Health and Sport Committee

Meeting date: Tuesday, October 3, 2017

Official Report 616KB pdf

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Technology and Innovation in Health and Social Care

Item 3 is the committee’s first evidence session on technology and innovation in health and social care. We have a number of guests, and we will start by introducing ourselves.

I am a Labour MSP for Lothian, and I am the convener of the Health and Sport Committee.

Good morning. I am the MSP for Rutherglen and the deputy convener of the committee.

I am the director of the Strathclyde institute of medical devices at the University of Strathclyde.

I am the MSP for Renfrewshire South.

I am the director of policy for the Scottish Lifesciences Association, which is a trade body that represents 140 companies in Scotland that do life sciences, including e-health.

Hello. I am the director of information technology at NHS National Services Scotland. We run most of the big national systems that support the health service in Scotland.

Good morning. I am the Lib Dem MSP for Edinburgh Western.

I am an MSP for Lothian.

I am head of project development at Scottish Health Innovations. We work with the NHS to help to commercialise innovation in the health service.

I am the MSP for Glasgow Provan.

I am digital health and care strategic lead at the Health and Social Care Alliance Scotland.

Good morning. I am an MSP for South Scotland.

Good morning. I am a consultant physician, a general practitioner and a professor of e-health at Edinburgh Napier University.

I am an MSP for the Highlands and Islands.

Good morning. I work for PA Consulting; I lead our digital work in health and social care in Scotland.

I am an MSP for South Scotland.

I am sorry—it was remiss of me not to mention that members might have some interests to declare. I declare that a close relative of mine works for a company that is involved in e-technology. Does anyone else have a declaration of interests to make?

I am director of a technology company that creates collaboration and communication platforms for organisations, including healthcare organisations. I no longer receive remuneration from that company and do very little work with it at the moment.

Who would like to ask the opening question?

I will start with a very general question. How easy is it for new technology to make its way into working practice in the NHS?

There are several routes in in Scotland. There is the SLA and its help with Healthcare Improvement Scotland. There is a route through the universities—a knowledgeable small company or a very large company can get in by finding the right clinical connections. The academic groups can do that.

The problem goes beyond that. As soon as such technologies get proved or CE marked—in other words, ready for market—the barriers to uptake become very high. I think that we are quite good at setting up the initial research programmes, but I think that we are very bad at implementing our own technology in Scotland.

I will answer the question in a different way. Under certain circumstances, it is incredibly easy to introduce new technology into the NHS in Scotland. We have direct evidence of having worked with NHS Education for Scotland to do just that. We implemented a live system to help to manage the education and training of trainee doctors in just four months. My answer is that it is incredibly easy to introduce new technology into the NHS; it is just necessary to have the right conditions in place.

I am a little surprised by Alex Matthews’s answer. My experience from years of working in the NHS is that the situation is more as Patricia Connolly described it to be. It is not really that easy to get new technology into the NHS. The more complex the technology is, the more complex the process will be, simply because of the structure of the NHS.

In my opinion, what is lacking is a comprehensive policy approach in Scotland, and we need to talk about that. We need to be more detailed in our planning of what we want, because technology is moving forward rapidly. I appreciate that Alex Matthews might have been talking about certain specific technologies that could indeed have been introduced in four months, but when it comes to key technologies that are relevant for things such as tagging, tracking, managing patients and managing pharmaceuticals, we do not have the right technologies. At the moment, we have a very difficult process for trialling such new technologies and implementing them, and that has economic implications.

Five years ago, the Government launched the innovation partnership; in fact, Ms Sturgeon launched it when she was the Cabinet Secretary for Health and Wellbeing. My organisation was given the job of delivering the partnership, and we partnered about 180 companies with more than 1,000 clinicians, who were self-selecting early adopters.

The outcomes are starting to come through to the procurement level. I would not say that it has been easy—I agree with Christoph Thuemmler’s remarks—but it has been a mechanism to help. Where we find a barrier is after that, even when the NHS has bought a new device. We have specific examples of that barrier; in one case, NHS procurement bought 30,000 devices that were better for patient outcomes and cheaper than existing products, but then they were put in a warehouse in Lanarkshire and there was silence. We call the issue of getting the information across adoption and spread. You can do all the research, prove that a device works and have a bunch of eager clinicians, but unless you do adoption and spread across the board, the result can be a damp squib.

If those devices are still lying in a warehouse, who is held accountable for that? It is a huge waste of public money.

They are not complex devices.

What are they?

They are drain tubes for surgery with a clever novel way of adjustment so that they are not stitched into the patient’s body.

Why are they sitting in a warehouse?

The reasons are information not being available, the fact that people have always used the old devices and the fact that the suppliers of the old devices are quite keen not to have their market taken away.

Who is accountable for that?

We have had a meeting with the NHS director of strategic sourcing—

Is he accountable?

He is very interested in the device.

The issue is not who is interested. Is he the person who commissioned that contract and who is, therefore, accountable for that decision?

I do not work for the NHS but, from my viewpoint, the answer to the question is yes.

What sums of money are you talking about?

In this example, the devices cost pennies—maybe £1.50 or something similar. It is a piece of low-tech but very useful innovation. It is patented and the NHS was very good about saying, “Yes, we will buy 30,000.” However, adoption and spread is the issue; how does the information get out for whatever it is—it might be a simple piece of plastic or it might be a complex e-health system.

Is the example that you have given repeated in many other areas?

Yes; I could give you other examples.

Will you write to us with more examples?

Yes, I will.

You mentioned the cost. In terms of clinical application, what is the impact on patient outcomes if this method is not being used? I presume that patients are losing out.

We have evidence from the NHS assessment organisation, which is called the Scottish health technology group. It has assessed the device and has written a positive report; the device was cost effective, the patient outcomes were better and they recommended it for NHS procurement. We were delighted with that and thought, “That’s it,” but—

I come at this from a slightly different viewpoint. I stand beside the NHS and we look at the innovation that originates within the NHS and how it can be rolled out more widely. We find a willingness to innovate; the facilities to make that happen are very good in the NHS. We can go in and work with companies and bring expertise to bear.

