The impact of C-19 on digital: smoke and mirrors?

A widely reported upside of the COVID-19 outbreak has been its impact on the advance the implementation of digital technology and processes to support remote working, self-care and remote care. In part, this has been achieved through lower commercial, financial and clinical barriers and not least the hard work of NHS workers and IT teams.


At the same time, whilst remote consultation has escalated, information supporting the news about adoption rates and usage of technology and platforms has not been as prevalent. Where there is data to indicate what is happening at the patient interface it doesn’t seem to add up to support the reported shift to digital as much as is implied. There is also a widespread call for a degree of caution to allow for the clinical and safety aspects to be properly evaluated. This article provides some critical thinking and suggests that some reflection is needed to address the challenges post-COVID 19 to ensure the value of these newly deployed technologies is truly realised.


Significant progress to advance the digital agenda has been reported across healthcare media since the pandemic took hold and a surge in digital platforms and technologies across acute, primary and social care services are credited with enabling the system to respond urgently to maintain services and manage demand. Most recently, the Digital Health NHS IT Leadership Survey reported a significant rise in optimism amongst IT leaders about the prospects for NHS digitisation compared with the levels reported last year (Source: https://www.digitalhealth.net/2020/12/nhs-it-leaders-believe-covid-has-changed-attitudes-to-digital/)


The UK Government was quick off the mark to publish guidance and special measures to permit relevant data to flow (https://www.gov.uk/government/publications/coronavirus-covid-19-notification-of-data-controllers-to-share-information) and Legal Directions (under the provisions set out under Section 259 of the Social Care Act 2012) were fast-tracked to enable NHS Digital to establish COVID related data to flow from a selection of representative national and regional Residential Care home providers in order to support pandemic planning and research (https://digital.nhs.uk/about-nhs-digital/corporate-information-and-documents/directions-and-data-provision-notices/secretary-of-state-directions/covid-19-public-health-directions-2020).


NHS Digital moved quickly to ensure that COVID-19 related information was included by default on the national Summary Care Record (SCR) https://digital.nhs.uk/services/summary-care-records-scr/additional-information-in-scr and by 27 April it reported that NHS staff had access to enhanced data to over 50 million patients https://digital.nhs.uk/coronavirus/updates/nhs-staff-can-now-see-more-information-about-patients.


These significant, national initiatives, as well as other factors, have been ‘called-out’ in a number of scholarly and credible editorial articles as early as June 2020. In the BMJ article Digital health and care in pandemic times: impact of COVID-19 Peek N, et al. BMJ Health Care Inform 2020;27:e100166. doi:10.1136/bmjhci-2020-100166, the authors acknowledge the rapid response by the UK Government to provide lawful cover for confidential information to be processed for a ‘COVID-19 Purpose’ as a key enabler for the rapid response to the pandemic. The article also cites the maturity and ‘readiness’ of established and readily scalable technologies and services, such as tele-health platforms, to enable the rapid roll-out of remote consultations in Primary Care and for Acute Out-patients appointments. In contrast to these ‘oven-ready’ platforms, apart from the AI-analysis of social media helping to predict the spread of the outbreak, AI technology has as yet, according to the BMJ article, played a minimal role in the reported surge of technology solutions to combat the virus and it’s health impact, although a number of potential applications are suggested.

Articles by The Kings Fund in early August (https://www.kingsfund.org.uk/blog/2020/08/covid-19-innovation-nhs) and the Nuffield Trust in late August (https://www.nuffieldtrust.org.uk/research/the-impact-of-covid-19-on-the-use-of-digital-technology-in-the-nhs) both acknowledge the “incredible” and “astonishing” pace of technology adoption and the lowering of barriers to adoption across the NHS. The Nuffield article points to the impressive statistic that the Video Consultation platform Attend Anywhere (nationally funded by NHS England and NHS Improvement was available to 183 NHS Trusts and 15,500 hrs of virtual consultation had been completed by the end of April 2020. Both these articles highlight the historical conservative nature of technology adoption in health and need to address a more fundamental re-design of services rather than using technology for components of the existing service models.

This is all extremely encouraging for long-time digital evangelists and practitioners. But is it all as it seems?

On closer examination, whilst there is an incontrovertible (perhaps unstoppable?) wave of positive action and real investment in digital underway across the healthcare system in the UK, we need to consider how far have we actually travelled and to what extent the real challenges for digital transformation are really being met and opportunities realised. By ‘real’ challenges we refer to the significant people, cultural and process-related factors that are required to shift at individual (i.e. customer/ client), professional practice, service and organisational level in order for technology to really work for the benefit of all.


Very little data is available as yet (at least, data that has open access) about the adoption (i.e. actual usage) of these rapidly scaled technology platforms, the nature of the adoption and the outcomes arising from their adoption. For example, what has and what is happening with the additional person-level COVID-19 information added to the Summary Care Record; how much and how frequently has and is it being used, what for and what benefits or outcomes can be evidenced? There is some openly available Management Information data published weekly by NHS Digital about appointments in General Practice that shed some light as to the challenges faced by digital transformation https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice--weekly-mi/current

The published data in the spreadsheet illustrates the drop in weekly appointment levels immediately following the national lock-down period starting in March and continuing at lower levels through April; a dip from approximately 6m pre lock-down to approximately 3.3m appointments per week. There is a steady rise to approximately 5m appointments per week by August and by October onwards the weekly appointments are back to pre-COVID levels. This clearly illustrates the period of change in service practice over the period from face-to face to remote appointments. It’s actually a remarkably rapid turnaround. What is pertinent to this commentary is the data about the ‘Appointment mode’. The Appointment modes are listed as ‘Face to face’, ‘Home visit’, ‘Telephone’, ‘Video conference/ Online’ and ‘Unknown’.

The Appointment mode usage trend is interesting; a snapshot of three weekly figures (Table 1) over the period from early March to early November 2020 demonstrates the point that a switch to remote consultation has occurred, however ‘digital adoption’ clearly has not happened yet.

Table 1: Summary of Appointment mode by sample weeks 02/03/2020, 03/08/2020, 02/11/2020


Face-to-face appointments have decreased by 23.4 % over the period between March and November 2020 and these appointments have been largely replaced by telephone appointments. The use of Video Conferencing has disappointingly, remained static at best and below .5% of weekly appointments.

The shift to digital channels in Primary Care is therefore somewhat less than implied by government and media outlets and more embryonic in terms of overall adoption. This may be an over-simplified appraisal and it is certainly the case that ‘remote consultation’ is a feasible way of managing demand, however such a conclusion is consistent with a number of consultancy and implementation projects promoted on commercial frameworks that have been commissioned by CCGs to deliver and implement a strategy to increase adoption and uptake of digital channels (Video Consultation primarily) in Primary Care settings.

This is but one example that illustrates the need for further examination of what is actually going on and how to improve adoption. It also reinforces the age old lesson that whilst deploying technology solutions is a good step forward, a more holistic approach incorporating patient engagement, service design, change management and staff training is required.


The Clarity Practice is well equipped to support organisations to increase the adoption of newly deployed technologies having supported numerous clients with their response to COVID-19.

Footnote:


The Clarity Practice is seeking the views of senior digital practitioners, through a series of simple and quick online surveys, about if and how their roles and the landscape for digital transformation has or is or is not changing for the better. Watch this space.


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