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1.
Introduction
The opportunity to provide comment to this consultation is welcomed. Assistive technology is an important issue for Health and for Social Care in Wales as we seek to ensure that our services are fit for purpose and sustainable, meeting people’s needs as they live longer and have access to a greater range of information than ever before.
We have a particular interest in ensuring that technology supports the welcome emphasis on greater integration across health and social care in Wales, in giving seamless and ‘joined up’ services to our citizens, and does not become a barrier to effective care coordination. There are four strands to the terms of reference of this inquiry:
* To examine how the NHS assesses the potential benefits of new or alternative medical technologies;
* To examine the need for, and feasibility of, a more joined up approach to commissioning in this area;
* To examine the ways in which NHS Wales engages with those involved in the development /manufacture of new medical technologies;
* To examine the financial barriers that may prevent the timely adoption of effective new medical technologies, and innovative mechanisms by which these may be overcome.
We offer some general observations as well as comments against each of the strands.
2. Overview comments
There is no common standard definition of medical technology and so there is potential linkage or cross over with other terms such as telemedicine and telehealth. The former is generally understood to cover technology linking patient to hospital or GP practice to hospital whilst the latter term is used to relate to technology that is usable in a patient’s home to help support their medical treatment.
A definition drawn from web research is very broad: ‘Medical technology is the use of a device or invention to extend the life of patients, relieve pain and reduce risk of disease. Examples of medical technology include medical and surgical procedures, medications, medical devices and diagnostic tests.’
A clear definition of what is included in medical technology would be welcomed, and confirmation that this can include devices used in home and community settings. If primary and community care settings are included in the remit of medical technologies – as we believe they should be – then there is a greater case for interoperability being built into the design and development of new equipment.
Within the UK the Medical Technology Group (MTG) is a collation of patient working groups, research charities and medical device manufacturers committed to raising the profile of and investment in medical technology. The UK spends 4.5% of the national healthcare budget on technology compared to a European average of 6.3%. As a result some technology based procedures are more common elsewhere in Europe than in the UK – pacemakers are implanted in Germany at twice the rate as that in the UK, for instance.
This position has been recognised by the UK Government making commitment to invest more in Life Sciences and the ‘3 million lives’ campaign to increase use of telehealth building on from the outcomes of the Whole System Demonstrators which covered Kent, Cornwall and Newnham Councils. This campaign has not been as been transformative as was hoped, with some concern that it took too much of a ‘top down’ approach, placed a strong reliance on manufacturers/suppliers changing the market, and failed to engage fully at operational level or to link across to social care, third sector and user groups. There are lessons to be learnt from this in Wales, and a key is to engage at all levels, so that front line practitioners – GP’s, District Nurses, Social Workers, Therapists and others – can see the benefits of technology in delivering good care outcomes.
This has been key for the take up of Telecare – so that front line staff, carers and service users see a benefit. This ranges from carer ‘peace of mind’ that they can go out, knowing there is some monitoring in place, to care managers targeting care visits to when needed rather than put in care to manage risk of ‘what might happen’.
Patient views and needs are also beginning to be recognised in that the UK Government Health Bill makes provision for taking forward pilots of direct payments for medical technology – such as insulin pumps, to be used to help manage medical conditions. This follows on from the use of personal budgets in social care, which have been received positively by the UK government. Expanded use of direct payments and a duty on local authorities to encourage and develop alternative models of care are a feature of the Social Care and Wellbeing Act in Wales that give a similar opportunity to bring supportive medical technology into the community level to support individuals to minimise hospital visits and remain at home.
Both UK and Wales Governments have recognised the need to encourage innovation and new development through having open awards processes. The Department of Health as a £20 million innovation prize budget and MediWales – funded through Wales Government - has operated innovation awards in Wales for Welsh companies over the past seven years.
It would therefore be useful to confirm that funding for innovation will continue at similar levels as now, or greater, to support Welsh based technology organisations. That funding should include partnership working as a core requirement for new proposals. An example of how this principle can be applied was the changed remit of the Health Technology Fund to be a Health Technology and Telehealth Fund (HTTF). It was a positive change for 2014/15 and has helped foster greater collaboration across Health Boards in Wales and with social care partners. Examples would be the sharing of ideas across the three Health Boards in SE Wales – Cardiff & Vale UHB, Cwm Taff LHB and Aneurin Bevan UHB ahead of bid applications, and the multi disciplinary panel approach in ABUHB that included social care partners.
3. Inquiry Themes
i. To examine how the NHS assesses the potential benefits of new or alternative medical technologies.
This does seem to vary across Health Boards, with little or no national strategy that is very evident. Take up does seem to be driven by local champions often working within specific disciplines. It may be useful to develop a network of champions as a practice group, supported by Wales Government, to be a sounding board for new innovations and to undertake clinical trials. To some extent this exists with the Life Science Expert Advisory Group – but their remit should be open and include patient perspectives, as well as opportunity for social care input.
It would also be helpful to have a strong policy statement – akin to the Department of Health ‘3 million lives’ campaign aims – from Wales Government to show that there is commitment to developing and using technology to support patient care.
Consideration of extending direct payments for patient take up of medical technology could also be considered – so that there is a user driver for change as well as a clinical driver.
ii. To examine the need for, and feasibility of, a more joined up approach to commissioning in this area.