John Brown alluded to the fact that, once a product is available that we are looking to roll out more widely, it becomes more difficult. There is certainly an area where success is not disseminated and practices are not shared as well as they could be. Attacking this more at national level might lift some of those barriers.

I really just have a comment. As politicians, we do not often hear pleas for things to be centralised, but a common theme in the written evidence is that variation at health board level causes a challenge on the ground, and that centralising commissioning and distribution would be a good thing. That is a challenge for us, so I wonder whether the witnesses would like to comment on that.

There is an appreciation in the community that lots of people can play a very important role. If criticism has been levied in this environment, it is that there is some confusion about the roles of organisations. Each organisation has an important role to play, and we would like there to be a co-ordinated effort to define roles and responsibilities, and to facilitate organisations coming together and working in a complementary way.

When we talk about centralising, many people envisage committees and large structures in the centre. The problem with centralisation, or at least with introducing similarity across the NHS, goes to front-line staff. Many of us will have experience of devices for patient monitoring in the home or the community. There tends to be enthusiasm for such things among certain groups, who can see cost or time savings—there tends to be what we call “pilotitis”, where everyone wants to pilot a bit of something—but I have to say that we tend to get kick-back from front-line clinical people. That is partly because digital medicine, e-health and personal monitoring are very challenging. They challenge both the clinician and the patient—and they monitor both, too. If a community group tries to introduce something without having a mandate for doing so and several nurses in the group do not want to use it, it will never be adopted. There will be no uniformity, and it will be very difficult for that group to get the business change mechanism.

For example, I have a device that saves time on wound care. However, unless a nurse uses electronic nurse management to manage their day and says, “I don’t need to see that patient because the results say that it is okay, or it is diabetes or blood pressure,” the current paper-based system, in which a nurse takes their bag out for the day, makes it very hard to change things. Digital technology is making fundamental changes to everything from diary management to who picks up results and who monitors what is happening. It is introducing centralisation and similarity, but in a different way.

More pilots than Ryanair, perhaps.

Yes. It is also very important to ensure that we look at requirements and that things are implemented across the board. It is very easy to implement something that is suitable only in a small geographic area. If implementation is opened up to a much wider area and it is managed coherently, we can ensure that the solutions that are put in place are suitable across the board rather than just in niche areas.

NSS spends a lot of time doing centralised activities. To take Alex Matthews’s point, certain conditions make things a lot easier when new innovations and technologies find their way to NSS. For example, it is easier when there is sponsorship by national bodies and when connections are made back into all the different health boards that are looking to deploy such technologies.

We have a proposal, which we put in our written submission, for a service that might support a single process—a funnel, if you like—for new technologies to find their way to the front line and provide the support that such initiatives require.

11:30  

It is a question of being able to get beyond procurement law and beyond governance, and of being able to get the funding for implementation and the support models that go with it. Funding for the tail needs to be obtained on an on-going basis. Often, funding is provided for the initial deployment of a new technology, but in order to run that technology for the health service, five or 10 years’ worth of funding needs to be made available to support it. The boards struggle on a daily basis with the sheer volume of the demands that are placed on them, and they need to be helped to implement change as they do the day job. Some central support needs to be provided. I do not think that we are saying that a central organisation should deliver the new technologies, but there is certainly a role to be played in supporting the boards.

What you have described appears to be a very cluttered landscape involving numerous hurdles that have to be overcome before a new technology gets to patients. Given the speed of technological development, are we not in a position in which much of the technology that is implemented will be yesterday’s news by the time it has got through that whole tortuous process?

Many of the controls that are in place are there for fairly good reasons; they are to do with things such as value for money, sponsorship and the willingness of boards to deploy. John Brown gave an example of the fact that there is no point in us buying new technology if the health boards are not willing to deploy it. We cannot control that, but we can certainly support the introduction of such technology. However, that takes time.

I am sure that I am not telling members anything that they do not know when I say that the NHS is an extremely complicated organisation. It covers many different clinical disciplines and comprises 22 health boards and 170,000 employees. There are 3,500 different locations on the end of our network. I can understand why people would have the impression that there are many hurdles, but that is because of the organisation’s complexity and the governance structures that sit underneath it.

Could all of that be radically streamlined?

I think that it could be.

Is there a willingness to do that? Is there evidence that that is happening?

I think that it is happening in places. Alex Matthews touched on this earlier—it is probably wrong to create the impression that nothing new is happening in technology in the NHS. That is extremely unfair. We are currently working on a number of things on a number of fronts.

I do not think that anyone is suggesting that.

No, but committee members could perhaps come away with the impression that nothing new is making it to the front line, and I think that that is not true.

I understand everything that Andy Robertson says, but the problem is that new technologies evolve, and they evolve on a global scale through globalisation. I understand that the NHS has all the problems that have been described, but the technology developments that we are talking about will not wait for the NHS. We need to find pathways that will help us to evolve and develop such technologies in Scotland for economic reasons, and then implement them in the NHS. We cannot take new technologies from a grass-roots level into the NHS and wait until they evolve at the speed of the NHS because, by that time, they will be yesterday’s news, as the convener said. That will never work. We tried that in the past, and it did not work.

There are risks in throwing 200 pilots at clinicians who are up to their necks in high levels of demand and who already have to deal with technologies that do not integrate with the existing platforms. Introducing a level of change that interferes with operational delivery will not help. There is no single right or wrong answer. We need to get the balance right. To respond to Neil Findlay’s point, there is an opportunity for us to look at how we streamline the process and make it more effective than it is at the moment. I am not denying that there is a need to do that.

We have touched on the length of time that it takes to develop such technologies and how quickly they change, but it is also necessary to look at how long it takes for new devices and technologies to get regulatory approval for implementation. At the moment, it takes an inordinate length of time for an examination of a technical file to be carried out. A company could have all the evidence ready to get something on the market as a CE-marked device, but it might have to wait six to nine months for a notified body to come and do the approval process.

