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Do we need 'intelligent transparency' in the English dementia policy?

The Secretary of State’s speech given in the King’s Fund had distinct twangs of ‘déjà vu’ for me.

There are six subtexts to Jeremy’s speech which immediately raise alarm bells for me in English dementia policy.

Allow me for a moment briefly to tell you what they are.

 

 

Jeremy Hunt, Secretary of State for Health, yesterday said at the King’s Fund:

“With 40,000 health apps now on iTunes, these innovations are coming sooner than most people realise. The future is here, but it needs to be more evenly distributed. Heart rates and blood pressure will no longer be simply a matter for the doctor – patients will know them and monitor them too. Data sharing between doctor and patient means power sharing too. Intelligent transparency creates intelligent patients with healthier outcomes. Get this right and it is no exaggeration to say that the impact will be as profound for humanity in the next decade as the internet has been in the last.”

The full text of Jeremy’s speech “Making healthcare more human” is here. Please check against actual delivery.

This immediately brought back flashbacks of a document recently produced by the leading global management consultants, Oliver Wyman, called “The Patent-Consumer Revolution”, with main authors Tom Main and Adrian Slywotzky.

Note point number 1 – “consumer power” is back.

The subtitle of that Oliver Wyman document is in fact, “HOW HIGH TECH, TRANSPARENT MARKETPLACES, AND CONSUMER POWER ARE TRANSFORMING U.S. HEALTHCARE”

I went in fact to the launch of this document in Baker Street.

I, in fact, quizzed one of the Partners how ‘transparent’ markets can – in reality – be.

Markets can be notorious for having hidden sources of division, such as taxes and tariffs. Also, they can be legislated for to have lack of transparency as a factor which give them competitive advantage. Take for example a failing private provider which hides behind a veil meaning that you cannot get it at its staffing numbers due to ‘freedom of information laws’. The current Secretary of State has never been in a hurry to iron out this anomaly in the English law which directly affects patient (or ‘user’) quality.

Jeremy remarks,

“If intelligent transparency is Patient Power 1.0, this is Patient Power 2.0. We have the chance to make NHS patients the most powerful patients in the world – and we should leap at the opportunity.”

Oliver Wyman is much more brash in its use of “2.0” in talking about ‘consumer markets’.

“But in fact the tech attack is far more. It is both the symptom and driver of a much larger and more significant change sweeping through U.S. healthcare. The consumer tech companies are making valuable contributions, but they are making them in the context of a fundamental redrawing of industry lines that puts the consumer in charge and sets the foundation for Health Market 2.0. The tech entrepreneur developing a new app may not realize it, but he is helping to create the infrastructure of a new, more powerful way of delivering healthcare. The consumer who loads it on her smartphone just because it’s cool is contributing in a tiny way to a cultural shift that is changing the way we think about health.”

And this matters because Oliver Wyman’s thesis is much more wide-ranging. It could have a profound impact on the way in which the medical ‘side’ of dementia policy is carried out.

Take for example the vision of Oliver Wyman management consultancy on the growth of the Apple app.

“And remember, many life-preserving and life-enhancing activities don’t actually require the intervention of doctors. Could a company like Apple persuade a substantial number of consumers to open up their medical records, share their biometric data, and treat their iPhones as their main point of contact with care, then it persuade them it’s fun and cool? In many ways that sounds like Health Market 2.0 in a nutshell. In a few years, consumers will look back and realize how antiquated the medical system used to be: Measure a handful of numbers (HDL, LDL, triglycerides, glucose, A1c) every 12 to 18 months, hear a few admonitions about diet and exercise, and forget them without any follow-up or coaching. Is that really how we did things? Why didn’t we think to demand more?”

 

Note point number 2 – “prevention” in public health creates new markets. Kerrrchhinngg!

If such ‘apps’ became widespread in the NHS, would taxpayers’ money be used to develop them? And, if so, would such innovations have commercial viability? For a NHS to be free at the point of use, there’d be ideological objection to the NHS charging for such apps, but it could be argued that the NHS could use charging for apps as a source of income generation. In the past, any element of introducing income generation has been interpreted as rationing services or producing a ‘two tier approach’, where you get an enhanced service if you can pay for it.

Would there be room for such apps in dementia?

In theory yes.

Risk factors for the vascular dementias include the usual risk factors for cardiovascular disease, e.g. ‘bad diet’, high blood pressure, uncontrolled blood sugar if diabetic, etc.

If you had non-invasive ways of measuring your blood sugar via your smart watch (say you were diabetic), or you were collecting information about your blood pressure all the time, you could have all your data uploaded into a giant computer. Such computer could look at your metrics as “Big Data”, as a corporate service to the NHS, and then ‘calculate’ your ‘risk’ of progressing onto a vascular dementia. And provided the NHS paid for this ‘middle man’, in theory you could be offering a higher ‘value’ NHS.

Or alternatively, you could be being fed a load of junk. At the moment, there’s no way of telling whether an app is actually making a positive difference to health, or merely feeding you a load of mumbo jumbo.

The sting in the tail comes from one sentence buried away in the Oliver Wyman report.

This leads smoothly onto the ‘big one’.

 

Point 3. English dementia care can be, theoretically, outsourced abroad to make it cheaper, while ‘adding value’.

Oliver Wyman asserts that: “The cornerstone of traditional medicine is the idea that all healthcare is local. ”

The argument goes like this.

