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The National Health Executive Podcast is the perfect place to garner insights from across all aspects of healthcare, as we get into the crucial ‘whys’ behind the stories and how they can impact all of us to improve our work, our lives and the care and services we provide as an industry.
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Episode 46
What happened to the most disadvantaged patients? And why did the digital front door, if we can call it that, why was it closed? The impact of what we might call an external shock on the innovation process, and I think it is one of the major achievements of general practise in this country.
This is the National Health Executive podcast, bringing you views, insight and conversation from leaders across the health sector, presented by Louis Morris.
Yes, welcome back to the National Health Executive podcast, and today I'm very pleased to be joined by Trish Greenhouse, who is professor of primary care health sciences at the University of Oxford. So, Trish, I'd like to talk to you about the NHS digital makeup today and the general direction we're going in. Now, you've been doing some research in primary care and GP practises, specifically looking at digitalized access and triaging. And if I may, what you found is that, these measures have somewhat exacerbated certain inequities. So, just to set the scene for our listeners, can you tell us a little bit about what you found?
Yeah, well, we followed twelve general practises for 28 months and we used a, method called ethnography, where one of our team spends each of those.
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We'D make repeated visits to the practises. We'd get to know the staff, we'd watch what happened, we'd interview staff and patients, and so we'd pull together a kind of story about how these different general practises were responding to the challenge of digitalization. And as you can imagine, those practises ranged from very high tech, where you've got a lot of partners and managers, and other staff who are very keen on digitalization. And the patient population, perhaps of young professionals who were quite happy with that. that's at one end of the spectrum, to the other end of the spectrum, where you've got traditional general practises, perhaps your street corner practise, in a bit of an out of the way locality, serving a population of patients who are actually not so digitally enabled. And those practises, often didn't provide as much in the way of digital services. And that was something that the staff and patients were fairly happy with. They were happy to continue with, the more traditional approach. Now, obviously it's much more complex than that, but I think the thing you want me to talk about today is what happened to the most disadvantaged patients and why did the digital front door, if we can call it that, why was it closed in the face of some of the people, who are the most vulnerable groups in society. and m I guess maybe the best way to get into that is to actually think about, certain people, certain individuals. And we did that in some of the papers that we wrote. We actually made up fictional characters who were based on real people that we'd interviewed. So here's one. here's a guy who's in his late twenties. He's got asthma but he doesn't have a home. he sofa surfs, he goes and spends time with his friends. and then when one friend's fed up he gets kicked out and he goes and spends time with another friend and he needs his asthma inhaler but he goes to a general practise and then they say to him, well no, you can't just walk in here and register. you have to go home and turn on your computer and then use the electronic, access portal and then you have to put all your details in and then we'll decide whether or not you're going to see a doctor or a nurse and whether you can see face to face or you have to be remote. So he says, well, hang on a minute, I haven't got a computer. I haven't even got a phone. so they say, well that's nothing. We can't deal with you then. Now, not many practises would actually turn someone like that away. Some would, more likely than the receptionist would say all right then you can stand here and I will ask you a load of questions and I will fill out the online form for you. So this poor chap who's not got a home, he's not feeling very well because his inhaler's run out. He's quite wheezy. He's got to stand there answering a series of questions which are being put to him in the reception area so there's not much privacy. This chap doesn't feel particularly good about that. He feels embarrassed. He's actually not particularly able to answer the questions because he gets given a whole set of alternatives. Are you saying it's this or this or this? perhaps he's not the brightest. And so what he does is he gets frustrated and he walks out before the end of, that little encounter. and then he tries again at a different practise and gets another kind of bit of a rebuttal. Now, some GP practises are very good with patients like that. They get the fact that they're probably never going to be, digital whiz kids. And they have a kind of workaround for patients like that. we see it also for elderly people, people who are visually impaired, people who are deaf, perhaps people who've got mental health conditions, perhaps people who have limited English, all that kind of thing. But the very fact is that the more you digitalize, the more you are going to make it difficult for, people who are not already on top of digital technologies and what we call digitally enabled.