First, the convener’s interaction with John Brown about the new devices that are stuck in a warehouse may get to the core of the problem. The initial reaction was to ask, “Whose fault is it? Who do we blame? Who bought this stuff that nobody is using?” Surely, the person who bought the stuff was doing the right thing by taking a risk, which is a key part of innovation. The problem is not there; the problem is with the roll-out of the stuff and how to engineer that. If we go back and blame the person who bought it, nobody else will buy anything new ever again, which will mean that we do not move forward. That mindset is critical to moving the innovation agenda forward, in my experience.

Secondly, there are ideas about innovative technologies that I assume could save money, make processes better and more efficient and mean that people get through the lists quicker—I assume that they tick all the boxes that health board managers would want to deliver on. There is no shortage of health board people who come here and tell us that they have not got enough money and resources to do stuff. If they are under that pressure, you would think that they would fall over themselves to adopt ideas or products that make things more efficient. Something is clearly missing in the chain of how people see their role as health board managers or directors that means that they do not grab that stuff and run with it. It might be their awareness of what is going on or their ability to execute policy in their boards. The panel may want to comment on that.

The last question that I will throw out is on what Elaine Gemmell talked about. Can somebody map out for me the pathway for innovative ideas? If I am a health service employee who works in a ward and has a good idea—probably not a high-tech idea, but perhaps an idea about how to reorganise the way in which things are laid out, do something a bit differently or change the information flow—how do I get that idea through the process? Who do I talk to and what do they do with it? Where does it go and how do we trial it? Unless you have innovation and continuous improvement bubbling up from the bottom, and unless people feel that their good ideas will be taken forward, you will not innovate or make improvements.

The witnesses have only 43 questions to answer. [Laughter.]

I have waited for 15 or 20 minutes to get in, convener.

Everyone wants to get in—that is the issue.

I will address the last question first. Scottish Health Innovations was set up in 2002 specifically to work with the health service to identify innovation that happens in the health service. When we started, we asked people about innovation and they told us that they did not innovate because it was not their job. Over the years, we have used evidence to build a pathway for them to get those ideas through. Four of the major health boards are represented on our board, and we work with the 14 health boards under a service level agreement. We have a relationship with each health board’s research and development department, and, if an employee has a good idea, the first port of call will be their own management, who will direct them to the research and development department or, in some instances, to Scottish Health Innovations.

We will evaluate the idea to determine whether it is useful and innovative. If other things might answer the same question, we point people in their direction. If it is truly an idea that should be developed for better patient care or better ways of doing things, we will pull together a team of people to take the innovation from the first idea right through the whole process. We will help with advice and resource and, eventually, by finding partners who will take it on to the market.

Does that address the issues that you raised?

I am happy with that answer. Are there any comments on the other issues that I raised?

I have talked about the 1,000 clinicians who work with 200 companies. They are the early adopters, but they are busy clinicians who see the point of innovation and want it. They are also happy to work collaboratively. The other people who get it are the top management of the NHS. Paul Gray, the chief executive, had a career in Government IT and really understands the issues.

One block or barrier is a lack of management support for innovation, which is not yet in the job description of senior managers in boards. Those 1,000 clinicians do this work off the end of a busy workload. Rather than rely on their goodwill, the healthcare system needs to fund a bit of clinician time to work on innovation with collaborators. That happens in many places, but it is not done yet in Scotland. The work relies on altruism or on clinicians who are interested in innovation for its own sake and find it enjoyable to work with companies to develop new products, but you cannot depend on that to create a system that will pick up innovation and implement it across the board.

We are speaking a lot about the NHS and what we can do within NHS structures, but it is also important to consider parallel universes. For example, at the moment, there is a lot of discussion about information technologies, mobile technologies and other new communication technologies such as 5G. Those technologies are the future. On a European level, they are being pushed forward, and there will be early prototypes in America in 2020—they are already on the way.

Those technologies will be essential to the way in which we will treat patients over the next decade or the next 20 years, so we need to talk about them. What we are doing at the moment is good—we are talking about the NHS, what is working or not working and how to get innovation out of the NHS—but we also need to look a couple of years into the future, otherwise we will all be on the back foot.

England invests double-digit million figures in that technology, whereas we have not a penny available in Scotland at the moment, so we are completely cut off. Those things need to be discussed. You cannot look at health technology as a single standing issue, because, in the future, we will treat more and more patients outside hospitals—that is a fact. When we do that, there must be connectivity with the point of care, which will shift out of the NHS and into the patient’s home, so we need communication technologies to connect in order to deliver the next generation of healthcare. It is important to look a little bit ahead rather than discuss what has happened over the past few years and where we stand.

I am interested in how decisions are made about adopting tech in the health service. During the summer recess, Alison Johnstone and I made a fascinating visit to the cancer research centre at the Western general hospital in Edinburgh, where a guy was testing drugs with a new machine that looked like a fish tank. It cost £250,000 and allowed him to do his job 67 times faster than he used to do it because of the number of drugs that he could test in a day. That led me to wonder about the parameters that are put around decision making on such technologies. What is the fulcrum over which a decision is taken to invest in that kind of tech or innovation against its not being cost effective?

I am conscious that we do not operate in a vacuum. Tech companies are lobbying clinicians and decision makers to choose their brands and are extolling the virtues of their machines. Can I have some views from the panel on how those decisions are currently taken? What parameters are used to decide, and are we getting it right?

I wanted to follow on from what Christoph Thuemmler said. We must be cognisant of what is going on elsewhere. Apple now has a complete med tech division and is promising such innovations as glucose sensors on its watches. There are commercial developments that patients want to access, and they will push us hard. Justine Ewing mentions Push Doctor in her submission. With Push Doctor on your phone, for £20 you can get a face-to-face consultation with a qualified GP and a prescription if you need it. I read every weekend about the locum problems all over Scotland and the millions of pounds that are being spent on locums, and I wonder why we cannot take some subscription to Push Doctor for patients through NHS 24. That would probably get rid of many of the actual go-and-see patient problems.

Those are commercial developments, and I know that it is a bit taboo to be considering them. We are rightly proud of our NHS, but we must look at areas where companies have developed the right solution rather than do it from scratch. That is true for much of the home monitoring, which is another area that we will come on to.

