DOCTOR WILL TEXT YOU NOW
Remote transmission of your vital signs, automatic drug administration, diagnosis by text message some specialists think that technology will drive the personal health care of the future and that it will be the saviour of the NHS.
A worried mother taps her baby's date of birth and her concerns about his health into an app on the iPhone assigned to her newborn by the NHS in the delivery room; sensors in a wristband, snapped on moments after birth, have already calculated blood pressure, temperature and oxygenation levels, transmitting them back wirelessly and automatically to the local paediatrician. A practitioner calls back within 30 minutes and advises calm - the baby's stats look fine, regular doses of the paracetamol-based painkiller Calpol should be enough. Text alerts remind her of when and how much to dispense. A follow-up call comes automatically the next day to check the baby's progress. The mother is reassured with the offer of a face-to-face check-up if she is still alarmed. She immediately texts a friend: 'Baby fine now. Anxious mum fine too!'
Elsewhere, a 30-year-old man is controlling his asthma remotely; sensors in his inhaler check his peak-flow levels and automatically dispense thecorrect level of salbutamol and steroids. His time consuming appointments at the asthma clinic are a distant memory. Prescriptions are emailed every two months to the closest pharmacy for collection. His girlfriend - who developed acute type 2 diabetes fiveyears ago - has reclaimed her life even more dramatically thanks to automatic insulin pumps that not only dispense the correct amount of insulin, discreetly and painlessly, into her subcutaneous fat whenever her sugar levels waver but also transmit that information to a base attached to her weighing scales which she uses once a week. This collates and sends information back to her NHS records. If her condition changes in any way, an MSN message sent to her PC offers a choice of appointments for a physical check-up.
Back at the local surgery, the reception area is quieter than it's been for years...Welcome to the decade of hands-free health care. While the past 20 years have seen giant strides made in the form of blockbuster drug breakthroughs (successes have included omeprazole for heartburn, clopidogrel for preventing blood clots in vascular conditions and metoprolol for high blood pressure) and improvements in early diagnosis in acute care, they have also seen an explosion in the number of people suffering chronic conditions (such as obesity, diabetes, asthma, arthritis) and the accompanying budget pressure has stretched health service resources to the limit.
Given that no political party thinks that the budget can be increased in real terms by more than one per cent next year, it would be easy to imagine that the future looks bleak. Scientists and academics
are genuinely concerned that the era of the 'magic bullet' - when new drugs and treatments just kept coming - is over. But health policy strategists are not quite so discouraged. If everything falls into place, the next decade, they suggest, could see us with smarter, cleverer health care that actually costs less while delivering impressive results.
Nick Bosanquet, Professor of Health Policy at Imperial College London, and a special adviser on public expenditure to the Commons Health Committee, has long given warnings that Britain's health service is facing a dire future. 'There is going to be a very serious funding crisis in 2011-12,' he says. 'Successive governments have stoked up costs and expectations, and that collides with financial realities, which means we are going
to have to take difficult decisions.'
To avoid disaster, he thinks we need to cross the 'digital divide'. He adds, 'We need a system that is closer to patients, with more support available for those with long-term illnesses. And we need to change the way we handle acute care, too.' As an example, he explains that there were 100,000
cancer admissions into hospital last year, many of which were avoidable. These are patients who suffer some sort of crisis out of hours and cannot contact their usual doctor. So they end up at A&E, being treated by doctors who are not oncologists, and being admitted routinely, just in case. 'If we make health care more focused on communication with patients- really using the technology that already exists - we immediately save money
and begin to take the strain off the system.'
Prof Bosanquet is working with the University College London Hospital team to set up a cancer centre where it will take only 10 days from referral to treatment, and which has no in-patient department. This, he believes, will be the experience of many cancer patients in the 2010s. ) Anyone who needs to stay over can book a [refundable] room in a hotel nearby,' he explains. 'In a trial, we have found they prefer it, and it's much cheaper than a £400-a-night NHS bed.' He adds, 'Researchers did think initially that patients might become fretful and worry outside a hospital, but the reverse has turned out to be true. They are far happier. And as technology improves they can keep in constant touch with their medical staff anyway.'
