Personalised health care: how can the NHS innovate at scale?

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Advances in science and technology have the potential to transform NHS services and improve outcomes for patients. Now with developments in areas such as genomics and digital technology offering a more personalised approach to healthcare, what can the NHS do to benefit from these innovations?

In this free online event, we discussed how local NHS organisations can adopt new technologies at scale within the challenges of a difficult financial climate. Our panel considered how best practice can be shared and replicated and what organisations can do to create a ‘culture of adoption’.   

In addition, our speakers discussed: 

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Key:
HE:    Harry Evans
CM:     Conor Megaw
RS:    Roger Spencer
IJ:    Indra Joshi


HE:    Hello, and welcome to this King’s Fund online event, Personalised health care: how can we innovate at scale? My name’s Harry Evans.  I’m a researcher in the policy team here at The King’s Fund, and I’ve got an absolutely fantastic line up with me today here, speaking about some of these issues.  

So, if I can start introducing. We’ve got Dr Indra Joshi, Digital Health and AI Clinical Lead, NHS England. Roger Spencer, Chief Executive at the Christie NHS Foundation Trust. Conor Megaw, Strategic Partnering and Healthcare Solutions Manager at Roche.

So, we’ve got a great discussion that we’re going to have here today. I’m going to be asking some of my own questions to our speakers, but we’ve also got the opportunity for you to send in your own questions and they’re going to come up here on my pad. You should be able to see a little box in the browser where you can ask your own questions. So, please do do that.  We’ll try and get to those a bit later on.  

The other thing I’d really love you to do is get involved in the conversation on Twitter, using the hashtag #KFonline, and please do send your questions, your comments through on that hashtag. I always enjoy looking at it after. It gives me a good sense of how the event went, and whether or not you liked it. Thank you also for joining us on a day like today, which is probably the second loveliest day we’ve had so far. So, thank you for joining us, and passing that up over your lunchbreak.

So, without further ado, I’m going to get onto some of the questions that we’ve got. Now the area of personalised healthcare - I’m aware that it’s a term which is used differently in different areas, and personalised care is a thing separately. But what we’re talking about here is technologies, and how they can better personalise the care that people get, but what I’d really like to do first of all, Conor, if I can come to you.

Can I just ask you, what’s your perspective on personalised health and care? What do Roche mean when we’re talking about personalised health and care?

CM:    Thanks, Harry. Well, I think you’re right. It’s actually a very broad topic, and at one level, it can be how does the patient get the right type of care that they want based on the outcomes that they’re seeking for.  
I think the Roche perspective is how do we get the right medicine to the right patient at the right time. Today, we’re really on a transformational cusp, I would say. They anticipate by next year that the amount of healthcare data available to us will double every 73 days, which is, yes, humungous. So how can we derive insights from that data? How can we help change the system to, I suppose, generate the most value for the NHS and drive the best possible outcomes for the patient?

So I would say the Roche view is, you know, really looking at that data at scale, using the amazing advances in analytics to deliver insights, and then it is adding value at discovery of medicines, develop the medicines, and then delivery of care. So, you know, how can system improvements be made, how can medicines be used as efficiently as possible, and how can we all get that goal, that patients get the best possible outcome.

HE:    That’s an amazing stat, isn’t it, that every 73 days, data can double. It just highlights the importance of this, and having the analytics and infrastructure to use that data.

CM:    I think petabytes are dead, and it’s yottabytes now apparently. So, it’s off the scale.

HE:    Petabytes are dead, great, what a quote. So if I can come to you next then, Roger. So what do you think are the big innovations on the horizon that the NHS needs to be looking at?

RS:    Well, so, of course, in my area in cancer the whole change is about personalisation. It’s about the individual, and no longer about, if you like, broad tumour types, and so, of course, genomics is an area which has got enormous applications in this sphere. Of course, we’ve also got some emerging activity going on in therapies that respond to that very specifically.  So advanced cellular therapies, molecular therapies and immunotherapies, and we’ve heard recently the introduction and approval in a very quick, short order time of CAR-T cell therapy.  That’s one example of an area which we will see great developments in.

HE:    Can you give a … CAR-T cell, what – 

RS:    So the idea, of course, is that we’re using an individual’s own biological material to produce the therapeutic agent, which allows them to target the cancer cells. Efficacy is incredible in comparison to what we might’ve used previously, which is a, kind of, much broader-brush approach to treatments that are available.

So this is a very exciting area, because of the complete resource that can come from these therapies, and, of course, you know, choosing which patients get a complete response is part of the process, some of the things that we talked a little bit about. I think the other thing I’d say is, of course, we’ve got great advances in the technology capabilities, and recently, we opened at the Christie Proton Beam Therapy Centre, the first in the UK.  

Of course the real issues there are, as technology advances, how can we deploy that to increase this personalisation question, and we’ve got a few other examples of that in the pipeline that I’m very interested in. Both of those things mean that we’re going to improve outcome and survival for cancer patients faster than we have been doing. We’re doing quite well at the moment. 64 per cent five year survival currently, but we need to make that even better, and about 25 per cent of cancer patients haven’t had their recent improvements matched in survival.  

So the answer to doing that is this personalisation, this individualisation, because in the common cancers we’re seeing great steps forward but in the rarer cancers, in particular, we’ve not seen so much and this is where we’re going to make enormous progress in the next few years.

HE:    So a really exciting area, but I mean, it’s also a really complex one, and Indra, maybe I can come to you on what do you think are the risks here? What do we need to be wary about and maybe cautious about, and then how can we mitigate some of those risks?

