At last, a consumer led NHS?

The two driving principles of the new NHS Commissioning Board are transparency and participation. If they are applied radically then they can transform the NHS, said Tim Kelsey, National Director of Patients and Information for the board, at last night’s meeting of the relaunched Cambridge Health Network. He envisions an NHS where patients are empowered through data to become consumers who shape the NHS and are more responsible for their own health. In words that he didn’t use but I heard for the first time yesterday patients are seen as assets not liabilities.

Perhaps the clearest indication that this is not the familiar empty rhetoric is that Kelsey was appointed to the job. A former investigative journalist and war correspondent, he founded the company Dr Foster when his GP was unable to give him and his wife any information on which might be the best hospital to chose for his first child to be born. Dr Foster used routine NHS data to inform healthcare in a way that hadn’t been done before, shaming public health and the NHS itself. Later Kelsey, who is irrepressible and always smiling, became the government’s transparency czar—committed to releasing geovrnemnt data both to improve public services and create new businesses.

Kelsey’s new position combines many more traditional roles like chief technology officer, chief information officer, and head of marketing and communications and includes public involvement, press relations, and the cursed Connecting for Health.

Another reason that the Commissioning Board might succeed in transforming the NHS is that for the first time in its life, said Kelsey, it’s “unconflicted”–in that, it doesn’t have responsibility for the delivery of services. It’s the “NHS bank” and could if it found services in England unsatisfactory move them to Boston or Abu Dhabi–”not that it’s going to do that,” he added hurriedly.

Now, believes Kelsey, is the time to transform the NHS because it’s going to quickly run out of money if it isn’t transformed. We may be close, he suggested, to rationing of drugs and closure of hospitals. If patients become active consumers then cost might be contained—as was argued by the banker Derek Wanless in his analysis of how to keep the NHS affordable in his report for the Treasury in 2002.

The first and most essential step in achieving the new vision is to create decent data on what is happening in the NHS. Current data,  said Kelsey, are poor. We know almost nothing about outcomes in primary care, which is a serious problem in that the Commissioning Board is required by law to commission outcomes. Some in the audience might have wondered whether the Quality and Outcomes Framework didn’t supply good data on primary care, but Kelsey is talking about data on individual patients (anonymised, of course) in as close to real time as can be managed. He gave the example that 2500 patients with dementia my be killed by GPs prescribing antipsychotics: we know how many antispychotics individual GPs prescribe, and we might know in some practices which patients are demented—but we do not know which demented patients are prescribed antipsychotics.

Data on secondary care are no better, said Kelsey, in that they contain no useful clinical data. We do not know, for instance, which drugs work in reality—as opposed to in clinical trials. He spoke with a smile of visiting a hospital that had 300 pharmacy databases that don’t speak to each other.

The aim is to have better data with primary and secondary care linked together by April 2013, and, he said, it is not really the board’s problem if GPs and hospitals cannot tell it what is going on. They will want to be commissioned and must supply by law data on outcomes.

I wondered if Kelsey wasn’t being overambitious here, and perhaps he was deliberately overstating his case to generate momentum. He seems to think that a combination of keeping data in the cloud and making it open access will allow the NHS to do by next year what it has never done before. But I thought back to the meeting on stratified medicine that I attended two weeks ago where there was much talk of the inadequacy of data and the complete absence of the clinical informaticists to find ways to stitch databases together and create useful data sources.

The second step in Kelsey’s vision is transparency, to “get the data out there,” so that individuals and organisations, including companies, can use the data to improve safety, quality, and responsiveness—and build businesses. He urged the audience to look at the website of Code for America, whose mission is to “help governments work better for everyone with the people and the power of the web. Through our FellowshipAccelerator, and Brigade, we’re building a network of cities, citizens, community groups, and startups, all equally committed to reimagining government for the 21st century.” Kelsey sees a Code for Health and wants not hundreds but hundreds of thousands to use the data. He’d like to teach people to code, pointing out that you can build an app after three days of training.

Participation is the third step, and Kelsey described how in New York City some 90  000 people a day report on problems in the city-scaffolding that’s not safe, bins that are not emptied. The city is increasingly run in response to real time data, and Kelsey wants the same for the NHS. “The rich complaining culture” of the British could be very useful

The next step is patient control. The constant analogy is with online banking. Increasingly nobody goes to a bank and nobody writes a cheque. Banks—and eventually hospitals– can be turned into restaurants or hotels. The hope is that such developments in the NHS can have an important effect on productivity. Kelsey wants to see an app store with 100 apps from next April. “But what’s the business model for companies to produce these apps?” asked somebody in the audience: “Who will pay?” That good question needs more thought, answered Kelsey.

