Note: This is the third in a series of posts the first looked at scale in direct to consumer solutions and the second looked at scaling across place based care.
Same same but different - Patients and providers
The first scaling innovation post closed with the following:
Direct to consumer tools are the best positioned [healthcare] solutions to scale. However the way they interface with healthcare providers needs to be vastly improved to enable better impact on improving health to more individuals beyond those that are already actively aware of their health.
The second post discussed some important factors for scale if the solution is aimed at supporting place based care. This includes variations in staff roles, expertise, and types of services as well as variations in the populations that provider organisations support. These variations add a level of complexity unique to each locality that can make it difficult to scale digital solutions for place based care across geographies. The second post ended with the following:
It’s unlikely that local variations will disappear. It’s much more likely that scale means flexible and modular solutions that can be tailored for the needs of each locality.
One key enabler which makes direct to consumer solutions more suited to scale is that the purchaser is the user. In the healthcare system the commissioner, purchaser and users are potentially all different people. This adds layers of complexity - when a solution vendor attempts to communicate the benefits of a solution each person in the chain potentially has different priorities.
Setting up to embrace scale
The future of health and care is expected to include many more connected devices or “smart devices”. These are devices that have micro-computers, software, apps, sensors or a combination of these within them, providing additional functionality to improve the management of health conditions. Examples of smart devices that are already available include smart inhalers and flash glucose monitoring systems. While these are already available direct to consumers they are also becoming more readily available through provider organisations within healthcare systems. Smart devices are now encountering place based care scaling challenges touched upon above and discussed here. However, changes occuring within the English NHS might remove some barriers to scale.
Personal health budgets are now being tested in the English NHS, these are a way of allocating the spend of existing resources to patients and carers so they have direct purchasing power on NHS approved devices. Personal health budgets potentially shorten the vendor-user chain allowing for user personal choice, which will in turn enable vendors to compete on usability and user preference. Personal health budgets have been established in some parts of Europe and it hasn’t been a smooth process so there are learnings that need to be incorporated.
In addition to personal health budgets the English NHS, through the GP IT Futures, is setting out to establish interoperable systems potentially removing another barrier to scale.
Interoperability enables data sharing across organisations, boundaries, systems and tools so apps and devices that the individual uses are a step closer to providing pertinent information to the clinical team. Information that can be used to improve how individuals are supported. Information flow can also facilitate scaling of digital tools. However sharing information is just one part of the puzzle any information needs to be understandable and actionable. Information across devices and apps need to measure the same thing which is defined in the same way with acceptable accuracy if any of these are different then information becomes untrustable and so unusable.
There are many challenges to scaling solutions some of which are in the process of being addressed but still only look at one small part of the whole problem. For example, personal health budgets shorten the vendor-user chain enabling patient choice but there’s no equivalent for individual clinician user preference. Instead all staff in a provider organisation use the same solution with minor user preference adaptations, how can staff be empowered to select the best solution that meets their individual expertise and user experience preferences?
Why scale? Why not hyper-local?
In the first post the question “Do we need scale?” was posed. With scale comes a number of benefits like reassurance and quality but there are also downsides. Scale means having more users which also means that there can be inertia to updates and change. Scale can only be achieved by targeting large demographic segments so it is potentially unavailable for those most in need and smaller communities. Of course the vendor can expand the solution to include aspects optimised to other demographics. This evolves an optimised solution into a more complex solution that can again be slower to be updated. Modular and flexible systems have potential to scale and these would be more tailored for each individual locality but once again updates and changes need to be optimised for each locality slowing down how frequently updates happen. The potential negative impact of these are the creation of stagnated systems. In addition with scale we get entrenched vendors who can be less incentivised to be responsive to user needs.
The ambition for solution vendors to scale comes from culture (tech and venture capital mindsets) and how vendors are measured as a success (financial markets). But does it match the sentiments of healthcare? Scale and income are perhaps not the most important things, and perhaps we should be asking what is the social impact (i.e. the impact on society and patients) and why is this not as important as financial return?
Vendors could relinquish scale and instead set out with the aim to reach the minimum number of users to make a solution sustainable and then prioritise being agile and flexible. This would ensure their solution can be updated to keep the healthcare system they support modern. Does this mean other areas or demographics would then not be able to benefit from the solution? No necessarily, approaches such as franchising and licensing IP can be an alternative approach to scale that enable flexible locally optimised solutions. Large provider organisations could be a franchisee or license IP so they can create an adaptation of the solution which meets their specific needs and that of their population. Of course they then need to have the right expertise and system support to be able to do this. Benefits of scale to the user can still be achieved by taking alternative approaches such as frameworks for quality assurance with process transparency.
We don’t stop to consider the detrimental effects of scale as well as the benefits to enable a more considered approach to how the future healthcare systems should facilitate scale. Scale might not be the best approach for all solutions and when it isn't healthcare systems could benefit from a broader variety of tools. Alternative approaches like franchising and licensing can help to achieve the benefits of scale whilst having agile and flexible solutions that can be localised by providers and vendors and continue to move capability forward avoiding stagnation of IT systems and healthcare tech.