IJ:    I think there are a few risks that have been spoken about, and you’ve mentioned a few as we’ve gone along, but one of the things is probably the standards in this space. In the drugs market, we know really clearly what we need to develop to, we know the process of developing, but in this, what we might call, emerging technologies, data-driven technologies, whatever frame or word you want to use, it’s not really clear what the standards are. It’s about putting those standards in one space, to try and mitigate some of the risks, and the other thing is trying to make people smarter. So we call them more intelligent customers, smarter customers, smarter care.  

So it’s bringing everybody on that journey. So it’s not just the people developing the technologies, but also, the people commissioning them or using them to say, “How do you actually look out for the risks that might be involved,” and, “Let’s bring you all together on this journey, so that everybody understands what those risks are.” Some of it is our role, as the system, to try and help people do that, try and mitigate those risks.

HE:    Yes, and I can already see that there are some questions coming in that vein. So we can come to those in a second. Conor, I wanted to come back to you. So those are some of the risks around how we communicate this, and issues around what, as a system, we can do to develop things. But I guess there are also issues within local NHS organisations a lot of the time about how they adopt some of these technologies. You know, they’re so complex, there are so many different technologies coming through.  So, how do you think NHS organisations can overcome some of those adoption issues?

CM:    Absolutely. So I think the starting point with that is it’s not about forcing technology into an organisation. It’s about technology supporting transformational change, it’s about the change management. So everything that goes with that. It’s having the right level of senior sponsorship and stakeholder engagement across the organisation. So, as we work with some of our partners, you know, we will see very often really high levels of engagement at the top of the organisation, and then a lot of work is done to bring the whole organisation on board with that.

I also think there’s the type of organisation that you work with. So are you working with an organisation that is, you know, forward-thinking? They’re not just focussed on in-year delivery, but really changing things for three to five years out. At Roche, we are quite keen to identify those partners develop, I suppose, projects with them, prove concepts at a particular site, and then look to perhaps scale into an integrated care system. So you know, perhaps some of the value that can be released back into the NHS will come from a primary care setting, despite the initial work being done in a secondary care setting.

So it’s really important that you’ve got that senior sponsorship in secondary care, and the integration through an ICS out into the community.

HE:    Yes, and you spoke a bit about partners there. So Roger, maybe I can come to you about the importance of partnerships in this area, and how you can foster positive ones.

RS:    I mean, it’s essential to understand really what it is you’re trying to achieve with a partnership. It sounds very basic, it sounds very straightforward, but the successful partnerships are where we’re very clear what the objective is that we’re trying to achieve between the partners, and what each partner brings.  

You know, certainly we have a precision cancer medicine partnership with Roche. It’s a partnership that’s built on existing relationships over a number of years, but we’re very clear what it is we’re trying to achieve together, what resources, capabilities each other can deploy to achieve that. We show senior commitment as, kind of, pointing out. We show what it is that we’re both going to invest in the partnership essentially, right from the top of the organisation, but, importantly, we have to have complete engagement of our expertise in that partnership.

So, there are many different approaches to partnerships, where you can see people have a general good idea, and they have general thoughts that they can produce some good results, but they’re not specific enough. That’s normally where the problems lie, and our experiences with partners such as Roche is very good and the current precision cancer partnership that we’ve got underway at the moment is a very exciting one. It’s looking together, with experts in our field, very specifically at where the future is going to be of digitising clinical trials for producing new tailored therapies for patients. It’s very exciting.

HE:    Can you tell us a bit more about that? I mean, how is the technology being employed in those clinical trials?

RS:    So, at the Christie, we have an experimental cancer medicine unit that’s been looking at being able to sequence patients, genetic sequencing of patients, so that they can match them to targeted therapies, or indeed where those don’t exist, to investigators that are looking in that particular area for that particular patient.

With the partnership with Roche, our plan is to sequence a much larger number of patients, in rare tumours in particular, so that we’ve got complete genetic profiling. We can do that at a much bigger scale with patients.  
Then the second stage really is to look at how we can get the data that’s associated with that aggregated with clinical information, and imaging information indeed, to create, if you like, the digital environment, that is appropriate for the future testing of risk stratifying patient groups, and matching them to therapies in an appropriate way.  

More than that, the third stage, the digital environment where new therapeutic endeavours can come in and use that digital environment as the clinical trials environment of the future, and this undoubtedly is the future of the development of new therapies. Obviously, having partners such as Roche, who have great capabilities in this area, but, obviously, the vision to see that we’ve got to adapt and adopt to this new environment is essential.

HE:    Yes, and it’s that, kind of, adapting and adopting that I think we’re really getting into in this conversation. So I guess the last of my questions, before we move onto the audience, is for you Indra, and it’s what can national bodies, what can NHS England do to support local organisations in overcoming some of those issues?

IJ:    I mean, there’s quite a lot of work that we’re currently doing already, and some of that, we can definitely push forward a bit more. One is to help create the environment. So to produce frameworks or structures where people can. We have things like the Accelerated Access Collaborative, which is being run in partnership with other government departments to say, “Here is a unit where you can do some of these innovative technologies.” We have things like the AHSNs, Academic health and science networks.

So we have created bodies already, where we are trying to help, and the other thing we need to do is create trust, I think, and that’s the most important thing for me, as a doctor, is also to create trust in the stuff we’re doing. I mentioned standards earlier, but it’s also being transparent about what we’re doing.

