< Project Overview >
A large proportion of chronic diseases that plague healthcare systems are preventable or can be brought into remission through lifestyle interventions; indeed, 70% of health outcomes are determined by social factors.
An emerging approach that is trying to address this issue is to utilise social prescriptions, which provide “a way of linking patients in primary care with sources of support within the community to help improve their health and well-being.” Social prescriptions can address mental and physical health through activities like sports and leisure/arts and can address social factors related to health through activities more focused on social issues (housing, food, etc.), education or skills development. One class of technologies which can be particularly helpful for social prescriptions are Internet of Things (IoT)-related sensors and wearables, which could facilitate the passive collection of real-world evidence through:
- Remote monitoring
- Collection of behavioural data
- Collection of personal health data (e.g. EKG, Bodyweight, Temperature, etc.)
- Collection of environmental data (e.g. air pollution, temperature, etc.)
The active utilisation of IoT to support social prescriptions faces several barriers and to understand how these barriers could be addressed, a team of researchers and practitioners from the Universities of Oxford and Sheffield and the Royal College of GPs (RCGP) initiated a project supported by the Pitch-In project; below we highlight the outcomes from the project and the insights we were able to gain, as well as ideas for how we will take this work forward.
Despite its promise and the support from NHS England, social prescriptions have not been able to scale – in 2017/18 there were fewer than 70,000 social prescription referrals across England.
To help scale the use of social prescriptions and facilitate its disruptive potential, digital technology needs to be utilised more effectively because:
- digital technologies make it easier and cheaper to obtain relevant information on individual patients, providers and the system;
- they can increase flexibility outside of the traditional place-based care approach (e.g. through remote monitoring);
- they provide 24/7 interaction and automated functionality with the ability to provide nudges to patients and for the user to deliver frequent feedback as needed.
There are several strategic, operational and tactical barriers that we must overcome to fully realise the disruptive potential of IoT-enabled social prescriptions. Three key barriers that we have identified include:
- Educational Barriers: Lack of familiarity with the technology on the part of the care providers, and with the domain on the part of the technology providers.
- Connectivity Barriers: Lack of knowledge of various stakeholder skills and interests
- Business Case: Lack of understanding in how IoT will/can generate value in a given application domain
What was done
To better understand the views of stakeholders on the ground about the potential role that technology could play in supporting social prescriptions, we convened a multi-stakeholder focus group in April 2019 at the RCGP headquarters in London with representatives including GPs, link workers, patients and social prescription providers. The aim of the focus group was to better understand the challenges and opportunities these stakeholders saw with regard to social prescriptions as well as to get insights from them on the role technology could play to overcome the challenges they faced, which directly helped to address the educational and connectivity barriers. We captured information about this using a worksheet and expert facilitation.
The insights from the focus group were used to design the agenda and approach for our workshops – namely that rather than focusing on specific IoT technologies, it would be best to focus on the data that stakeholders would need to capture to more effectively and efficiently deliver their services. Two workshops were held with two key user groups – social prescription providers (workshop held in Oxford in May 2019) and social prescription prescribers (workshop held in London in June 2019). We utilised personas that reflected generally prevalent health conditions (teenager with mental health difficulties; adult with type 2 diabetes; elderly individual with complex needs experiencing bereavement and social isolation), worksheets and expert facilitation to capture insights from participants.
The focus group yielded some very important insights about the gains and pains stakeholders experienced in relations to the use of social prescriptions (Table 1 – deliverables) as well as the key job to be done in this domain –“A joined up and well-coordinated SP ecosystem.” The gains and pains were disaggregated into strategic, operational and tactical needs of our two key user groups (Table 2 – deliverables). We did not have much success in eliciting examples from our stakeholders on how technology could be used to address the gains/pains but this is not to say that examples of the use of technology in this domain do not exist; rather, it may reflect the small sampling of stakeholders we were able to work with in this Focus Group. One general comment with regard to how technology could add value for social prescriptions is to determine, “What does it do that Google can’t?”
The results of the Focus Group helped us to better direct our approach for the workshops. Instead of focusing on specific uses of technology and IoT, we asked our stakeholders what data they wanted to capture when either prescribing or providing a social prescription. To facilitate the process of identifying some metrics, we used personas, an established design thinking approach, to help focus our participants. Using facilitated group work and our worksheets, we then captured information about what data related to inputs, outputs and outcomes technology could help us capture (Table 3 – deliverables).
Deliverables and outputs
Table 1: Outputs from the Focus Group – highlighting the gains and pains related to social prescriptions.
Table 2: Outputs from the Focus Group – highlighting the strategic, operational and tactical needs of two key users groups in using social prescriptions.
