Technology will free up hospitals to focus on critically ill within decade
HOSPITALS as we know them will disappear within a decade and most people will be treated at home, the man leading a review of technology for Jeremy Hunt has told The Daily Telegraph.
Dr Eric Topol, an eminent American geneticist, is half way through a yearlong analysis of how technology can make the NHS better and more efficient. He said improvements in sensors that track patients’ vital signs, such as heart rate and blood pressure, will take care out of hospital and into the home.
It comes as figures show that NHS hospitals racked up a deficit of almost £1billion – twice that which was forecast – in the last financial year.
Meanwhile, the number of patients waiting more than a year for treatment rose by 75 per cent. NHS Improvement said the “worst winter in a decade” had brought an extra 222,000 patients to A&E units between January and March.
Dr Topol is due to deliver an interim report in June. In an interview with The Telegraph today, he said: “Over the course of the next decade there will be a big trend toward at-home monitoring. People won’t need to be in a hospital. Unless they’re very acutely ill in the intensive care unit, or they’re just coming out of the operating room, most people will be perfectly well at home.
“You can just imagine the implications on the workforce over time, because then you don’t need the staff of a hospital. It’s so expensive to support hospitals, it’s so labour intensive and so much of that can be taken over by technology – and it will be.”
Dr Topol said at-home monitoring would mean the pressure for ever more hospital beds would be reversed. “Most people in hospital are not in a critical condition,” he said. “Almost all would be better off in their home. In the typical hospital a nurse might come in to do a blood pressure or vital sign check. Well, we’re talking about having sensors which have continuous, real time monitoring in the person’s home. It’s far better monitoring.”
He added that as a result huge hospitals, where large numbers of often elderly patients frequently spent days tended to by lots of staff, would be replaced by smaller, specialist treatment centres.
“I can’t see ICUS disappearing,” Dr Topol said. “But we will see a major reduction in the need for hospital beds and facilities.”
ON CHRISTMAS DAY last year, Brian Thomas walked into A&E at Addenbrooke’s Hospital in Cambridge.
He was a bit groggy but his wife, Jackie, was not really concerned.
She knew he’d been out late at the pub the night before, and thought he was just hung-over. Waiting for them was a hospital operating on what is traditionally the most poorly staffed day of the year. With rotas filled by inexperienced nurses and junior doctors, it’s known even within the NHS as the worst time to get sick.
The triage nurse began to take Mr Thomas’s vital signs. According to Sian Coggle, consultant in acute medicine and infectious diseases at Addenbrooke’s, in many hospitals he might well have been parked on a seat. “The nurse would probably have thought, he’s been at the pub, he’s had a few too many, he’s a bit dehydrated.”
Instead, something else happened. As information about Brian’s case was plugged, detail by detail, into the electronic health record (EHR) system at the hospital, a yellow box popped up on screen. The software had assembled the information and come to its own assessment.
“The box effectively said: ‘This person is really sick, have you considered sepsis?” says Ms Coggle.
It turned out that Mr Thomas was not hung-over. He had Bacteraemic meningitis – sepsis, in other words. “Because our system flagged it up the team knew they had to get antibiotics into him in timely fashion,” says Ms Coggle. “Whereas before …”
She trails off. The evidence is all too clear about what might have happened before. Research demonstrates that for every hour that antibiotics are delayed in sepsis cases, mortality increases by eight per cent. It is a time-critical condition, every bit as much as cardiac arrest or stroke.
Without the trust’s EHR, there is every chance that Mr Thomas would have been left for hours on a plastic chair in A&E, possibly to die on Christmas Day. Instead he was home two days later and suffered no long-term consequences.
The digital revolution
Just two years earlier, that outcome would almost certainly have been very different. In 2015, Dr Coggle began looking at how quickly sepsis was being addressed across Cambridge University Hospital’s NHS Foundation Trust, which comprises Addenbrooke’s Hospital and The Rosie maternity hospital.
Initially it was hard, because there was no data. When she began to collate that data, however, she was horrified to find that only 11 per cent of sepsis cases were meeting the recommended onehour target for the administration of life-saving antibiotics after diagnosis. “It was pretty dire,” she says.