A paperless NHS—perhaps by April 2015—is the last part of Kelsey’s vision. Why is it that secondary care is still using tatty paper records and consultants  are writing to GPs rather than emailing patients with a copy to their GPs?

The vision of Kelsey and the Commissioning Board is still in evolution, which is one reason why Kelsey wanted to share it with the Cambridge Health Network. He is well aware that not everybody shares his vision and started his talk by telling the story of talking to 300 NHS people working on cancer and a doctor telling him : “Mr Kelsey, you are a visionary, and I frankly find your vision complete nonsense.” Another doctor said: “Patients just want to see a doctor.” Yet another doctor was quoted as saying “I will never use a computer.” to which Kelsey responded “He shouldn’t be a doctor.”

The audience of the Cambridge Health Network, which includes a goodly number of entrepreneurs from both the public and private sectors, was generally enthusiastic about Kelsey’s vision, but one young doctor while sharing the enthusiasm was worried about changing the culture. He said how he worked with six other surgical registrars and had asked for a computer—one between seven. “Why do you need a computer?” was the response from the hospital manager. He told the story as well of a friend high up in information technology who had sickness in the family but didn’t use IT at all when seeking care. When asked why not he said “it’s not what you do in healthcare.” In other words, there will need to be cultural changes among doctors, managers, and patients.

There needs to be, concluded Kelsey, an unarguable benefits case for collecting and releasing NHS data—a case that is made to clinicians and the public. There will also need to be lots of products and services produced from the data. The vision is more likely to be achieved by “pull” from patient and consumers than “push” from policymakers at the top of the NHS, and to that end Kelsey would like to see the NHS become a social movement.

PS. A wholly unscientific but still interesting poll of people attending the meeting asked what Kelsey’s legacy should be: 46% said joined up patient data across all providers, 28% more people using online healthcare than online banking, 18% universal patient access to their own records, 5% a paperless NHS, 3% 1000 apps built by NHS employees, and 0% three million followers on Twitter for David Nicholson, chair of the NHS Commissioning Board.

Competing interest: RS is a member of the Cambridge Health Network, which is free. He’s known Tim Kelsey for around 15 years and is the chair of Patients Know Best, a start up that uses information technology to enhance patient clinician relationships and might well flourish in the NHS that Kelsey envisions.

2 comments

  1. Please start using the term NHS England. Sad, but now that we in Wales are drifting further and further from the benefits of Eng. healthcare, it is too misleading. Many still don’t quite grasp the cut from Eng. and therefore fail to realise that talk of patient-involvement and choice etc, simply does not apply. In Wales, there is increasing big-brother control.

    Very limited consultation on changes to services that are to be funded by repatriating income from England, translate: with the exception of neonates, no longer access services on the Eng. side of the border, even when closer geographically and culturally more aligned. (Only those who knew to check the July board report know that funding bit.)

    GPs who keep promising to arrange (but don’t) McMillan support for an elderly wife with chronic health problems herself, caring for a terminally ill husband at home; who laugh at middle aged patients when informing them of a parent with bowel cancer or parkinsons, then give inaccurate information; and promise to phone an elderly patient with test results “in 4 days” then 2 weeks later, having heard nothing, the patient with great difficulty manages to extract an appointment for 10 days later to see said GP for the results (and had to fight for that, initially told would have to wait 4 weeks!)

    These do not help give confidence in NHS in Wales!! Likewise, GPs (OOH and regular) shunt any vague hint of chest pain on the emergency services, instead of first assessing the situation. Skilled time is wasted on patients who go to A&E – yet I’ve increasing sympathy with them seeing no point in going to their GP. If they can even get to see a GP. Because too much emerg care time is wasted because GPs can’t or won’t do the basics. Then A&E depts keep ambulances waiting for an hour – even 5 hrs of more – without the options to fine the hospital as in Eng., which presumably would fund additional resources when needed. I hope someone is assessing the bottlenecks throughout the whole system, in both countries, but rather fear I hope in vain.

    Perhaps it is just as well GPs are not going to be in charge of commissioning in Wales! For they do not tend to “know” their patients, never mind indulge in any objective 2-way discussion.

    Whose body is it? The govt hope to require clinicians to involve family in end of life decisions: will they change the law then, so no longer do we have the right to decide for ourselves about our own body and life? Many patients choose not to involve family. Surely that should be an individual right? Yet the govt’s plans look likely to have the side-effect of removing yet another right to privacy, already much eroded in today’s society. All very sad.

  2. I’m well aware that the four NHSs are all moving in different directions, and I must get used to always specifying which NHS I’m referring to.

    You make some very interesting points here, and I wonder a) if you might post this comment on the BMJ site where this blog is also posted and b) you might write a blog–for PKB or the BMJ–on the NHS in Wales.

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