It's crept up on us

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Part of Time to Think Differently

You may not have noticed. Think about it.

You need some cash; you pop to a machine in the high street, poke your card into the slot and instantly they know who you are and how much money you’ve got and they give you some of it. Take a flight; go online, figure out the time that suits you, book it, print out the ticket, go to the airport, get another ticket from a machine, park the car, check yourself in – job done. Go shopping? Pick up your own groceries and use the self-checkout.

Suddenly, bank clerks, travel agents, parking attendants and checkout assistants are as useful as lamplighters and watchwinders. What happened? 

Well, I can tell you. In industry, they are using a strategy that will be anathema to the NHS. A phrase that is almost blasphemous and may only be barely whispered in the vaulted corridors of the health service. In a National Health Service industry that is committed, dedicated and devoted to doing more for patients to improve their journey and experience, industry is going in the opposite direction.

Industry's new phrase? I'll tell you, but if you are of a nervous disposition, read no more. Here it is – 'How can the customer add value to the business?' Ooh ouch! In plain English – how can we get the customer to do what we used to do? How can we get the customer to manage and collect their own money; arrange their travel and print their own tickets; select, pack and pay for their own shopping?

The reason for this question? Well, it’s obvious, isn’t it? No retailer can afford a 'buy one get one free' offer and a shop full of shop assistants. Airlines simply can't afford budget travel and ground crew, travel agents’ fees and commissions. Banks want us online not on the high street, where rents, rates and utility costs make it impossible to give us free banking.

And, do you know what – I like it. I like not having to queue in the bank to get my cash and I like sorting out my own itinerary and I sure love speeding through the supermarket avoiding the woman with a groaning trolley. I can customise my shopping and tailor the experience. I feel like I am in charge.

The NHS? Well, The King's Fund's very own finance guru, John Appleby, has warned us about funding prospects for the service after 2015. More cash savings and perhaps not even ringfenced funding. The NHS will be forced into changing its ways by the economy (stupid)…

Pressures on budgets, costs and staffing suddenly take us into the world where we have to ask – how can we get patients to add value to their health care?

Every year in October I travel to the frozen wasteland that is Dusseldorf, to Medica, the world's biggest exhibition of medical devices. Everything you need to equip a hospital is there. And everything you need to maintain an elderly person safely in their own home or a patient with a long-term condition is there: peak-flow meters that connect with an iPhone and can send the results around the world to the best consultant, or across town to the asthma nurse or call centre; urine test paper that can be photographed by a mobile phone and whizzed for analysis to… well anyone, anywhere; apps for Blackberry and Apple that create new salad days for care and make hospitals history.

I think it is only a matter of time before the public starts to say; 'Why do I have to queue on the phone to get an appointment with my GP?' 'Tell me why I have to have a day off to speak to someone I can talk to on Skype from my desk?' 'Why can't I use near-patient testing and the technologies I take for granted in the real world outside the NHS?'

My mother is 93 years old and has an iPad. She wants to know why she can’t FaceTime the practice nurse. So do I.

Roy Lilley is an independent health policy analyst, writer, broadcaster and commentator on health and social issues.



Comment date
19 June 2019

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Comment date
07 May 2019

Thanks for a thought-provoking piece picking up on the vitally important and highly relevant theme around patient empowerment.

Pawan Randev

Comment date
31 October 2014
Which paper are you referring to, Keith?

Keith Chapman

Comment date
06 August 2014
Why cant your mum Skype the doctor - it increases workload!!!!
Those working on the frontline having been telling those not working there this for some time.
Now the evidence backs us up - Lancet Aug 4, 2014.
And GPs are already struggling - probably a good way to bring the whole system to its knees.
And why does everyone who theorises think that all those who actually do the work have an attitude problem?
This is just plain insulting. It gets us nowhere and doesn't address why the NHS doesn't adopt technology. The paper in the Lancet suggests it's because we recognise bad ideas when we see them. Not listening to those on the frontline gets you Mid-Staffordshire.

Mike Maynard

Executive Editor,
Comment date
12 April 2013
Technology is great, but often misused. The 0845 number and voice mail being the obvious examples. It's only a local call with a connection fee and a 40 minute wait until you actually talk to someone. A quick and easy to remember number for medical advice would cut waiting times in A&E at a stroke. Standards of care are improving in hospitals mainly because they can't ban cell phones any more. Patients aren't so isolated. When I saw my consultant a few months ago, he was using his Ipad to connect to the hospital server, because it's so much quicker. Technology can only improve things is used properly.

Charlotte Davies

Lead Analyst Healthcare & Life Sciences,
Comment date
11 April 2013
There's significant engagement and tech adoption from patients and organisations and professionals who are keen to exploit technology and aren't afraid of change. But capabilities and attitudes vary and always will in different segments of the healthcare sector and in patients/consumers. Hence you need Skype plus F2F plus phone for the foreseeable future and I agree that the digital divide and IT literacy is something that backs the multi-channel approach up .

