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In the past week, the NHS 111 non-emergency medical helpline has seen an unprecedented rise in demand, as concerned citizens seek information on symptoms of Covid-19.
Sarah Wilkinson, CEO of NHS Digital, says the services have experienced “rather unpredictable demand”. This has made managing the peaks in usage quite tricky. “We are not just facing a little more demand,” she says.
Wilkinson’s team had load tested the 111 service to ensure it could cope with a 12-fold increase over the highest peak usage the service had experienced. “We did a lot of load tests on the 111 system,” she says. But the service was inundated following a BBC early evening news broadcast, and demand was 19 times higher than the highest previous peak.
Understanding how the various bits of a system work is a core part of any business continuity plan. “Nothing is different in a crisis,” she says. “You still need whole-system thinking, but you have to do it fast.”
For Wilkinson, fixing the system during a crisis can quickly become a bit like a “whack-a-mole problem.” Fixing one issue leads to a knock-on effect popping up somewhere else in the system, and during a crisis, it’s paramount to think of the system as a whole. “The hard part is to think about front-to-back service being provided,” she says. “At moments like this, organisations find new ways to push boundaries; people question their assumptions, they are bolder and more decisive.”
It’s this decisiveness that enables them to push what they can do with a system to overcome the barriers of what it can do to drive through changes and new capabilities. “Generally, when people are under pressure, necessity and need becomes more important,” says Wilkinson. “That’s why people become more focused and take risks they wouldn’t take in a day-to-day environment. They know management will support them.”
Everyone is working towards a common goal. In the NHS Digital main office, at Skipton House in London, Wilkinson says there are armies of people still at work at 10pm at night.
Healthcare and the use of wearables
Beyond the coronavirus readiness plans, among the big themes Sarah Wilkinson, CEO at NHS Digital, is seeing is patients wishing to contribute data to their own patient records. For instance, smart watches such as the Apple Watch can provide useful data; other wearables can monitor blood glucose.
“We will have many patients who look after themselves at home, and may want to send in information, such as taking their own blood pressure, and provide other basic observations about themselves,” she says.
However, Wilkinson says patients are frustrated when GPs don’t use such data, because legal definitions prevent it from being used in a clinical environment.
For Wilkinson, this willingness of people to contribute time and effort has enabled NHS Digital to drive delivery and create more capabilities in its digital services.
“The more you ask people to stretch their capabilities, the more they become energised and excited,” she says.
One of the big takeaways for Wilkinson since the coronavirus outbreak is the growing need to move people to online services. “It is imperative to enable people to access the 111 triage process via online services and the NHS app,” says Wilkinson. “Looking at the past few weeks, it strikes me that, fundamentally, there is a new, unprecedented demand for citizens to use digital channels.”
The NHS advises people who feel unwell not to visit their GP or go to the hospital. Using the digital 111 channel avoids the need for people to visit their GP or hospital. The crisis has also meant that NHS Digital has needed to look at new ways for people to work.
“Clinicians are working in different places and are being asked to care for people in different practices,” says Wilkinson. “They need access to records, which means a lot of protocols need to be adapted fairly radically. We are continually evolving our clinical response protocols and guidance is being adapted very quickly.”
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In fact, the process to update clinical algorithms in NHS Pathways, the system that underpins the back-end routing of patients using the 111 services, has needed to change.
“There are extremely rigorous change controls,” she says. “We’re trying to cater for potentially 55 million people with different conditions, a number of whom will have rare illnesses. The algorithms themselves are designed by our clinicians, and are rigorously reviewed by an independent national clinical governance group.”
But with the coronavirus outbreak, clinical responses have needed to evolve rapidly. “Occasionally we get a sub 24 hour break, but call scripts are evolving daily,” says Wilkinson. “We deployed our very first workaround in five hours.”
As more cases of the coronavirus are logged, and the NHS prepares for a rise in infection rates, there are likely to be many unforeseen circumstances that NHS Digital will encounter. For example, she says: “We need to look at how we manage sick notes when a large number of people require them.”
NHS Digital is also receiving “a lot of demand for data”. “This has privacy and data sharing implications,” says Wilkinson.
It’s still early days, but for Wilkinson and NHS Digital, the coronavirus outbreak is proving to be a driver for change: changing people’s ingrained behaviours. “A real opportunity of this crisis is that citizens and clinicians will look for new channels they wouldn’t otherwise use, because the impetus is much greater,” says Wilkinson, adding that NHS Digital is having conversations with clinicians about remote working.
Even in a crisis, she says: “There is always an opportune moment to drive things in the right way. Digital access to healthcare is a good thing and drives people’s behaviour. They have a better interest in their own healthcare.” If the coronavirus outbreak helps to shift people’s attitudes to that, they will become more aware of their health.
As an employer, the health service is in a unique environment. “People work in health because they care,” says Wilkinson. “They’re not doing it for money and prestige.”
“We have well-motivated employees who care,” she says. “There are lots of people who are motivated by tech and really enjoy creating tech solutions that are robust. There is an engineering mindset; people enjoy being stretched to the limit, and are able to iterate code quickly.