The current commissioning process for new technologies is not completely obvious as there are different strands and different organisations that have a part in the process. The overarching body covering medical technologies and agreeing their use is NICE (National Institute for Health and Clinical Excellence) and their Medical Technologies Evaluation Programme. They will use accredited health organisations to undertake evaluation work – including the Cedar Evaluation centre within Cardiff and the Vale University Health Board.
There are a number of other organisations that undertake appraisal of technologies, including the NHS Wales Informatics Research Laboratories. It may therefore be helpful to have a clear mapping of what is done where so that ideas and designs can be submitted to the right place – depending on whether it is a direct patient used aid, a medical procedure, a new type of treatment, etc. The operational perspective and patient ‘receiver’ perspective should be included right at the design stage – so that the right solutions are commissioned for the right issues. The aim should be for a clear development pathway that ensures designers and developers have access to the right clinical forums for their type of product, as well as access to ‘expert’ patients who can give the user perspective, and the inclusion of social care and third sector partners to look at the best ways to commission, with agreement as to desired outcomes.
There should be learning from the ways that assistive technology has developed in the UK – both successes and failures – so that best practice is followed, with good governance arrangements allied to a patient centred approach. This should be explored in terms of supporting better access to medical technologies, learning from telehealth experience in Carmarthenshire/Hywel Dda and in North Wales, working with Betsi Cadwallader LHB.
iii. To examine the ways in which NHS Wales engages with those involved in the development /manufacture of new medical technologies
This might seem to be predominantly for discussion by NHS organisations rather than local authorities, but social care is well placed to see the ‘end user’ impact of medical treatments as people are supported to live at home and in the community. It is also the case that local authorities can be a ‘critical friend’ in taking a community and social perspective to balance a medical model perspective. Some general observations might be:
* Ensuring that Wales companies are given priority consideration so as to support the Welsh economy
* An open and transparent decision process using a panel that fully represents the whole of Wales and different arms of health care and social care.
* Support to range of technologies – including home based technology to support patients at home and not just technology in secondary care. This would have to consider integration and interoperability with Telecare/Telehealth that is already deployed. Existing collaboratives and partnerships should be utilised so that there is shared learning and avoidance of duplication
* Supporting a strong patient panel to ensure that the patient/user experience of medical technology is heard and informs forward development
* Learn from the positive and negative experiences of the 3 million lives campaign
* Take full account of the learning and experience of Telecare and Telehealth in Wales, including the person centred approach to risk management and accessibility. Telecare monitoring centres can provide some support to roll out of assistive technology for health needs, as an existing resource in place - there have been examples of a combined approach in North Wales, and an integrated approach is certainly supported by the newly reformed All Wales Assistive Technology LIN.
iv. To examine the financial barriers that may present the timely adoption of effective new medical technologies, and innovative mechanisms by which these may be overcome.
The first point is that with more partnership approaches to identify, commission and assess new medical technologies then the more scope to pool some funding to take effective new solutions forward.
The second point is draw upon research facilities to support the trial and testing of new technology, with developer funding to take this forward being an important part of business planning to give greater new product assurance. The experience from Telecare and Telehealth has been an over reliance on supplier innovation and solutions and a failure to always have good ‘field testing’ before products come to market.
A third point is to use end user/patient and operational views to identify those technologies with best development potential – in other words to understand the market place for the particular technology. This will vary from highly sophisticated devices that may be at the level of one per LHB in Wales to simpler technologies that support a wide range of conditions.
A fourth consideration is to look at scope for small scale business investment in innovative solutions – ‘crowd funding’ approaches have been taken forward in the US to develop good ideas through to marketable products, from mobile phone apps to telecare solutions for older people.
Finally it may be worth thinking about enabling mechanisms for the public to purchase more health and social care technology for themselves by making “accredited” devices available on the high street. There may be scope for an all Wales (or regional) approach to develop a social enterprise to either manufacture or warehouse and sell direct to public, using skills from Economic Development in Wales Government or in local authorities.
4. Summary Points – Ten Point Plan
i. Presenting a clear definition of medical technology and specific elements under this term (and what is not) so there is clarity with other terms such as telemedicine.
ii. Confirmation of continued investment in Wales at same or increased levels, with partnership and integration as key investment criteria
iii. Clarity as to network of champions – practice group and patients – with defined role
iv. Presentation of a strong, high level policy statement from Wales Government indicating commitment to technology to support patient care.
v. Consideration of direct payments options for patients to use useful home based technology to support their self management of health
vi. A clear development pathway for designers to reach the right clinical forums and access to expert patients and social care partners
vii. Ensuring that Wales companies are given priority consideration so as to support the Welsh economy
viii.An open and transparent decision process using a panel that fully represents the whole of Wales and different arms of health care.
ix. Support to range of technologies – including home based technology to support patients at home and not just technology in secondary care
x. Supporting a strong patient panel to ensure that the patient experience of medical technology is heard and informs forward development
5. Concluding remarks
We believe that a partnership approach should underpin the development of medical technologies in Wales as a fundamental means of ensuring access to the right technology at the right time and in the right place. The greater the awareness of what technology can do and what the areas of need are, then the greater the potential to firstly identify solutions and then deploy them to best affect.
Gio Isingrini
President
ADSS Cymru
14th August 2014