The Slow Journey to A Flexible Health Service

Innovation is coming but who will pay for it?

In the most recent episode of Movers and Shakers, the Dutch neurologist Bas Bloem painted a picture of the future of Parkinson’s care. It’s a future where patients book an appointment with the consultant when they are ready, not on a rigid timetable, where they have access to advice from a wide range of experts on everything from diet to exercise, and where smart devices can give doctors an up to date readout of your current condition without a face to face appointment.

This more flexible approach, cutting down on visits to hospitals which are time-consuming and costly for both patients and doctors, is widely seen as an important way for the NHS to modernise treatment, not just for Parkinson’s but for a wide range of conditions.

I say bring it on. As well as Parkinson’s I have an ocular malignant melanoma which has meant I have been a regular visitor to an oncology clinic at Moorfields Eye Hospital for twenty years. In my treatment for both conditions, there are a few signs of a desire to be more flexible but change continues to come at a snail’s pace in the NHS.

Every Moorfields appointment ends with the admin staff scheduling your next visit - four months away for most of my time with a condition that needs constant monitoring, but happily now extended to eight months apart. What this used to mean was that at 0930 one Thursday I would arrive to find that 35 other patients had been assigned appointments at the clinic and we would all wait between 2 and 5 hours to go through a number of tests before finally seeing the consultant

But this week the hospital got in touch to say my appointment next April had been cancelled. In fact, Moorfields contacted me four times - two emails, two texts - to tell me this news, with no explanation.

Until, that is, I logged on to the DrDoctor platform linked to in two of the messages and found a lengthy letter. It explained that the hospital had begun “making changes to how we manage our follow-up appointment process to make clinic bookings more efficient and to ensure all patients are seen when they need to be.” Now, instead of getting the next appointment as you leave the clinic, the patient will be contacted between four and six weeks before they are due a follow-up. The theory is that this will mean fewer patents will want to change an appointment or simply fail to turn up.

It is a long way from the self-scheduling advocated by Bas Bloem - and with cancer that would be far too risky - but it promises more flexibility than when a whole clinic is automatically booked for another visit months ahead.

When it comes to Parkinson’s, my appointments with my excellent consultant are still scheduled nine months ahead as I leave the clinic. But an experiment in Devon and Cornwall is demonstrating what a more flexible model could look like. It is called Home Based Care and its mission statement declares that the old system of rigid face-to-face appointments has had its day:”This model of care whereby patients visit their specialist clinician for a time-locked review, regardless of need, is unsustainable and outdated for a Parkinson’s Service.”

Instead around 200 “Parkies” have been given easy access via telephone or video call to a range of clinical staff - it might be the neurologist, it could be a Parkinson’s nurse - when they feel they need help, rather than on a fixed timetable. As a safety net they are asked to wear a PKG smartwatch for a few days which gives the medical staff a readout of their symptoms, and can trigger an intervention if there is an unreported decline in their health.

There is now a new initiative to learn the lessons. from Home Based Care and roll the service out more widely with more advanced technology. - full disclosure, I am on a Patient Involvement Committee for this new project. But right now the future of the original service looks uncertain.

Come next April Home Based Care will need new funding and a hard-pressed Devon Integrated Care Board (ICB), with many other urgent calls on its cash, will have to decide whether it provides value for money. The team behind it will argue that it is paying off in all sorts of ways, for instance cutting the number of people with Parkinson’s ending up in hospital after falls. But the ICB may look at the cost of the PKG smartwatches and ask why so much should be spent on tech for people with Parkinson’s. There is also the cost of training staff in radically new ways of working, albeit ones which should make them ready for the digital future, such as how to handle data from smart devices.

Innovation in the NHS can be a slow painful business - one small healthtech business told me recently that it had taken two years to get the go-ahead for a contract worth just £7500. But it would be a tragedy if a scheme like Home Based Care, which is. totally aligned with the NHS strategy to cut the daily traffic to hospital outpatient appointments, was allowed to founder.