Customer experience - the missing piece for our health systems
Daniele Wiseman
Senior Consultant - Afiniti LLP Consultants | Passionate about Making Change Stick
I came across a very high level and frankly, far too superficial article from the BBC, written in September 2022. It asked if the NHS could learn from Germany’s health system. Interestingly, at the same time as a result of my job search, I been exploring the extent to which software and AI can help to improve the patient experience here in England (The devolved nations manage their own health services so the discussion below relates to England only) and the extent to which the challenges faced here are replicated in Europe and beyond.
This is how I approached this:
The problem statement which the government is always trying to solve is centred around and measured by financial viability and patient outcomes. The BBC article from 2022, compares mortality rates for UK and Germany and concludes:
The German system is better staffed and stocked than the UK, relative to the population. Analysis by Nuffield Trust shows in 2019 the UK had around nine nurses per 1,000 people, while in Germany there were about 14. The disparity in bed numbers was wider - with Germany's eight beds per 1,000 patients more than three times the UK figure….
Whilst this really resonated with me I read further and Dr Kristien Niemietz, whilst believing the German model could be a blueprint for reform here, she concludes:
Switching to a social health insurance system would not be a panacea.
Germany at that time (2019) was spending more per year as a share of GDP than the UK. Meanwhile
The World Health Organisation has predicted a global shortfall of 15 million healthcare workers by 2030. [1]
So, whatever the value of the social model Dr Niemietz is referring to, I’m not intending to evaluate all the challenges faced by the NHS and in Germany, or draw any conclusions. My intention is to take a quick look at both the UK and German health systems so that I can talk to you about the missing piece.
England
The problem statement for England, is that the NHS is struggling with a shortage of qualified staff, which is a global issue as mentioned above. But much of the frustrations for patients regarding the health service centre around perceived inefficiencies and a sense that money is not spent wisely by NHS England or the Trusts. While most industries have at least embarked on eradicating by now, a silo’d approach to their organisational model, many have not entirely succeeded and the 'federal' system for healthcare (Trusts) in the UK is facing the same challenges as their commercial counterparts.
NOTE - The impact of a silo’d system and inefficiencies arising out of funding challenges and a shortfall in resources did not prevent NHS staff stepping up to the challenge of a global pandemic and unprecedented demand on its services and its staff. Thank you NHS.
There is a missing piece, it sits on the back of what is being done to facilitate the different parts of the NHS to collaborate effectively and make the best use of its resources to improve the patient experience. As a patient I have experienced the best efforts of nurses and administrative staff going awry when they have to pass a patient through to another service. Administrative Efficiency can arise from inaccessibility of data but also the inefficiency of interactions relating to that data and is reflected in feedback from patients. To address the inaccessibility of data, in a fragmented system a significant investment is needed to deliver a back office that brings together different datasets.
Each Trust, group of Trusts and Integrated Care Systems (ICS) – made up of Integrated Care Boards (ICB) and Integrated Care Partnerships operate as independent financial and healthcare delivery functions. The challenges this presents both for efficiency and patient experience has been recognised by NHS England (merged with NHS Digital recently pursuing national initiatives, but not a portfolio management function and not prescribing the technology the Trusts should use.)
NHS England is to deliver a programme between now and 2027, to implement a Federated Data Platform (FDP) enabling the integration of Trusts data by implementing local instances of the Federated Data Platform in each Trust to enable the sharing of information and intended to solve the problem of the current fragmented data services.
Each NHS organisation with an instance of the NHS FDP will have the ability to connect and share information between them when it’s helpful and in relation to any personal information, where data protection law allows it. For example, to discharge a patient from hospital into a care setting.
