Post Title

Many people are looking to digital tools and apps to revolutionise the way health and care is delivered, including facilitating an increased emphasis of supported self-management by patients. With a number of promising digital innovations becoming available for use and a rapidly developing evidence base, the future looks bright. However, as Programme Director Lesley Soden writes, could the practical issue of payment risk putting up a roadblock to progress?

Like many people, I use a handful of health and wellbeing apps on my phone – some of which come with a subscription fee. With these fees often only amounting to a few pounds a month, it wasn’t until I sat down to write this blog that I really added up how much I was spending. It turns out digital health technology doesn’t come cheap!

To take a fairly typical example, someone using a selection of the most popular apps and digital tools to eat healthily, manage their weight, keep active, stop smoking, help managing their anxiety and address sleeping problems could easily tot up an annual spend approaching £400.

Whilst these digital apps and tools are a boon for some of us, we shouldn’t forget that a significant proportion of the population are currently priced out of accessing health and wellbeing support in this way.

Health inequalities related to socioeconomic factors and household income are nothing new.

The gap in life expectancy between the most and least deprived areas of England has significantly widened in recent years. People in the most deprived areas were four times more likely to die prematurely from cardiovascular diseases and 2.2 times more likely to die from cancer than people living in the least deprived area. The relative inequality gap in suicide rates is still almost twice as high in the most deprived areas compared with the least.[1]

Grasping the nettle

Last September, the Health Innovation Network hosted a roundtable to look at the urgent need for new payment models for digital tools, including the viability of an ‘apps on prescription’ approach. We developed a number of proposals with senior stakeholders in the NHS and social care landscape for how to tackle the financial and practical aspects of how these digital solutions are to be purchased and paid for.

It does not seem fair that digital solutions that could address significant population-level health challenges are only available if the individual pays for them. In some parts of the country, access to digital solutions are starting to be funded[2] however these examples are rare. Does it seem right that the privileged few can afford apps to the keep themselves healthy, but those individuals who are economically challenged aren’t able to access them?

Why can I get medicine prescribed by my GP but not a digital app that would help with losing weight? If I pay £9 for each medicine prescribed, why can’t I be prescribed an app in the same way? If a GP could prescribe evidence-based apps for their patients who are exempt from prescription charges we could take a bold step towards ‘levelling up’ preventative healthcare[3].

Unlocking the potential of digital apps and tools

With Covid-19 worsening the digital divide and health inequalities in general, now is the perfect time for the NHS to be taking advantage of the digital solutions that keep people engaged and change their health behaviour. There is a wealth of evidence that shows that digital solutions can contribute towards prevention of ill health or better management of a long term disease[4].

Smoking cessation is just one example of how changing payment models could deliver real benefits to both patients and the NHS. In 2018, the Government estimated that smoking kills about 78,000 people a year and costs the NHS about £2.5Bn annually. Smokers are about three times as likely to be in the lowest earning segments of our population as the highest earning groups.

Fast forward to 2021 and we have a number of evidence-based apps that we know can help people stop smoking such as Quit Genius, Quit with Bella or Smoke Free – but in most areas there is no mechanism for the NHS to fund or subsidise access to these apps for the groups who might need help the most.

For these populations the NHS as a payer should be looking at all digital interventions that are evidence-based and demonstrate a clear return on investment.  For some of the small companies that we support through the Health Innovation Network, it is difficult to identify who and where in a patient pathway should be paying for digital solutions. For example, MUTU System one of the NHS Innovation Accelerator fellows that provides a 12-Module web-based programme app for expectant and new mothers, to improve pelvic floor strength. But identifying the NHS payer for this evidence-based solution has been challenging – would it sit within the maternity pathway or within the continence pathway, or perhaps would it be GPs or physiotherapists prescribing? Some of the proposals in our recent report could be applied for MUTU System, whether that is maximising the NHS transformation funding available, or population level commissioning.

With an expectation that the pandemic may have caused a significant increase in the number of mental health problems in young people, the digital tool MeeToo is an example of one way technology could help managing this crisis. MeeToo is a multi award-winning app that makes it easier for anxious young people to talk about difficult things. This digital platform is informed by psychological research, and fully moderated intervention to harness the power of peer support. This preventative support supports the 61 per cent of children and young people who are referred for mental health support by their GPs referrals, but who are not eligible because they don’t meet the high threshold criteria for CAMHS[5]. Imagine if a GP could make a referral for a young person with anxiety to CAMHS but also use a tool like MeeToo to potentially prevent deterioration in their mental health during the long waiting period for NHS treatment.

The pandemic has proven the NHS can adopt technology and innovation rapidly and at scale. Payment models might not be headline-grabbing in the same way that vaccines, oximeters or even remote consultations might be – but if we want to unlock the enormous potential of digital apps and tools to support the NHS recovery, we need to take urgent positive action before the opportunity slips away.

[1] https://www.gov.uk/government/statistics/health-inequalities-dashboard-march-2021-data-update/health-inequalities-dashboard-statistical-commentary-march-2021

[2] https://www.oxfordshiremind.org.uk/sleepio/ https://www.oxfordhealth.nhs.uk/apps/sleepio/

[3] https://static1.squarespace.com/static/5d349e15bf59a30001efeaeb/t/6081711f326bde0eea34a3f6/1619095840963/Levelling+Up+Health+Report+Digital+Final+2.pdf

[4] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/819766/advancing-our-health-prevention-in-the-2020s-accessible.pdf

[5] https://digitalhealth.london/innovation-directory/profile/meetoo