In the near future, patients can look forward to becoming consumers, says Karol Sikora, the medical director of Cancer Partners UK, and an honorary consultant oncologist at Hammersmith Hospital, London. 'By the end of the next decade, we will be dealing with health care very differently,' he says. 'There will be much more quality information available on the internet. Programmes will be developed to guide patients through their choices and help them make decisions.'
It is not only the health professionals and academics who are looking at the way attitudinal changes will shape the next 10 years or more. Big business is very excited, too. The Dutch electronics giant Philips announced in November that it is investing several million Euros in the health care home monitoring market in Holland; the company division responsible reported more than €l billion of revenue in 2008, and, according to a Reuters report, is expected to grow at double-digit percentage rates. Philips estimates the global market at about €100 billion.
'It is all about expanding care beyond its current boundaries, like the hospital,' says Walter van Kuijen of Philips. As the population ages dramatically - the number of over-65s is estimated to double by 2050, and a third of these will be over 80, according to the European Social Network – there will be a concomitant rise in the number of chronically sick. 'They will need continuous treatment and monitoring,' van Kuijen says.
Philips is a leading partner in the EU-funded €20 million Heart Cycle project, started in 2008, which is researching technologies for home telemonitoring systems where patient and doctor will play active roles in carrying out care. The project aims to create a 'patient loop' that gives patients regular feedback on their state of health and progress towards achieving planned health goals, as well as a 'professional loop' in which relevant data on a patient's state of health and how they are following treatment is automatically communicated to a professional information system. This second loop will allow doctors to monitor each patient's condition and therapy response to create ideal individual care plans, as well as allowing them to identify deterioration or sudden cardiac events that require immediate remedial action.
The march for new ideas goes on. In Britain, the Engineering and Physical Sciences Research Council awarded 10 research grants worth a combined £16 million to projects ranging from a collaboration between Swansea University and Boots to produce the first affordable home-based stroke detector, which could be available by 2015, to the development at Newcastle University of a handheld sensor to test for infectious micro-organisms such as MRSA.
Paul Williamson, the head of wireless medical at Cambridge Consultants, a company that develops products and provides business consulting, thinks a technology-supported, patient-centred society is not only possible, but unstoppable. 'The demand and the interest are already there,' he says. 'The third biggest sector of apps for the iPhone is health-related. You can download a peak-flow record for asthma, for example, or charts to work out your fertility.' There's even a swine flu tracker that collates information on cases in Britain.
In February Google set up Google Health in association with IBM, encouraging people to store their personal health records online with them (although not their NHS records). It did cause some consternation, suggesting it was perhaps a couple of years ahead of its time. Some found it a step too far in the democratisation of data: David Davis, the Conservative former shadow home secretary, said, 'Google is the last company I would trust with data belonging to me.'
'What's out there is fairly clunky,' Williamson points out. 'You have to manually enter your own information - figures, medication, etc. And then scroll through for an interpretation. What will be happening in the next decade is that these processes will become automated, seamless. People already have mobile phones so we should be able to connect that directly to a monitor; then a drug delivery application could plot trends and give advice and feedback to the user.'
And who will be paying for such developments? Williamson believes that the pharmaceutical companies will be most interested. 'They want to build value into their products so they last longer than their patent. They could fund the connectivity, and provide coaching and advice through the internet.'
Meanwhile a £12.4 billion scheme, NHS Connecting for Health, is currently updating our national records for the entire NHS. 'There are concerns about the security of such a gigantic enterprise,' William admits. 'And although no system is entirely foolproof - someone can always leave a laptop on a train - the benefits outweigh the risks.'
The real problems with such a technological system will be the issue of compliance. For every tech-savvy person who adores using their computerised health care, there will be those who 'fall through the cracks,' Karol Sikora says. 'Those who can't access information, or don't speak English as a first language, who are poor or not clever enough. But it is the job of the state to step in and protect these people. Government will have to work out what to do.’
