Feature: Providing digital health services for people is going to depend on contributions from inside and outside the NHS, and it needs an effective identity mechanism
“The application that works for my mum who has dementia will probably be written by someone with a mum who has dementia.”
It was an unscheduled appearance by Matthew Swindells that provided the most telling comment at NHS England’s Empower the Person conference last week. A brief reference to the personal relevance of the effort to NHS England's national director for operations and information reflected its importance for hundreds of thousands of people, and reflected a key point made by the national director for operations and information: that it’s about building an ecosystem for innovation rather than a single perfect solution.
The event provided a platform for officials from NHS England and NHS Digital to outline the direction of work, with a recognition that there is an urgent need for more digital options to help the health service cope with intensifying pressure. The development of the ecosystem, in which people and companies outside the NHS make a big contribution in app development, was a recurring theme.
It could be a surprise to some, given the service’s history of the highly prescriptive and only partly successful National Programme for IT; and it has had an inconsistent history with the freer approach, having closed the Health Apps Library for a while in 2015.
Also, there is no prospect of the NHS opening up much of its data, one of the big enablers of apps development for other public services: there are too many pitfalls around patient privacy.
But it got the effort back on track last year with the opening of the Digital Apps Library and the Developers.nhs.uk online space with limited data, development tools and a testing facility. And one thing that will make a big difference was conveyed in a phrase used by NHS England’s chief digital officer Juliet Bauer: “digital by desire”.
The fact is that some services are difficult to use, and the health service needs to create others that people not just need but want to use. Outside developers can bring the perspective to make it possible, and Bauer said that stimulating the market for app development is a key element of the NHS strategic approach to digital.
“We need to make it easy for people to provide the services they want to provide, and at the moment we don’t necessarily do everything in that space,” she said. “We need to stimulate the market because it’s not going to be us that provides everything, but us that enables those things to exist.”
A big element in this is still a work in progress: the development of a secure, reliable mechanism to confirm a patient’s identity.
Adam Lewis, NHS Digital’s programme director for citizen identity, explained: “We need to make it simple and safe for people to access things, find a way of linking people to the right information, and ensure that once you know who somebody is they can make decisions more freely and easily through the tools.”
He provided an outline of an NHS identity platform that could link with services provided nationally, locally or by accredited third parties, and would provide a sign-on to services, proof of identity, and give patients the ability to manage their NHS profile. This does not necessarily have to be built from scratch, but the team is still working on what alternatives might be appropriate.
“We don’t want to reinvent the wheel,” he said. “If there are other initiatives on identity appropriate for use in health we will allow those to be used with appropriate changes.”
This raises the obvious question of whether GOV.UK Verify, the online identity assurance platform developed by the Government Digital Service, could have a role. The NHS Digital team is looking at its potential, but so far has been non-committal about its prospects – not surprising given its slow adoption in government services so far.
It might also be possible to extend the capabilities of Patient Online, the NHS mechanism for basic processes such as booking a GP appointment and ordering repeat prescriptions.
The other question is around integration with personal health records, online tools for patients to bring together information on them from different NHS bodies. The NHS is still finding its way in how to use these, but Lewis said they could provide an effective data integration point and encourage the broader development of apps.
“If they can launch an app to a population of 20-30 million people and, rather than going through a painful registration process and onboarding, it should in theory encourage the market significantly,” he said.
A discovery project is underway to look at existing personal health records from the NHS and the private sector to understand how they need to be further developed.
Standards, data and questions
Other needs to underpin the effort were identified: digital design standards to support usability; data on any pilots to show what works; ensuring that the developments are in line with the NHS Five Year Forward View; and questions from NHS employees on how the digital plans fit with their issues and the national strategies. It is always possible that someone in a trust will think of something that has slipped the attention of those at the centre.
There has been progress in the field. Standards and tools for apps developers are now in place, and Bauer said the number of applications available through the relaunched Apps Library has begun to increase – it is now close to 50. As the common standards evolve and developers become more aware of the potential the number will continue to rise.
She qualified this with an acknowledgement that the NHS cannot just provide patients with a route to thousands of tools and let them work out which is best for them; there has to be some guidance in helping them make good choices.
This is part of a picture in which the NHS is developing its own digital tools for patients and clinicians, but it provides an extra momentum that the leaders hope will make a big difference to the future of the service.
Swindells summed up what can be achieved: “If we can say ‘My data should be made available and can open up an identity in a secure way’, we can be part of the transformation the NHS and wider society needs. We are doing the heavy lifting, dealing with some tremendously complex problems to develop the interoperability and that ecosystem.”
Image from Imperial College NHS Trust