Breaking into the NHS

No, not burglary. Digital Catapult had a half-day event on “NHS: The Procurement Minefield” last Monday. The first speaker was Mahiben Maruthappu from NHS England, who listed six big challenges for the NHS, or things that are needed more of: prevention, innovation, self-care, breaking silos and scaling, IT interoperability, and making the financial case. (Most of these sound like they would fit any major organisation really…)

He then listed three focus areas: organisational change to handle new kinds of services and local innovations (no surprise there!), combining innovations to achieve synergies, and achieving national scale. In terms of medical issues, diabetes, cancer and mental health are the three big priorities for the next ten years.

The other speakers weren’t as interesting to my ears, but the panel discussion towards the end had some good nuggets. For example, in answer to a question about how best to get into the NHS as a new service provider, the answers included having inside knowledge, “talking clinical” (i.e. not just business and tech), having a global view, and being adaptable and having perseverance (expect that anything will take years…). Someone even called the NHS “the hardest market to crack”, and recommended going direct to consumers, even if you then have to go to the US and Australia.

Some food for thought there, though mostly confirming the impression I’ve already got from other health and medical startups about the difficulties involved in working (or trying to work, to be more precise?) with the UK national health care system.

Digital health & wellbeing conferencing

Last week saw the second of UCL’s behaviour change conferences, this year subtitled Digital Health & Wellbeing. And quite a bit bigger than last year’s first one. I spoke in a panel on “Challenges to creating sustainable, high impact interventions” (see below), and also had a poster on Club Soda’s Month Off Booze programme (a “prize-nominated poster” no less, though the prize went to someone else…).

UCL panel tweet

Some of the themes that I picked up on over the two days were:

Tailoring of messages – e.g. app prompts, emails, social media messages and so on. The more personalised these can be made, the better the engagement. This may also include personalizing the tools by the users themselves (e.g. adding bookmarks and notes).

Importance of good design – nobody likes an ugly app. Some features divide opinion (e.g. cartoon talking heads), some are not liked by anyone, and sometimes people take you by surprise. For example, German youth much prefer factual information about alcohol harms to “fun” factoids. Well, thinking about this a bit more, perhaps it’s not so surprising that teens don’t find funny the things that public health officials think they should do…

Communities/social support – several interesting projects included some elements of this, and with good results too.

Not just apps – this is one of my personal bugbears, but I did hear other people as well talk about the fact that apps are no longer the only game in town. They may be a part of a bigger intervention, or they may not be included at all. And sometimes the preferred medium is not what you expect at all: in one example, people much preferred text messages to emails, as emails “reminded them of work”(!).

Not just RCTs – a few critical comments on these too. There are alternatives available, which can be much quicker and easier to do.

New recruitment avenues – GumTree was mentioned several times as the source of study participants!

Evaluation of eHealth/mHealth interventions – this research is making progress. A Cochrane review of digital alcohol reduction interventions is nearing completion, with some interesting findings on what seems to work and what doesn’t. I’m really looking forward to reading the full study soon.

Poor engagement levels – an oft-cited figure was the 20% of apps that are only ever used once and then ignored. And very few are used at anything like “frequently”. This creates problems for evaluation as well, as the drop-out rates in some studies can be over 90%.

Dose – again, several speakers mentioned this as an open issue. What is the “dose” of a digital intervention, can it be altered, how to measure it, and does it make a difference?

Qualitative data too! – A fascinating comment by Nikki Newhouse: when she interviewed people about their use of a website, the stories completely contradicted the researchers’ conclusions from the quantitative data. For example, people had seemingly spent lots of time on one page, but had in fact found it so confusing that they had often “gone to make tea instead” and not actually read it at all!

All in all a stimulating two days again, with lots to take away and ponder.

Two approaches to innovation in health

Two events I went to the other week, both dealing with innovation in health (care): one a meeting for the government’s Accelerated Access Review (AAR), the other a Nesta day on “People Powered Health”. And two rather different approaches to innovation.

