Can doctors prescribe apps instead of medicine?
In 2012, the then Health Secretary, Andrew Lansley, made a speech about the potential for GPs to prescribe smartphone apps to allow people to monitor and manage their own health. He said, “innovation and technology can revolutionise the health service, and we are looking at how the NHS can use these apps for the benefit of patients.”
Policy Exchange has been looking at how technology can improve the way in which the public sector operates and delivers public services, particularly in health. From cost savings and better collaboration to higher quality care and more convenience for patients and practitioners, the potential benefits that digital tools – such as online health information and mobile apps – offer the health service are huge. However, there are several obstacles to integrating digital initiatives into the patient experience of the health system – from digital literacy among users to the role of health practitioners in promoting digital technology.
The challenge & the opportunity
The financial issues facing the NHS are well-documented, with the ‘Nicholson challenge’ seeking £20 billion in efficiency savings at a time of rising demand. Meanwhile, polling has suggested that the NHS is the number one area the public wants protected from cuts. There is therefore an apparent conflict between the need to save money, while also working to maintain – and hopefully to improve – the service. Yet closer analysis suggests that in this bleak cloud there is a silver lining: 70% of NHS spending – equal to around £77 billion – goes towards treating long term conditions. Happily, it’s here that digital technology has the potential to make big gains.
To give just a few examples, by using technology hospital staff could communicate through digital video or email with a patient with arthritis in the comfort of their own home. Individuals could use an exercise app to track and change their behaviour, helping to reduce their chance of heart disease. Specialised social networks could connect people who have been diagnosed with the same medical conditions, such as depression, allowing them to share their experiences and find support.
Research for the NHS found that digital tools like an online triage service, video consultations, and online booking systems could unlock cost efficiencies of up to £3 billion. In addition, every 1% reduction in face-to-face interactions with the health service could save up to £200 million. Research by the Department of Health found that innovative uses of technology in the management of long term conditions reduced death rates by 45%, visits to accident and emergency departments by 15% and emergency admissions to hospital by 20%. In short, technology offers to provide a better, more personalised health service while at the same time reducing costs.
So what are some of the roadblocks to making digital technology a bigger part of the NHS? Whereas some opportunities to save money and improve the quality of care through technology rely on the success of IT management and solutions, those described above rely on the digital skills and engagement of patients.
It is here that the first challenge arises. There is evidence that the heaviest users of the NHS are also the most likely to be digitally excluded. People with long term conditions and disabilities are three times more likely to have never used the internet than those without these conditions. Among those over the age of 65, nearly 5 million lack basic digital skills such as the ability to search for information safely. The same age group accounts for over half of NHS spending.
A second challenge for policymakers and health providers to consider when thinking about digital health tools is the level of health literacy. 43% of UK adults cannot fully understand written health information, rising to 61% when numerical information is included. Research has also found that 40 to 80% of medical information provided by doctors and practitioners is forgotten almost instantaneously. But online health information has the opportunity to provide people with easy-to-understand language and multimedia tools to aid them, and can act as a complement to the information they receive from their GP.
Thirdly, digital health tools need to prove to patients – and especially to health practitioners – that they’re credible. Currently, marketplaces such as Apple’s App Store and Google Play offer ratings and reviews for the 40,000+ mobile health applications available to consumers, such those that track running or aim to nudge a user towards healthier eating. These reviews most often provide information about whether people liked the functionality, design and usability of the app. But this kind of feedback does not provide any information on health outcomes. The reviews also do not tend to detail by how much people curbed their alcohol consumption after downloading a beverage calculator, or if a cessation app helped someone quit smoking long term. Doctors will understandably be wary of prescribing a tool with little or no evidence that it improves patient health or care.
The NHS is making headway
The good news is that the NHS is making headway in improving digital literacy through the Widening Digital Participation programme. NHS England has partnered with the Tinder Foundation to train 50,000 people who are socially and digitally excluded to be able to access health information online. In September 2013, the Tinder Foundation was awarded £1 million to deliver the project by April 2014. Volunteers train people through digital health classes, courses, one-to-one sessions, group sessions and online learning.
