Shifting to a world of prevention: A GP's story

For this post, I caught up with Dr Manpinder Sahota, a GP in Britain's NHS. We first interacted over Twitter, where we met on the topic of shifting healthcare to a world of prevention. Dr Sahota said he had a vision for building a GP practice with a focus on wellness and prevention of disease, and was curious if technology could play a role in that. So I hopped on a train to see him, and what follows is the interview at his practice, in Gravesend. For those who have never visited, Gravesend is an ancient town in north west Kent, England, situated 21 miles east south-east of Charing Cross, London on the south bank of the Thames estuary. Gravesend has one of the oldest surviving markets in the country, its earliest charter dates from 1268. For my American readers, Gravesend is where Princess Pocahontas is buried, having died there almost 400 years ago, on a ship bound for the Commonwealth of Virginia. Back to the present day, Gravesend [and the borough of Gravesham that it falls under] faces the challenge of childhood obesity, with 38.9% of 10 to 11-year-olds resident in Gravesham being overweight or obese. Demographics are changing, with 17% of the population of the borough of Gravesham having been born outside of the UK. 

Hearing about new models of care with Dr Manpinder Sahota at his GP practice

Hearing about new models of care with Dr Manpinder Sahota at his GP practice

1. What is your role & responsibilities?
I've been at the Pelham medical practice since 1999. We have 7 GPs, over 2 sites and almost 14,000 patients. I'm the Diabetes lead and a GP trainer as well. I also provide free acupuncture to some of my patients. 

2. What are the key challenges you're facing in the year ahead? 
In a place like Gravesend, where 50% of patients are not tech savvy, getting reminders on their mobile phone or 'choose and book' [Note: Choose and Book is a national electronic referral service which gives patients a choice of place, date and time for their first outpatient appointment in a hospital or clinic] doesn’t mean anything to them. Furthermore,  many can just about get to the local hospital on the cheapest bus, and often they can't afford a taxi to a hospital that is further away, so services such as 'choose and book' are of no use to them.  I'm seeing the local population getting sicker and sicker, and although some of my patients are living longer due to being on 9 or 10 drugs, they usually have very little quality of life. 

My main challenge is educating people in lifestyle changes, especially those from the lower social classes. I've found that if I can give them a practical bit of advice or even encouragement, it does lead to lower blood pressure and loss of weight.  

Patients only seem to listen when they are about to have ill health, many times there is no motivation to change behaviour, diet and exercise, especially given education levels can be quite low. 

I'm interested in pre-Diabetes and screening for pre-Diabetes, that is where the biggest change can happen. Usually, my patients know a bit about Diabetes from someone in the family, so there is some emotional trigger, which can help in our conversations. 

3. What is your big vision for moving to a world with a focus on prevention of disease?
My overall big vision is to get away from prescribing drugs, there are dangers of polypharmacy and I want to get people to rely upon themselves, and use lifestyle medicine as the first discussion point, before we go down the path of handing out tablets. I'm also thinking about depression, back pain, obesity related diseases, and am keen to provide Tai Chi classes, Yoga classes and Meditation classes at this new centre.

4. Tell us more about your new centre
My new centre is not replacing the existing GP surgery. It would be a new GP practice with a preventative component, One idea is to have a gym at the top of the surgery where Tai Chi classes could take place. I want to be able to prescribe patients a 12 week course on diet and nutrition with a personal trainer. There is a national program where certain courses for diabetes prevention can be done. No current funding, but in the future, there should be money coming from it. If the NHS wont fund my ideas, I will go to the British Heart Foundation or National Lottery. 

5. Switching over to technology, there is much talk about giving patients online access to their medical records, in the hope that it will improve the quality of care, shared decision making as well as patient outcomes. How often do patients come in and ask for a paper copy of their medical records?
Very rarely, it does happen though.

6. If today, your practice was able to offer online access to medical records for your patients, as an estimate, how many would use it?
I estimate 25% would use it. The remaining 75% aren't that educated and/or don't have computers. In fact, 10% of the patients visiting our practice need an interpreter during the visit, as they don't speak English, or don't speak it well enough. 

Our other practice is in a deprived area. Over there, the patients tend to believe the doctor knows best, and they don't want to be involved in their treatment decision, patients actually want a paternalistic healthcare system. Quite a lot of my Indian patients, believe that the doctor is God, and if you give them management options, they are not interested.

