In Australia, people are not required to register with a GP or a practice. Consequently, they see multiple GPs which impacts the continuity/integrity of their medical record. Compared to the USA, the public healthcare systems of Australia, New Zealand, and the UK lack the expertise in change management and purchasing support. These are just two findings by Senior Policy Lead for digital primary care at NHS England Dr. Dimitri Varsamis.

Dr. Dimitri Varsamis is Senior Policy Lead for digital primary care at NHS England. End of 2020 he published a report titled Incentives and levers for digitising and integrating primary care in New Zealand, Australia, and the USA - lessons for the UK’s NHS. Dr. Varsamis researched primary care digitalisation prior to the global coronavirus pandemic. He undertook the research that resulted in the report as part of a Churchill Fellowship.

The complexity of the NHS 

The UK is globally recognised as a very accessible healthcare system. Healthcare insurance is tax-based and at first glance, the NHS may seem like a centralized entity. In fact, it is far from that. “There are actually four NHS entities - the English, Scottish, Welsh, and Northern Ireland NHS. Additionally, there are a lot of different bodies and organizations in the United Kingdom that have NHS in their name but follow separate budget strategies. This makes the UK similar to New Zealand or some of the smaller healthcare ecosystems in the US,” says Dimitri Varsamis. 

It’s easy to get confused about how the NHS works, especially when it comes to digitalisation efforts. NHS Digital and NHSx are two separate entities, both related to healthcare digitalization. How do they differ? “In simple terms, NHSx is trying to bring together the WHY of changes -  the strategy, the policy. NHS Digital is there to figure out the HOW - it is in charge of developing standards, and giving guidance about local systems,” explains Dr. Dimitri Varsamis. 

How do US, UK, New Zealand and Australia compare? 

In his observation, the US healthcare system is the most innovative one of all the systems he analysed. This is understandable since the US are still the largest digital health market in the world. “A lot is being developed around how primary care interacts and works with the rest of the system. For example, a company called Heal is bringing together remote monitoring and home visits, which are two separate things in most countries. Innovators are developing solutions to bring together primary and community care. Equally, when it comes to US health care systems such as the Kaiser Permanente, the Veterans Health Administration, or some of the more localized health care systems, which are associated with universities and very big Medical University Centers have well digitized primary care that is connected with the rest of hospital care,” illustrates Dr. Varsamis. 

Change management is an issue in public systems 

One of the challenges present in public healthcare systems is that budgets are focused on a relatively short term future. As observed by dr. Varsamis, because of short-term pressures, most politicians tend not to be as interested in what's going to happen to the health and health care of their population in 10 to 20 years, especially when there may have been an election coming up. That happens everywhere and causes all sorts of issues. One of dr. Varsamis’ observations in the research is that the public health care systems of Australia, New Zealand, and the UK, lack the expertise in change management and purchasing support. He illustrates that through New Zealand’s organisation of health care.

New Zealand has approximately 5.500 GPs working in about 1000 practices. On top of the 1000 practices is an additional layer on the primary care side, called the Primary Health Organizations. In his observation the middle layer creates an additional level of complexity, that doesn’t necessarily support efficiency because a middle layer doesn't have the push from the top or the pull from the bottom.  “There are 30 Primary Health Organisation. In my eyes, that was a great opportunity to centralize the resources, skills, and expertise you need in change management. The additional layer of the PHOs looked like the right approach towards digitalisation because the number of entities under one PHO is not too many or large but also not too small. However, some primary health organizations in New Zealand offer a lot of change management support and beyond, but that is not the case everywhere.”

What dr. Varsamis sees as a potential solution is to organize the change management system at the national level, have a helicopter or hovering team of change management experts going around the country helping primary care systems at a local level to digitise. “But you end up realizing that actually, such a service would most probably be offered by a consultancy. Consultancies are expensive and not something that most healthcare systems can afford,“ he adds. 