Ultimately I think the biggest challenge from an IT/workflow perspective will be managing and properly using information, akin to the 'blood' flowing around the system: accuracy, relevancy, privacy and security are hugely important here. Parallel to this, the design and procurement of IT needs to change so its better built into services and workflows.

Another key question is whether the new funding reality and efficiency targets facing the NHS will actually accelerate ICT adoption and force big changes in IT procurement as organisations look to reduce costs. There's huge potential to use IT to generate cost savings, but the devil is in the detail and I think there's a significant issue of skills shortage and complexity in the new structure that will hamper this.


Cognitive Behavioural Psychotherapist,
Comment date
10 April 2013
Really interesting piece by Roy, we developed our Cognitive Behavioural Therapy App due to the enormous demands placed on primary care mental health services..I work in one and now that 50% drop out before they get to see anyone. Our app is designed to be used at the "coal face" either by G.P./Psychological Well Being Practitioner or Cognitive Behavioural Therapist as it offers treatment solutions for Anxiety, Depression ,Panic and Work Stress. The demand is there from service users but professionals (imo) are running away from digital and mobile technology in fear of their careers. To sum up 25,000 downloads to date

Peter Kent

UK Information Projects Manager,
Macmillan Cancer Support
Comment date
09 April 2013
If we are going to empower patients we need to begin by recognising that they (we) are not an homogenous group. Many of us have only occasional and brief contacts with the health service whilst others, those with long-term chronic conditions for example, have a lifelong relationship with health services. Similarly, we have differing relationships with technology and differing attitudes towards it as well. For every 92 year-old mother that has an iPad and wants “face time” with her practice nurse there is another mother (e.g. my 88 year-old mother) that wants nothing of the sort.

“Empowerment” originally had only positive connotations but now (having been inducted into the lexicon of professional jargon) can have overtones of oppression. For every empowered person liberated by the remoteness that technology can bring there will be another that risks becoming more isolated by it. A sceptic might argue that it is the bureaucrats and the profit seekers that are empowered by the use of some technologies.

If we are to genuinely empower or liberate patients, we must also recognise the diversity that exists in the population. Apart from the difference between mothers, there are the differences in culture, class, education and income. Much of the demand for empowerment and even patient choices has been driven by the white, educated middle class. This is fine and has generally been the case over many years with the middle class driving a good deal of social, economic and political change that has benefited people of all classes. However, that does not make it entirely altruistic. Ask any parent whose child did not get into their school of choice because the sharp elbowed middle class parents worked the system better than they did.

There is evidence that the people demanding empowerment through technology do so because its use enables them to spend less time in doctors’ consulting rooms and more time at work. If you are retired or unemployed, this may not be such an important consideration and having a human interaction and conversation may be more helpful. Patients that use the internet to obtain information and make informed choices about treatment, which hospitals to attend and how to manage a health disorder are more likely to be white, educated to degree level and in a professional occupation.

Finally, if we are going to empower patients we must also empower health professionals. One reason why the nurse may not do face time is because she or he may have little or no professional or even personal experience of using the technologies involved. When we piloted information prescriptions in NHS trusts we found a wide variety of equipment much of it ancient and often unavailable to nurses when they needed access to it. We also found many of them were unfamiliar with simple actions such as use of passwords and log on procedures. This was compounded by the almost hysterical risk aversion in parts of the NHS that prevents staff using the internet fully and even communicating with patients and partner organisations by email.

So by all means let’s use technology but let’s also use it intelligently. There is a risk of creating greater inequality by thoughtless use of new technology. Much as there are people that are financially poor there are people that are technologically poor (and one often accounts for the other) and many of the people will be patients with long-term multiple conditions for whom increasingly sophisticated use of technology may not be the answer.

George Margelis

Comment date
04 April 2013
Great discussion Roy.
However it is important to remember that the patients with greatest need are often those with the least resources or least desire to change. As a result just making access easier does not necessarily lead to greater uptake and successful implementation.
The other challenge is to ensure that there are clinical models available via the technology that can deliver health outcomes. The analogy with banking remains flawed, because banks have limited delivery models. The take money in and give money out. That can be easily automated and pushed on to the consumer. Healthcare is much more complex, so if you want to push it out to the patient you need to firstly provide them with sufficiently functional tools, and secondly ensure they have the health literacy to deliver safe high quality care. We spend a lot of time and money training clinicians to do that, we need to ensure we have a model for educating the relevant patients to also be able to provide that for themselves. If we don't then we are being negligent by replacing high quality safe care for low cost unsafe care.
Patient empowerment and engagement is a great goal, but let's not underestimate the work involved in delivering it. Its not just make the gadgets available and they will do it. It requires clinical governance, evidence based clinical models and investment in education. That should deliver the outcomes we want., but won’t be a cheap and quick solution.

Harry Longman

Chief Executive,
Patient Access
Comment date
01 April 2013
Comments are full of enthusiasm for new technology, and so am I. But I'm also concerned that while making healthcare easier and lower cost to access for many, we don't raise barriers for some who do not have or can't use the technology. Often these are the most needy. So... needs before nerds, if you please.

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