Williamson agrees. 'While automated systems remove the errors that occur when data such as blood pressure readings are manually entered, and you can set up text messaging to remind patients to take drugs, you cannot make them do it. The World Health Organisation has said that the most important factor in health outcomes is patient compliance.' But he thinks that many organisations already target those least able to cope with the technology. 'Equipment is already being trialled on those in care homes, the elderly, the chronically sick, the less educated.' He is emphatic: 'You won't have to be a whiz kid to work it.'
Indeed, it may be the elderly who do best from hi-tech revolution, becoming more empowered by the changes. A spokesman for Continual Health Alliance, a not-for-profit industry group that has also become involved with the security aspect of this new technology, says, 'Connected health solutions will allow people to age independently and securely in the comfort of their own homes. Individuals can maintain contact with professional caregivers and loved ones without giving up their independence, dignity or security.'
Not everyone thinks we should be getting so excited. Terry Young, Professor of Healthcare Systems at BruneI University, says, 'I don't subscribe to the point of view that it's all going to be about sensors and computers. We are human beings, not motor cars.' He is focusing on different trends in health care. 'For the past decade, the NHS has been looking at the processes such as Lean Thinking [the concept of creating more value with less work] that revolutionised industrial quality and productivity after the Second World War. If we can adapt these to health care-let's say we could deliver care twice as efficiently- imagine the impact it might have on our current budget of about £100 billion a year.'
The second trend he spots is for further transparency within the health service around value for money. 'The National Institute for Health and Clinical Excellence [Nice] has been quietly revotionising the way we decide to purchase drugs or technology, and the remit is expanding, ultimately to include the services we receive. And although, as periodically, it comes in for criticism, it means that decisions are increasingly based on evidence. I believe better articulation of value in service provision can only be a good thing. Britain is seen as a trendsetter in this area.' He is less concerned that the next decade may see less money available for the NHS. 'There is always the chance of disaster, but it could also benefit the system if well-thought-out efficiencies were a key result. The quality of care doesn't need to suffer as long as careful service design is managed by high-quality leadership.'
For patients, the extent to which we embrace technology-driven health care will come down to one issue: trust. For many it will seem too remote initially; impersonal and therefore unreliable. But 20 years ago we would never have felt secure about doing a large portion of our banking and shopping online. Today, it is second nature.
And what of the surgery staff and the doctors? Are they welcoming these changes with open arms? Dr Prit Buttar, a GP from Abingdon, is not so sure that general practice will change dramatically. 'I'm very cynical about anything that is supposed to make life easier,' he says. 'These new systems may give me more data but they won't stop me doing what I'm doing. The only research done on patient self-monitoring has shown that those who do it have a higher level of anxiety than those who don't - although we don't know why that is. And you do get something intangible from a face-to-face encounter that you don't get from collated data. You can't reduce medicine to something that can just be measured or quantified.'
As an example, he cites a patient of his with diabetes. 'He's had the condition for six or seven years so ought to be comfortable with treatment. Had I simply been reading his stats from afar I might have been frustrated by his inability to manage a relatively simple programme. But sitting down with him I was able to pick up that he is depressed, and that is affecting the way he complies with treatment. Now we can work on that together.' He adds, 'In Lord Darzi's reports on the NHS, he claimed patients value convenience above everything else. But I don't agree. I think they fall into two camps: those for whom ease of access is all, and those for whom continuity really matters. You won't achieve that without face-to-face contact.'
But, Karol Sikora says, 'Patients' time will be more valued than it is now. You won't wait at your doctor's convenience. The next generation will be a lot less forgiving of doctors. And hospitals will welcome patients and be a much nicer proposition than they are now.'
'You will still have appointments,' Paul Williamson says. 'You won't easily replace the interface between doctor and patient. People say primary care is over, but I disagree.'
Source: Lambert, V. Telegraph Magazine, 02 January 2010