The Government first. AAR is a big thing, on how new treatments, medicines, and devices could more easily be brought into the NHS. I attended this final stakeholder session as a “health startup” representative, mostly just listening to the discussions, and quietly shaking my head. Just one example of the many issues needing attention that someone raised is the Cancer Drugs Fund – how is that existing monster going to fit in with any new processes and organisations? A government minister gave a pep talk, said how excited he was, and concluded that he is looking forward to significant progress in the next six month. Someone sat next to me quietly noted that with the time it takes to complete the NHS budget processes, not much can possibly change in the next 18 months at least. Not exactly agile…

The Nesta thing then. A whole day of presentations, most pretty interesting. One of my highlights was a talk titled “From South Sudan to West Essex”, or how the Rapid Results Institute’s methods born in the developing world have made a big difference for local NHS services in the UK. Basically it was all about empowering people to do the best in their jobs, setting ambitious targets, and being willing to ask the patients what they would prefer to happen. And there was more on topics like peer support (e.g. Peers for Progress are doing interesting work).

And interestingly, several people said at different times and in different ways that randomised controlled trials are not the only – and not always the best – method of finding things out. Which should be obvious, but clearly it isn’t, so good that it gets said. I will have much more to say on this topic, but on another day!

Alcohol units, risk, communication – and a whole load of nonsense

The UK Department of Health released their long-awaited updated guidelines on safe levels of alcohol consumption last week. The headline news was a small reduction on what is recommended as “safe” drinking for men, and that the limits are now the same for women and men. The predictable consequence was an avalanche of moaning. Pick any newspaper from that week and you will find a column inviting “the nanny state government” to come and take the poor oppressed journalist’s last bottle of wine, but only from their cold, dead hands. Yes, there was also some intelligent commentary on the findings and methodology of the review behind the new guidelines (David SpiegelhalterThe Stats Guy), but mostly it was all predictably sad, confused, and badly informed.

The reasons are not at all mysterious. (1) Alcohol is a touchy subject; most people in the UK drink, and any talk about the harms is taken as an accusation of their personal choices. (2) Risks are difficult to understand (and in this case they are also very difficult to estimate – the medical evidence itself is still far from settled). And as a consequence, (3) Risk information is difficult to communicate well.

There is not much that can be done about the first two. Which means that the third issue becomes even more important. I’m not sure how much better the publicity for this particular announcement could have been, but surely it can’t have come as a surprise that it was so badly received.

And for every journalist and pub commentator saying that their drinking never did them any harm, why not take a moment to consider the bigger picture. A small change in cancer risk might be acceptable to you personally, but from a public health perspective, looking at 50 million people in the UK, even a small reduction in alcohol consumption and therefore the number of future cancer cases will mean enormous savings for the health care system. That’s what the guidelines are all about.

Two views on behaviour change

I was at the Food Matters Live exhibition again today. We tasted lots of drinks for Club Soda’s dry January programme The MOB, which will again have non-alcoholic drink reviews/suggestions for every day of the month. Our tastings included camel’s milk (disappointingly very similar to cow’s milk), half a dozen tree sap drinks (varying quality), and a countless number of “healthy” fruit juice drinks (healthy to very varying degree I would say…). We also tried an “oxygen” drink, which is basically a fruit juice that has been foamed. Rather heroic health benefits were made for this concoction as well. I do get that oxygen is very good for you, but I’m not sure eating/drinking it is the best way of absorbing the goodness.

A panel discussion on food and behaviour change had Ben Goldacre and Richard Wiseman on it. BG’s opening was a very good brief statement on how most of the misleading media stories on food and health actually come from academia (in particular press releases). He noted that clean, good quality information is the first thing that is needed by consumers if they want to eat a healthier diet. And that requires good evidence-based quidance from the experts.

RW talked a bit about health information and messaging as well. “Keep it simple, keep it positive” was his summary. We as humans like simplicity and positivity. So far so not controversial.

Where things got more interesting was around the “what is to be done” question. BG was quite adamant that the main issues are top-down: society and culture need to change so that people can more easily make healthier choices. RW on the other hand insisted that there are still small choices everyone can make, despite the social pressure for fatty and sugary treats (this difference came about while discussing children, and children’s parties’ catering in particular).

Hmm. I will now make a horrible generalisation, and probably libel many good people (including BG who I have a lot of time for). But there is probably something here, between a stereotypical doctor and a humble psychologist. An “I will tell you what is best for you and you will do exactly so” versus an “I will try to help you to make better (but not perfect) decisions for yourself”? I would take the latter any day myself.