Yeah, you explain the issue fantastically there, and you say in the paper that what needs to be done as a result of this is co design services with these imbalances in mind. So my question will be, who needs to be looped into these discussions and what would those discussions actually look like?
Yeah, so there are some really good, examples of efforts at co design. The problem with co design, it's a buzzword, it's what everyone said, oh, yeah, we must co design. Everybody being one big happy family in some kind of focus group or something like that. but the most vulnerable people in society are often the ones who are not confident to attend that kind of, that kind of activity, or they just don't want to, or they don't know about it. And so what you get, if you're not careful, is your lovely co design process actually doesn't tap into the people, whose needs are, most pressing. There's also this idea that there are some groups of, quote, disadvantaged, unquote, patients that perhaps everyone feels quite sympathetic to. the elderly, for example. Everyone wants granny to be properly looked after. We're all going to be elderly at some stage. and then there are other, people that we have a bit less sympathy for. And that's why I use the 29 year old homeless guy. Perhaps he's also taking drugs. he might come in and make a bit of a rumpus in the surgery because he's frustrated, because he's a bit impulsive. And actually a lot of us have rather less sympathy for people like that. but that young man may have had adverse childhood experiences, for example, which makes him less trusting of institutions like healthcare. and I think if we come back to your question about co design, you can certainly get a group of, the practises elderly patients together. They bring together on a Tuesday afternoon, they're not doing a lot else, they're all retired. they'd all behave in the kind of way that you'd expect, good patients to behave. But if you try to co design services with drug addicts, for example, with homeless people who perhaps won't turn up, etcetera. The co design process is a little bit more difficult. But we did find some examples of what I would call multiply disadvantaged patients, disadvantaged groups, who had managed to have input into the design of services. And there's one practise I'm thinking of in particular in a very deprived part of, a city in the west country. one of our researchers from the University of Plymouth made links with a, homeless hostel and, had multiple visits to that hostel to talk to the people that were coming there in the day, time to say, how would you want your general practise to be designed? And actually, these people, just like the young man that I described, who's fictional, by the way, they'd quite like to be able to just walk in and ask to see the doctor. They don't particularly want digital services. And actually, that's one of the problems with co design is the implication is that there is a possible design of a digitalized service that will tick all the boxes. But when you get the patients in, some of them say, well, we don't want any digital services, thank you very much. We just want it to be traditional because, we're the sector of society that, that just doesn't carry smartphones, etcetera. so you may come up against a bit of a brick wall there, but the idea of co design is that you base it on the stories and experiences of vulnerable groups and what we call emotional touch points. An emotional touch point is, I described one with the young man when the receptionist is asking him lots and lots of questions, and finally he just has had enough and he walks out, because he's upset, he's angry, he's frustrated, all those emotions. So what we do with co design is we say, what was it about our service that was making him frustrated and angry and upset? And one of the things is the very brittle, very kind of constraining, very highly structured nature of the questions that are being asked and the volume of questions to fill out these online forms. And one of the changes that has happened in technology design over the last couple of years is that the requests for, e consultations or that weigh in, the questions have got a lot fewer and you're allowed to use more free text. And so, they might say, why do you want to see the doctor? And you just write, because blah, blah, blah. And of course that's more conversational and it's less threatening and it's less annoying. so that's an example of the way, you know, co design might work on a small scale to precipitate different designs of, the tools.
And as you explain these imperfections in certain GP practises, I believe a lot of these digital innovations are the root of the COVID pandemic and the mass acceleration of digital, I guess, adoption. Are these growing poles just as a result of that? Or is there a way, as you've explained, of, I guess, preventing these things from happening in the first place? Or was it just something we have to accept because of the global pandemic?