“Sometimes it would be up to four hours. We realised we had a problem. Then we realised we could use Epic to prompt people.”
Epic is the electronic health record system that may well have saved Mr Thomas’s life. It went live across Addenbrooke’s and The Rosie at 2am on October 26 2014, taking the trust all- but paperless literally overnight. Such was the scale of the cultural revolution that the moment remains etched on the memories of most of the 10,000 regular staff at the trust’s hospitals. More than 5,000 old computers were thrown out. About 7,250 new ones were installed. “Rover” devices (customised ipods) which could scan bar codes on every patient wristband became ubiquitous. And the system to which all these bits of hardware connected allowed realtime access to real-time information, from scans to heart beat monitors, anywhere. “If I need to prescribe a drug, I can securely log on and do so, even from the Maldives if necessary,” says Dr Gareth Corbett, a consultant gastroenterologist.
The system can also be programmed so that, when certain parameters are met, it issues alerts, such as the sepsis flag to Brian Thomas’s triage nurse, which was set up by Ms Coggle and the trust’s ehospital digital team.
Others include the Paediatric Early Warning Score, PEWS. “It allows us to escalate serious cases much quicker,” says Hannah Nunn, senior sister on the paediatric ward. “We get them up the chain quicker. That makes us much safer. It can save lives.”
From that “dire” figure of 11 per cent, almost 80 per cent of patients diagnosed with sepsis at Addenbrooke’s are now being given antibiotics within one hour; 95 per cent get the right drugs within 90 minutes. “This is not an IT programme that sits in the basement,” says Dr Jag Ahluwalia, director of digital at the trust.
“This is just how a 21st-century hospital has to function. What is the data telling us? How can we help our clinicians to make use of that to treat people effectively, to save money and, ultimately, to save lives.”
The cost of this Big Bang digitalisation at the trust – the Epic EHR software, new computing equipment, hand-held and mobile devices, IT infrastructure and support – is thought to be around £200million over 10 years.
But there are also savings. Thanks to the Rovers scanning medication bar codes and checking them against patients’ wristband bar codes, there has been a dramatic reduction in errors administering drugs. This and allergy alerts in the system prevent adverse reactions, saving many hundreds of “bed days” each year, and millions of pounds in the process. Such is the extent of the change that patients have at times grown frustrated with doctors fiddling away at screens.
“When they see us on the Rovers they sometimes think we are just on our phones,” says Hannah Nunn. “Apart from that they are so used to technology in their lives, they assume that every hospital is like this.”
That is far from the case. There are more than 200 hospitals in the UK, of which only about 10 per cent have computer systems on a par with Cambridge University Hospitals.
Overcoming the past
The reality is that though medicine is synonymous with some of the world’s most celebrated technological breakthroughs, from the discovery of DNA to heart transplants, the NHS is synonymous with what is likely this country’s most dysfunctional implementation and roll out of technology, ever.
The National Programme for Information Technology (NPFIT) was a decade-long attempt to digitise the whole of NHS secondary care – that is, hospitals (GPS are considered “primary care”). Ordained by central government and imposed upon an often resistant NHS staff, it was an utter disaster. By the time it was shelved in 2011, it had cost more than £12 billion. Parliament’s Public Accounts Committee described it as among the “worst and most expensive contracting fiascos in public sector history”.
Since then, however, the realisation has grown within government that hospitals could not simply languish in the age of the paper and pencil as the rest of the world went digital.
In 2015, a national advisory group on “health information technology” was set up, chaired by Robert Wachter, an eminent American doctor. Like almost any doctor you talk to in the NHS, Dr Wachter understood that what was at stake was more than a few shiny screens.
“In order for the NHS to continue to provide a high level of healthcare at an affordable cost, it simply must modernise and transform,” he noted. “This will involve enormous changes in culture, structure, governance, workforce and training.”
The prize on offer for pushing through such change is equally enormous. A recent report by Mckinsey estimated that digitisation of records alone could save up to 11.5 per cent of health expenditure – that’s £14.5 billion a year. Money is just the start. For digitisation of patient health records means data. Vast troves of it. The NHS, if it can digitise patient records and treatment data across primary and secondary care, will be sitting on what Harry Evans, of the King’s Fund, believes is “the single richest data set on medical health anywhere in the world.”
