Talk given by Mark Brown as part of a panel discussion ‘There’s an app for that, but does it work, is it safe and should the NHS adopt it?’ at Mind Tech Symposium 24th November 2014 in London.
Apps are applications. An application is the act of putting something into action. That’s all apps are; some kind of technological process that is being applied to a particular problem. In some respects it’s ridiculous that we should be asking questions about whether it’s safe for the NHS to be ‘adopting’ applications, because what we’re really asking is ‘should the NHS use or suggest others use a tool developed to solve a particular problem to solve the particular problem it was developed to solve’.
The people who build apps are engineers. What engineers do is they solve problems. Give them a problem and they solve it. So on one side we have problems and other the side we have problem solvers. Where’s the problem then? Surely the NHS should be falling over itself to enable the production of a whole variety of apps that meet patient and clinician defined needs. Everything from electronic patient records through new ways of managing conditions to mitigating their effects. It should be simple. Simon Stevens’ NHS Five Year Forward View talks about ‘harnessing technology’ like technology is an unruly stallion and the NHS a kind macho horse wrangler wrestling it into submission.
I think there’s a confusion in NHS land about apps and tech more generally. Apps, for whatever reason, have been placed in the category of services that the NHS provides or treatments that it it prescribes rather than placing them in the category of tools that patients or clinicians use to solve specific problems.
There is a sense in which apps are still seen as things that are commissioned as a finished package: a finished package that must look like a digital version of an existing real world service and which must have the evidence base to match. Apps must be big and showy and promise to do everything. There’s an enticing, and wrong, idea that apps that actually really solve problems can be commissioned from a statistical analysis of need and a spec drawn up by someone sat in an office. That’s not how apps work.
Every time we talk about apps or tech I feel the dread Ghost of Failed IT Past rearing up behind us, rubbing its bony hands together and promising baffling interfaces, top down edicts and ‘you will use this, we’ve bought it now!’
At present the NHS finds it difficult to lock step with the world of app development. There are three main ways that it fails to do this: failing to understand ‘tech time’; not understanding business models; and not serving up good problems and not allowing good development practice to happen.
One of the first problems there is tech time. The world of technology moves on even if you want to slow it down. We aren’t talking about building special bits of technology (although we might be, if we can get this bit right) we’re talking about making apps that run on platforms that people actually have. The time it takes to build an evidence base for an app to the standard that some would demand is often longer than the life of the platform it might run on. By the time the thing is actually implemented it’s already woefully out of step with users expectations. This matters because apps that are right for one particular moment and one particular set of needs go off quickly like bags of salad in a fridge. How someone wants something to work and how much it works the way they want it to is the heart of adoption. Unless you want to force apps on people (I can see the Ghost of Failed IT Past rubbing their hands again), a great app for a platform no one uses anymore is the right answer three years too late. Tech time has moved on.
Business is an uncomfortable idea for the NHS, but tech doesn’t happen without money. We have a huge log jam here. Often the NHS wants evidence before it will put up any money, but it can’t have evidence until some work has been done and something has been tested. But, the main game in town is selling to the NHS for most apps, unless they are going direct to the consumer. So the rules of the game are ‘you put up all of the money for development, testing and building the evidence base and we still might not buy it’. At present it’s impossible even to cost how much you’d need to spend to get an application approved by the NHS as being clinically safe, never mind how much it would cost to establish whether it was clinically effective. This kills most investment stone dead.
The NHS is famously sniffy about direct-to-consumer health apps, talking about them being unsafe, untested and ill-conceived. It can’t have it both ways. The NHS as a major customer needs to get better at inviting in developers to solve problems and better at investing in the evidence base by giving opportunities to actually build things and, as we’ve heard and will hear, making sure that useful processes for development that meet people’s needs actually happen.
Good apps come from engineering solutions to well defined problems. Unless the NHS is a clever investor, it will always be buying big things created at a distance from the needs of real people. (I can hear the Ghost of Failed IT Past cackling in anticipation now.)
As far as I see it there are two choices: either the NHS dives in and helps to make happen the world it wants to see; or it stands there, crosses its arms and complains as the world happens around it.
The idea that there is an app already in existence to solve all problems is obviously nonsense, as is a blind faith in a digital solution always trumping a human-faced one. Both are straw men that suit people to maintain. Boundless, unfounded optimism is really the same as absolute arms crossed cynicism: both are just ways of refusing to engage with the messy business of how we actually make technology happen.
I’d say it really is the job of people in the NHS, and those that support them, to really get their hands dirty and think about how good apps happen.