So one of the things I do at NHS England is work for the transformation unit, called Empower the person. So we very clearly have a roadmap. You can have a look at our roadmap online, but we’re very transparent about the services we’re developing and the tools that we use to assure those services. I think that transparency and explaining what we’re doing, to not only the public, but also to other services, so we work very closely with our regional and local teams, really helps to create that trust, to say, “Okay.  So, you are developing an environment to create things, but how does the rest of the world know about that, or even just the rest of your region?” It’s to be a bit more transparent and a bit more open about what we’re doing.

HE:    I mean, that’s really interesting. I’m going to come onto some of those issues later but, I think, again, we’ve got some good questions coming through here, but the first question that I perhaps wanted to come back to Roger about was a question from Sharan Ahluwalia from Imperial College London, who’s a student. It’s a really great question. It’s how can the NHS attract the greatest minds in technology, considering it’s competing with the private market who want the same skillset, and also the budget constraints of the NHS. So how are you competing for some of those minds?

RS:    So it’s a very important question really because, whilst we have some very interesting and exciting technology that everybody’s here talking about, critical to its development and adoption are actually the people that we’ve got. We’ve got some absolutely fantastic people working at our centre at the Christie, but I think we’ve heard mention of, you know, what are the ingredients to create that environment? How do they come about? How do we create them?  

Well, much of it really is a consequence of the adoption of the strategy for accelerated access to medicines, but also, in the response to that, which really was the government’s industrial strategy, the Life Sciences industrial strategy, really which created this opportunity to focus on our ourselves, on combining our efforts from the NHS with our academic partners, and also with our commercial industrial partners. That triumvirate, it’s described as the triple helix in the industrial strategy, is essential to create that environment where we can attract international expertise to the questions that we are trying to solve for our patients.

More recently, in recent times in Manchester, at the Christie, but also in our broader health system, because we’ve got a devolved health system, as I’m sure everybody knows in Greater Manchester, we’ve had some great success actually in recruiting people from North American cancer centres. This is an opportunity to get the very best leading minds from the world involved in our activities here. It’s a very difficult thing to do when we’re part of the NHS, but it’s done because we’ve partnered academic partners and our commercial industrial partners.

HE:    Yes, and it’s a really important, isn’t it, about how we can actually leverage the relationships we’ve got. Not just necessarily get all of that in-house.  

Another question on workforce, but maybe on the clinical workforce side now, so maybe, Conor, I can come to you on this one. So Nick Parry Jones who is retired now, but does honorary lecturing, asks how the new technologies can be used in teaching undergraduate medical students.

So I guess, you know, we’ve had the Topol review recently, and that was maybe more about how the skills to use technologies might be embedded in the undergraduate curriculum. I suppose there’s an additional question about, well, how can we leverage new technologies as a means of teaching undergraduate medical students. Do you have any thoughts on that?

CM:    Absolutely, and I think we were discussing this a little bit before we went live on air. You know, there’s all sorts of exciting developments around virtual reality, augmented reality coming through. Helping medical students to actually even just work around a bedside and work on some of the perhaps softer skills, but then also, you know, in the surgical setting, perhaps actually practice without there being a patient involved.

There’s also some really interesting learning technologies that have come out of places like Harvard Medical School, to really help invert what’s sometimes referred to as the ‘forgetting curve’, where people have lost 80% of what they’ve learnt within two weeks. This technology has been proven in published literature to actually invert that to remembering 80% at two weeks. That’s just through adopting, as well as traditional teaching, some online app-based learning technologies to really help medical students to retain knowledge better.

IJ:    It’s difficult though, isn’t it, because I think when you talk about the medical curricular, what gives and what doesn’t give? You know, there’s a lot in it, which is obviously quite vital, and trying to use modern technology, but I would also argue that we’ve got to focus on postgraduate curricular as well, not just undergraduate, and uses of innovative ways there.  Especially, like, simulation training, for example.

HE:    What would that look like for you then?

IJ:    So, I’m an emergency medic. I used to work in an A&E. You would have simulation training around a body, a plastic body. We used to call them Billy or Bob or whoever, or Annie, but, you know, there were seven of us all crowded round. But now you can use virtual simulation to actually go in and understand, and the aviation industry is a classic example of where they’ve done this really well, and, as medicine, we are adopting this, but slowly. It’s coming.

HE:    Why do you think it is slowly, because actually, it’s quite interesting what you’re saying.  So yes, there’s always … and this is the challenge with the Topol and the clinical workforce, and thinking about how do we embed these new technologies into education, but actually, you know, if we’re talking about the means for educating the clinical workforce, then technology might actually be able to make some of that stuff easier. It might be able to make some of it simpler, and, therefore, free up space in the curriculum. 

IJ:    You might be able to, but it’s a challenge, isn’t it? I mean, it’s the same as any transformation. It’s not necessarily about education here. I mean, both of you have talked about transforming how you do something, and, yes, digital is a way of transforming, but transforming education is just as challenging as it is to add technology into a company. So I would say those same challenges apply. It’s winning hearts and minds, understanding the problem, what can be done to deliver it, and let’s not forget about the elephant in the room, cost, yes?

RS:    So the other element that I think we all should remember in our jobs in the NHS is the cultural question. I mean, there is no question. I recently did an introductory session at the Association of Laparoscopic Surgeons of Great Britain and Ireland, and after my introduction, there was a panel who were running commentary and a question and answer session in a very large-attended auditorium, with three livestream robotic operations going on.  

