Opinion

Towards a transformed Health Service

John Coulthard, a former NHS IM&T manager, heads the NHS team at Microsoft, having previously been Chief of Operations for the Managing Director of Microsoft UK.

John Coulthard believes that future healthcare will be “predictive, preventative, pre-emptive and participatory”: the four ‘P’s. These four, with the technologies that will make them possible, will transform the shape of the Health Service, accelerating the shift from hospital to community and person-based services.

Advances in molecular biology and in biological informatics will allow doctors to screen a single drop of blood for thousands of genetic markers and diseases. This will enable clinicians to predict the likelihood of a disease emerging over a lifetime and to help people take steps to prevent it through lifestyle changes, diet or prophylactic medicines. Diseases that do take hold will be treated very much earlier and with highly personalised medicines. Finally, people will assume a far greater role and responsibility in maintaining their own health, participating with community health workers and clinicians in keeping themselves fit and free from disease and taking a full part in the treatment management of their own diseases.

This model of future healthcare and disease management will require not only human skills and new approaches on the parts of both clinicians and patients, it will also require powerful software systems, particularly in bio-informatics, medical analytics and advanced clinical-decision support.

Lifestyle and genes are increasingly being seen as the critical factors in the spread of many of the most serious diseases including the chronic diseases that the developed world will face over the next decades. Participatory and preventative approaches will help deal with lifestyle factors. Genetic causes will require prediction of risk and early pre-emptive treatments. Many of the most effective drugs being developed now for future use are also highly toxic. They will have to be personalised to the genetic and proteomic profile of each patient. This introduces a fifth P: personalised medicine.

This vision has its ultimate inspiration in the work of Lee Hood, one of the pioneers of the Human Genome Project, and a principal founder of the new systems-biology approach to medicine. Today, Hood is hailed as one of the leading visionaries of how advances in molecular biology, genetics, bio-informatics and healthcare IT will merge to create a new approach to medicine. John Hopkins Medical School recently compared his impact on medicine to that of Bill Gates on computing.

Bill Gates himself, Coulthards boss, is a long-time enthusiast for Hoods thinking. Gates spotted Hood as a rising star and gave $12m to the University of Washington in 1992 expressly to help lure Hood to Seattle to create the first systems-biology department. Hood had conceived the systems-biology concept while at CalTech, believing that a multidisciplinary approach including mathematicians, information scientists and IT specialists was necessary to meet the new challenges of genetics and protein-based analysis, both in pure research and in healthcare. Opposition from biologists within CalTech torpedoed Hoods plans to set up the new department there, but Gates took up the cause and persuaded the University of Washington to establish the department instead, with Hood as the first director. Gates has continued to champion Hoods ideas, and in 2005, he gave a further $10m to Hoods Institute of Systems Biology.

Knowledge exploitation

Coulthard believes that knowledge, and the way people use knowledge, both within and outside the Health Service, is the key to achieving Hoods vision of a transformed healthcare system. If you compare Lee Hoods vision of the 4P healthcare environment of the future with what we have now, which is people living their lives in relative wellness until they suddenly become chronically ill, and then remain chronically ill for typically the rest of their lives, what we have now is a service that promotes a lack of concern in peoples minds about their health.

So people go on smoking. Perhaps more worryingly, they go on eating the wrong kinds of foods. What you can see is two poles, with Lee Hoods 4Ps Prospective Medicine at one end and the current system of late acute care at the other. The question is: what is going to shift us from where we are now to the scenario of 4P Prospective Medicine? And the answer to that is information and people.

Microsoft has a part to play in this healthcare revolution, Coulthard said, because the company is founded on the principle of turning corporate information into a form that is useful for non-IT specialists what Microsoft has recently called being people-ready and its ability to span increasingly from very large systems to personal devices and home technologies. What Microsoft is about, above all, said Coulthard, is the intersection between people and knowledge, and the people within organisations who access and exploit knowledge. Microsoft will increasingly provide, at scale, the ability for people to be part of those four Ps. Its a broad spectrum, from members of the public through to clinicians and specialists.

Coulthard places emphasis on the ability to deliver at scale as a key component in all future healthcare systems. He sees the appointment of Ray Ozzie, the inventor of the ground-breaking corporate groupware application Lotus Notes, as Microsofts Chief Software Architect, and the arrival in Redmond of similar large-scale computing luminaries such as Don Ferguson, the father of IBMs WebSphere architecture, as a highly significant step in the development of this agenda.

Microsoft is working hard to turn the vision into reality, Coulthard said. Examples of this 4Ps approach are beginning to appear. Microsoft is currently working on a project that shows how predictive technology begins to change the shape of healthcare. We have developed an algorithm that looks at a patients vital signs, predicts if their condition will improve or worsen, and then flags it up to the doctor. This is currently in place in an NHS hospital, and has succeeded in cutting right down on the number of emergency interventions needed. Patients are treated sooner, before a crisis erupts. It allows clinicians to first predict, and then pre-empt any cardiac crisis. Doctors time is used far more efficiently, stress is reduced, and, most important of all, patient outcomes have been greatly improved.

Key role for informaticians

John Coulthard believes that IM&T specialists within the Health Service deserve more support, a better career structure and greater organisational stability. If information and data are going to become vital to the Health Service, he said, then we have to look over our shoulder and ask where are the IM&T organisations that are going to deliver all these transformational changes in the NHS in the future? Do we have sufficient, capable and motivated individuals in the Service, who are working in organisationally stable units, to deliver that? I have to say, I don't think we have. I still meet some colleagues of mine from my days as an NHS IM&T manager in the late 1990s. But most of them have moved on. Their organisations dont exist. There is no definable career pattern that they have followed, if you compare them with clinicians.

My biggest concern is that the NHS should be people-ready. The key here is finding sufficient, capable and motivated people to deliver the National Programme, deliver the level of excellence that NHS IM&T requires, and deliver the clinical outreach that the NHS needs. If you can find those people, and pay them as much as you pay the doctors, and reward them effectively, and put them into stable and well-managed organisations, the NHS will save itself an absolute fortune. And doctors will be able to do a much better job for their patients than they currently do.

We also need a lot more clinicians involved in NHS IM&T. Clinicians are vital to the whole process. We need far greater clinical involvement in healthcare informatics. We need more doctors involved in healthcare management and in the British Association of Medical Managers. And we need many more doctors with MBAs, and we need many more MBAs who have been to places such as the Kings Fund or the Tavistock Institute. If you can get that kind of cross-fertilisation between all these different groups, then we will start to move away from the episodic, late acute, mode of healthcare that we have today, towards the longitudinal, lifestyle approach that will entail greater health in the population, and less chronic disease.

William Payne is a freelance writer.