The other thing that we are falling behind with on that side is our innovation pipeline. We are not funding devices and med tech development in Scotland as we should be. I work with people around the world—in Hong Kong, Singapore and the United States—who are building up large wealth packages because they are developing companies and research projects together. We really have fallen behind.

11:45  

Going back to Alex Cole-Hamilton’s question about decision making, if a company has a very large piece of equipment such as a surgical robot, it can apply to the health boards. It would need very good cost-saving arguments, but big companies perhaps can do that. It may be worth talking to companies such as Medtronic about that.

With small and medium-sized enterprises and more day-to-day stuff, it depends on whether they have clinical opinion leaders and whether they can push through clinical barriers—people’s natural resistance to changing their way of working. Imagine that a big organisation is trying to roll out a piece of human resources software. In the NHS, everyone gets to try the software and say, “I don’t like it. I’m not using it in my job.” We might have a complex clinical management need, but everyone is empowered to say yea or nay to new pieces of technology, so things become difficult. That is a natural human reaction—I understand that push-back.

On innovations that come from elsewhere, we must recognise that, although the third sector is a major innovator in both digital health and digital care, there are few—if any—examples of its working with or connecting into the NHS and social care. That is partly because it is seen not as a partner but as a safety net, whereas it actually provides a third of social care services and does a huge amount of clinical research. That issue could be addressed by giving the third sector a seat at the table, including on decision making. It needs to be considered as part of the fold, not as an afterthought.

The answer to the question is that adoption is highly situational—it depends on the technology and the linkage into the clinical community. A new piece of technology is normally picked up by clinicians. If a national organisation is involved, technology has a better than average chance of being adopted, but governance of the adoption of new technology is, by default, at the board level. If a decision is made to adopt something nationally, a layer of national governance will be put in place to oversee its deployment board by board. If a piece of technology passes that initial threshold—if it is picked up by people who are willing to sponsor it through the health service and push for it to become a national programme—things become a bit more straightforward.

There is a rough guide to lobbying in the NHS and getting products through the system.

I am sure that there is—or there should be.

You just gave us it.

I will not comment on the decision-making process, but we need to recognise that, although it is often easy to identify ways to save clinician time, translating that saved time into a cost saving is complicated. At the heart of the issue is the ability to take a clinician time saving and translate it into a better balance between health and social care that achieves a shift away from hospital, residential or locality-based care towards care in people’s homes, whereby people take more responsibility for their own healthcare and start to self-diagnose, self-treat and engage a little more in their care.

I am grateful for that. Committee members are all too aware of pharma companies’ efforts to lobby MSPs to exert such influence as we have on the Government in respect of its dealings with the Scottish Medicines Consortium and the licensing of drugs. Tech in the health service is commodity based—it is about selling goods to the health service.

Last year, the Parliament passed the Lobbying (Scotland) Act 2016, which will tighten up the rules on lobbying parliamentarians. How pervasive is lobbying from tech companies that are trying to sell their equipment to the NHS, and how effective is that lobbying?

Andy Robertson talked about the situational aspect of adoption. Where do we need to tighten up the rules in that regard?

Before I respond to your second point, I want to respond briefly to your first. It is about adoption and spread. Your example is about adoption; the issue is spread. To go back to Andy Robertson’s point, as long as that happens board by board, it will not be easy.

A once-for-Scotland approach would be a great step forward. If NHS Greater Glasgow and Clyde, which is the biggest health board in Europe, decides that technology A saves it a lot of money, why do the other 13 boards get to say, “We’re not interested”? That happens; it is the sort of thing that we get all the time. A once-for-Scotland approach—

It might be that NHS Greater Glasgow and Clyde is wrong.

It might be, but it will have evidence to back up its decision.

The current approach leads to siloisation. We are a tiny country. The NHS in Scotland looks after a population that is smaller than that of Yorkshire, and the current approach is not optimal, at least in terms of the uptake of new technology.

A big global company with a big budget can afford to lobby. One of the things that drive me is the Scottish economy, and Scottish companies are nearly all small companies and cannot afford lobbyists. They develop stuff and work with clinicians, and they do what they can to spread the word about what they are doing. I agree that hard lobbying by big pharma—we have big pharma members—can be counterproductive; sometimes big pharma deserves that.

Most Scottish companies are trying to develop a home market. If, when their salesmen go to the United States and are asked how many of their products they sell in their home market, the answer is “none”, the people in the US say, “Well, why should we buy it?” Most life sciences companies in Scotland are small or medium sized and do not lobby, because they cannot afford to. Rather, they work with clinicians to try to get the message across.

Professor Thuemmler, you talked about how essential connectivity will be in future if we are to treat more and more people away from traditional clinical settings. Concerns have been raised about security and privacy when it comes to sharing the electronic patient record. In your submission, you referred to

“Bad press related to unauthorised data dissemination, for example the case of the Royal Free in London which did pass on rich patient data to Deep Mind”.

PA Consulting received some negative press a couple of years ago regarding the uploading of data sets on to a Google tool, and potentially uploading patient data to offshore servers—I know that you maintain that you safeguarded that data appropriately.

People have concerns about privacy and security. You said:

“Central databases are susceptible to malignant attacks such as ransom attacks”.

You also said

“A comprehensive merger of all existing information into one centralised data base will be almost impossible.”

You described a tendency towards

“Uncritical and uninformed procurement with excessive spending on technology consultants”.

It seems that there is a lot that we are asking the NHS to get its head round—we are almost asking it to be in the vanguard of digital security. Do we have the staff to do that? Are we training people appropriately? Are we always going to be running to catch up?

Thank you for the question. We all know that there are issues to do with security—I need only remind you about the WannaCry attack. Of course, these are the risks and issues that go with centralised databases.

If we are talking about the electronic health record, the question is this: what do we have in mind? What are we looking at? The future is not the electronic health record, because we still have and will always have—even more so in future—distributed databases. They are growing everywhere like mushrooms—at the different NHS trusts, at GP practices, at dentists, at pharmacies and at physiotherapists. The problem is that we will always have distributed databases rather than a database that sits in one computer. That is not so bad, actually, because it gives a little bit more protection. Imagine if all that data were in one supercomputer. Even if that machine were mirrored into different locations, if it came under attack, it would be a huge problem. You do not necessarily want that. That is why we will see more and more distributed healthcare and, consequently, more distributed databases, and that is why we need modern communication strategies. That is extremely important. I cannot stress enough the importance of the developments around those new technologies—5G and so on.

