Changing the system, not the person: Increasing time to care in Dermatology

At the beginning of my fellowship...

My objectives were to create a way to measure ‘time to care’ in a specific clinic in Dermatology outpatients (Basal Cell Carcinoma Clinic) and to identify how this was affected by the implementation of an almost-fully Electronic Health Record (EHR). Then, my aim was to use this measurement to see if altering the way clinicians use the EHR to input data, showed an improvement / difference in the ‘time to care’ measurement.

During my fellowship...

The fellowship has been an incredible journey, made more ‘interesting’ by being at the time of the COVID-19 pandemic and the sweeping changes that Healthcare has gone through in adopting and trusting digital services.

Early in the fellowship, I was invited to attend the NHS Expo in Manchester where I got to discuss my project with Sir David Behan – Chair of HEE, who then invited me to the Board of Health Education England and to share my vision and reason for being a Topol Fellow.

I was then able to discuss this opportunity with the then-President of the British Association of Dermatologists (BAD) Dr Ruth Murphy, who became a great champion of what the Topol Fellowship was aiming to achieve; so much so that she put money behind a further 5 places for the second Topol cohort to be reserved for digital work in Dermatology.

Through the BAD, I was able to advocate for a new part to our National Meeting – showing what informatics and digital projects dermatologists were doing and sharing adoption of digital ways of working. We also created an ‘AI in Dermatology’ day which was sadly suspended due to COVID.

Locally, I have been part of setting up the Health Education North East and North Cumbria (HENEnC) Faculty of Digital Health with Dr John Davison. This project was started before the Fellowship but has grown to support 2 rounds of Flexible Portfolio Trainees (FPTs) in Medicine and Clinical Informatics (7 trainees in total). The project commissioned the Institute of Coding in Newcastle University to create a Clinical Informatics Training Resource, the first of its kind to be signed off by the Faculty of Clinical Informatics. Our Peer Support network for Clinical Informaticians continues to grow officially and unofficially with Leadership Fellows choosing to help leadInformatics work, with new Registrars going part-time, new Informatics posts being created, and current FPTs being given more of a grounding in what is expected from such a new specialty.

I have continued to lead our North East ‘Informatics In the Pub’ events – which have nowgone virtual – where we have had talks from other Topol Fellows and have grown the events from being a local meeting to a National Group, with speakers from across the UK and events being hosted in London, Manchester, Newcastle, Leeds and Coventry.

During the early months of the pandemic the fellowship was suspended and my job had all face-to-face elements stopped. We got in to using more Teledermatology and Telehealth resources. I was able to put together a bid to help expand the provision of Teledermatology in the North East. Sadly this was not taken up at the time, but it was nevertheless an experience of using Agile delivery to create a minimally-viable product to be vetted by others for use. I still hope this work can be used in the future to help streamline Teledermatology provision.

On re-starting the second half of the fellowship I rotated to a different hospital and grappled with a very different way of working, but found myself being able to discuss new and exciting projects with a Trust who will soon take on large-scale digital change, and share with them the insight and learning from my experience and my fellowship on how to do this as best as possible.

In the BAD we have had support to bring Digital Dermatology into the fabric of the organisation, with a new AI in Dermatology Working Group, and the 5 new Fellows being under the wing of Dr Murphy to help bring their future learning to the wider group.

Lessons learned:

1: Digital is People – leading change is always about people, but in some ways this is never more so than in the case of someone who is a Digital Leader. No matter how good an algorithm, electronic device, or electronic ‘thing’ is, it’s nothing without the people using them or understanding who they are supposed to help.

2: In healthcare, there are a lot of people who have amazing ideas, but don’t have the time to develop these or implement them. The protected time gives a healthcare worker breathing space to use their deep experience to find novel solutions to problems that have been plaguing them. It also gives permission to create, test, fail, succeed, support, learn and teach, and has been utterly invaluable for personal progression and self-improvement.

3: Working in a silo gives you a siloed view – the fellowship has been about learning from lots of different and interesting people throughout England and in very different specialties. I have had my eyes opened to the different skills that my cohort have all had, and how complementary they are when used together. I hope to never forget this aspect of having a diverse team when pursuing future projects.

4: There is a confusing pull between conservative values of tried and trusted and the want to modernise and ‘be more Digital’. Healthcare is inherently about trust. Without trust in what any healthcare professional is doing to you, there would be no modern medicine. This has been hard fought for and a long time in build’slowly but surely’ iterative way of improving healthcare. Without this focus on trust at the centre of new ways of working, especially with Digital, there will be slow progress. Having ‘trust’ baked in to being central to uptake of new way of working will allow improvements to be realised at an unprecedented speed.

5: Influencing national change is easier than local change: this has been the hardest lesson to learn. With local change actually requiring true change, this is always going to be the hardest to make happen. Healthcare is complex, complicated, and not always logical in its rules and delivery. Having a team, and especially a local senior advocate, who can guide you through the local practices to ensure a safe implementation of a project, and understanding how these changes can create consequences – sometimes dangerous, but also hopefully brilliant – are key to providing lasting safe care with the changes one implements.