Is the English government's enthusiasm for health ‘apps’ and ‘data transparency’, for the benefit of patients – or markets? Or even a trojan horse for a pay-NHS?
This month Jeremy Hunt MP gave what he told us was his “most important speech as health secretary".
The speech – delivered at the Kings Fund, and entitled “"Making healthcare more human-centred not system-centred" - fulfilled its function of generating blockbuster headlines, mostly focused on the ‘7 day NHS’ and consultant pay.
But there's been relatively little comment on his new 'big idea' - a patient-centric transformation in a post-bureaucratic age, which he calls "intelligent transparency".
Hunt was keen to tell NHS staff that the beneficiaries of this 'intelligent transparency' are NHS patients and staff. But who else stands to profit?
"The future is here", Hunt told us in his speech. "40,000 health apps now on iTunes, these innovations are coming sooner than most people realise."
But how useful are these apps? How safe are they? Will they be effectively regulated? Who will get their hands on the data they generate? Who will be providing them?
You will perhaps remember Ali Parsa, who promised us his private firm Circle could run a full service NHS hospital at Hinchingbrooke. It collapsed after corner-cutting on staff led to severe patient care failings. Parsa’s new initiative is the 'Babylon app', which promises to put "a doctor in your pocket" – for a fee. The energetic ex-Goldman Sachs banker has managed to get this new ‘health service’ accredited by the official NHS regulator, the Care Quality Commission – as have others, such as Dr Now (which seems to be targeted at employers).
Are apps preferable to healthcare professionals because they provide "better care" - or because they are easier to commodify and outsource?
Will Cameron and Hunt's promises of "24/7 NHS access" turn out to mean, not 24/7 access face-to-face with a trained and regulated healthcare professional, but 24/7 access to an app? After all, the internet never sleeps.
Will paid-for ‘app’ access to NHS-accredited primary care professionals turn out to be a Trojan horse to normalise a ‘two tier NHS’, where you get an enhanced service if you can pay for it? Might a ‘pay-to-use’ NHS be easier to introduce, culturally, in 'new' areas like apps? Intriguingly, not even in reference to apps, is the word 'free' mentioned once in Hunt's speech.
This matters enormously, because of the perception that the NHS is heading gradually, in a totally undemocratic way, towards a 'pay-for' service; as reported elsewhere on this site.
Hunt's speech offers very valuable glimpses into his vision for the future of the NHS. The analysis which he presents on ‘apps’ bears remarkable similarity to a recent paper by global management consultants Oliver Wyman called “The Patient-Consumer Revolution”, authored by Tom Main and Adrian Slywotzky. Its subtitle is “How high tech, transparent marketplaces and consumer power are transforming US healthcare.”
Hunt’s version of Wyman is less brash, of course. Hunt does not talk about 'consumers' or 'markets'. But otherwise the Hunt and Wyman versions are essentially the same.
So where Hunt says:
“If intelligent transparency is Patient Power 1.0, this is Patient Power 2.0. We have the chance to make NHS patients the most powerful patients in the world – and we should leap at the opportunity.”
The Wyman report says
“But in fact the tech attack is far more. It is both the symptom and driver of a much larger and more significant change sweeping through U.S. healthcare…a fundamental redrawing of industry lines that puts the consumer in charge and sets the foundation for Health Market 2.0. The tech entrepreneur developing a new app may not realize it, but he is helping to create the infrastructure of a new, more powerful way of delivering healthcare.”
The Wyman report tells us this new approach to delivery is a way of overcoming
"The cornerstone of traditional medicine - the idea that all healthcare is local."
A 24/7 NHS is easier (or at least cheaper) to deliver if bits of it can be outsourced to other jurisdictions in different time zone. But how well regulated will this be? In the U.S. the anti-regulation forces appear to be winning the battle to make sure apps (and the data they generate) are only lightly regulated, if at all. And such deregulation could be headed our way under the US-EU TTIP trade agreement, heavily influenced by the pharma, apps and ‘medical devices’ lobby who want to “rebuild America’s battered economy by selling the country’s ‘health ecosystem internationally”.
Not just apps, of course, but that’s a big part of it. And note that George Osborne's one big idea for the UK economy seems to be based on a similar 'internet of things' including 'interconnected technologies in healthcare'.
Meanwhile Hunt talks in glowing terms about the "honest diagnosis". But "honest" compared to what? A NHS GP's duty of care is to his or her patient, but an app is likely to have been developed with expectations from shareholders.
Information about your blood sugar, blood pressure or exercise regime could be amassed non-invasively, say from a "smart watch", and such data uploaded onto a huge reservoir of "Big Data". Presumably an 'honest broker' could, albeit at a fee, compute the risk of cardiovascular or cerebrovascular diseases in the population. Such data would be hugely useful to health insurers, of course.
“Could a company like Apple persuade a substantial number of consumers to open up their medical records, share their biometric data, and treat their iPhones as their main point of contact with care, then it persuade them it’s fun and cool? In many ways that sounds like Health Market 2.0 in a nutshell.”
Meanwhile you yourself might be the recipient of an app that makes a positive difference to your health and wellbeing – or one that feeds you a lot of mumbo jumbo and produces a new gullible market of ‘worried well’ to create wealth for shareholders.
Of course, it’s very hard to disagree with Hunt on the notion that transparency is desirable.
But real transparency means better information on how diagnoses are made – particularly where this is contentious and has life-changing implications. Dementia is a classic example where misdiagnosis is common, and yet seems to have been formally encouraged through financial incentives to doctors. In dementia, diabetes and other common conditions, there is also a controversial shift towards ‘pre-diagnosis’ (and treatment that may be of dubious value to patients, though useful to big pharma) in dementia, diabetes and other conditions. This creation of new markets is far from transparent.
Real transparency might also mean knowing about the current and previous activities of private providers of health and social care. But private providers are exempt from many of the reporting requirements that apply to the NHS - and also from freedom of information laws. The government’s solution to improve transparency here? Significantly weaken those freedom of information laws for the state, too. Well, that’s one way of ‘levelling the playing field’.
But ultimately, for all the neoliberal theory, lack of transparency is fundamental to how domestic and international markets operate.
Markets are notorious for having hidden sources of division, such as taxes and tariffs. The veil of ‘commercial confidentiality’ private firms can hide behind, means we cannot properly get at information on their failings, or the causes behind them (such as low numbers of properly skilled staff). Their duties to investors mean they have an inbuilt incentive to externalise their costs onto patients in as un-transparent a way as possible.
It’s hard to oppose violently “Intelligent Transparency”, any more than it is to oppose “Intelligent Kindness”.
That is, unless of course the marketing gloss behind “intelligent transparency” can be removed, to reveal something which is inherently unintelligent and opaque.
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