Remote doctoring is only part of online health

Abstract

In England, the use of everyday technologies to provide easier access to urgent care and to improve health began at scale in the late 1990s with the telephone. Over the past 12 years, remote health advice and information have become an established part of the NHS scene. 2010 was the first year in which more people contacted NHS Direct over the Internet than by telephone. That trend is expected to continue as smartphones become ubiquitous, as more tools become available for people to self-serve online, and as we continue to learn how and where these approaches add most value for patients and the NHS. Reports that Professor Sir Bruce Keogh is drawing up plans to introduce online consultations1 are very welcome. But experience clearly shows that, in health as in other sectors, the transformative effect of the web does not lie primarily in opening up new channels for traditional interactions. Its greatest power is to enable safe, high quality self-service, underpinned by the best available medical expertise, to support patients themselves to manage their health and make better informed decisions about their care. It is commonplace now to look at retail banking as an indicator of how technology can drive new business models, improving customer experience and reducing cost by harnessing people's willingness to do things for themselves. In retail banking, the creation of digital services has enabled rationalization of the physical estate, something the NHS badly needs. Between 2000 and 2010, the number of UK customers registered for telephone banking increased from 16 m to 46 m but began to fall from their peak in 2006. Over the same period, online bank accounts multiplied from 1.4 m to 40 m and continued to rise beyond 2010, approaching the telephone as the leading remote channel. Meanwhile the number of high street branches fell from over 12,000 to under 10,000.2 The revolution in banking has not come about through replacing visits to the branch with remote access to clerks and managers by telephone or web, but through technology-enabled self-service. The debate about remote consultations now starting in the NHS is reminiscent of the banking sector in the 1990s. Over several years, the senior leaders in a major retail and business bank developed a blueprint for the banking of the future. They envisaged technology instantly bringing a range of data feeds to lending officers’ desktops, including economic forecasts, both local and national; business sector performance; and personal credit history – essentially using digital resources to augment the traditional model of thousands of lending decisions by individual experts. The technology to support this vision turned out to be relatively expensive and slow in coming. Meanwhile, in the back offices, a real revolution was taking place as analysts, statisticians and programmers developed the software that automated decision-making and provided self-service credit decisions for millions of customers, rendering the original blueprint obsolete before it ever materialized. The NHS's early attempts at remote self-service have shown themselves to be safe and popular with patients. In 2009, the National Pandemic Flu Service (NPFS) carried out 2.7 million remote assessments, enabling 1.8 million people to access prescription-only antiviral medication without seeing or even speaking to a qualified health professional.3 Forty percent of these assessments were self-service over the web. The safety and effectiveness of the NPFS did not depend on individual judgements by the hundreds of staff around the country who were rapidly recruited and trained in response to the pandemic, but on the medical expertise embedded within the assessment algorithm. Day by day and week by week, as researchers learned more about the virus, the algorithm was updated in real time, giving every patient the benefit of the most up-to-date medical knowledge, wherever they happened to be. Similarly, the power of NHS Direct's suite of 40+ digital symptom assessment tools lies in the quality of the medical expertise which underpins them, coupled with growing experience in how to apply consumer digital techniques to present health information and support decision-making online. The symptom checkers have now been used over 12 million times,4 and the mobile apps launched in May 2011 have been used over a million times. Continuous careful monitoring of adverse incidents gives no reason to believe that these digital tools threaten patient safety. We are just beginning to see the benefits of people taking the technologies they use every day, and applying them to manage their health. The rapid adoption that we have seen of digital health tools by consumers, will increasingly enable high cost face-to-face and physical resources to be devoted to the people and situations that need them. The greatest potential is the use of technology to support patient self-management so, while supporting remote doctoring, we need to take care that it does not become a distraction from the real prize.