It compares and contrasts the use of remote monitoring technology in the US and UK to support patients at home, both in terms of release from hospital and to manage long term chronic conditions.  Its main conclusion is that the UK is far better positioned to benefit from this than the US.  But there’s one proviso - that the UK needs to put in place a system that allows patient records to be shared between those involved in care, including the patients themselves.

The report acknowledges that this is currently lacking in the UK, but predicts that this will be remedied during the course of 2010 by the introduction on Summary Care Records (SCRs).

Pam’s obviously not spoken to the British GP’s Council.  This week their chairman - Laurence Buckmann, made a presentation to the Local Medical Committee’s Conference calling for SCRs to be scrapped, ostensibly because they require a patient to opt out, rather than opting in.  It’s part of an ongoing campaign against SCRs by the British Medical Association (BMA) that makes Luddites look progressive.  And which seriously threatens innovation within the NHS.

The Summary Care Record scheme is almost always prefaced in the media with the adjective “controversial”.  It’s not because patients find it controversial, but because of a well publicised storm that has been whipped up by members of the medical profession within the UK.  Ostensibly they fear for the security of patient data; their opposition is on the pretext that patients should opt-in, rather than being automatically included, with the option to opt out.  One would have thought that fifty years experience of getting patients to sign organ donor cards might have suggested that this would not work.  Look a little deeper and you see the underlying slyness.  Taking this approach is almost certain to ensure that only a small percentage of the population signs up, so that SCRs never achieve the critical mass to be successful.   It’s a cynical attempt to lobby for failure and to preservation the status quo.  Sadly, the new Government appears to have been sufficiently fooled by these views to call for a review of the scheme. 

Aside from their campaign to delay the project on the basis of security doubts, there’s a steady drip feed of comments suggesting that having accessible records will not provide any benefit.  On the British Medical Journal blog we hear that they are “unaware of any evidence that the SCR will dramatically improve care”.  A well publicised report from University College London reports “no direct evidence of an improvement to patient safety although findings were consistent with “a rare but important impact of the SCR on reducing medication errors”.

The UCL report, sensitively and non-provocatively titled “The Devil’s in the Detail”, highlights that “as of 1 March 2010, of the approximately 8.5 million people who had been sent information about the SCR, 0.65% had opted out. 1.2 million SCRs existed and 14,266 had been accessed.”  It observed that fewer people had registered than had been expected, explaining this on a “clunky” interface and complex registration process.  They failed to observe that a contributing reason may have been a vocal campaign by GPs, backed by the BMA, for people to boycott it and the fact that most local GP surgeries had not signed up, so you couldn’t actually set your SCR up.

Even where SCRs were used they experienced “wicked problems”, (I love the emotive use of words in this report - Wicked Problems is actually a chapter heading), foremost of which was tension over defining what data should be included.  In my experience, SCRs have been hampered by a largely academic debate over what they should contain.  Rather than trying them out and using an evidence base to see what is useful and what not, deployment is being pushed into committee rooms, whilst patients are left with a healthcare system that relies on shuffling mountains of paper around and repeating data inputs multiple times. 

What was also striking in the report, and I don’t know whether this is following practice or not, is the absence of patients from the design, governance and implementation networks.  The report claimed that it initially tried to measure whether the use of the SCR had contributed significantly to patients’ satisfaction, but abandoned this because they found it impossible to judge.  In other words it’s the same old story - Doctor knows best.  And at the point that the patient does get involved, Doctor tells them not to use it.

Once outside the GPs grasp, the report becomes more positive.  Amongst nurses, “the highest users of the PDA device were, unsurprisingly, those who considered themselves confident with the technology and were keen to innovate. The PDA aligned with such nurses’ identity and values (as a mobile workforce, they saw a mobile technology as very appropriate). Working in an organisation where they were not routinely given a simple mobile phone, they felt valued and rewarded when given the more technically sophisticated PDAs. High users of the PDA commented that they felt it increased their credibility in the eyes of the patient, partly because they could show the patient his or her own record at the bedside. It is possible, but only a hypothesis at this stage, that a demonstrable link with the main NHS records system made the nurses seem more a part of the trusted NHS system in the patient’s eyes.”

At that point it’s worth jumping across to the Healthcare at Home report.  Having compared US and UK practice, it concludes that shared health records are absolutely vital to its success.  It’s setting its hopes on the availability of SCRs in the UK to replicate the success in managing chronic disease management that it’s seen in the US.   They highlight the experience of the Veteran’s Association, which has used home telehealth, combined with case management for a number of years.  They’ve seen a 25% reduction in bed days, 20% reduction in admissions and an 86% patient satisfaction rating.  As a result they’re scaling up their approach to reach 110,000 patients by 2011.  (UCL please note - someone knows how to measure patient satidfaction.)