Primary care records

In the UK the vast majority of people are registered with an NHS practice. In Australia on the other hand, people are not required to register with a GP or a practice. Consequently, they see multiple GPs which can impact the continuity/integrity of their medical record. Australia did establish a national infrastructure called My Health Record which should have all the patient data. However, the reality is, not all providers are connected to it. As explained by dr. Louise Schaper in episodes 105, it’s a Catch 22 problem: doctors can’t rely on these records because they are incomplete and consequently, are also not motivated to add data to My Health Record.

Other countries are seeing a similar problem. Is the idea of having a country level patient health record a utopian desire? “We've always thought of the ability of patients to have access to the record and own it, as a way of empowering patients to own not only the record but also their health and care. However, when it comes to country-level patient records we've definitely learned in the UK of how not to do things. There was a National Health Service program for IT led by the Department of Health in the mid or early 2000s. The idea was to basically move the whole of the NHS in England towards a single, centrally mandated electronic care record for patients. We wanted to connect general practices to hospitals in terms of a single record. Originally that was meant to cost a couple of billion British pounds over a few years. In the end, according to some of the people involved with the program the costs amounted to around 20 billion pounds,” says dr. Varsamis with a comment that the end cost was much higher than originally planned. Additionally, the program didn't deliver everything it needed to do. “Yes, they developed electronic prescribing and the ability to book appointments electronically for hospital care, a single NHS email service, but not a single national record. We've learned from those mistakes and, and we are developing local health and care records within smaller geographies where the bodies in health care, hospital, general practices, community services, social care, and so on develop a single standard and record of or how to share the data within their individual records. These locally developed health information exchanges are important and they're great. But we must make sure they are not in too small geography units. They need to be big enough so that if patients move or need to be seen by somebody outside that geography, they still have access to a good enough detailed record. On the national level NHS Digital could make further attempts to create the right standards and technology for the national sharing of patient data,” comments dr. Varsamis. 

Tune in for the full discussion: 

Some questions addressed: 

• Dimitri, You just finished a report about Incentives and levers for digitising and integrating primary care in New Zealand, Australia and the USA – lessons for the UK NHS. How did your perspective of the UKs healthcare system change? How would you compare your perception of the system before and after this research? 

• I’ll make a guess: from the four systems you analysed, is primary care in the US most digitised, since the US is the largest digital health market? 

• What were your expectations and assumptions regarding what you will discover? What differences between countries did you notice (around the research topic of course)? What did you get inspired by? 

• One of your observations was that the public healthcare systems of Australia, New Zealand and the UK lack the expertise in change management and purchasing support. How does one notice that? What could be the solution? 

• Major differences in how primary care is paid for in Australia compared to the UK drives different behaviors. Can you tell us a bit more about that? 

• In your position inside the NHS, you oversee how primary care is digitising. More specifically, looking at the lifecycle of digital-related commitments and requirements in the GP contract. What’s your reflection on the past year? Has your work become more intense because things are now moving much faster than they did before? 

• One of the things you mention in the report is that in Australia there is no detailed patient record that follows the patient as they move practices. Australia did establish an infrastructure called My Health Record which should have all the patient data. However, the reality is, not all providers are connected to it. As explained by dr. Louise Schaper in one of the previous episodes, it’s a Catch 22 problem: doctors can’t rely on these records because they are incomplete and consequently, are also not incentivized to add data to MHR. In your perspective: are national patient record a utopian desire? How does NHS approach this? Will it be up to the patients to adopt personal health records solutions that will allow them so easily store their medical data on their own and share it with their doctors? 

• In the UK GPs tend to work for NHS practices, with limited private practice and the vast majority of people tend to be registered with an NHS practice, therefore receiving free-to-use services. While this sounds great, I did get across a lot of critique regarding the waiting times for a GP appointment. This then indicates that this was potentially an additional factor that contributed to the success of Babylon - one of the first mobile apps for medical triage and advice. How do you see Babylon changing the GP landscape in the UK and comment the critique about waiting times? 

• You have a BEng (Hons) in Medical Electronics from the University of Kent, an MSc (Hons) in Medical Diagnostics, and a PhD on biosensor development, both from Cranfield University.  How come you work in the NHS, not in a development company?