From : Dr Henry Potts & Amy McKeown
Subject : How organisational structures stand in the way of e-health

Healthcare sees great potential in information and communication technology (ICT): e-health and now m-health are touted as being able to deliver better services while saving money. Yet for technology to be able to deliver hoped for benefits, the organisational, managerial and financial structures have to be right. The much-documented problems with Connecting for Health, for example, relate as much to organisational issues as technological ones.

ICT can have a profound effect on healthcare because it is a disruptive technology, not simply doing familiar activities better, but doing them in a whole new way. But new ways may not fit existing structures, and existing structures may prevent the benefits of e-health being realised. To illustrate this, we explore as a case study the use of computerised cognitive behaviour therapy (cCBT) for treating mild depression and anxiety.

Anxiety and depression are major public health issues. Cognitive behaviour therapy (CBT) is a well-established and effective approach, but it is costly compared to drug treatments and the NHS is short of trained therapists. There is strong evidence that CBT can be successfully delivered via a computer and over the Web, and indeed NICE recommend cCBT. These automated systems teach the user about the principles of CBT and help them apply these principles to their own situation.

As with many conditions, early intervention is successful and cost-effective in anxiety and depression, and cCBT has repeatedly proved effective in a variety of sub-clinical, population settings, notably through work in Australia with the MoodGym tool. That is, cCBT can reduce levels of symptoms and prevent people from going on to develop more serious mental health difficulties.

Mental health problems are stigmatised. We know this stigma stops people from seeking help and seeking help early. Accessing an online resource is a way for individuals to seek help while avoiding having to admit their problems to a healthcare professional. Making cCBT available online is, thus, not only effective, but can also help reach a population who would otherwise go untreated.

The costs in cCBT are in development, which has included the costs of demonstrating effectiveness through randomised controlled trials. Actual running costs are small. Hosting a web server is cheap. Thus, the total cost per user falls as user numbers increase.

So, cCBT should stand as a classic example of e-health improving quality and cutting costs. It is effective, it can reach a broader population and marginal costs are small. Yet cCBT adoption has been slow in the UK. Why? We suggest two classes of problems: barriers to adoption and inappropriate financial models.

It proved difficult for commercial providers to market cCBT. Even after the time-consuming and expensive process of carrying out RCTs and getting NICE approval, the fractured nature of NHS procurement meant providers still had to market to each individual PCT. Obviously many providers have to market to individual PCTs, but novel technologies face greater difficulties.

In another context, one of us recently carried out research on the adoption of an electronic patient record system to support community-based clinics. Negotiations between the provider hospital trust and successive PCTs were found to be very different from each other. Each PCT asked different questions and had different concerns. Yet the populations being served were fairly similar; there was no clear reason why each PCT negotiation should be so different. If a particular issue, say network security, is important, then surely all the PCTs should have raised it. If the measures in the proposed service are adequate, then surely all the PCTs should be satisfied with them. Yet we found that issue dominated one set of negotiations but was barely mentioned in others.

This lack of consistency suggests that the PCTs do not know what questions to ask and do not have the ability to judge technology solutions. This will come as no surprise to those who have long argued there is insufficient e-health expertise at PCT level. That lack of expertise can slow down the adoption of new technology.

Plans to abolish PCTs and move to smaller clinical commissioning groups will only exacerbate this problem. With insufficient in-house expertise to advise on initial contracts and on deploying and running services, commissioning groups seem likely to look to consultancy companies ever more. That said, and returning to cCBT, commissioning groups may help overcome another barrier to adoption. In the past, it was PCTs who made the decision to buy cCBT, but that procurement decision was detached from the GPs who were expected to offer cCBT to patients. GPs are often unaware that their PCT has cCBT available. With GPs not engaged, PCT licences for patients to use cCBT systems go unused. Commissioning groups may better connect frontline staff with procurement decisions.

A central financial model for the NHS is that the money follows the patient, yet this does not fit with the disruptive nature of cCBT. The usual financial arrangement for cCBT in the NHS is that, presuming a PCT has bought the service, a patient can be referred to cCBT by their GP. As money follows the patient and clinical activity, each patient’s use of cCBT has to be tracked and, if only on a small scale, a funding decision stands before a patient gets access. But this works against some of the benefits of cCBT. It loses the value of cCBT in reaching a large population if a gatekeeper is put in the way. Instead of avoiding the stigma around mental health issues, we put the barrier back into the system.

Imagine an alternate approach. Imagine if the NHS centrally offered cCBT online to all-comers. Usage would be hugely increased. cCBT would be able to reach a wider population unwilling to go first to a healthcare professional. Because the marginal costs of cCBT are low, the total cost to the NHS of making cCBT more widely available would be comparatively small. This isn’t just a pipe dream. It is close to the approach taken by the Dutch government to e-mental health services. But back in the UK, central NHS Web services have long been under-resourced.

We have specific interests in cCBT, but this article is not intended as an argument specifically for cCBT. Rather, the point is that novel information and communication technologies do not necessarily fit existing structures and their benefits will be lost if this is not recognised.

Outside of healthcare, we have seen commercial sectors invent new business models in response to ICT innovation. So, Amazon makes money in a very different way to a high-street bookshop. Such changes were not straightforward: it has been a painful transition with many high-street bookshops closing. But although healthcare has some catching up to do, we can at least learn from these experiences.

These days, although uptake remains low, cCBT is an established approach. The new focus in research is on m-health, the use of mobile phones and related devices in healthcare. We can envisage mCBT, delivering CBT over a mobile phone, soon appearing alongside the many other m-health systems for which we have an evidence base: appointment reminders, smoking cessation, improving medication adherence, supporting self-management of long-term conditions, m-learning etc.

In the commercial world, the mobile sector has developed rapidly. New services have appeared, and alongside them, new business models. This world, of SMS re-sellers and short codes, is still alien to healthcare managers and clinicians. If m-health is to advance quicker than e-health, we need healthcare services that understand mobile and that are flexible enough to cope with new ways of working. The NHS needs to be able to develop and share expertise and infrastructure in m-health. Instead, disease specific silos, fragmented budgets and inexperienced commissioning groups threaten to keep technology adoption at a snail’s pace.

By Dr Henry Potts of the Centre for Health Informatics & Multiprofessional Education (CHIME) at University College London, and Amy McKeown of Xanthis, London. This article appears in the September/October 2011 edition of National Health Executive.