Now, you know, clearly, the technology for robotic assisted surgery has been around for some time. It’s in commonplace use now. It’s been adopted, but there’s a real cultural question now, which is moving from the traditional surgical approach to this robotic assisted approach.  It’s the sort of thing that is, not so much a barrier, but is one of the critical factors in changing the educational or the academic approach to any of those sorts of developments.  

We hear lots of our colleagues in the technology, the medical technology, that’s associated with that, make reference to what is today’s daily digital interactions. You know, the capabilities of young people in the digital arena, which often surpass what might be basic levels of activity in some of these associated educational skills. 

CM:    I mean, I would say reflecting on the undergraduate side of things, there’s so much to fit in across, I suppose, a five year education, but you look at something like today, you know, maybe five years ago, this would’ve been held in front of a live audience. So, how can technologies like this … the technologies are there.

It’s just adapting to different people’s learning styles. We see colleges and higher education facilities offering the day starts at ten o’clock instead of nine o’clock, just those sorts of changes can really help adapt to today’s lifestyle, and that’s something that should be considered.

HE:    That’s a really good point. This is so different for different people, and we need to adapt to the differences in society as well, and the same is true of patients. Actually, I’ve got a question here from Zoe Price, who’s a project manager at GIRFT, Getting It Right First Time.  She asks, with the impressive growth in medical technologies, how can we go about pushing digital resources out to those who are non-digital natives, and maybe not engaged in digital, and maybe, Indra, I can come to you on that first.

IJ:    Yes. I mean, we have a programme at NHS England called Widening Digital Participation. I think we’ve partnered with the Good Thinking Foundation, but the idea is to go into communities where you might not be digital natives, but not just that, but you might not have access to digital tools. I mean, we’re a slightly different audience sitting here in the lovely King’s Fund, but not everybody has an iPad, not everybody has a mobile phone that has access to data. So, how do you create environments where you can actually go and maybe, I don’t know, use an app or access the internet, and also create champions, like a human champion who can help you do that within a certain geography of a location?

RS:    It’s an interesting area, this, and intuitively, I think we all have this view that people from a certain generation may not be in a position to deploy and use the digital environment to its maximum benefit. Interestingly enough, we have a couple of clinicians leading clinical trials in the Christie who have had some insight into this, where, actually, the evidence they found is that the older generation patients who are not always, at the start of their journey, that literate are the ones that persist with digital reporting of their symptoms and activities using digital tools better than the younger generation of patients.  

That’s one of those counter-intuitive bits of evidence that has been produced, and clearly is to do with more than just your abilities or your learned abilities. It’s more to do with that…it’s to do with the importance of it, and it’s to do with the importance of how you work together in your social circle, and that sort of thing. So, it goes a bit beyond this immediate technology question.

HE:    I think you’re right, Roger, and it’s not necessarily, and, actually, focussing on demographics and the kind of things that we might expect to make a difference isn’t necessarily the way to do it. It remains the case though that there are many people who don’t have as much access either through capability, or whether or not it’s that they don’t have access to the technology.  

So there are different things, but I’m really interested in posing a question of my own, which is, how can industry, how can the NHS, how can they actually use technologies to try and reduce some of these inequalities? How can we use technologies in the other way, rather than just assuming that it’s about mitigating the risk of them exacerbating health inequalities? How can technology reduce them? Maybe, Conor, I can come to you on that.

CM:    It’s a great question. I think that, you know, as an industry, we are really keen to see the adoption of technology to drive those improved outcomes. I am going to flick back a little bit to the original question, because we’ve answered it from a patient perspective. You know, there’s what’s the adoption technology within the healthcare system itself, and especially at the interface between the healthcare professional and the patient.  

We’ve been doing some really interesting work, collecting PROMs in multiple sclerosis patients up in Glasgow. What’s critical to success there is how the MS nurse introduces that technology to the patient, and we see no difference in uptake by age or sociodemographic. 

So I think it’s investing in the change programme, and I suppose the selling in of the technology, and, you know, okay, this particular programme is Bring Your Own Device, which is reliant on the patient having a smartphone. The ubiquity of the smartphone today, I think we need to stop using that as an excuse around not adopting technology and move forward. That’ll actually drive greater ubiquity of that very technology. So, let’s not step back and wait for it to be 100%, but let’s move forward, show the benefits and outcomes, and then, again, that will just drive that further adoption.

IJ:    I think about it more from a population health perspective. So at the moment, the examples we’re giving are very individual, for you the individual, or me the individual, but if you take a large set of data, and you take whatever it is that you’re using to capture that data, and you look at a care pathway and you say … okay, let’s take atrial fibrillation, it’s a nice easy one. How many people are getting atrial fibrillation, what’s the chances of their having a stroke, and then what can we do to optimise in that care pathway, the reduction of that stroke?

So you might have a device that you put on your chest to measure your heart, or you might have something on your mobile phone, or you might not have any of those things.  You might just go into a hospital at point of care and have that captured.  

What we should think about is from a much larger – if we take it up a level – population health, how can we then reduce the inequality? So, that person who does come in at point of care, we’re actually capturing earlier in the journey, which probably goes back to the personalisation or precision medicine point, sort of, coming back to our original, what we were talking about. I think that’s how we do genuinely try and focus on to reduce health inequalities.

RS:    Yes, in the cancer space, of course, there are some great examples, some of which are at the forefront of the long-term plan, about the whole point that I think Indra’s making about this idea of the population approach to this. What you really want to see – I think Conor mentioned it earlier on – is the digital advances, the steps forward supporting that approach, that population approach that’s looking for the opportunity.  

