There are not many economic sectors with their own rate of inflation, but healthcare is one. Spending on the National Health Service has risen at 4% a year since its foundation in 1948, according to research charity Nuffield Trust, with its share of the economy rising from 3.5% of gross domestic product in 1949/50 to 7.9% in...
This isn’t just a British situation. PwC’s most recent US medical cost trend data shows that national health expenditure rose from 5.2% of GDP in 1961 to 17.4% in 2013, and other countries have seen big increases. But with more than 80% of UK healthcare funded by taxation, healthcare inflation is a problem for government rather than individuals – particularly given strong public opposition to any changes to the NHS.
Since 2010, Conservative-led governments have slightly increased NHS spending in real terms while making deep cuts in other public spending. The 2015 summer Budget set out plans to increase spending on the English NHS by £10bn in real terms by 2020/1, compared with its 2014/15 budget of £113bn. But the government also wants efficiency savings worth £22bn, asking the NHS to do significantly more for roughly the same money.
Healthcare inflation is caused by factors including people living longer and requiring more care towards the end of their lives. Another comes from the introduction of new drugs and techniques, with another being the NHS’s use of increasing numbers of highly skilled staff, who tend to enjoy higher-than-average wage growth. Also, as the Nuffield Trust points out, while in sectors such as manufacturing new technology often replaces human staff, in healthcare it tends to augment them.
The role of IT in making the NHS more efficient
IT alone cannot deliver the major savings that would counteract healthcare inflation. What it can do, however, is support the kinds of transformational changes that may make significant differences, such as reducing the length of hospital stays and helping people to avoid needing treatment in the first place.
A prerequisite for any project of this kind is an electronic patient record (EPR) system. The introduction of an EPR can produce its own savings by ending the need to manage and store paper notes, but can cost tens of millions of pounds. However, one NHS trust has developed an open-source EPR, avoiding licensing costs.
Open-source EPR at Moorfields
OpenEyes is a specialist open-source electronic medical record application developed by Moorfields Eye Hospital NHS Foundation Trust, which is unusual among NHS organisations in having a single speciality. Moorfields uses OpenEyes across all of its 20 sites. It is also used in clinics at Cardiff and Vale University Health Board and at Maidstone and Tunbridge Wells NHS Trust, and NHS England is funding its implementation at other trusts.
The software includes advanced features including tools which allow clinicians to generate digital drawings, which graphically represent clinical conditions and procedures, which are then stored in patients’ records. James Morgan, the chief clinical information officer for OpenEyes and professor of ophthalmology at Cardiff University, says the software is already highly reliable. “We haven’t had a failure once,” he says.
But the NHS can present a challenging environment for the introduction of open-source software. “Trusts are comfortable buying off the shelf,” says Morgan. “Clinicians don’t always understand the costs of developing software, which has to be run through a proper quality assurance and testing process.” The latter means that OpenEyes relies on the input of experienced software engineers to provide code ready for the clinic.
There are other problems, including the fact that many NHS trusts and boards use Microsoft software. OpenEyes runs on Unix rather than Microsoft servers, and its graphics use HTML5 Canvas objects, which are not consistently supported in old versions of Internet Explorer used in many NHS institutions.
Nevertheless, Morgan believes the use of open-source software can save NHS organisations money and allow greater flexibility, particularly smaller ones that cannot afford to customise proprietary software. “We need to build communities with knowledge of clinical priorities who can generate code,” he says.
With good record systems in place it becomes easier to analyse data on patients. Western Sussex Hospitals NHS Foundation Trust assesses whether newly admitted emergency patients are at risk of developing acute kidney injury (AKI), which is linked to up to 100,000 deaths in UK hospitals each year, although up to 30% of cases could be prevented.
The trust transfers the results of creatinine blood tests – the main way to identify AKI – to patient records as soon as its lab produces them, and is about to trial sending the results to doctors by email. If a patient has AKI, a red flag appears on the record. But it also applies an algorithm to the lab test result, along with data from its vital sign monitoring Patientrack software and its patient administration system. If this indicates a patient is at significant risk of developing AKI over the next seven days, an amber flag appears.