There is also encouraging work happening within local communities. A good example of this is the Bromley by Bow Centre, a community organisation in East London working in one of the most deprived boroughs in the UK. It has been one of the flagships in the NHS Widening Digital Participation programme described above. Working with more than 2,000 people each month, they run a range of projects and services that aim to help individuals do things such as change unhealthy lifestyles, learn new skills and find work, often through programmes embedded with digital skills training. Social prescribing has played a role in these projects.
Social prescribing involves GPs referring patients to non-clinical sources of support, where appropriate and depending on their needs, and can take a range of forms. Previous research has looked at how prescribing physical fitness, volunteering or joining a club can help deal with mental health issues. Work by Nesta found that of over 1,000 GPs surveyed, 90% thought that patients would benefit from social prescriptions and 59% of people said they would like their GP to prescribe them. Significantly, social prescribing can have a digital dimension. At Bromley by Bow Centre they work with individuals to design a suitable package of services. Where appropriate, a GP will prescribe classes to learn how to access health information online.
NHS England and the Department of Health are also investing in online NHS services. The NHS Choices website receives 36 million visits per month, and is Europe’s most popular health website. Currently it provides functionality including a symptom checker, a tool to find your nearest hospitals and doctors’ surgeries, feedback tools, and a library of mobile health apps. All of this is a step up from just looking at health information, and moves towards a model that involves behaviour changes and digital interaction with patients.
There are still huge gaps
Skills training at the scale described earlier can only achieve so much. Even while meeting targets, with current levels of support, the Widening Digital Participation Project will reach just a small fraction of the digitally excluded users of health services. Meanwhile, social prescribing among GPs is still a long way from being mainstream, with only nine per cent of the public having ever received a social prescription. Additionally, health practitioners often lack confidence in available digital health tools even though doctors are used to innovation and using new devices.
To its credit, NHS Choices does work to increase trust in its apps library by listing only those that have been reviewed by a clinical assurance team and meet their safety and quality standards. However, this does not provide any insight into the health outcomes and progress of those who use the apps.
For clinicians, there is still a need to establish the credibility of these digital tools in an acceptable manner, similar to how a new treatment goes through clinical trials. A review of 42 mobile health technology studies found that “more trials are needed to robustly establish the ability of mobile technology-based interventions to improve healthcare delivery”. Yet there are currently just three clinical trials that involve smartphone apps in the recruitment process running in the UK.
For digital tools such as online health information and apps to make a difference to the NHS and to the lives of patients, the technology needs to instill confidence in patients, carers and clinicians beyond the simple ratings and reviews systems currently available. To see an increase in practices such as prescribing digital skills or apps, there must be an infrastructure that provides information about their effectiveness while keeping pace with technological advancement. The people who take part in the Widening Digital Participation Programme will provide a unique testing and feedback resource for NHS England to contribute to the ongoing development of the NHS Choices Platform. Evaluation will be crucial for developing services for users with a range of experiences and engagement with digital tools. There is also a need for health and wellbeing apps delivered through NHS Choices to prove their efficacy. Traditional clinical trials might not be the appropriate answer, but well-designed, crowdsourced and comparative studies can help give health practitioners better evidence about the digital tools available for recommendation to their patients. For instance, the app SmartQuit was developed based on the first randomised, controlled trial comparing the effectiveness of smoking cessation apps.
How people interact with online information alongside health services has important implications for government, such as cost savings, efficiency gains, and better quality care. The key to embedding digital tools in the NHS is confidence in their effectiveness. There is unlikely to be a one-size-fits all approach, but with specialised pilots such as the Widening Digital Participation Programme, an increase in social prescribing, and an evidence-led approach to the use of mobile health apps, there are interesting and creative possibilities to increase the successful use of technology in our health system. From all sides of the political spectrum there have been dire warnings about the future of the NHS’s finances and the need to reshape care. Yet given the potential gains from digital health and digital literacy, there is reason to be optimistic, and even excited about the opportunities.