Computer analysis of such data would almost certainly lead to pioneering and cost-saving treatments. “There’s really a lot going on in data analytics,” says Dr Shaun O’hanlon, chief medical officer for EMIS, a provider of EHR software for GP practices. “We’ve got 40million patient records on EMIS. You can analyse that database to create risk scores for diabetes, coronary disease …”
A view to the future
Today, the insights from so-called “Big Data” analysis are allowing start-ups to claim that their technologies – in areas from ECG analysis to drug delivery – will deliver greater accuracy in the near future than humans can now.
Yet the biggest savings of all will come not from treating people in different ways but not having to treat them at all. Increasingly, the NHS is focusing its time and technological effort on keeping people out of its waiting rooms, wards and operating theatres altogether. Given that an NHS bed costs about £350 per day, it’s easy to understand why. Rooms at the Dorchester hotel cost about the same.
Part of the movement towards prevention will involve capitalising on the fashion for consumer health tech devices, like Fitbits, which track users’ exercise regimes. Other, more sophisticated devices, such as smart spoons, have handles that can record the tremors of Parkinsons’ sufferers and track the deterioration of their hand control.
At a simpler level, the NHS now recommends some smartphone apps which it thinks effective and thus save it money. One is for insomnia. Others are being looked at which allow patients with mental health problems to track their mood. Such self-reported data can then be assessed for patterns which might predict if they are at risk of an “event” – as attempted suicides are euphemistically known.
From the hospital to the home
According to Eric Topol, an American geneticist who is currently leading a review of technology in the NHS for Jeremy Hunt, the Health Secretary, the combination of apps, wearables and sensors will combine in the next few years to move healthcare “out of the hospital and into the home”.
“People won’t need to be in a hospital,” he says. “Unless they’re very acutely ill in the intensive care unit, or just coming out of the operating room, most people will be perfectly well at home with sensors which offer continuous, real time monitoring of blood pressure, heart rate and the like – better than hospital but with a much lower expense factor.”
The consequences for hospitals and those who work in them will be profound, says Mr Topol.
“Just imagine the implications on the [NHS] workforce over time, because with [home sensors] then you don’t need the staff of a hospital to support patients. This is a very significant thing. It’s so expensive to support hospitals, it’s so labour intensive and so much of that can be taken over by technology and it will be.”
Mr Topol’s is a vision in which the need for the giant “hotel hospitals” of today, where large numbers of often elderly patients frequently spend many days tended to by large numbers of staff, simply disappears. Instead of needing ever more beds, he thinks, the pressure will go the other way.
“Over the course of the next decade there will be a big trend towards athome monitoring,” he says. “So we will see a major reduction in the need for hospital beds and facilities as we know them today. I can’t see ICUS disappearing, but those other wards …”
This is a radical concept, in which patients using cutting edge technology keep themselves healthier for longer and then, when they do fall sick, are monitored at home for as long as possible.
It is a future in which the biggest costs of the NHS – hospitals and the staff in them – are all but eliminated.
There is, then, no doubt that technology is driving a healthcare revolution. But what is equally certain is that it will be felt very differently across England’s deeply fragmented, un-national National Health Service.
“There are pockets of excellence. But it’s really hard to get the whole NHS to do it,” says Mike Hannay, the chairman of the Academic Health Science Networks.
“We’ve got an ageing population which is growing fast and no government, of whichever colour, has the money to keep spending the way we do to treat that ever-ageing population as we do now. Society just can’t afford it. So the most valuable thing we can do is keep patients out of hospitals, out of GP surgeries, and help individuals keep themselves healthy at home.
“That’s the way to a sustainable NHS for the next 70 years. In fact without that, there soon won’t be an NHS at all.”
A Technology Intelligence Podcast on the future of health is available at telegraph.co.uk/technology-intelligence-podcast Some names have been changed
‘People won’t need to be in hospital, unless they are very acutely ill in the intensive care unit’
‘That’s the way to a sustainable NHS for the next 70 years. Without that there won’t be an NHS’