If you could outsource diagnostic services, say send digitised MRI scans to a cheaper diagnostic unit in India or Taiwan, then the cost of running them will be cheaper. This will be useful for exerting budgetary control over the NHS budget. In fact, the ideal would be to do away altogether with hospitals, and just have a supply chain of bits of the system being done most cheaply, e.g. low-cost diagnostic workers ‘reading scans’ not specialist neuroradiologists.

This is disruption ‘at its best’.

 

Point 4. The argument for outsourced dementia privatised medical healthcare can be made by rubbishing the NHS subtlely.

On Twitter yesterday there was a joke doing the rounds along the lines of: “Mrs Hunt: “What would you like for breakfast Jeremy?” Mr Hunt: “Mid Staffs”.” hashtag #r4today.

That might also be the Jeremy Hunt answer to whether India or Taiwan, being an outsourced industry, would be any more unsafe. Hunt can attempt to argue that international jurisdictions haven’t inferior safety standards, particularly if Morecambe Bay or Mid Staffs are not ‘isolated incidents’. Throwing sunshine as a disinfectant into bad parts of the NHS are doing potentially makes it easier to argue that somebody other than the NHS can ‘do it better’?

And ‘doing it better’, in theory should be the function of effective management of performance in NHS institutions. Hospitals should want to improve the quality of their services first internally, rather than getting the regulator to do all the work. Such financial incentives for this to happen in the system must be ironed out in dementia policy. It’s what Roy Lilley calls ‘too much time weighing the pig, rather than fattening the pig’. We must all be concerned, in fact, if improvement comes from the regulator not HR, or in fact “NHS Improvement” is in fact a hybrid regulator – new jointly-led Monitor and TDA.

The advantage of process mapping each part of the supply chain is that it becomes easier to fragment the delivery of care, disposing of continuity of care to some extent, such that services are much easier to sell off and privatise.

The theme of ‘intelligent transparency’ was expanded in a number of areas by the Secretary of State, including how data could be used to identify problem areas in patient safety. The unfortunate aspect of having so many metrics of patient safety is that clinical commissioning groups are bamboozled as to which metric represents the most accurate measure of a particular organisation.

But patient safety in dementia policy does indeed bridge a number of areas – Jeremy mentions one of them in his speech, the quality of care homes. With the majority of people with more advanced dementia choosing to live at homes, rather than in a residential home, there has to be some sort of measure of the quality of home-help too. Ideally, unpaid carers need reassurance that they are meeting an appropriate standard of care, without having such standards as a stick to beat them with.

 

Point 5. ‘Intelligent transparency’ should apply also, say, the sheer volume of potentially incorrect diagnoses being currently chucked out by the English NHS.

Patient safety, however, is more than that in dementia policy. For example, there’s never been a proper analysis of the ‘safety’ of the diagnosis of dementia. In other words, how reliable is the diagnosis that people are receiving from the NHS? For ‘intelligent transparency’ to work here, we need some sort of information about how diagnoses are made as ‘dementia’, say to reach national ambitions, which later turn out not to be dementia, such as minor cognitive impairment or depression? Such misdiagnoses, which can happen not as a mistake but because circumstances change, matter hugely not least for the patient.

 

Point 6. Competition is ‘back’.

Jeremy Hunt has never really got into the debate about whether competition drives up quality. This remnant from the Alan Milburn era, which became turbo-boosted in the notorious section 75 clause of the Health and Social Care Act [2012], gives ‘competition’ huge ideological importance. The main purpose of introducing competition is that introduces private markets; and if this is coupled with ‘radical change’, Hunt is able to give it some degree of urgency.

Take for example this section of his speech:

“Self-directed improvement is the most powerful force unleashed by intelligent transparency: if you help people understand how they are doing against their peers and where they need to improve, in most cases that is exactly what they do. A combination of natural competitiveness and desire to do the best for patients mean rapid change – without a target in sight.”

Most people feel intuitively that competition is not actually the determining factor to improve post-diagnostic services in dementia, however so defined, but collaboration perhaps is; or even a combination of competition and collaboration, called ‘co-epetition’.

In the same way, we all want to outperform each other with our Apple Watch apps, we all naturally want to be the person in the village with the lowest risk for vascular dementia – or something like that.

 

So do we need ‘intelligent transparency’ in the English dementia policy? 

Ironically, I do we do feel some sort of ‘intelligent transparency’ in dementia policy, but not for the reasons Hunt describes.

I think we should open up private providers, increasingly a ‘factor’ in both the NHS and social care, to the same freedom of information requirements, particularly if we are to ‘liberalise’ all parts of the market to an ‘equal playing field’.

I think NHS England should provide metrics about the volume of misdiagnoses in English dementia policy currently. A more intelligent way of constructing English dementia policy would have been to ensure that GPs had the skills, training and resources to diagnose dementia more accurately? Otherwise, we truly are running the risk of a high volume low quality approach.

We should be asking the right types of questions. I think there’s lots of excellent work being done by dementia advisors and dementia support workers. But if we’re to look at information, we should also be willing to look at whether dementia advisors or clinical specialist nurses are most likely to deliver a principal NHS outcome of reducing avoidable hospital admissions? Such data are actually vital for commissioning decisions.

Yes – it’s all a bit ‘motherhood and apple pie’.

It’s hard to oppose violently something which is ‘intelligent’ or ‘transparent’.

That is, unless of course the marketing gloss can be removed easily, rather, to reveal something which is inherently unintelligent and opaque.

 

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