OneLondon: Building a Connected Health Ecosystem for 10 Million People

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjasa Zajc. Today, we're going to dive into OneLondon, an ambitious project working to provide a single patient care record for 10 million people across London.

[00:00:28] Since its inception in 2018, OneLondon has evolved, connecting more healthcare providers, expanding patient access and tackling critical challenges like end-of-like care, sickle cell disease management and more. I spoke with Luke Reidman, a key leader behind OneLondon, who shared his insights on how the project is transforming care coordination,

[00:00:53] how public was involved before the plan for OneLondon was designed, and how OneLondon is navigating the complexities of integrating 24 different EHR systems. We also discussed the rise of virtual wards and remote monitoring, and how these new models of care are shaping the future of healthcare delivery.

[00:01:16] This discussion was published at the Open Air International Conference in Reading last autumn. Enjoy the show, and if you haven't yet, make sure to subscribe to the podcast and check out our newsletter, which you can find at FODH.substack.com. That's FODH.substack.com.

[00:01:38] And if you will enjoy the discussion, I will really, really appreciate it if you take a minute or two to leave a rating or a short review. I know the process is not super friendly, but your opinion matters, and it's the fuel for the show. So thank you all the listeners from the past who already took the time to leave a review, and thank you to those that will do so in the future. Now let's dive in.

[00:02:16] Luke, thank you so much for taking the time for a short discussion here at the Open Air Annual International Conference. Yesterday, you had a presentation about OneLondon, which is a project that is aiming to provide a single patient care record for 10 million people across London.

[00:02:40] I had an interview with Gary Metallisters two years ago, and he explained a little bit about that, and I will definitely add that link to that discussion to the show note. But let's start with the last two years since that interview took place. Is there anything that still stands out to you in terms of what has happened with the project in the last two years? What were the key successes, and how is the project developing?

[00:03:07] Because I'm thinking, you know, when this idea was initially formed in 2018, it was probably different to what it is now, because I'm assuming it's evolving. It's not a static thing. Yeah, so thanks very much for the last one. I've really enjoyed the first day at the Open Air Conference, meeting some old friends and making new ones. It's a great community.

[00:03:35] And the opportunity to seek it out, what we're doing across London, is important, so that I can set out what we're trying to achieve, but also have challenges back. I do accept just that there's challenges that some made us think in a different way, and it's a really important part to really support the rest of the world. And you're right to say that what we set out with 2018 and what we're doing now is different,

[00:04:03] and probably with our vision for the next step is different again. And it is one of the interesting observations that I tried to make yesterday in my thought, that it's fair. Whilst I think my concept, and the concept a few of us had as needed, is always about a day to through it. Where do you start to trust a multitude of service, community, and with your public? So the easiest step was to create a...

[00:04:31] And like James Matthews, it looks like London, it connects up London, so that data could just be used at the place of K. And when I look at that over the last two years, that's, you know, that's sort of more than doubled its use over the last two years. And more areas are connected. And you saw yesterday in some of the areas beyond London and north of London are now connected. You can see that after you start to see. That goes from stance to straight. And that's a really important component part of the whole picture.

[00:05:02] When I look at the opening HR platform that we brought along with that, it's been a half year to do now. The use of that for all patients in their last few months of life has doubled in last few. And we've sort of kept looking at about three quarters of those people who it's known, but they sort of may die. And that's a really great achievement. I'm waiting for detail on them very quickly.

[00:05:29] We've also, as of January this year, and second is first step for patients to have access to their record clues. So in England, we have the NHS app. And we've plugged in these care plans now into the NHS app. The patients will see them. From next year, patients will be able to request changes or initiate their own care plans. And that's another big step on that journey, let me say. And I say, do you have two steps around that?

[00:05:56] Literally, you know, but we've taken a difficultly difficultly difficult self. I remember that I think it was about 20,000 of those in England. For larger single groups in London. They have a very 4D already voted to specific prayer. And in particular ethnic groups. And then about three quarters of those in London now have their own care plans. So that's another important group.

[00:06:24] And the second bit is we'll extend that to further groups as we go through this year. So we keep extending the capability of the care planning. And it's actually, you know, the concept is based on what some other countries do. I was over in Valencia and stayed in a few years ago. And they had a very broad use care planning sheet across their system. That was underdined by contracts to help services there that were 10 or 15 years long. And we're outstated to this country, a contract to help for the 10th year annual yearable.

[00:06:54] So we have very different arrangements. It was at a worse, you know, right? I'd say the other thing. The other thing I would point out is this real issue about trust. And because you've talked to God to demonstrate to our diverse services and communities across London, that what we're doing is safe. And so make a difference to the care or make a difference to your life as a country. And we have good evidence that that's actually happening now.