7. We hear so much about how wearable technology is changing healthcare. How many of your patients are coming in and showing you apps or wearables with respect to behaviour change (such as using a FitBit as a tool in increasing physical activity)?
Hardly any patients are showing up at appointments with this kind of technology.

8. What are your thoughts when you hear the term 'Big Data' in healthcare? How does it make you feel as a GP?
We are already overloaded with information, letters from hospitals, from agencies, if we have to look at even more information, that would be too much for us. We are doing too much administration work already, any new information would have to be controlled very well. We are literally drowning in information, as everything in the NHS gets sent to a patient's GP.

9. How might 'smarter homes'  in the future help you as a GP in terms of prevention?
Technology that could help spot rises in blood sugar, oxygen, pulse rates. Patients are already bringing in paper to their appointments showing their rising Blood Pressure levels. For current hypertensives, I'd like to see a patient's BP readings at home on my computer screen prior to the patient's visit. Patients could save admin time if they could pre-enter this information for me to see. What if we could get food diaries into patient's medical records, that would be great for preventing Diabetes. To be able to understand what they are eating on a daily or weekly basis, the carbohydrate content etc. 

10. Who influences you?
I follow Dr Aseem Malhotra and Jamie Oliver, they are both leading a national conversation. I hope to see celebrities and sports starts taking up the baton in health prevention and get involved in their local areas. What if we had footballers like David Beckham or Wayne Rooney helping to spread this message? Kids would listen to those people, rather than us. 

[Disclosure: I have no commercial ties with the individuals or organisations mentioned above]

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The Tyranny of The Should

Many of us lament at the paternalistic attitudes and behaviours, we both witness and experience, when dealing with healthcare systems. We hope that this is now the era when we can really transform healthcare, wearables may play a role in that transformation, or perhaps not. Now, one of the aspects of Digital Health I find most fascinating is the potential to change our behaviour, both at an individual level and a population level. So many firms have already launched some form of wearable technology which can monitor activity levels, heart rate and sleep. Many more are about to jump in this year. There are increasing levels of interest, excitement and expectation from these devices. Can simply tracking how much we walk, run or sleep really be the panacea to all our problems in healthcare? I don’t believe so, but some do. “The future of the NHS is in Apple’s hands”, is the headline of a post, by David Claire. He believes that the soon to be launched Apple watch will have a fundamental impact on the way the NHS runs. He even goes as far as to predict, “If self-awareness is the first step to kicking bad habits then the preventative care factor alone of the Apple Watch and similar devices will save the NHS billions.”

During 2014, I personally tried so many different pieces of wearable technology, hoping I could gain new insights about myself and use them with their apps to support my desire to live a healthier life. The truth is that none of them really worked for me. None of them engaged me for more than a few weeks, and also I just didn’t find anything that truly integrated with my life.

Two of my most recent purchases, in December 2014, have been the Samsung Gear S, and the Basis Peak. I had high hopes about the Basis Peak, as it can automatically detect when you fall asleep and when you wake up. I stopped using it to track my sleep after 3 nights. Why? I just didn’t feel comfortable wearing a watch whilst I slept. Apparently, we “should” be walking at least 10,000 steps a day. So I set my daily goal with the Samsung Gear S at 10,000 steps. A message pops up when you’ve achieved 50% of your daily goal, and how much time you’ve got to achieve your goal. Samsung’s website says the Gear S provides a “smart wearable experience.” Surely, if was a genuinely smart wearable, it would know that it’s about to going to rain all afternoon, and I’m unlikely to meet my goal?”

The Samsung Gear S highlights how much time I have left to complete my goal of 10,000 steps

The Samsung Gear S highlights how much time I have left to complete my goal of 10,000 steps

There have been headlines recently about “sitting disease”, and how being inactive is dangerous to our health. Hence, I’ve programmed my Gear S to bleep if I’ve been inactive for 30 minutes. Not particularly useful when you’re in the middle of eating lunch with a friend, despite the device itself knowing I was at lunch because it popped up a calendar reminder 10 minutes before the lunch meeting. Still a way to go before we can truly regard these devices as smart.

What also bothers me about these devices is that currently we’re simply digitising flawed messages. Does simply being told to be more active, or eat less, or sleep more actually make a difference? There is now scrutiny on the recommendations of 150 minutes a week of physical activity. I “should” walk 10,000 steps a day, and when my watch informs me that I haven’t, then I don’t feel that good. We hear lots of talk about “Gamification”, the idea that gamifying health can make a difference. I was chatting with Dr Pritpal S Tamber a few months ago, and he mentioned the term, “Shamification.” Is making us feel shame or guilty about our behaviour really the way to improve health, both of individuals and populations?