FDP will help provide NHS staff (frontline clinicians, operational staff, and planners, including NHS England) with timely information and insight, promoting the efficient use of resources to support the delivery and planning of patient care. [2]
In their document ‘Integrating care - Next steps to building strong and effective integrated care systems across England’ the intent in driving change across the NHS is described as:
The use of digital and data to drive system working, connect health and care providers, improve outcomes and put the citizen at the heart of their own care. [3]
Notwithstanding the commitment and vision demonstrated in the funding of the FDP programme, recent discussions with providers about software and AI, have highlighted for me a need which has not been sufficiently articulated and addressed in the FDP programme and I believe it will be left to the individual Trusts. The integration of system data for both patient and operational purposes is not going to be enough, when the Trusts and NHS England will also be judged on how patients perceive the efficiency of data accessibility and their ability to navigate their patient experience - for patients, the integration needs to appear seamless.
The inaccessibility of patient records across different Trusts and groups of Trusts presents hurdles for staff and the potential for patients to fall through the net. In addition, failure to leverage more fully integrated patient data as a result of the federation of separate entities results in a perception from individual patients that an institution is failing as a single entity. This perception arises from their personal patient experience, the media, or friends or family members working within the system. It is also the result of the commercialisation of the latest retail technologies which has raised expectations from patients of a more ‘joined up’ experience.
Germany
The fragmented approach to NHS care and additional private healthcare available in England has been under much scrutiny in recent years and one of the health care systems which has been looked at as a potential model for changes here in England is Germany.
All of the German-speaking countries?enjoy a high level of health care. Infant mortality rates are much lower…and life expectancy is higher than in the United States.
Probably the earliest national insurance system the Krankenkasse? (“sickness fund”) offers Germans care at the point of access (public insurance) about 88% of the population on production of a health insurance card. “An employee’s public insurance also covers family members. The unemployed, retirees, or those on welfare get government-paid coverage. Moreover, the German government has almost nothing to do with the delivery of healthcare.”
The more affluent can opt out of the system, and private coverage is available for people who can afford to avoid the basic care of public facilities. (11%) [4]
Only those with private insurance will need to pay and claim back from insurers although some publicly insured may have to pay for specific treatments.
Technology
Interestingly Germany and other European countries seem to be ahead of England’s FDP programme, with both Electronic Health Records (EHR) and Personal Health Records (PHR) universally available with the patients’ consent.
The Appointment Service and Supply Act (TSVG), adopted on 14th March 2019, requires the German statutory health insurance funds to provide policyholders with electronic health records from 1st January 2021 onwards.
They help, for example, to avoid duplicate examinations since a patient’s medical information is available in a well-documented and well-organised form. This improves the quality and cost-effectiveness of medical care as well as patient safety. However, there are potential disadvantages too. Valid security concerns have been raised following the discovery of certain vulnerable points in personal health records (PHRs) that are already on the market.”
Results obtained in countries such as Israel and Denmark 5 (5,6,) which have long been integrating electronic health records into their healthcare system.
indicate there are great benefits in the sharing of patient information like this. I’m assuming the initiation of the FDP programme for England has arisen out of such comparisons.
The patient has data sovereignty for all personal health records, and decides who is allowed to see which information. Healthcare service providers provide patient data using existing practice management software; the patient can, for example, add data recorded by fitness trackers, and the health insurance company can upload billing data at the request of the patient. (7) [5]
Patient health records (as opposed to EHR records), represent another demand on data services and when commercialized as in Germany PHRs there is a concern this could result in data leaks or the proliferation of different systems making data access difficult for medical professionals and administrative services.?
In Germany, patients can choose between different PHR systems such as "TK-Safe", "Vivy" or "AOK-Gesundheitsnetzwerk.
The point. Patients access to healthcare shouldn’t be impeded by time spent navigating systems. Regardless of the choice of EHR or PHR, accessing the right medical history will depend on the patients consent (as with the NHS App and current GDPR requirements in England) and data privacy has to be guaranteed to obtain a patient commitment. In England, many Trusts send emails with passwords to guarantee security and a biometric system guards the data in the NHS app. Access to this data on a shared or federated platform will require trusted security which is easily navigable across the whole demographic.