So a great example with lung health checks is Greater Manchester, where you’ve got low-dose CT scanners in supermarket car parks, and the populations that are very hard to reach and difficult to get to are the people that turn up there.  They have a lot of information and data of their own with them that can be used and incorporated in their care pathway, in the way that’s being described.  More than that actually, the results of that show absolutely fantastic early detection, which is one of the most important areas that we can focus on to improve outcomes in cancer patients.  

We, in that study, saw a real shift in what essentially is treatable, curable cancers being detected, a much bigger proportion of them being detected earlier, so patient survival better.  Of course, this is the sort of thing that can be promoted as well, using the general developments in digital technology through channels that people are much more used to now, rather than the conventional, the traditional ones. That’s another method by which these technologies can be adopted to get closer to reducing those inequalities.

HE:    Yes. Well, I’ll move us on actually, but there’s a question here which is related, which I think is about the impact that technology makes on patients. So, it’s from Melanie Woodnick, who’s a public affairs consultant, and she’s asked how can organisations demonstrate the value that technologies have made to patients, and evaluate the impact that it’s made, whilst considering some of the costs that are associated with that? I wonder, Conor, if I come to you first on it.

CM:    Absolutely. So, I think perhaps of the partnership that we, Roche, have with the Christie, it’s got a number of key phases. We’ve been analysing and compiling an economic evaluation of what we believe the benefit could be, of a rare or uncommon precision cancer partnership.  There’s then building the capability and then once the capability’s built, it’s measuring the impact.  

So, this partnership is a research partnership, but ultimately, Roche and I believe the Christie desire is to see improvements in clinical care. So, it’s measuring the impact, the impact on patients, the impact on the NHS and the impact on UK from an economic perspective. What we want to be able to do is take the great work that is being done at the Christie, and see that scaled across the whole of the UK, so we see those improvements in care delivery and outcomes being achieved.

So, it’s making sure that there’s clear mechanisms in place to measure that impact across a number of different metrics, and then that will support future investment into that scaling.

HE:    Yes, and Roger, did you want to add to that?

RS:    So, I think you can see some of the more structural changes in the NHS that are responding to this question essentially. So, the development of integrated care systems, and the way in which the system, if you like, is much more streamlined.  

This triumvirate approach that I talked to you about earlier on, about the partnerships with academia and also with commercial partners, looking at the question on a population health basis essentially, in Greater Manchester. In the devolved area of Greater Manchester, of course, this has been front and centre for the last couple of years, in understanding how we can deploy the resources in what you might describe as a non-traditional way. So, not just focussed on, essentially, treatment and intervention end of things, and looking at it the way in which it integrates all the way through, from early years education, all the way through the pathway. You know, investment in prevention and public health, for example, can have considerable payback, and understanding the modelling of that. That really gets to the heart of that question.  

In Greater Manchester, the focus has really been about this integration and joining things together. So, in terms of adoption of technology and new therapies, Greater Manchester organised itself together, so that all of the bodies associated with the health and social care came together to create something called Health Innovation Manchester.

This is the ASHN resource that Indra mentioned earlier on, the Academic Health Science Centre, the Clinical Research Network. In other words, all the resources that are at the frontline of innovation. Not just coming together to join the innovation bit together, but coming together with all of the commissioning organisations, the local authorities and the providers of care, so that there is a streamlined process to work together with commercial partners to move innovation rapidly into adoption. To get this, they’ll try and address this inequality question, and there’s some great examples of advances that you could think about in that, in successful liker bids, in successful digital sprint bids. You know, we could talk about how that’s working better.

It’s quite boring for people because it’s not really talking about the technology end of things, but it is important to think about how is our NHS system geared towards the adoption of these technologies. You know, the boring end of it is it needs this system streamlining, so that you can move very quickly from an innovation into adoption and delivery.

HE:    Yes. I mean, you say it’s very boring, but the King’s Fund have written a couple of reports on that subject, if you want to hear more.

RS:    Well, King’s Fund and Nuffield Trust, and a number of the health service’s research centres and the NIHR, of course, have developed, relatively recently, evaluation capabilities. You know, you can get an evaluation capability now almost anywhere, which is something that wasn’t that prevalent two years ago, let’s say, and, obviously, the King’s Fund have got expertise in this area.

HE:    Yes. Indra?

IJ:    Just going back to the original question, I think was what can you do to evaluate these technologies. So, Public Health England, I think they’re now into their next stage. They’ve done an early prototype of how you actually do that, particularly population health products, but also how you evaluate technology that is impacting care, and to think slightly outside the box of our traditional methods. You know, you build, you deploy, you evaluate, but actually, start evaluation right from when you build, so that when you’re actually deploying, you understand what the capabilities are. So, yes, do look out for the PHE toolkit when it comes out.

HE:    No, definitely. So, we’ve got some more questions coming through, and actually touching on some of the points you were making there, Roger, about adoption, and there was one in particular that I thought was quite interesting from Claire Parker, West Hampshire CCG Digital Innovation & Delivery Manager. So, looking at adoption spread, obviously, there are forums and conferences like this where you can go and spread best practice, but thinking outside of those, what are the best ways to share work, to support the spread of innovation across the NHS? Maybe I’ll come to you first on that, Indra.

IJ:    So, one of the things we’ve done in particular is set up just simple stuff, you know, like a weekly touch base or a monthly touch base with either your regional team or your local team, and say, “Well, we’re doing this from a national perspective. How can we help you, both regionally and locally, to either implement or adopt what we are setting out?”  