[00:07:24] And that allows us to do some other things. So we've started to tackle in the last few months how we bring together T4 in crisis there with mental health conditions. And how we have common approaches to where we link those up across London. And we're thinking in doing work around how we link urges and emergency care together across London.

[00:07:45] And we're also thinking about how we extend this concept to the digital front door so that the NHS app in London is a front door into all services. And through that, we try and deliver some capability digitally and try and avoid some demand. We've got to do the primary care or secondary care or whatever as well. So they are sort of not delivered yet. The mental health is close to delivering at the end of November. The first step will be delivering the first of all institutions.

[00:08:14] And the digital front door stuff next year. So it's all to pray for. The NHS app that you mentioned, is that specific for London or is that the national NHS app? It's the national NHS app. Okay. Does it concern you in any way, the feedback that you are going to be getting from patients and that it will become either confusing or that there would be too many requests for changes?

[00:08:42] I think because we're trying to build it slowly. And I think the key to this is to make sure that it's not a digital project or a data project really. It's a project where we need clinical leadership.

[00:09:00] And so for the end of life work, it was the physicians who were specialists in palliative care who took on the leadership of that project, designed the content and the forms that were needed. And then they worked with their patient first. They're responsible for working with their patient to initiate that care plan. The patient's sickle cell. It's a hematologist who are specialists in sickle cell disease. And there are, I think, four or five centres from that across London.

[00:09:30] Again, they're responsible for initiating that care plan. So where we have a very engaged specialist commission, I think they're up for receiving the feedback from their patient and then putting that into a management process so you can oversize and improve things. If we were to open this up generally to all patrons in one step, I think then we'd get sort of bad ways of difficulty, but you may not be able to cope with it. So we need to take a step at a time.

[00:10:00] This is a, I think it's a new thing. It's all right. And trying to get paracy in the patient, if you like, record where the patients have the cordials themselves and access it is so unoptical. But if we take it a step at a time, I think we're all better. Yeah, yeah.

[00:10:23] I kind of had the whole population of London in mind without really thinking that it's a very specific patient. No, you're right. We're segmenting it carefully as then going to the next step. But the next few groups are, you know, there's this, there's a cast here that we call living well. So how, if you've got frailty or recurse chronic problems, you know, you may have for 10 or 20 or 30 years.

[00:10:49] This group that are not going to get better, you talked about some of our talks yesterday. How do we bring those chief organs to this? So it's a big assessor group. And it just challenges some of the previous ways that you run an organ. It'll be interesting to offer that. How do you decide on which care plan is going to be the next ones, which patient group is going to get the care sense? Okay. So now that we have some traction, we are getting more interest.

[00:11:19] So we have probably got five or six areas you would like there planning to be done through this school, of course, one thing. But you've got to think of what are the conditions for success and what you want to try to define it as clearly as possible. So you've got a grievance about what the conference is through. And you've got a grievance about who's trying to truly lead this. And that we're not too prickly opening this up, too widely achieved generally.

[00:11:48] So there is a sort of, see in those organizations and those clinical networks who have asked for some support, we then have a sort of open process to try and parasite what are the next steps. So we've got patients who are in crisis in mental health condition. We've got a big group. Maternalism is a big group where we need to share their core more widely across London and help the patients.

[00:12:18] And if you think of those two, they may be very large numbers. We need to think what's the next one with tackle. So that the way we'll decide that is have the clinical groups across London agree. If you can agree and you will take responsibility and we'll likely prioritize you more quickly than if you can't agree. Okay. You mentioned the importance of trust.

[00:12:41] And one of the things that happened during the One London Project was the engagement of the public and really consulting them on their understanding of what they think they should see in single care record. It's something that friends also did when they were creating their strategy. So first research to see where people stand and how much do they understand. Can you explain that a little bit more?

[00:13:07] And are you still engaging with the public now to kind of keep up with that trust when you're rolling out new things? So the first large scale public deliberation, we call it. And it builds on work that some other countries have done. And we had an advisor from Canada, who's a world leader in this, came over in 2019 to help us with the first one.

[00:13:31] It also builds on, you can remember the Irish government took a public deliberation around the rights and rules around abortion. And so we build on some other things that some other places have done and some local council approaches in England and the UK have used this.

[00:13:56] So that first one was, we wanted to understand people's attitude towards how they expect us to use their data and for what purpose. So we were defining the contents of a record for understanding what public attitudes were. And as I presented yesterday, very high compliance, high 90% expect us to use their data for improvement and expect us to use their data to research. And that's very welcoming.

[00:14:22] The subsequent deliberations, and we've run four in total, and we will run more every year to 18 months, we'll run the last deliberation in London. And have taken us to a point where, you know, we almost are receiving instructions from the public about what our next step should be and where they want to go. And they want more of this. You know, the public want more of this. They want it in a safe and secure way. They want it in control.