In answer to your question about how many staff and how much effort and so on we need, I am not telling you anything new when I say that the NHS is a 70-year-old organisation that works in almost the same way that it worked back in the 1940s. Of course we need to think about new strategies for managing it. We have to look into how the big technology companies, such as Apple, do these things. Big organisations such as Apple and the pharmaceutical companies are basically going into the health market—industrie fordert so. Those organisations do not want to sell technology devices; they want to provide services in the future. We have to get our head around the fact that in the future many services will be provided by third parties and integrated in organisations such as the NHS. Therefore we need a new strategy and a new structure—it is inevitable.

I agree with Professor Thuemmler that the electronic patient record needs to be distributed; that is precisely the policy that we have been pursuing for some years. There is currently no one big central database for the health service. The WannaCry attack—which I came to the committee to explain the details behind—had nothing to do with databases and how data was distributed.

We have been pursuing a policy for some years now on these technologies, but it is very difficult for us to pursue the things that 5G will bring to bear when some parts of the country do not have 3G and some parts do not have fibre to the cabinet. As we try to keep up, we have to consider that to some extent there is a least-common denominator with the NHS.

With regard to the companies in other countries that are investing, we put 2 per cent of our NHS revenue into IT, but the US, where Apple and some of the bigger companies are, is at 6 per cent and above. In general, we are struggling to keep the lights on with the complexity that we already have. Innovation brings another layer that will need to be funded and supported from a change management point of view.

I am happy to explain what we have done in terms of the architecture of the systems in Scotland. We have not pursued the Big Brother approach of having a big centralised database. We are trying to move things to the cloud and adopt the new technologies, but it is complex and is going to take us time.

I saw Professor Thuemmler smile wryly when Andy Robertson said that the WannaCry attack was not a database issue.

It is true that the problem was that the Microsoft files were not updated, because the update patches had not been loaded. It was a database problem, although not one caused by a technical issue; it was caused by human error because someone had not updated.

I agree with the point that Andy Robertson made about spending on IT, although the absolute figures that the NHS spends on IT are quite significant. Where I struggle to agree is when he says that we cannot think about 5G when some parts of Scotland do not even have 3G. That would mean that we would always live in the past, and Scotland could never evolve to top technology simply because it does not have 3G in some areas. I would dispute that, because we need to play in that upper league in order to give our technology SMEs a chance. They cannot develop if we do not have the infrastructure. It is not necessarily an NHS issue—the problem lies in digital. We put a very strong emphasis on health, but we also need to talk about digital health. Where is our infrastructure? How can we convince the telecoms operators to provide technologies such as low-power wide area networks? They have that in England but we do not—why is that? In a way, that holds us back.

12:00  

Mr Robertson, do you think that spending only 2 per cent of revenue on IT is inefficient? Does that have to increase?

It inevitably needs to increase. The strategy for the digital transformation of the health service is under development right now—it is due in December. We are at the stage at which you have to invest more in IT to get returns in your business. That is not to say that the NHS has to spend more, but I think that we have to spend more on technology and innovation in order to fund the service transformation that has to take place.

I am interested in the adoption of technology in the Scottish NHS compared with its adoption in the global marketplace, because technology is never developed just for the Scottish market. With that in mind, we have developed a digital health and care institute in Scotland that was specifically designed to enable the testing of new technology followed by its adoption by the Scottish NHS. Do panel members have any thoughts about whether that has been productive or whether there something is else that it should be doing? Should it be working differently?

I will answer the last question first. We have been tracking the work of all the innovation centres over the past six years. Three of them are in the life sciences area, including the DHI. We talked to our members in digital health, one of which—Sitekit—is based on Skye. Campbell Grant, its owner, was part of the DHI board at the beginning. I will speak carefully because I know that I am on the record, but let us just say that the innovation centres have not delivered the economic benefits that the Scottish Government wanted them to deliver five years ago. There are reasons for that, which I can go into in detail.

The Scottish economy is another aspect, along with Mr Whittle’s point about comparison with other healthcare systems. Some of you will know that new mothers get a post-natal document called the red book. About three years ago, Sitekit, which is based on Skye and has an Edinburgh office, developed an e-red book and tried to sell it to NHS Scotland. The lead clinician loved it but procurement was an issue.

Campbell Grant is now selling that e-red book very successfully to English health trusts. They seem to have managed to get to a place where they can take on such innovations, and Campbell has now opened an office in London with a lot of software engineers. He is a proud Scot; he comes from Skye and I do not think that he is going to move his company to London soon, but—as our submission says—if we do not crack the issue within the next few years I do not think that we will have a digital health sector left in Scotland. It will go where the market is.

Maybe you could write to us to follow up the issue of why those innovation centres have not delivered.

I am happy to do that.

Does anyone else want to come in on this issue?

We have dealings with the DHI, the basic idea of which is good. I also want to be careful here. At the university level, we are involved in global 5G research. I am the convener of the health vertical at the Institute of Electrical and Electronics Engineers, which is a worldwide engineering association with more than a million members. I am also the convener of the health vertical at the 5G Infrastructure Public Private Partnership, which is a European initiative. We are linked into that, but the contributions so far to any 5G work at Napier is zero—zero from the Scottish Government, and zero from the DHI. I know that Strathclyde is also struggling.

As I said, the money that goes from the English Government to English universities looks completely different. We are talking about a first wave of double-digit figures in the millions, with the prospect of hundreds of millions over the next year being distributed to three universities. In Scotland, the investment is zero. I hope the situation will change, but that is where we stand.

I want to pick up on a point that Patricia Connolly made earlier. It sums up some of the discussion that we have had today about how, although we can procure a lot of this new technology, getting staff and clinicians on the ground to use it can sometimes be challenging, even if we adopt a once-for-Scotland approach. If we have so many local variations, even within health boards—some surgeons operate in one way and some operate in another even within the same department—how do we get clinicians to accept and adopt new technology and use it in their practice for the benefit of the health service and their patients?