I think the second thing is, and I always harp on about this, and I know it’s maybe a bit boring, but making clear that the standards are. So, we have something, like a PHR toolkit, a Personal Held Record toolkit. So, it’s just a basic toolkit to say, “Well, this is what you should have if you want to build a personal health record, and these are the things we have done through use of research.” NHS Digital has written this, and it’s a really good toolkit to say, “Well, here’s how it will be able to be adopted quite easily. So, I would say those are two examples of what we’re doing to help that.

HE:    Conor, are you doing work here supporting the, kind of, spread of innovation?

CM:    So, I think you can look at it on several different levels, but one of the levels that definitely spreads the awareness of technology is publications. So, you know, I would envisage that some of the capability that we’re building up in Manchester with Roger’s team will enable them to do a lot of leading-edge science. Leveraging technologies that sit in the Roche Group, perhaps also other technologies as well, and, obviously, with those publications and those conference presentations becomes a greater awareness of those technologies.  

Standards is a really interesting one. In the genomic space, I think that there’s still a lot of catching up that needs to be done around the standards, different laboratories operate a different set of standards. Then the incorporation of genomics information into electronic health records is handled completely differently, depending on who the vendor of that EHR is. I think there’s a thought leadership piece to be done by organisations like the Roche Group, but also by some of the innovators in the field, and, of course, the national bodies.  

It’s beneficial for us if there are standards because then we can truly aggregate, have a population level, sort of, clinical genomic database, if we’re thinking about genomics, and see that rapid transformation of the care that can be delivered. That personalised, individualised care, not that every breast cancer patient gets the same treatment, but we really have the evidence base in place, to make sure that the treatment is tailored to the patient, based on their genomic profile. So, I think there’s a lot of approaches that can be taken for that widespread uptake.

HE:    On the, kind of, innovation question, and we’ve talked about culture already, but there’s a point here about the workforce in general, and actually, you know, we’ve got … I can’t remember what the latest figures are. I think around 40,000 nurse vacancies. We have real workforce pressure at the moment, which I think, when we’re looking at the Topol review, that needs to be in the back of our mind, that there’s real, real stress on workforce at the moment. Those are the people that we need to adopt and spread these innovations.  

There’s a question here from Candice Dawson, who’s an SCP PMO team member, and she asks, is there a danger that the workforce pressures facing NHS providers will slow down the adoption and roll-out of new technologies, and potentially stagnate growth? So, maybe if I can come to you first on that, Roger. What do you think about that?

RS:    I mean, it’s an interesting question, and I guess what I would say is it’s a very real question at the moment, and there’s a risk to the whole delivery of service and the bigger question, the long-term plan, etc., because of the workforce pressures. I’d like to say that was no different in innovation than it is in service delivery at the moment. I think it’s the same risk. In fact, if anything, in the innovation space, it attracts and recruits people, often at the expense of other standard service delivery areas.  

It’s a critical question that, obviously, there’s significant work going on right now, led by Julian Hartley from Leeds, and Dido Harding, on trying to address the question of how we can adjust and take account, effectively, of the developments from a technology point of view in our workforce plans.  
You know, it’s not necessarily that technology will be the answer to workforce shortages. What we need to do is understand how we can integrate the smarter working opportunities that come from technology, to address the way in which the traditional workforce models have led us to, effectively, a shortfall at the moment.

Certainly, as the questioner says, it’s a very important question in the adoption, that it could well be that it slows it down. Frankly, the workforce question is a problem already in service delivery generally.

HE:    Yes, and it’s definitely a wider question, and that you can only look at one element of that in an environment such as this, but it does feel like a very important one, and I suppose headspace is really what we’re talking about here. If there’s so much pressure, you know, do we have the headspace to transform in the way that we need to, but I think that it’s a really great question.

I’ve got a question here which is more general.  I guess it’s thinking about the timescales for some of the technologies that you’ve talked about.  It’s from Nick McCullough, who’s from an advisory board company, he’s a senior director and researcher on insights, and he says that having the right data, the right quality, is a continuing challenge for the NHS, particularly considering where a lot of trusts are in terms of their digital maturity. So, what do we think about the panel for a realistic timeline for the average trust?  

I think, actually, that’s quite an important part of this, is that we’re not talking about the leaders who might be there in a couple of years’ time. We’re talking about the herd. Where do we think the herd are with this, and I think we can probably talk generally in terms of technology, in different kinds of emerging technologies. Indra, maybe I’ll come to you first on this. How’s that going? Where are the majority of trusts?

IJ:    It’s really difficult to say, because unless you put them all out … we do have something called a digital maturity index, which some of the GDEs have completed, and they are available to see, but I would say this is a multi-pronged approach.  

One of the things I always say, in an A&E, you know, I code people on what they come in with. Nobody ever taught me about coding. It was, kind of, done on my induction, and I was like, “Oh, yes. Tick a box, and any box will make sure that the hospital gets paid properly,” but we always were reassured that there was a coder somewhere down the line who would make sure that, actually, we coded properly.  

What I would say is you have to do it from the multi-pronged approach. We talked earlier about undergraduate training, but also, teaching people at some point that this is important now. The capturing of data, this is important. The quality, the proportionality, what’s the diversity of that data, and we don’t always talk about that.  

