go to the loo.  On one occasion, she couldn’t get off the loo and she was there for six hours, and no-one knew about it until her daughter came.  One of the simple technology solutions that she benefits now from is sort of use of sensors and those sensors mean that when she gets out of bed the light comes on, when she gets back into bed the light goes down. It means she doesn’t have risk of falling in the way that she had historically had and why does that matter?  Well, because falls cost the NHS an absolute fortune, they cost people’s lives in terms of the quality of those lives and because time is muscle.  If you get admitted into hospital, as an over 80 year old person, then you’re going to lose an awful amount of muscle condition in a very short space of time.  So, getting these things right, anticipating and preventing is absolutely key. 

Quality is an absolute key component of what the TSA is all about.  We’re a standards organisation around service delivery, have been for over twenty years, and we’ve had a code of practice for the telecare industry which has now been redeveloped and thought through in a different way to be about the outcomes that matter to the end user and this can be applied to a wide range of services and I would commend it to you as commissioners and I’m going to just end with two final slides.  

One is, analogue to digital.  In around 2025, telephony services, point to point telephony services in the UK will be turned off. In other words, the analogue systems that many of our technologies sit on top of will no longer be there.  We’ll moving to internet protocol systems.  Now I’m not a technical expert, some of you and some of you will know what that may well mean in terms of the way in which systems will operate in the future.  

We as an organisation convened government regulators, NHS Digital and others to work together on this problem and we will be publishing in October the beginnings of an outline of a roadmap which we think will be helpful to the industry, to the NHS, to colleagues in social care and beyond in thinking through some of the implications of all of this.  And if you want to find out more, we have a conference which brings together the best in the sector and we’d love to see you at it.  

Thank you very much.