Business change is a real issue and the NHS needs to address that. We have been doing some work with John Jeans, who advises the Prime Minister’s office on medical technology and chairs the DHI. He is very medtech savvy and has been around the industry for many years. We have been looking at some of the things that are coming up.

People are busy in the NHS. When someone wants to save time by putting in more monitoring that patients can use for themselves in the community, there is really nobody with the expertise to do that. I would create a team in Scotland to fund the universities and work with them to bring on their companies and technologies. It would analyse the situation and spend some time and money on changing, for example, management at home or diabetes chronic care.

We need to send in a business change team as well as the clinical team. When something is implemented well in a small community, it can be rolled out and mandated as the way to do things, once it has been proved that cost savings have been made in the area.

I am sure that, like me, Christoph Thuemmler and many others have talked about this many times. How do we get over the barrier? It will mean taking a different type of look. I would also get providers—the Apples and Googles and so on—involved. There might be some incentive for them, or some funding could come from them. They could make money in lots of different ways, such as from adverts rather than from selling services directly.

If people are happy using social media and different types of monitoring to interact with some of the big providers we should not be afraid to start thinking outside the box about how we make savings.

It is also important to understand that certain requirements have to be satisfied. We must not underestimate how important it is for the end users to be part of the development process. They have to be on the ground and invested in the innovation as it moves forward. That means that you have an invested stakeholder who wants the innovation to be a success.

You then have key opinion leaders who can take innovation and roll it out to their colleagues. They can underpin all the—

I am sorry to interrupt you, Elaine, but you are using a lot of jargon—“key stakeholders”, “end users” and so on. Could you use plain English, please?

Apologies. People who are going to use the technology need to know why it is useful for them. What will it do for them? What improvements will it make for them?

If they are involved in the process of developing that new technology, rather than having a solution imposed on them, they will be much more likely to be invested in using it.

Are you talking about clinicians or patients?

For this particular question, I am talking about clinicians, who will see a benefit from it.

How do we do it, then? I suppose that the committee is looking for some answers.

We talked earlier about there being lots of people in the innovation landscape who can brings lots of different skills to bear. It is important to realise that the NHS also has a significant role to play in that and should be part of a development team. The technology in industry and SMEs is part of the jigsaw puzzle, but the clinicians in the NHS, working from the inside out, also have a role to play in showing what will be required in infrastructure, training, how technology will fit with current practice, and any changes to care pathways. If clinicians are in at the beginning, the technology will develop in a way that is helpful for the people who are going to use it.

The people who access the services also need to be at the heart of the process, so that we build solutions that address real rather than perceived needs. That is called co-design: it is an approach that understands people’s needs and involves them in creating services, rather than build something that no one is going to use. We have a great example of that in our project called our GP. We have collaborated with more than 1,000 citizens and practice staff in creating three innovative GP digital services, which are there for potential implementation.

Thinking about adoption, we need to consider the awareness of digital health and care among the public and ask what people know about it. In England, where they have made access to GP digital services pervasive, there is still very low take-up, because most people do not know that those services exist. We must consider marketing and what will happen to raise public awareness and change the way in which people think about how they access the NHS.

We must also consider what we will do about the digital skills that people need to access services. The fundamental statistic is that a third of people with long-term conditions do not use the internet. How will we bring them on board, and how will we do that in a way that does not increase or exacerbate health inequalities?

We can consider structures, clinicians and the NHS, but until we involve and consider people, we will not solve the problem.

I agree with everything that Zahid Deen just said. We have started to pull out some points from Clare Haughey’s question and we have come to the point that Patricia Connolly made earlier. The technology that we need to deliver better health and social care is becoming increasingly commoditised and as a result is becoming easier to buy. That has moved the focus on to the other things that we have been talking about, such as decision making, technology selection and work to develop and implement the technology and deliver the business change around it.

One of the things that we see most commonly is that the skills, capability and capacity to do that work are not readily available in the NHS and other health and social care organisations. For me, the key is, first, to ensure that those skills and capabilities are made available, so that we can do the work to select and implement the technology, and secondly, to build on that on an on-going basis, so that health and social care organisations can take responsibility for delivering technology themselves. At the moment, that is something that does not happen as much as it should.

You make a very important point. It is clear that the NHS as such does not have many of the skills that are needed to come up with the technologies that we are talking about and envisaging. We need to somehow build those collaborations with the skills that we have in Scotland. We have excellent universities with departments that have skills that could be more than useful to development and implementation but we are not making enough use of those skills and resources that we have. It is important that we bring together the resources and skills that we have in Scotland to manage the processes.

I want to pick up on Ms Haughey’s question and I am afraid that I am going to use a bit of jargon. There are two barriers, one of which is called clinician autonomy: the doctor can take the decisions that she or he thinks are the right ones for the patient, no matter what. You might say, “This new way of doing it is much better and it costs half as much”, but the doctor might say, “That doesn’t matter. This way works, I know it works and I am not going to change my mind.” That is not an insurmountable barrier, but you have to know that it is there in order to work out how to get past it.

Another barrier is service redesign. Many new technologies and innovations need the whole process to be redesigned. Christoph Thuemmler said that we need expertise in taking on innovative systems, but I would go further. The previous chief executive of NHS Scotland said to me, “This is like trying to redesign and rebuild an aircraft while it is flying.” Doing the service redesign while the service is still helping patients is a very tough job.

However, I see well why you are looking for solutions. One idea with which we have toyed is that boards should be given, dare I say it, an aspiration—I will not use the word “target”. Somehow or other, the adoption and spread of innovation should be part of what boards are expected to do and, if they do not do it, questions should be asked. At the moment, that does not really happen.

12:15  

I will come back to that point in a minute.

I will echo what Zahid Deen said and talk about the users. If we look at the adoption of technology for self-monitoring, we find that when we put such technology in patients’ hands it is well received.

