Thanks to social media, it's now possible to engage with leaders in healthcare, in a manner that was not feasible a few years ago. Using Twitter, I recently connected with Ben Gowland @ccginsider, Chief Executive of Nene Clinical Commissioning Group (CCG), which is the organisation responsible for commissioning healthcare for most of Northamptonshire, England.
Given the recent changes in NHS England, I was curious to hear Ben's perspective on the future of healthcare in England, especially the role that Digital Health may play in that future. It makes for fascinating reading, especially if you're a Digital Health startup!
1. Many people are still confused about clinical commissioning in England - could you explain what it means, and how it differs from the prior approach?
There are generally two parts to this question. The first is understanding what ‘commissioning’ means. The way the NHS works is that the money to fund healthcare is raised through general taxation, and then this money is distributed to commissioning organisations (like Nene) to buy (or ‘commission’) healthcare services from provider organisations (such as hospitals) for their local area. So Nene CCG has a budget of £660M to commission healthcare for the population it serves.
Whether commissioning is successful or not is determined by the extent to which commissioning organisations use the money to improve health outcomes and experience. At its crudest level this means whether people live longer, healthier lives, as a result of the way that the money is used.
But of course the big challenge facing the NHS, and the majority of healthcare systems, is that in the current economic downturn there is less money available. Health inflation outstrips any growth in funding and the demand for healthcare services such as accident and emergency attendances and emergency admissions to hospital continue to rise year on year. Public expectations also rise every year. So the real challenge facing commissioning organisations like Nene is how do we improve outcomes and experience when there is less money available.
Which brings me to the second part of your question. Clinical commissioning means that those now responsible for commissioning healthcare are clinical commissioning groups (CCGs). CCGs are membership organisations of GP practices, so for example Nene has 60 member practices. These GP practices elect some GPs to be directors of the organisation, who in turn are supported by management directors (like myself) to run the CCG.
The point of this is that 90% of healthcare contacts happen in primary care. GPs have always been the ‘gatekeepers’ of the NHS. As such they are the group best placed to understand the needs of the population, because they see patients every day. In the past commissioning organisations were essentially management led organisations, and it is this shift to being membership organisations of GP practices that represents the biggest difference from the past.
At the heart of the challenge to improve outcomes and reduce expenditure is the need to reduce the reliance of the healthcare system on acute hospitals. This requires a bigger focus on prevention, better services in the community and the ability to manage patients with long term conditions outside of hospital. The challenge for clinical commissioners is to make this a reality, a challenge that previous iterations of commissioning in the NHS have been trying to do for many years without success.
2. How many patients & staff are covered by Nene CCG?
Nene CCG covers a population of 625,000, and has around 200 staff. Nene is one of the biggest CCGs in the country. Some CCGs cover much smaller populations (the smallest covers a population of 70,000) and as a result will have far fewer staff.
3. What are your 3 biggest challenges over the next few years?
The headline challenge for all CCGs is as I have started to outline above: how to improve outcomes and experience in the current financial environment. Within this there are specific elements that are important, so I have tried to pick 3:
- How to transform general practice so that it can strengthen its gatekeeper role and partner more effectively with other parts of the health and social care system
- How to integrate community health and social care services in local communities around the needs of individuals
- How to change the hospital sector so that it supports the delivery of out of hospital care and provides specialist services as required, rather than acting as the default point of healthcare provision
4. Do you believe Digital Health technologies have a role to play in helping you meet those challenges?
For me the biggest component of all of these challenges is the need to shift the role of individuals within healthcare. Currently we receive healthcare when we need it. When we are ill, we transform from citizens to ‘patients’ and let others (health professionals) make decisions about our healthcare. There are many reasons for this, and a key one is the information imbalance between health professionals and patients. Technology has a key role in enabling individuals to take control of their health throughout their lives (not just when we need it), as well as becoming partners with health professionals in decision making and treatment when the need arises.
More specifically there are some key information technology challenges impeding progress today. Effective ‘risk profiling’ populations to identify those at highest risk of admission to hospital so that action can be taken in the community to prevent it is an ongoing challenge. We are also still struggling to enable information systems between different provider organisations to talk to each other. If we want to commission whole pathways for patients rather than simply commissioning services from individual organisations (which we do) we need joined up information across these pathways.
5. What are your staff & patients asking to be done differently in the future (where technology might help)?
A key challenge is tackling variation. It starts with identifying where variation exists, understanding it, and taking action to reduce it. Variation exists everywhere: between individual clinicians, between GP practices, between hospitals, between the behaviours of different populations. Alongside this is the systematic implementation of best practice. It still takes far too long for proven new ways of working to be systematically embedded within the NHS. If we could do these two things: reduce variation and rapidly implement known best practice we would be in a much better position to manage the current challenges.
We are currently seeing significant growth in the regulation of the NHS. There is now a chief inspector of hospitals and a chief inspector of general practice, and there are a multitude of organisations with responsibility for different aspects of regulation. Much of the current demand is to support organisations to be able to meet the requirements of these different regulators.
6. If UK entrepreneurs and innovators want to develop Digital Health technologies that can benefit Nene CCG, what's your advice to them?
New ideas tend to fall over for two reasons. The first is that they do not look at the financial return on investment. CCGs have no money, and so can only spend on what will reduce spending overall. The days of commissioners making decisions on how to invest their growth money have long gone! The second is ensuring that total cost to the commissioner will be reduced. New services often stimulate new demand, and so there needs to be clarity that it is existing demand that is being impacted. So for example it is no good demonstrating that COPD admissions will be reduced for a specific cohort of people with the introduction of a new digital monitoring service if the total number of emergency admissions goes up (whether COPD or otherwise), because the money identified to pay for the new service has gone. Often new community based or easy access services tap into previously unmet demand, which means that even though they are busy as commissioners we do not see a corresponding decrease in demand elsewhere in the system.
The funding available to the NHS is fixed, and determined by government. A new technology can provide lots of benefits but key to bear in mind is where the money will come from to fund it. We will always look for a reduction in expenditure elsewhere. I think partnerships between CCGs and those introducing new technologies on some sort of risk share basis are the most realistic way forward. Where these are directly offered by providers commissioners are much more likely to be responsive.
Prevention is the biggest area where technologies can help and yet it is one of the areas that is hardest to demonstrate a return on investment. Proving what is not a hospital admission that would have been had it not been for the new technology is very difficult indeed. One of the key individuals in any area for those wanting to operate in the prevention field is the Director of Public Health. These posts are now based in local councils (county councils where there are two tier authorities) and having them on side early on will be critical to success.
7. Some technologists, primarily in the USA, believe that the future of healthcare delivery may be the smartphone. Do you think it's realistic that in England in 2018, patients will be performing certain diagnostics on themselves using Digital Health technologies?
If you think about the need to develop individuals as partners in their healthcare rather than simply recipients of it, I think there is a huge role for personal technology like smart phones in enabling this. In my view the quicker we can get to this the better. Where now we have some individuals monitoring simple things such as the number of steps they take through a pedometer, empowering individuals means they need to be able to monitor a whole range of diagnostics to monitor their ‘healthiness’ and identify at the earliest possible stage the requirement for intervention.
There will inevitably be a nervousness and resistance amongst the professions to this. Many pathologists were resistant to near patient testing when it was introduced and we are talking about something that is a whole stage on from that. As a result initial demand for this technology is likely to come from individuals themselves wanting to take control of their own health rather than via the professions. The bigger challenge will then be getting the professions to accept the results as valid!
[Disclosure: Maneesh Juneja has no commercial ties with Nene CCG]