[00:14:50] And we have a regular group for the public at our first three public cross-wonderance who are helping us with some of this work and are pretty well engaged in this work, you know, much more regularly now. So I think yes is the answer. We will continue it. I can't see us being successful if we don't. We don't do this. And it's a really important reflection for our clinical and organizational team.

[00:15:17] It is that the public have to have parity in the decision making. Yeah, yeah, absolutely. There are several kind of projects inside London. In London, we mentioned urgent care planning, universal care planning, transfer of care and mental health. Given that, mental health has become a huge kind of priority that needs to be addressed ever since the pandemic.

[00:15:44] Can you explain a little bit more what you're trying to achieve on that level? Yeah, so with all of these programs where we're trying to take a whole London approach, we've got to think about the sort of three or four things we need to be successful in to make the overall project. So the first, you know, if I take mental health issues across London, I think there are eight stupid mental health institutions across London.

[00:16:14] And whilst to some extent they've worked on common protocols for care and support, I haven't previously collaborated on a single platform. So they have to use the same data defined in the same way for the same purpose. So the first thing is getting them to collaborate in a way on the detail which they've not done before. And that's quite a big step.

[00:16:41] And the second thing is then saying, what's the most acute problem where we think we can make a difference? Because mental health is a huge broad spectrum of conditions and problems. So what we've decided on is that there's a lot of liaison needed between natural health services, acute hospital services, family care, the police and social care.

[00:17:09] So this space is very unconstructed from a sort of digital flow piece of work. So we're trying to plug that gap and we're starting with patients who may be sectioned against their own will. Because we think that the professional opinion is there's no guess for outside themselves or to other people. And this is a group of patients who the care is fairly variable.

[00:17:36] They tend to wait either in police cells or in the forward and the hostile AMEs for long time to decide to be made. And the communication and sign-offs between the various permissions takes a long time. Because it can be faxed still, it can be email still, people have to be phoned up. So if we can join this through a single digital assistant and link it in to the shared record and the care planning tool, then we can sort of revolutionise this going forward. But it's just a first step.

[00:18:05] And it's really important that when we take the first step into a new area, you think very carefully about how we make those first steps success. Because if we fail, we'll put back the journey a good few years. So we're going cautiously. But my hope for that is that if we can be successful in the next 12 months, at the moment I think we will be successful, then we'll start to get into more complex areas.

[00:18:32] And I think mental health collaboration across London will build in a way it's not really built to be cool. You know, there are some staffling facts. So I've got two sons and one of my sons is a policeman in London. And, you know, he tells me that when he was on the beat, although he was not being that particular job anymore, half of the call-outs they had to were their people who had some mental health condition.

[00:18:58] So the demand into other areas of society and other public services from this group of patients, through no fault of their role, it's really huge. And so if we can improve the effectiveness of those services, then I think you start to relieve some pressure and deliver better care. And we've got to think of this in the sort of wider society terms that we're trying to drive. Because the police are also pressed for money and resources, you know, and they struggle to cope with what they may say is not their,

[00:19:26] you know, their parity isn't necessarily enough to be after people with mental health conditions. Their parity is speaking of the public service, you know, so they have different priorities. So we sometimes need to jump out of our space into a bigger construction of what we're trying to achieve social. Yeah, yeah, yeah. The connection of social care and health care is definitely an important one. I always say that I love the Finnish approach where they actually have health care and social care joined up in one ministry.

[00:19:52] So you already, you know, from that point on, kind of show that that's the two things that go together. So it's interesting. I think we'd say now probably in the second half of the pandemic, we did in this country bring social care into the department of health. But at ministry level, I'm not sure that has really effectively moved out into joining up services more effectively than locally.

[00:20:22] Yeah, I think it's a long way to do it. Oh yeah, absolutely. Absolutely. And one of the things that you mentioned yesterday is that there's 24 different EHR systems across London. So it was a huge project to start to connect those. And what I'm actually wondering is, how is the move towards hospital at home, care at home, virtual work, making your job even more complicated? Because there's new players,

[00:20:51] new entrants that are trying to cater to these needs, capture the data, and then they potentially bring in, you know, new data models or new ways of structuring data that's not compatible to what you already have. Yeah. So then, if you like the virtual ward stroke remote monitoring journey, you know, I'd say 20 years ago, you know, there was some primary care service system, GP,

[00:21:19] if you were offering what they call the hospital at home service, where on their GP system, they'd have a list of patients who were looked after at home. And their community separate or a GP star could be in such short contact and regularly. So this has been going on in various guises for a long time. In the pandemic, the acute problem became, how do we decompress hospitals so we can admit patients to A&E more effectively and least to our patients?