In our submission, we mentioned the piloting of NHS Florence. All that somebody needs to do to be monitored by the Florence app is to be able to text and answer some questions or take a fairly simple measurement on an instrument. Overwhelmingly, the patients really like the system, whether they are monitoring diabetes, blood pressure or heart failure. We have also tested it a little bit for wound care. However, it is becoming difficult to disseminate the app because it pushes the clinicians into a different way of working. They need to decide who will look at the Florence results and who will talk to the patient if they need to talk to a clinician.

There are barriers for patients. One is that we are not providing them with access to such technologies to find out how they can improve—and how their mental wellbeing improves, too, when they feel that their chronic condition is being monitored.

I will ask about some of the cultural barriers to the use of such technology in the NHS. I was looking particularly at the attend anywhere pilot. I am a Highlands and Islands representative and it is key that we cut down on journeys to hospitals for routine out-patient appointments. We need to do that systematically. It will save us huge sums of money and save us flights. As a busy working mum, I know that it will enable people to be a lot more productive while they interact with the healthcare system. However, I am disappointed to see that only one patient was enrolled in the pilot in six months.

The technology is not new at all and it is not difficult to use. The barriers must be cultural. There must be barriers among the patient group, who expect to go to see a doctor face to face, and barriers among the doctors, who like to have patients in front of them. The savings and improvement in service are obvious and the technology is not even new, so if we cannot get people to adopt new technology for the attend anywhere pilot, how will we get them to do that for anything?

I am familiar with the attend anywhere pilot. It has not been that bad. I think that the example that you got from one of the submissions was a particular surgery where there was uptake of only one, but it has proved quite popular with clinicians.

It is helpful if we can identify technologies that become popular with the clinicians, who then have to amend their back-end way of working. That is the business change element that we spoke about. Clinicians see the attend anywhere platform as being helpful to them in the short and long term, especially in remote and rural locations, where such contact becomes quite critical. In fact, we have taken that technology and put it into secondary care now: GPs are using it to contact secondary care clinicians to help them with the assessment of patient results.

There is an inevitable march of technology when we put such measures in place. Admittedly, the attend anywhere platform is not advanced technology, but it is a big step forward for a GP who is trying to manage a broad base of patients. Some patients like it, but some like going to their GP, if that is the point that you are making about culture. However, we need to stick with such technologies and ensure that they are available and that we give patients choices as technology is adopted throughout the country. It would be wrong to give up on such innovations and put them on the back burner.

Maree Todd raises an interesting point. We should not just dump technology on the NHS, on clinicians or on other people. A lot of investment is needed in change management and the softer stuff—the cultural change that is required, the training and the time to understand the technology and how to use it properly. It is about changing processes and changing thinking. That investment is not taking place; it needs to happen across the spectrum. We are just putting money into the hardware and the software; we are not putting it into those softer elements, but the success lies in doing that. We have lots of innovation and technology, but it has not been rolled out and it is not being used.

We have taken evidence on NHS governance, which is another area that we are looking at, so we know that in the current climate, where budgets are declining, people have less time for training and for doing things like this. What we are hearing here ties in with the evidence that we have taken.

Just a word of warning on the systems that we are talking about here—telemedicine, basically. There is a problem, in that medicine is not only see, speak and hear. Medicine is touch, feel, and smell—everything. I can say from a physician’s perspective—indeed, a GP’s perspective—that if I can only see a patient I might miss out on a lot. I love patients to be close by so that I can assess them through touch, feel and so on. I can then make an assessment and go through a whole process so that I can really get a result.

However, there is progress on that front. We are talking about things such as the tactile internet, where you can remotely touch people. I am sure that more of these things will come. I make the point again that without communication technology, such things are not going to work. There are reasons why these technologies do not experience an explosive uptake, but I think that they will come. It will just take time. We also need to build on our digital infrastructure to enable them.

I was looking at the dictionary definition of “innovation”. It says, “a new method, idea, or product”. Innovation has a positive connotation, but some innovation might not be positive. For example, years ago, you would have to physically walk to the doctor to make an appointment. Now, you phone up. However, if you have to phone 96 times to try to get an appointment, as one person recently reported to me that they did, that is not necessarily a positive innovation.

I use that as an example to make the point: are we evaluating current practice adequately to assess whether innovation is needed to improve services or is just trying to patch a hole in the system?

I will talk about innovation in relation to medical devices. My information is that well over 40,000 different medical devices are in use every day by NHS Scotland. The Scottish health technologies group, which is the bit of the NHS that does the assessment—much as the SMC does for drugs—has probably assessed about 60 of those over the past five years, since it was set up. That is a very rough assessment but it is of the right order of magnitude.

You touched on assessment; the scale of that is an issue. The SHTG has developed a fast assessment method called the innovative medical technology overview process, which is a maximum 12-week programme. We like it very much, because SMEs find it easy to use and it gives them a fast response. Sometimes the most useful response is, “We will never buy that.” It is good that they know that quickly so that they do not waste money trying—

This is for devices—

Yes, it is for devices.

And where does it fit in with the Medicines and Healthcare products Regulatory Agency?

One aspect of the assessment is that you have to have an EU regulatory marking for your product. That is taken as given.

It is similar to the way in which the SMC acts on pharmaceutical products. The MHRA licenses the devices and then the SHTG—

And then the SHTG makes a decision on whether a device goes into the NHS. Is that how it works?

Yes. A company that tries to sell the NHS something that does not have a CE marking will not sell it. Everyone understands that.

For clarification, I note that the SHTG does not say whether a company can sell to the NHS or not. There was maybe a misunderstanding about that.

The NHS will never buy anything that does not have a CE marking or other regulatory approval. The assessment of whether an innovation will pay for itself and will deliver—the things that we are talking about round the table—is difficult because of the scale. Most of the 40,000-odd devices that have been sold to the NHS are in use, even some of the more innovative ones. However, the innovative medical technology overview process is a huge step in the right direction.

So we do not know whether devices will provide value for money or do what it says on the tin.

For most of them, that may be the case.

Maybe I can say a bit more, as somebody who is connected to an SME and works with other SMEs and bigger companies. Most companies put an enormous amount of effort into gathering evidence on the benefits of devices and doing calculations on the health costs. Papers on that are provided to the NHS by the companies, and most devices will not move to sale unless they can show such benefits.

