Technology and humanity in healthcare: the Topol Review
11 February 2019
The eagerly awaited Topol Review for Health Education England, Preparing the healthcare workforce to deliver the digital future, has been released.
The review saw leading US physician and futurist Eric Topol – Professor of innovative Medicine at the Scripps Research Institute and author of multiple popular books (including The Patient Will See You Now, The Creative Destruction of Medicine and the forthcoming Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again) commissioned by the UK Department of Health and Social Care to lead an independent review into digital medicine, genomics, AI, robotics and other technologies are likely to affect clinical health care professionals in the next twenty years.
In particular, Topol was asked to assess how these technologies would be deployed to provide safer, more effective and more personalised patient care, and the implications of such developments for clinical roles, including training and development. The review provides an important complement to the recently released Long Term Plan for the NHS, which set out a ten year vision for the service as a whole but on many points relating to healthcare professionals referred to the directions anticipated to be set by the Topol Review.
This is very much in line with the PHG Foundation view, that technologies are tools that should free up clinicians to exercise skills and knowledge that cannot be automated and maintain the person-centred, relational elements of care that are so valued by patients
Gathering the evidence
The new Review was produced by a working group led by Prof Topol, which drew on knowledge from a wide range of experts, including a Review Board, three expert advisory panels on genomics, digital medicine and AI and robotics, seven roundtables with almost 300 participants in total, one to one interviews with other experts and an online call for evidence that generated over 100 submissions. The PHG Foundation was pleased to contribute evidence, experience and perspective on issues relating to the implementation of genomics and other new technologies to roundtables, interviews and the formal evidence submission process.
Setting the baseline for the new medicine
Several important assumptions are made throughout the Review, notably that whilst there is ‘remarkable potential’ for digital healthcare technologies (a blanket term used to include genomics, wearables and sensors, AI and apps, robotics, virtual and augmented reality, and more) to improve quality and efficiency of care, ‘implementation must only be carried out when there has been robust clinical validation’. This is a view that any health professional or policy-maker can strongly endorse, but is an important reminder that though the pace of change in technology is accelerating, and the need for agility is growing, clinical validation to ensure patient benefit will remain essential.
Recommendations included that:
- NHS Boards should take responsibility for safe and effective adoption of proven healthcare technologies at scale
- The NHS should strengthen systems to disseminate early adoption examples of effective, evidence-based technological change programmes
- NHS organisations should use validated frameworks to implement technological solutions and ensure staff are trained to use these
- NHS should work with stakeholders across sectors to review the regulation and compliance requirements for new health technologies, including cyber security, data privacy and data anonymisation
A new role for patients and citizens
The ‘new medicine’ is expected to require ‘extensive education and training of the clinician workforce and the public’ and cultivation of a cross-disciplinary approach including newer specialisms such as includes data scientists, engineers, and bioinformaticians. These are accurate observations, leading on to some important new recommendations around patient education – a new and perhaps unexpected emphasis for Health Education England – including:
- Programmes to engage and educate the public about genomics and digital healthcare technologies
- Patient education developed between the NHS, patient and carer organisations
- Co-design of technologies and transformation projects with patients, citizens and staff
- NHS online content should be a vital trusted source of health information and resourced appropriately
Other important assumptions are that patients must be at the centre of assessment and implementation of new technologies; that patients ‘willing to take greater charge of their care using digital tools and algorithms’ should be empowered to do so but that this should ‘always be an opt-in choice’ – significant phrasing in the push towards both greater use of technologies and greater patient responsibility for health.
Getting the most out of genomics
Of the different technologies reviewed, genomics is seen as one of the most advanced and likely to impact to some extent on all health professionals in the near future. To this end, core ‘genomic literacy’ training is recommended (presumably falling short of a full blown Masters in Genomic Medicine) with access to lifelong training available for a fast-moving field. Perhaps just as important is the proposal that the NHS should work with regulators to develop a ‘clear, robust framework’ for the use of genomic data by staff that ‘safeguards patient confidentiality, and inspires the support and confidence of citizens’.
The review also proposes development of accredited genomic training in key clinical specialties to help health professionals incorporate genomic testing and (presumably proportionate) genomic counselling into their practice, and calls for a framework for ‘genomic leadership’ across specialities and primary care settings to encourage and disseminate best practice and simplify patient referral systems. Expansion of the professional genomics workforce is also supported, with the suggestion that the NHS Genomic Medicine Service should build capacity for specialists in genomic medicine, genomic counsellors, clinical scientists and bioinformaticians.
Building on AI and robotics
In a similar manner to that for genomics, the Review calls for new educational resources for all health professionals in health data provenance, curation, integration and governance; the ethics of AI and autonomous systems; critical appraisal and interpretation of AI and robotics technologies. Presumably these would need to be tailored appropriately to meet the likely needs of different roles. This aside, the recommendations seem to focus on generating and accessing expertise in these new areas for the NHS, including:
- Increase the numbers of clinician, scientist, technologist and knowledge specialist posts with dedicated, accredited time to design, implement and use digital, AI and robotics technologies
- Attract skilled data scientists to work in the NHS from around the world
- Develop national Industry Exchange Networks and opportunities for the NHS professionals to partner with academia and/or the health tech industry
- Supporting the workforce
One of the most important cross-cutting recommendations, and one strongly and repeatedly advanced by the PHG Foundation, is the necessity of allowing NHS staff ‘dedicated time for development and reflection on their learning outside of clinical duties’. Without this, how can anyone beyond exceptional enthusiasts develop new knowledge and skills? The Review proposes that there should be new efforts to identify and develop new workforce trainers and educators, and for employers and Professional, Statutory and Regulatory Bodies (PSRBs) to support general digital literacy training at all levels, including in ethical and patient safety considerations.
It is further proposed that HEE should establish as a counterpart to the existing Genomics Education programme a new NHS Digital Education Programme to oversee the implementation of a national digital education strategy.
With respect to existing and new specialist workforce development in genomics, digital medicine, AI and robotics, it is suggested that they need extra support to ensure continued innovation, and that the NHS should:
- Develop or expand both educational programmes and attractive career pathways
- Commission flexible and responsive training for specialist roles
- Work with PSRBs and other bodies to introduce and strengthen accreditation of newer specialist groups
Seek to attract graduates in engineering or computer science or allow healthcare students to train in these areas Develop courses to increase the number of specialists in the evaluation and regulation of technologies
Giving the gift of time
Finally, the Review also proposes that technologies offer ‘the gift of time’ that can deliver better patient-clinician relationships with ‘a new emphasis on the nurturing of the precious inter-human bond, based on trust, clinical presence, empathy and communication’. This is very much in line with the PHG Foundation view, that technologies are tools that should free up clinicians to exercise skills and knowledge that cannot be automated and maintain the person-centred, relational elements of care that are so valued by patients.
One of the most important cross-cutting recommendations, and one strongly and repeatedly advanced by the PHG Foundation, is the necessity of allowing NHS staff ‘dedicated time for development and reflection on their learning outside of clinical duties’. Without this, how can anyone beyond exceptional enthusiasts develop new knowledge and skills?
Taking the next steps
All in all, this is a well-reasoned, forward-looking and eminently practical report, which we should expect to be taken very seriously indeed by all those concerned, not least the Department of Health and Social Care, NHS England and Health Education England. Looking ahead, the PHG Foundation is continuing to work on implementation issues for genomics, AI and other technologies in healthcare, not least in our major My Healthy Future project which examines the wider potential policy implications of future scientific technological developments, and will be reporting later this year.