I mean, one example I sometimes give, I harp on about A&E because that’s where I’ve trained, but you often get people who are of no fixed abode, or don’t have a name that you know, and so they, kind of, fall into a generic category, date of birth, address, etc. So, how do you actually capture that data quickly, but accurately as well, so it’s reflective of what their problem is? So, we’ve got to start training people, the workforce, all of that, in that space, as well as having the machines or the technology that’s quite easy to use. You know, so you don’t have to go through 30 different boxes to find chest pain of cardiac origin, which is quite often what happens. It’s difficult, but I think we’re getting there.

HE:    I imagine we’ve got some people in the audience just thinking, “Ah, that story.” You know, data analysts, researchers thinking, “Oh, no,” but it’s the reality of it, and we’ve got to acknowledge that.

IJ:    That’s the reality that we face, and it’s the time as well. I want to spend time with you, the human, to help you, to care for you. I don’t want to be sitting back there scrolling through a box trying to find what the code is for what I did for you. Some of that should be quite intuitive and should be coded properly, but, again, I mean … 

CM:    I think there’s a big debate in this space. At the HIMSS conference a couple of weeks ago, there was a lot of discussion around healthcare professional burnout, from such a requirement and a burden, to code down to the nth degree, and I suppose there’s two approaches. You can really strive for the highest quality of data at source, or we can use machines or technology to turn unstructured information into a structured format. I’m not sure which side it’s going to come down on. The Roche Group – 

IJ:    Maybe a bit of both.

CM:    Maybe a bit of both. The Roche Group owns a really exciting organisation called Flatiron who are oncology specific, and they use machine-assisted human abstraction to turn … if you think about the breadth and depth of oncology data, the pathology reports, the images, etc. So, to turn those into a structured dataset.

The FDA are now getting to a stage where they’re quite comfortable, that the real world evidence that’s in there could actually be used to create a virtual control arm for a study, which is a paradigm shift, because, potentially, in the future, we’ll no longer have two arm studies. We’ll just have an active arm against a digital or

 So, there is technology out there. There’s all sorts of NLP in the AI space, and so on, that is taking those unstructured text notes, and turning them into a structured format. So, yes, Indra, I think  you’re right. It’s probably a bit of both, but we need to protect the workforce, and to spend that time, as you say, with the patient, doing the great work that they were trained on.

HE:    Great. Did you have anything to add on that, Roger?

RS:    So, I mean, Conor’s given you a great example of one of the assets that Roche are deploying in our partnership, and I guess, you know, that links back to this question that was really being asked. You know, are we digitally mature enough? Where’s the average hospital? Where are we in this? As you know, to essentially produced an NHS England assessment of this not that long ago, but interestingly enough, also talked an awful lot about the experiences in North America who have been slightly ahead of us in their experiences, should we say, with this. That’s why I touched back to that example of the asset in North America.  

I think the reality is that we will always be focussed on how can the lowest catch up. So, people won’t be too interested in some of the very, you know, advanced things that we might be able to do, that won’t yet come into practice. They’re much more interested in what the normal everyday practice they’re going to meet in the street, as it were, will be. I think it’s a very difficult area to tackle, because there’s been a change from a national strategic approach to this in the last couple of years. There are very good industry examples about it. So, it’s very difficult to say.  

As ever, there will be the traditional bell curve on this. What we really want to do is understand, in direct answer to the question I think, whether or not it will be three years before the middle of that bell curve is somewhere approximating day-to-day transacting of activity, in the manner with which people would expect us to be hitting standards that Indra has been talking about.  

I’m absolutely no expert in any of this, but they’re the sorts of issues that we’re grappling with. It’s a little bit like the change of the system, this trying to take this population health approach. I guess all I’d say is that I think there’s some very informed approaches to trying to create a much more streamlined approach that can accommodate the heterogenous activities associated with the data management and it’s curation that is required for the adoption of these technologies.

HE:    I think that’s really interesting. I mean, there’s a few questions coming through about how we support the middle of the pack on this, but it’s challenging because, in my experience actually, all organisations are doing something interesting. So, middle of the pack just depends on which metric you’re choosing as your key one. So, it can be really difficult, but I think there is a lot of really interesting work going on.

So, there’s another question here about partnerships, and I think it comes on to some of the points that you’re making about how digital companies can work with the NHS a bit more.  
So, Conor, maybe I’ll come to you on this. It’s from Lisa Riddaway from NHS Northamptonshire CCGs, and she asks, clinical companies have robust trialling, etc., to provide assurance, but digital companies are perhaps less tested within the NHS. So, I guess this is making the distinction here between potentially pharmaceutical companies and newer companies in this space. They may bring some unexpected challenges for commissioners, which I think is probably something that we all recognise. What tips does the panel have for overcoming some of these challenges?

So, I guess it’s working with organisations that are new entrants to the NHS market, perhaps. What can commissioners do to mitigate some of the risks from that, and I’ll come to you Conor first.
CM:    So, I would say, starting off, don’t underestimate the benefits that those technology start-ups provide, in terms of their agility. They’re interested in working with the NHS. You know, it’s no different from a large-scale commercial partnership, like Roche might go into. So, it’s really around the shared value, what are the goals of both organisations, but I think that those smaller technology companies actually, their agility is really high.  

You know, depending on what the product, the digital offering is, there’s all sorts of standards from the MHRA, etc., to really help drive that. We’ve got the NHS app library. So, you know, there are standards out there that should help direct and shape the relationship. I think that, from a Roche partnering perspective, you know, the likes of the Christie is an important partner, but as are those start-up technology providers who might do something very differently. Flatiron that we’ve been referring to was a start-up less than a decade ago, and they’re now a multi-billion dollar company. So, you know, don’t underestimate them.