I think that the problem arises when, whether they have those papers or not, every group in the NHS wants to pilot devices for itself. That is an exhausting process for staff and everybody else. However, it would be unfair to say that the medical devices industry does not put great efforts into providing information on the efficacy and costing of its devices.

We have seen costings with regard to how some devices impact on patients, and unfortunately they show very high costs as well.

Working with the NHS, we have created an innovative environment that lets clinicians and healthcare workers come to us with ideas for innovation. We have a responsibility to make sure that that goes on and that ideas can be developed into things that will be useful.

We have talked about very specific ideas that will work in one geographic area but not necessarily in a wider area. Part of what we do is a very full evaluation of proposed technologies before we determine whether they should be developed further. That brings in whether the idea is a good one, whether there is already a solution, whether the company is trying to solve a problem that has already been solved in other areas, what the intellectual property position is, and whether the technology is currently available. All of that will happen before we start to develop IP.

As things stand, we move forward with only approximately one in 10 of the innovations that come to us from the NHS. There is always a good reason or explanation as to why we will not move forward with an innovation. Sometimes it is just about putting people in contact with areas where development is already going on, because we do not want to reinvent the wheel. That brings me firmly back to the idea that, if there is a co-ordinated effort towards innovation, we can identify pockets, put people together and help them to work towards a solution, rather than having many different solutions in place throughout the country.

Can I clarify something? An innovation goes through that process, and then ultimately it has to go to each health board for analysis. After going through the process, it then has to go through another 14 processes.

Even if a company has SHTG endorsement or a big green tick from the innovative medical technology assessment, it still has to sell most products board by board. There are big strategic procurements that are done centrally, but—

Each board will review the papers and all that stuff, so there are another 14 rounds to go.

Yes. That is the spread issue.

Is that similar to the SMC process for pharmaceuticals? A company gets a central approval for use of a drug in NHS Scotland, and then each health board assesses it and decides whether there is a role for it within its area. That happens quite routinely within a certain time after the central pronouncement.

There is a similarity. As far as I know, the NHS would not take on a drug in Scotland unless it has been through the SMC process—unless it is a cheap generic or something like that.

The fundamental difference with the technology assistance is that it can get through without the central assessment.

Exactly—and there are so many of them.

I am sorry; we are running very short of time. I want to give everybody an opportunity to make one final comment. A number of points have been raised and the discussion has been very interesting. This is a very clichéd way to do it, but that is me: if witnesses want to get their tuppenceworth in to develop the future strategy, what is the key point that you want to put in? We will go round the table.

12:30  

I would ensure that the innovation pipeline from university through to the NHS is properly funded, as the university end, in particular, is neglected. With that funding, I would ensure that patient groups are brought in as real end users to help in the development and testing of products and incoming technologies.

We have pretty good strategies and we do not need another one. We need to make the ones that we have work. I support a one-liner that Andy Robertson drafted in the NSS submission to the committee:

“At the heart of the main failures”

of strategy

“has been the inability to translate the strategy, governance and relationships into consistent widespread delivery”.

That is at the core of everything that we have talked about. We have strategies most years, but seeing a change is what matters.

The systems and infrastructure are a sound foundation—I am not sure whether that has come through today. As I said earlier, if we truly want to be innovative and to change and transform the NHS’s services, we have to look at different methods of investment to bring new technologies into our environment. Governance and linkages to the academic world, and a different flow, with a recognised single funnel for innovations, can all be done on the back of the new strategy.

What do you mean by “different methods of investment”?

The e-health funds that are in place today are the 2 per cent of NHS revenue that goes to IT. If that cannot be bolstered, we will have to look at other ways to bring in investment to support the deployment of new technology. I am not sure whether that would count on reductions in cost in other parts of the health service that technology could support or whether it would be new investment from Government decisions, but we need that increased investment to be able to bring innovation to bear faster than it does today.

My message to leave you with is this: do not underestimate the innovative nature of the NHS and the talent and ability to innovate that is within it. Clear roles and responsibilities are important, as is an innovative environment to help to coordinate all the various bodies that can help innovation.

I echo what Patricia Connolly said about co-design being needed as part of the strategy, so that people and the third sector are involved in creating and designing solutions.

The previous strategy did not have an implementation plan, and that is why we have failed to see the progress that we want. We did not know who was to deliver what, or when it was to be delivered by. We still do not have any widespread national patient-facing service, not even for online booking of appointments or repeat prescriptions—that cannot continue.

We need coordination on innovation; we need a national innovation lead or someone who will take this issue strongly and help to coordinate all the partners who are involved.

Is leadership the key thing?

Absolutely.

That is a point that we did not get in, but we should have done. Time has beaten us.

I have been asked to clarify 5G PPP—it is the 5G Infrastructure Public Private Partnership, which is a European technology programme that is running between 2012 or 2013 and 2020.

We need to have another look at how the NHS R and D development funds are distributed. It does not make sense that each trust tries to develop its own things. Even if development is controlled by agencies on an NHS-only basis, we need to enhance the collaboration of the NHS with outside companies, such as SMEs and Scotland’s universities, as Patricia Connolly has said.

Protected time for NHS staff when they do trials is also important. You cannot ask a workforce that stands with its back to the wall to trial new things; the outcome will not be good. Nobody would do that.

In almost every instance, the technology that we need to deliver excellent health and social care in Scotland exists. Therefore, the challenge is to establish the right conditions to put it in place. That covers a lot of what we have discussed. It is about making sure that there is sufficient clinician and patient involvement in developing and deploying technology, strong top-down and, at times, directed leadership on how the technology should be deployed consistently across the system, and sufficient investment in business change to make deployment successful on the ground. We need to embrace modern technologies and the methods for deploying them, and we need to be proportionate about how we apply governance to the projects and programmes that are charged with bringing in technology.

A wider observation is that I am always concerned about talk of establishing a single place for innovation within an organisation or system, as that can prevent innovation from happening elsewhere.

I thank everyone for a very interesting discussion. Many of the points that you have raised will give us food for thought as we take this issue forward. If you have any more information for the committee, please do provide it subsequently.

The meeting will now go into private session.

12:36 Meeting continued in private until 12:53.