Leveraging the latest technology to ensure data security and patient satisfaction is welcomed by younger members of the medical profession who have grown up with a powerful computer in their pocket, using the Cloud and an expectation that self-service will usually be an option. In response to headlines about a shortage of doctors in Germany (reflected across Europe) medical student Laurin Gerdes is quoted saying:
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What is also needed is more mindful digitalisation of processes, by, for instance, embracing artificial intelligence (AI) solutions. [6]
Patients
Patients (customers) want to experience their customer journey orchestrated so that they are seamlessly navigated through whatever diagnostic process or treatment they find themselves needing. Although it isn’t important for them to know how the integration is taking place, or how the federation is working, they must be satisfied with their interaction with the NHS, not frustrated by its inefficiency. Patients want to book appointments, see which consultant and hospital they are being referred to and obtain test results without calling multiple hospitals with reference numbers and wasting time on hold, all of which create dissatisfaction, even if the collaboration between different hospitals has actually, improved.
Trusts are very different in their approach to technology. Decisions are made by a Board and senior clinicians and their pre-disposition to advances in technology, along with their understanding of the need to comply with GDPR can mean that some Trusts are piloting AI while others are filling out forms on pen or paper (slight exaggeration!).
The patient experience, at the heart of the Healthcare sector, has not yet been sufficiently foregrounded other than through surveys and where care is managed efficiently within any of the 42 ICS Systems across the UK.
The British Social Attitudes (BSA) survey?is a ‘gold standard’ nationally representative survey that uses a robust methodology to explore public views on a wide range of issues. [7]
Thankfully, the Integrated Care Systems guidance acknowledges the opportunity for Trusts to collaborate and share best practice in this space. It comments on
provider organisations being asked to step forward in formal collaborative arrangements that allow them to operate at scale;
So whilst NHS England will not be prescriptive about software such as CCaaS (Contact Centre as a Service) there is clearly an opportunity to interest Trusts in delivering an orchestrated customer experience and to potentially have more consistent ways of working in place when the FDP is fully implemented.
This integration of the shared data, for patients and for operational services, management reporting etc. can benefit from a user interface/overlay which successfully manages or reflects the patient journey. This applies to many other countries with complex health systems too. (There are over 40 Trusts involved in the pilot for FDP and the learning from these pilots may help to build a value proposition for a more cohesive synergy of integrated data and customer experience, and at least an understanding of the need for the FDP not to be a purely back office venture.)
All these developments to bring greater efficiency to the NHS, can benefit greatly from improved software integration and security initiatives. The patient may fear some of these developments and be hesitant about the sharing of data which is why their customer journey should be curated and managed to offer an easy access point and seamless interaction with as many different hospitals or Trusts they need to access without the frustration currently experienced.
Maintaining a digital thread through visits to different Trusts and in accessing data from different systems, can be as straightforward as implementing a CCaaS. There are many benefits in a patient being able to reply upon an orchestrated customer (patient) journey, speaking to an agent with a clear understanding of process and issue management, who can provide support tailored to each patient’s needs and across multiple organizational boundaries. The NHS needs a CCaaS to extract value for patients from its FDP. This is the missing piece.
It can be introduced in a federated way, as individual Trusts accept the need to keep patients informed, or it could be introduced by ICS, to provide a ‘one stop shop’ for patient needs.
It is clear that the 115 countries in EMEA operating public, private and mixed method health systems may have learnings for us here in the UK. In addition,
The European Commission issued recommendations that will facilitate access to health data across borders in full compliance with the General Data Protection Regulation. The recommendations propose that EU Member States extend this possibility to patient summaries, ePrescriptions, laboratory tests, medical discharge reports and images and imaging reports, including the 'Integrating the Healthcare Enterprise' profiles (IHE profiles), which were established in 2015 and whose specifications are also applied to the digital eHealth Service Infrastructure (eHDSI).