[00:21:49] So do with the groups of patients we can discharge out of hospital or stop getting into the hospital. And so a particular focus we brought on that group and how, you know, the concepts of virtual wards could support them. And as you say, at one point in London, we had sort of 20 different suppliers. We're probably down to a smaller group now. And through the work you've done, we've tried to, over time, set some conditions into that work. So the data must be available

[00:22:19] either back into your hospital or GP electronic record so we could then get to it through the shared record. Or you must directly make us there from the shared record and there are different mechanisms for the different suppliers. The other bits of this is about how social care and local councils already have a lot of remote monitoring in people's homes should be people who are frail. And so what we see is

[00:22:48] the people with frails sleep who are aerobly and the people who have health conditions who need monitoring a healthy virtual mechanisms. The Venn diagram of those overlap is quite a lot. So what we see from a public point of view, public desorff fund use, we're sort of doubling up resources and capability in those homes. So we have started, and this work has started in Southwest London, looking at whether we can combine our resources to have one approach that serves both purposes. Again, that's early.

[00:23:18] But as we build the platforms around OneLondon, we are applying conditions that can reduce the number of suppliers, still allow some innovation to take place, but then make sure the data that's available is widely available at the point of need again. So the principles that we have established over the last two years are followed. But it is complex, right? I wouldn't want to. And it's not perfect. It's the story of old technology that you have a core of stuff, but then lots of things get bolted on.

[00:23:48] And then it feels unmanageable. So you need to reconstruct it all so it becomes manageable again. And it's what we see, you know, software suppliers and technical suppliers will revise their products in a few years. And that cycle's vastly shorter. So it's the same with us. We are moving much more to a technology cycle with improvement than a sort of traditional health-driven improvement cycle. And all that needs to be driven with consensus. What kind of stood out to me

[00:24:18] when you were talking is the, with universal care plans that you need professionals to agree on how they want to move this forward, which can be very difficult. But at the same time, I guess it's the only way forward. And if we just look from a little bit further in to the broader picture in the UK, I find it as a very interesting example where this realization, yeah, where you came to this realization

[00:24:47] that kind of doubling down on the number of decision makers is what makes sense. So, the UK went from 200 family-changing groups to 42 integrated care systems and one London specifically then further kind of doubled down on five integrated care systems. So, generally speaking, it's in the public interest and it's very easy to understand that as patients we want, you know, to have our data connected

[00:25:16] in our regions or on national levels. It's much more difficult to actually put that in practice. So, how do you see the approach that the UK took and what maybe, I don't know, other leaders could learn from that or if there's any other examples that kind of stand out to you in Europe, you can also mention those. Yeah, so, I think, I think the, you know, there are some other examples in Spain, in the Nordics that I would cite are good examples of

[00:25:46] at scale because I think scale is really important part that we need not to explain in this conversation of how you bring communities together with common aims to deliver something in common that benefits both the way the service runs and the treatment patients and the public get but also from the public's point of view the benefits then as well because both communities have to see the benefit of us to be successful. I, at one level following the 2012

[00:26:15] Health and Care Act in England there was a splitting up into 32 different commissioning groups in London and that was very difficult to try and have a consistent set of approach from and at that point we were trying to work with the, who was willing to collaborate on some things it may only have been a third of them and as we've reconstructed the way health services are organised in England

[00:26:45] into the 42 integrated care systems then I think that has helped but it's still very early in that journey because even with an integrated care system they've still got so many GPU practices so many hospitals that are all their own businesses all their own entities that all have their own decision making capability so what is it that makes people collaborate at scale and look outwardly to a greater extent than look inwardly to a greater extent

[00:27:13] and that can only be how you bring benefits either benefit in the use of resources and efficiency benefits in care and outcomes to patients or benefits that the public want and they're strongly advocating for that so what we had to do is take some sort of brave steps I would say and bring the public together because when we brought the public together in 2019 that was the first I would say

[00:27:43] that's a world class in terms of scale and output to liberation that gave us a different almost a different political access to have a conversation with our local servants to say whatever you think in your hospital or your practice your public want this to happen and here's the evidence that you're probably wanting to happen so that we could have a different way of having that conversation with services and really shine a light on previous decision making we then get

[00:28:13] over the last five years there has been a I suppose a resource constraint in terms of money and that's probably helpful because it means people have to think how can we share more and do more collaboratively get less money and get bigger benefit so I'm not sure a land of plenty is where we need to be because I think that does drive lots and lots of individual decisions and the third thing is I suppose

[00:28:42] we've tried very hard to bring together our five integrated care system with a regular set of discussions so we converge on our strategic and delivery plans over time I don't understand the problems my job as a leader is not to impose my job is to support and bring people along and to understand the problems and try and help them work through them I don't really believe in leadership by performance management I sort of believe in leadership

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