Well, it's interesting, isn't it? I mean, one of the things I'm quite interested in is the impact of what we might call an external shock on the innovation process. And, there's a guy in America called Andrew van de Ven who's written a book called the Innovation Journey. It's quite old now. but Andy van de Ven has done some great work. And one of the things that he talks about is shocks that you. I mean, war is another big shock. You know, you get massive development and, advancement in technical innovation in wartime, but pandemic is a pretty big shock. And yes, we had to immediately, or within the space of a fortnight, three weeks, shift general practise from a face to face model to a remote model. And I think it is one of the major achievements of general practise in this country. that we did that, we did it really, really quickly, we did it effectively, for infection control purposes. And so we responded to the shock. and then the question is, well, hang on a minute, what do we do now? What do we do now? Covid is still around, but it isn't the threat that it used to be. At the beginning of 2020, what's going to happen? Are we going to go back to where we were before? Are we going to keep the innovations, or are we going to have some kind of hybrid of the two? And this is the piece of work that we've been doing, over the last two and a half years, is looking at how general practises face that strategic decision. And like I was saying at the beginning, you know, some of the practises who were very digitally advanced and who served a population of digitally advanced patients, you know, the young professionals who get the tube to work, who are very happy to have a smartphone video consultation type thing. Actually, the shock of the pandemic gave them a huge boost. And those practises and there aren't very many of them are now. It's almost science fiction walking into those practises. Well, you know, they have rooms that look more like they have things like a gaming chair for the doctors to sit on while they're doing all their remote consultations. but with other practises where they've got m a more mixed population, particularly when they've got patients at multiple deprivation. So they're poor, they may not speak English, they've got multiple health conditions, they've got very few digital technologies. Actually, winding it back a bit and saying, look, we're going to go back to a mainly in person service is quite a good idea. So the point is, one size doesn't fit all, I should say. I'm sort of implying that people who are poor don't want digital services. That's actually not true. one of the things about not having much money is that you often don't get much choice about when you consult the doctor. For example, you may not be able to get time off work, whereas if you're in a professional job, you can usually adapt around it. and if the aspect of, disadvantage is simply that you are in a low paid job where you can't really negotiate time off, often those patients really want remote, but what they want is low tech remote. They want text messaging, they want to be able to phone up and talk to the doctor. but what they don't want is, for example, a video consultation which uses a high amount of data when they actually have only got a low level data package. So it's much more nuanced than. Oh yeah. For all the, sort of, well off patients we can have digital, because that doesn't work either. We need to make sure that there is a low tech, remote solution for, people who want that. But we also need, to have the in person walk in services, for multiply disadvantaged patients.
Just latching on to what you said just then and before about some GP practises being the scenes of science fiction films. And while other services are winding it back, would it be fair to say the NHS is guilty of somewhat running before it can walk? Now that might be unfair to say, but just as a hypothesis for what made me think this is, he went back certain months to the spring budget. The chancellor, Jeremy Hunt, he was talking an awful lot about AI and this is extending the piece somewhat as well. But he was talking a lot about AI. Whilst I couldn't help but say even now, some trusts are just. Only just launching eprs, and that's quite a juxtaposition.
I don't think it's the NHS that's trying to run before it can walk. I think it's government, actually, policy. M. I've been studying it policy for 30 years. and, some of the policy ambitions are a bit, unrealistic, I would say. But if we're not ambitious, we'll never achieve anything. So I think it's. I'm not so sure that I want to blame policymakers. I mean, you know, I don't think it's. You're guilty. I think it's saying if we want to make the most of remote and digital tools, we need an ambitious strategy. We need to kind of aim high. On the other hand, what we also need to do is learn lessons and adapt and adjust. And I'm just writing some policy recommendations with the paper I'm writing and the one size does not fit all message is one of our big bottom lines is, look, it's fine where it's working. make sure that you support practises to be able to buy the technologies they need and use those, in a way that benefits everyone. But when it's not working, you need to know when to stop pushing, I suppose. And so what I want is a mixed economy.
I mean, I'm glad you mentioned policymakers because that is what I wanted to talk about next. And you've already mentioned somewhat there about your policy recommendations. What do you think the next government, whoever it is, whatever colours they fly, needs to be doing as soon as on 5 July. What do you think the health sector needs to focus on? Whether it be primary care and speaking in a capacity, whether it be a former GP, now an Oxford researcher, or just simply a person. What do you think the next government needs to do?