Wow! Unpacking this with the knowledge that the UK is no longer a member of the EU, I still see the sharing and the instant access to patient data as a value for those injured on holiday and those affected by natural disasters or terrorist attacks as being of great value.
Patients as Customers
Notwithstanding the exciting developments in data sharing and data integration, and with this being an objective for many governments, there is the missing piece The future of digital technologies and AI is reflected in visions delivered through consumers, the commercialisation of new technology bringing acceptance of new technologies and then enabling the same capabilities to be developed and applied across other sectors. Consumers and patients will have expectations for the interactions they have in every part of their life. And we will need to meet their expectations by reflecting that ease of use in the interactions they have with the administrative and executive parts of society. The consequences of not applying this layer of ‘user interface’ is the perception that an organisation is failing to provide the level of service patients expect and the investment in managing patient data and operational data for the NHS, will simply result in the reporting of national measures. The patient needs to receive a more joined up experience, which our digital and AI technologies can now deliver with greater agility and greater security – this holistic management of their patient experience is what the patient wants to be reflected in their patient journey.
The Rt Hon Sajid Javid and Rt Hon Michael Gove published a document on behalf of the government in 2022 outlining their plan to deliver:
A more joined up approach will bring public health and NHS services much closer together to maximise the chances for health gain at every opportunity.
The document, ‘Joining up care for people, places and populations’ articulates the plan to focus on joining up services underpinned by a ￡330m programme with Palantir, Accenture and other to implement the FDP. It is intended to join up the fragmented services emerging from the pandemic. The paper says:
Citizens with access to more information will be more empowered to make decisions about their care and have more choices about where and how they access care. Working with local places and ICSs, we will remove unnecessary barriers so places will be empowered to do what is best for their citizens.
Section 1.2 of this document articulates challenges which will be addressed, and it commits to greater cooperations between health and social care. The challenge will be, with the restructuring and improvements being made at the ‘place’ level, how the patient will be served especially during the transition. Exciting but challenging times, and loads to read on the internet, if you’ve the time! I have an insight, from my interaction with the NHS in recent years that although they have become quite good at communicating change, there is still a need for software accessing the newly integrated platfom to provide a curated customer journey (across health and social care) and avoid some of the experiences described in Section 1.2 of this document.
Section 1.2 (verbatim)
This is, however, far from the norm everywhere, and as the challenges of demography, the possibilities of technology and the expectations of citizens all grow, we will need to move beyond a health and care system where organisations and services operate in a compartmentalised way. People have a range of needs which cannot always be addressed neatly by one organisation or another. There is a greater need for holistic care that fits around these needs; our services, processes, institutions, and policies need to catch up. We know that, currently the public often experiences:
The engagement of and communication with the end-user, patient, customer, client or consumer, is the key to success in the implementation of all new systems and processes, in any language.
No AI involved in the authoring of this document, just a few thoughts on recent reading! Long read and bringing together several strands of thinking - please do let me know if you have anything to contribute in the comments.
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5?"#SmartHealthSystems Digitalisierungsstrategien im internationalen Vergleich Auszug Israel“, Bertelsmann Stiftung, November 2018 https://www.bertelsmann-stiftung.de/en/publications/publication/did/smarthealthsystems-auszug-israel/
6?"#SmartHealthSystemsDigitalisierungsstrategien im internationalen Vergleich Auszug D?nemark“, Bertelsmann Stiftung, November 2018 https://www.bertelsmann-stiftung.de/fileadmin/files/Projekte/Der_digitale_Patient/VV_SHS-Studie_Da__nemark.pdf
7?"Elektronische Gesundheitsakte: Erste Erfahrungen im Test und im Betrieb“, Deutsches ?rzteblatt, 24th October 2018 https://www.aerzteblatt.de/nachrichten/98723/Elektronische-Gesundheitsakte-Erste-Erfahrungen-im-Test-und-im-Betrieb
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