HE:    Yes, and Indra, you’ve done a lot of work in this space.IJ:    We’ve done quite a bit of work in this space. So, maybe I’ll use it to plug some of the work we’ve done. So, three things I would mention is, as an overarching set of behaviours and principles, what is it that some of these people who might not be understanding the healthcare space need to refer to, but also commissioners who might not be familiar with data-driven technology.  

So, we published a code of conduct for data-driven technology. That’s on the gov.uk site. We published it last September, but re-released it again, following lots of feedback, last week.  The other thing is something that we’ve got called digital assessment questions. Conor mentioned our apps library, but on the back of that is a set of questions that cover things that you should look out for in terms of standards, like technical stability, but interoperability, etc.  

The third thing which is quite new as well is what we published with NICE, PHE and a couple of other people, is what we called an evidence framework for digital health technologies. Which also includes a cost impact assessment, which is quite difficult sometimes, when you’re really new to this space, to say, well, people develop a product, and they say, “Oh yes, well the population who have obesity are X million. Therefore, my product will affect X million.” Actually, if it’s only deployed in a certain area, in a certain region, it’s only going to affect those number of people, unless it’s actually marketed outside of that region.

So, it’s just about helping people along that journey, all these tools that we’ve developed, so yes.

HE:    Yes, and do you have any tips then, Roger, for working which – 

RS:    So, I think, just listening to colleagues, there’s lots of support, if you like, it you can describe it in that broadest way out there. There are a number of catalyst arrangements going on that come as a consequence of the latest tranche of the industrial strategy. So, you know, if you’re a start-up in this area, I would be looking to some of those supporting mechanisms and frameworks, to, if you like, make sure that you’re not going to trip over some of the very complicated landscape that you’re entering into in the NHS.

I think that the good news is that there’s an awful lot of activity in this area and interest in this area, because I think people really are rising to the challenge of trying to get this never thought of before innovation, to improve outcomes for patients. I think it’s a very exciting area, and it’s almost the best example of us not thinking in the same traditional way that we were. This space is where it can happen, and I would just be pointing to some of the infrastructure that exists at AHSNs, in particular, the national network of the many of the things that have already been mentioned.  

What you want to see really is the kind of enthusiasm, and Conor mentioned Flatiron, which have moved, as he says, to be the world leader in the ability to curate and manage and use, make it useful, data in oncology, which is obviously one of the reasons that our partnership is so exciting really, from an NHS point of view anyway.

HE:    I mean, there is a lot of support out there. You know, you can see why people feel a bit confused, a bit overwhelmed by everything that’s going on at the moment, but it is great to see that there’s emerging resources out there for local organisations to draw on, available in all good bookstores, I think, Indra.

So, we’re going to wrap up now, but I just want to give you all a chance to just maybe give a couple of reflections on the conversation, maybe about where you think this space is going, what makes you optimistic for the future. So, Conor, perhaps I’ll come to you first.

CM:    Yes, absolutely. So, I’d say this field is complex. It requires partnerships, and it requires the national bodies to, I suppose, create that air cover and to support those partnerships, but I genuinely believe that, together, we can help the NHS to be more efficient. It can keep on delivering the fantastic outcomes, and take them to the next level. It’s great to see different colleagues from different parts of the healthcare system sharing those sorts of views today.

RS:    So, there’s no question that the development of technologies is going to improve outcomes for patients in the next ten years, in a faster pace than we’ve ever seen it before. My enthusiasm for that is abound really, in what is a very difficult environment for healthcare delivery at the moment. In other words, you know, we can see that there is going to be steps forward in improvements, even though the delivery environment at the moment is really challenging.

HE:    Great, thanks Roger.

IJ:    It’s always difficult being the last one, isn’t it, and then you have to come up with something new.

HE:    You have to come up with something…

IJ:    Yes. I’d reflect what Conor and Roger have said, but one of the things I think is really important is this working together. So, we talk about partnerships, but also across organisations collaboratively, be it either national, regional or local, but working together, and also working with your workforce. We talk about user-centred design, but I can’t advocate that enough. Good design principles when you’re trying to solve a problem, and then using all those theories behind it to actually do it, and this is complex, but I do get excited about it.  I do get really excited about what we potentially can do.

HE:    Yes, I know. I get excited about it too, and it’s one of those challenges, to really recognise the risks and the problems in this space, while also saying … but there could be something. There’s lots here. There’s lots we need to be thinking about, but if we’re not thinking about the risks, then we’re not going to get the full benefits from it. So, you know, we need to think about both.

I think that’s really come out of the discussion here today. So, thank you very much Indra, Roger and Conor for your input, and thank you to you the audience for listening. We had some really great questions. I’m really sorry we didn’t get to all of them. If you want to watch it yet again, or if you didn’t get a chance to watch the whole thing, it will on demand a few days after we’ve finished broadcasting. So, please do tune in after that, send it to your friends and family, and Tweet about it. Continue Tweeting about it, #KFonline, so I can go and read your messages afterwards.

Thank you very much. Thank you for giving up your sunny lunchtime to watch this.  I’ve been Harry Evans, and this has been a Kings Fund online event. Thank you very much.

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Speakers

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Harry Evans

Researcher, Policy, The King's Fund

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Dr Indra Joshi

Digital Health and AI Clinical lead, NHS England

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Conor Megaw

Strategic Partnering and Healthcare Solutions Manager, Roche

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Roger Spencer

Chief Executive, The Christie NHS Foundation Trust