Table 3: Outputs from two workshops held to understand how IoT could support social prescriptions. *Persona A: 16 year old girl of Korean descent (her parents immigrated from Korea) was found by her parents to be self-harming for the past 3 weeks (she cuts herself with a razor on her inner forearms). **Persona B: 40 year old male of African descent has just been diagnosed with Type 2 Diabetes. He is married with two kids and has an office job that requires him to commute 2 hours per day. ***Persona C: 75 year old deaf woman of Caucasian descent whose wife of 40 years passed away 2 years ago and who is finding herself increasingly isolated and lonely.
The key impact from this project comes from the insights we have gained, which will allow us to design future projects and also inform the design and operationalisation of policy in this area. The key insight we gained from this project was that IoT in the context of social prescriptions needs to be seen as a means to an end – namely, IoT technologies can play a role in enabling social prescriptions by collecting information that would be of use to key stakeholders, in our case this was limited to social prescription prescribers and providers, using social prescriptions. This relates to the barriers we originally wanted to address (e.g. educational barriers, connectivity barriers, business case) in the following ways:
- Given how fast technology is evolving and how little time healthcare professionals have to keep up with all of these technological evolutions, the most practical way to education healthcare professionals about the use of IoT for social prescriptions would be to explicitly highlight the social prescription-related data, which should be something the healthcare professional needs, that could be captured by the IoT technology.
- IoT providers looking to enter into this space should make their unique selling proposition based on the data their technology can capture. Further to this, they should design their technology with busy healthcare professionals in mind:
- It should be as easy to use as possible;
- The data flows from the technology should be able to be integrated into existing data flows and ideally with the electronic health record used by the healthcare professional;
- The hardware components should require infrequent upgrades so that busy healthcare professionals do not need to be retrained in how to use it;
- Software updates should be seamless and should be mindful of integration into existing data flows and usability requirements of the healthcare professional.
Social prescribing supports individuals to identify their personal goals and facilitates the use of community assets to meet these goals. Technology, and IoT, in particular has a very important role to play in supporting the development and delivery of social prescribing because technologies like wearables and sensors can provide essential insights about individual preferences, behaviours and outcomes that previously were not possible to collect.
From our focus group and workshops it was apparent that the healthcare professionals we worked with were not fully aware of the benefits that IoT could provide them with. One potential reason for this may be that IoT technologies are not currently designed to meet the needs of healthcare professionals and healthcare professionals may also be unaware of how to educate themselves about the benefits IoT could provide them with.
To address these two areas, we plan on progressing our work by facilitating interactions between healthcare professionals and technology providers/developers to design 2-3 ideas based on the outputs from our workshops. that we will seek to pilot. In early 2020, the RCGP and University of Oxford Department of Primary Care will also initiate a project to design and deliver a training course aimed at educating GPs about the use of technology in improving patient care. This work is part of an EIT Health-funded project called PREDIGIT, which is being run by the University of Oxford team alongside RCGP, IESE business school and the University of Grenoble.
On the larger work around social prescribing, our focus groups and workshops highlighted the general lack of knowledge about how social prescriptions are being used in practice. These insights were used to successfully approach NHS England with an idea to utilise the RCGP’s Research Surveillance Centre, a sentinel network of 1,100 nationally representative GP practices (~15% of the total practices in England), to create a social prescribing observatory that is updated weekly with information on social prescribing utilisation across the country and for different segments of the population. This can be found on https://clininf.eu/index.php/social-prescribing/
Finally, we would like to address one very large gap in this project which was the lack of formal and thorough engagement with patients. We are in the planning stages of initiating a project that would see us working more actively with patient groups to garner insights on IoT-related elements that they would find useful in business to consumer IoT technologies that could help them adhere to social prescriptions – both self-prescribed as well as those prescribed by a GP.
This project gave us the opportunity to work together more closely with the RCGP and University of Sheffield on a project that aligned with our individual and joint interests – namely, how can we use technology to promote health. We have been able to leverage this project to create two follow on projects exploring how GPs can be trained to use digital therapeutics and another project looking at the general barriers and facilitators for the use of IoT to support health and social care.
It would have been great if we were able to engage more patients and patient groups in our workshops. While we had great clinical and commissioner input, we did not have a wide enough group of patients for our workshops.
I think if there was a common and shared list of contacts within all of the Pitch-In project groups, it might have made it easier to coordinate some of the workshops and also increase learning/sharing between the different Pitch-In projects.
What has Pitch‑In done for you?
Pitch-In gave us the chance to come together as a multi-stakeholder group to explore the critical role IoT could play in improving patient and population outcomes while optimising resource utilisation.
Dr Anant Jani, University of Oxford