I’m not surprised that research shows wearables being are not being used after 6 months. You get called into a series of meetings, or your child is sick, and suddenly, life gets in the way of maintaining a healthy lifestyle. At present, the device or app won’t take that into context, it will still ominously display that you haven’t met your goal.

In the US, wearables are getting on people’s wrists from employer wellness programs. In the UK, a survey found 55% of business leaders would look at the health data from an employee’s smartwatch or health app, if that employee called in sick. Employees calling their boss and pretending to be sick could become a thing of the past. However, in the same survey, just 6% of employees would want their boss to have access to the health data from the watch or phone.

You might believe that it’s easy to deceive the system, because you could put the device on your dog, cat, or even another person. Yes, that’s true right now, but that could be impossible after 2018, if research in Australia is successful. Researchers at the University of New South Wales are embarking on a 3 year study to develop an algorithm that can verify who generated the data, so that the data could be fed back into mainstream health systems.

So many are hoping that these emerging technologies can integrate into our lives and provide the “Digital Nudges” to that will empower us to live healthier lives. The Internet of Things promises smart homes with all our devices connected to each other. Mitsubishi of Japan have showed their concept of a smart home. In their vision of the future, your fridge would connect the data from the sensors on your body with the data on the contents of the fridge, and display recipes on the fridge door. Is this concept dystopia or utopia?

Today, childhood obesity is of growing concern, around the world. A fascinating use of technology may be tested in schools in Dubai this year. Using a payment system linked to the child’s phone and an app that contains information on the nutritional content of food in the school cafeteria. So if the child tries to buy a burger at school, and that burger would take them beyond their daily nutritional allowance, the payment is declined, and the app suggests something healthier. Now that system is under the control of parents, but is this the route to dealing with obesity with adults too? In an increasingly connected world, do you want machines and algorithms limiting your choices, or would you prefer the freedom and autonomy to eat what you want, when you want?

What if the government offered you a way of paying for public transport using wearable technology that would also monitor your health status, provide suggestions, and even reward you if you decided to walk than take public transport? Such a scheme just launched in Beijing, with a plan to roll out to 400 cities across China. 

In the UK, it appears the NHS will have a “huge rollout” of wearable technology as part of a “revolution in self care”. Being able to monitor patients remotely, especially those with a chronic condition, is admirable. If entities in healthcare will be able to monitor us remotely, surely that’s always going to be a good thing? Perhaps not. Given the huge financial pressures facing the NHS over the next 20 years, we may have to ration access to care. In the future, could all this data collected about our behaviour be used to ration or even deny care? I’m not the only one who is asking that question.

In a great article by Hamza Shaban examining the impact of sensors collecting data about our health on the pricing of health insurance, one sentence stands out, “Imagine a pricing scheme that would punish sleep-deprived single parents or the dietary habits of the working poor.” A world where our health insurance premiums decline when we behave within the guidelines, and rise when we deviate from the guidelines. Will you avoid watching late night movies on TV because sleeping less would increase your health insurance premium next month?

Should doctors “Google” their patients? A really fascinating BBC podcast highlights the potential for the impact on the trust between patient and medical provider. There is a huge need to understand what happens to you in between visits to the healthcare system. In this new world of monitoring, if your healthcare provider has recommended you cut down on alcohol consumption, but can then obtain data on how much alcohol you’re continuing to drink, is that too intrusive? Today, the National Institutes of Health announced it's searching for a wearable or otherwise discreet device capable of measuring blood alcohol level in real time.

There is a fine line between “Digital Nudges” and “The tyranny of the Should” – and it’s not clear to me that we’re having the right conversations in the right places. Will we be nudged into living healthier lifestyles because we want to or because we should? Is everyone a winner or will there be losers? Is there really a place for autonomous decision making within the context of improving our health?

Hugo Campos, a patient in the USA, concludes his recent interview with a critical question, "Will WE have autonomy over ourselves and the data WE create?" Progress of technology can be easy to predict, what we can’t predict very well are the consequences of technologies. In the realm of Digital Health, some believe that power is moving away from the healthcare systems into the hands of consumers and patients, but over the long term, is the power going to move full circle? This year celebrates the 800th anniversary of the Magna Carta, an ancient symbol of justice over tyranny and protecting individual liberties. In 2015 and beyond, do we need a Magna Carta for Digital Health?

[Disclosure: I have no commercial ties to any of the individuals or organisations mentioned in the post]

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