“IT complements any good work you’re doing. The IT won’t help unless you’ve got a good process in place”
Richard Venn, Western Sussex Hospitals NHS Foundation Trust
“The idea is we target those that get an amber flag,” says Richard Venn, a consultant in anaesthesia and intensive care and clinical lead for the project. “When you’ve got a red flag, apart from good basic care, there is not much you can do about it.” An amber flag gives the trust the chance to prevent a case of AKI. Over two years and 50,000 patients, 2.5% have received a red flag and 5% an amber one.
Venn, who was the co-author of the algorithm, says it can be worked out on paper. “IT complements any good work you’re doing,” he says. “The IT won’t help unless you’ve got a good process in place.” But on paper someone has to do the calculation then put a sticker on the notes. With software, the risk is worked out and passed on automatically.
There is significant potential for algorithmic condition prediction for emergency patients. “The potential is the deteriorating patient,” says Venn. “If we get to them quickly, they won’t have to go where I work – the intensive care unit.”
Averting a visit to intensive care is good for the patient and saves money, but Venn adds that it may be harder to use risk predictions outside hospitals, due to less data and a range of security issues.
IT care in the community
However, some NHS organisations are extending the use of IT into the community, a move which itself can improve efficiency. Cardiff and Vale University Health Board has increased the efficiency of its community staff by 12% to 16%, by issuing cheap netbook computers that provide remote access to software, including Civica’s Paris EPR.
Cardiff and Vale – not covered by English NHS efficiency targets, but subject to similar cost pressures as part of the Welsh NHS – used to rely on paper notes left in patients’ homes and staff returning to an office to complete paperwork. Now, using the netbooks, community healthcare staff can access and update records as they talk to patients, and involve them in choosing equipment for home use, such as beds and commodes. Staff can check emails and write documents at home, in a car or in an office, meaning they spend less time on travel and administration and more time with patients.
Mark Cahalane, the board’s mental health and community services manager, says the NHS has been slow to offer IT to staff working in patients’ homes, compared with easy-to-wire hospitals and doctors’ surgeries.
“We had to find a way for the market to provide us with devices and network capability to provide a full electronic record”
Mark Cahalane, Cardiff and Vale University Health Board
“We had to find a way for the market to provide us with devices and network capability to provide a full electronic record,” he says. On the hardware side, that meant using cheap netbooks with lower specifications to make them unattractive to muggers, as well as robust security, including no data held on the device, memory sticks disabled and automatic disconnection.
By creating more capacity in community services, Cardiff and Vale eases the pressure on its hospitals by allowing patients to leave them earlier. “Wards are very expensive, patients don’t want to be on them and they are safer at home,” says Cahalane. It makes sense all round to treat patients at home where possible. “Everybody knows it’s the right thing to do, but to do so you have to become more efficient.”
Self-service patient records
Some doctors are extending patient records to patients themselves, with the aim of helping them manage their own health. Shahid Ali, a Bradford GP and professor of digital health at University of Salford, is running a trial with Virgin Media Business which has equipped six patients with networked devices, including weighing scales, blood pressure monitors and fitness devices. These are linked by Bluetooth to the patient’s mobile phone, with measurements automatically sent to the surgery’s VitruCare system, software developed by Ali and others to help patients and clinicians understand their health data.
Around 30 GP surgeries in Bradford, North Yorkshire and Cumbria use VitruCare, with most measurements taken manually rather than automatically. It is designed to make records more accessible to both patients and clinicians, including visualisations that show progress towards health goals such as losing weight. Patients can see how they are doing, while doctors can intervene when it is most useful. “The clinician can work in a much more proactive way,” says Ali. “We can manage patients by exception.”
“Helping patients manage their own health is truly the future of healthcare”
Shahid Ali, University of Salford
This is not the case at the moment, according to Ali. “We tend to be reactive in the NHS, and wait for something to happen. We don’t leverage the power of patients.”
Helping patients to stay healthy and spotting potential problems earlier should make the NHS significantly cheaper to run, by reducing treatment of preventable diseases and conditions caused by lifestyle choices. “This is truly the future of healthcare,” he says.
Read more about NHS IT and operational efficiency
- How Luton and Dunstable University Hospital has integrated IT into clinical workflows with converged infrastructure.
- Mobility is one of the big drivers in the NHS. We look at how consumerisation trends are improving healthcare.
- How The Royal Free Hospital implemented SAP’s Business Objects dashboard technology to fathom complex data more efficiently.