Well, I think the, policies in any sector, but particularly the health sector, need to be driven by values. And, you know, let's say, for example, we get a Labour government. What are Labor's values? What is the government there to do for people in relation to health? And I think one of the traditional labour values is equity. You know, if you, went to see the play Nye recently and all about Nye Bevan and setting up the NHS, and Nye Bevan was driven very much by the fact that he was brought up in the welsh mining community where some, but not all people had access to healthcare. And what he wanted was for everybody to have access to basic level healthcare. And I think we mustn't forget the principles on which the NHS was founded. so coming back to what the government should be doing, I would say that digital, all digital, including AI, including the really exciting developments on the horizon, are tools for delivering on a vision which should be underpinned by our values about what kind of a society we want. So let's not lose sight of that. what I hope will happen with the next government, whatever colour it is, is that the kind of health service that is ethical and reasonable and fits the society we want to have will be delivered through technology. So it's not a question of which technologies we want, it's a question of what kind of a service do we want and particularly how much effort and, what kind of measures are we going to put in place to make sure that the most disadvantaged people in society can still access care. And we started this podcast with you talking to me about, disadvantaged people and how they might find it more difficult to access services. So I very much hope that that's going to be a big priority for what I think is going to be a new Labour government.
Yeah. So I guess it's about ensuring digital as a facilitator rather than a disruptor, rather than ploughing on for progress sake, make sure as many people benefit as much as possible.
Yeah. And I think the other thing that I would like the next government to do is to recognise the ongoing effort and resource that is needed to support remote and digital care. So one of the things we've demonstrated is that whenever you, put in place a new technology, you know, be it if you're the first time you ever downloaded PowerPoint, for example, it took ages to work out how it worked, but after actually not all that long, you realise that this was a very powerful tool and you could do really interesting things with it. Now, in general, policy recognises that they have to put money on the table to buy the technologies and money on the table to show you how it works. What they are not so good at doing is putting money on the table to continually refine and embed those technologies, including picking up on the upgrades and the improvements and the, configurability, but also training new members of staff as they get appointed, and adapting the technology and the work routine to respond to new policies as they come in. I mean, for example, the appointment of new staff groups. We've got pharmacists and nurses and, physician associates and all sorts, working in general practise, but we need to continually adapt and train and retrain teams to make sure they're getting the most out of technology. So there's a sort of ongoing embedding process that needs to happen. And I've not met anybody from government, or indeed opposition who really grasps that. They sort of think it's plug and play. They think, well, we'll just buy the technologies and everything else will follow on, but it doesn't. It needs an awful lot of ongoing work.
And as we've mentioned, we are in the midst of a general election. For those who have been living under a rock, is what you've just explained, though, what the next government or the next parliament will be judged mostly on come 2029, presuming there's not another snap election, is that what really, people will, I guess, judge them for?
I can't speculate on what the next government is going to be judged on in 2029. That's definitely not anything that I'm an expert on. I can speculate from a personal perspective. I'm sure that's not what your listeners want to hear about.
No worries. And speaking back to our listeners, we've talked about a lot on this podcast, as we usually do. We go from pillar to post. Have you got any final words for our listeners from three points that you'd like to really hammer home, that we really need to see in this current political climate and current NHS landscape?
More resources. Haven't really talked about that, but another one of our findings was that there's actually a lot of good stuff going on. There's a lot of very committed people. But the NHS is underfunded, it's, understaffed. and we've got to the stage where the resilience of practises is really not very good. and people are leaving. People are leaving in droves. the other thing is, the material and technical infrastructure of the NHS is seriously problematic. Just like our schools need a lot of repairs and perhaps some new ones built similarly with the big buildings and the technological infrastructure, we need a big, effort there, because we're already seeing breakdowns in the infrastructure, servers crashing, all that kind of thing. we've had a cyber security incident in one of the hospitals, which is still going on in London. We need to attend to the infrastructure big time.
Yeah. So it's not so much a facelift with a fancy new policy name or fund. It's more, I guess, open heart surgery really needs, I guess, reform from the ground up.
Yeah, yeah, absolutely.
And you have been listening to the National Health Executive podcast thank you so much for tuning in and make sure you catch the next one. See in a bit.
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