EFFICIENCY
Dr Henry Potts of the Centre for Health Informatics & Multiprofessional Education (CHIME) at University College London, and Amy McKeown of Xanthis, London, dig deep into ICT efficiency issues in healthcare.
H
ealthcare sees great potential in infor- mation and communication technol-
ogy (ICT): e-health and now m-health are touted as being able to deliver better ser- vices while saving money. Yet for technol- ogy to be able to deliver hoped for benefits, the organisational, managerial and finan- cial 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 health- care 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 il- lustrate this, we explore as a case study the use of computerised cognitive behaviour therapy (cCBT) for treating mild depres- sion and anxiety.
Web-based therapy
Anxiety and depression are major public health issues. Cognitive behaviour ther- apy (CBT) is a well-established and effec- tive 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 princi- ples 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. Ac- cessing an online resource is a way for in- dividuals to seek help while avoiding hav- ing to admit their problems to a healthcare professional. Making cCBT available online
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is, thus, not only effective, but can also help reach a population who would otherwise go untreated.
Fragmentation
The costs in cCBT are in development, which has included the costs of demon- strating 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 prob- lems: barriers to adoption and inappropri- ate financial models.
It proved difficult for commercial provid- ers to market cCBT. Even after the time- consuming and expensive process of carry- ing out RCTs and getting NICE approval, the fractured nature of NHS procurement meant providers still had to market to each individual PCT. Obviously many provid- ers have to market to individual PCTs, but novel technologies face greater difficulties.
Lack of consistency
In another context, one of us recently car- ried out research on the adoption of an electronic patient record system to sup- port community-based clinics. Negotia- tions 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 con- cerns. Yet the populations being served were fairly similar; there was no clear rea- son 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 men- tioned 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 tech- nology solutions. This will come as no sur- prise 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 con- tracts and on deploying and running ser- vices, commissioning groups seem likely to look to consultancy companies ever more. That said, and returning to cCBT, commis- sioning 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.
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