Routine genomic testing for cancer patients, machine learning algorithms for triaging patients and applications of therapeutic gene editing were just a few of the topics discussed at the PHG Foundation’s recent conference ‘From Hype to Healthcare’. However, alongside the optimism at the potential of these new technologies and others, there was also caution over the many challenges to overcome if they are to be successfully embedded into healthcare.
And there is good reason to be cautious. New technologies are often over hyped and in reality some way from being able to do the jobs they are touted to be capable of. As a recent recruit to the PHG Foundation, I have sometimes found myself surprised (and frustrated) to discover how long it often takes even more developed technologies backed up with substantial evidence to make it into mainstream use in the NHS. Why is this the case?
Evaluation can be complex and takes time
Dr Sarah Byron, Associate Director of the NICE Diagnostics Assessment Programme, spoke at PHG’s recent conference where she described the challenges faced when evaluating novel diagnostics. She estimates that it now takes about 10 years for a new medical diagnostic technology to be routinely adopted compared to 17 years a decade ago; a big improvement but still slow.
Part of the issue is that evidence for effectiveness of a medical device takes time to generate and can be complex to interpret for technologies with indirect benefits. For example, the benefits of an early diagnosis device will depend on the effectiveness of the resulting treatment the patient receives, along with the wider impact the early treatment has on the NHS, such as reducing potential costs and pressure on the system.
Unravelling these benefits is not simple. In addition, companies may underestimate the level of evidence required for a test, especially when it comes to real world implementation and clinical utility. For example an assay developed in one laboratory may not work on equipment in another, or a test designed for a condition such as sepsis may be highly accurate but not fast enough to be useful in the patient care pathway. By producing more guidance and increasing communication with industry and stakeholders, NICE is hoping to identify and resolve issues like this earlier, helping to further streamline and speed up diagnostic test assessment.
An over-stretched and under resourced NHS
A review of three NICE-approved medical devices found that the device introduced under a nationally managed scheme showed more rapid and complete uptake than the devices which were not part of a national programme. This does not necessarily mean that all new technologies should be mandated nationally, but highlights the need for providing a high level of support and infrastructure for implementation.
However, a 2018 report by the Kings Fund found that relatively simple innovations with proven high clinical and cost effectiveness were struggling to be adopted at scale across the NHS. A major reason was lack of funding to take technologies forward to be implemented at scale, even after successful pilots. Furthermore, even well designed innovations often required system changes that the NHS was simply unable to afford the time, money and staff to implement, despite clear evidence that these changes would bring major benefits in the long run.
Lack of incentives
The PHG Foundation has argued that adoption of technologies that can transform the NHS’s ability to meet future needs (rather than just solve immediate problems) should be prioritised. The NHS Long Term Plan emphasises the need to make better use of technology and redesign care pathways. However, the health system is currently resistant to innovations that focus on long term goals and do not deliver immediate rewards and/or direct benefit to those implementing a new technology. Indeed, current systems may actually discourage improvements. It has been found that some service providers rejected new patient support technologies because it would reduce the demand on services that are rewarded through ‘payment by results’ systems.
Although efforts have been made to create an environment with leaders that encourage and support innovation in the NHS, these are not always successful. To help new technologies be adopted faster and more widely, there must be better recognition and rewards for those leading the way – as strongly advocated for by the PHG Foundation in our evidence to the NHS Long Term Plan consultation.
Other barriers to adoption
The need for better communication is consistently raised when it comes to adoption of new technologies. The PHG Foundation’s report on new ctDNA testing services for lung cancer found that successful implementation depended on communication between testing laboratories and clinicians, as well as actively engaging clinicians face to face to describe the benefits of the service. Others have also shown that good uptake of new technologies is dependent on active interaction with senior clinicians and designated project teams – but due to lack of funding, innovators often had to resort to less effective website and conference communication.
The Academic Health Science Networks are already playing an important role in connecting and promoting innovation across different sites, but the fragmented structure of UK health services means this is not easy. A joint report by the Innovation Unit and the Health Foundation reported similar findings, and called for dedicated organisations to promote new technologies more widely.
Future challenges
Whilst it is clear that the problems highlighted above need to be resolved – and that there are many vital contributors to this endeavour, not least NICE’s Diagnostics Assessment Programme – a key aim of the PHG conference was to also look further ahead to anticipate future challenges. These range from the potential impact of consumer based tech on the healthcare system, to evaluating technologies aimed at very narrow subsets of patients. An overarching theme was the increasingly rapid pace at which technologies are being improved upon and updated, requiring plans to be put in place that allow their timely evaluation and regulation without delaying progress. This will be particularly applicable to future uses of artificial intelligence, a topic the PHG foundation is currently addressing.