One of the most important messages this report brings back is the need to “Make every interaction count”.  It observes that where there is real benefit, particularly in a fragmented delivery system, such as is case with hospital, GP and social care in the UK, that we move from focussing on the particular function of each professional delivering an intervention to joining the dots, where each intervention can reinforce the others.  That means messages from previous visits can be constantly reinforced to help cement a health regime, whether that’s taking medication, appointment reminders or health measurements.  What they all need is the provision of consistent information, both to the patient and to each health professional they interact with.

Experience from California shows that in a lack of accessible medical information compromises quality and cost, and that the availability of data across organisational boundaries, as well as between clinician and patient, improves care (see the report for references). 

It is difficult to understand the antagonism of the BMA and GPs towards sharing information, other than as an attempt to maintain control of a hierarchy that owes its form to a Victorian Guild structure rather than a modern approach to evidence based medicine.  I think that many nurses understand the benefits.  But the higher you move up the professional chain, the more reluctance there is to accept that the patient is part of the solution, rather than being the raw material of the day job.

Sadly, it appears that the GPs have the ear of our new health minister - Simon Burns.  The Government has announced that they will ring-fence health spending, and it looks as if they’re also ring-fencing the ingrained prejudices of those within the NHS.  I’ve often referred reader to Clayton Christensen’s excellent book analysing the healthcare industry - the Innovator’s Prescription, and I’ll do so again.  He argues that the mix of healthcare professionals we will need in the future is different from the mix we have at present.  We’ll need fewer specialists, those we have will need to be better trained in intuitive medicine in a multi-disciplinary team environment, and that the work done today by general physicians will be taken over by nurse practitioners.

It is telling that in the UCL report, this last group was the one who found most benefit in SCRs.  That should have been an important part of the report’s conclusion.

In conclusion, if you happen to be Simon Burns, or someone who talks to him, or advise him, please realise that we do need Summary Care Records.  If you question why, go out and read the Innovator’s Prescription and then read the Healthcare at Home report.  Don’t listen to what the profession may be telling you - their agenda is one of survival.  Look at healthcare with disruptive eyes and think about the patient.  Ask why a GP has a stronger claim to ownership of that data than the patient themselves?  It needs to be accurate and trusted, but it also needs to be shared.  Patient accessible records are a vital component of giving people the joined-up healthcare system they deserve.  And it might even make it cheaper.

It’s a bit like the case of a child who has hitherto only been allowed chocolate on Christmas Day.  Now they’re being led into a chocolate factory and told they can eat as much as they want.  The inevitable result is a very happy child for a few hours, until they’re violently sick.  At which point they either vow never to eat another chocolate, or learn to treat it in a more sensible manner.

Today the medical industry and energy utilities are being shown the doors of the chocolate factory.  We have yet to see how they behave once they enter it.  Some may emerge as triumphant Charlies, but others risk becoming the commercial equivalent of Augustus Gloop and Veruca Salt.

The first point to address in this new world of data overload is the assumption that we’ll be able to do lots of useful things once we have this data.  There are lots of companies painting a picture of automated homes and lifestyle medical devices based on analysing this tsunami of data, but as yet we don’t know how much can be inferred from it, let alone how we will be able to use it to control other devices.  The assumption that having over a million times the volume of data every year (one reading every three seconds instead of one per year) is going to tell us anything useful is still exactly that - an assumption.  The nightmare scenario is that it doesn’t - it’s just random noise.

I fervently hope that’s not the case and that the data is useful, but to confirm that needs a lot more work.  mHealth and smart energy aren’t the only markets facing this problem - the U.S. military acknowledged it recently, when they said “we’re going to find ourselves swimming in sensors and drowning in data.” We are moving from drawing a straight line through two points to drawing one through a million of them.   At the most basic level, it involves a fundamental change in the underlying business model.  Both the medical profession and the energy utilities currently work on the assumption that if they hear nothing from us, they can ignore us for the next year.  Now they’ll be hearing from us every few seconds.  It’s not just the volume of data that is available, but the question of how to react to it.  That new granularity will show deviations from the straight line, whether it’s raised blood pressure or turning on the hosepipe to water the petunias.  What should a supplier do about it?

In the past, the safe route has been to ignore everything, not least because you don’t known about it, and it will probably have gone away by the time of the next data point.  Once you let the cat out of the bag and tell the consumer that you are monitoring their every move or cup of tea, then they will expect more feedback.  That means more resources on the part of the provider, which is likely to mean more cost.  Where’s the business model that supports that?

It suggests that the industry needs to step back from some of the more complex technology and fanciful gadget push that is appearing in the market and instead concentrate on answering the basic question.  Which is “what can I usefully do with the data”?  That means working with simple sensors that can collect the data, and back end systems that can then aggregate and mine it.  When the UK’s Technology Strategy Board was collecting input for their Assisted Living Innovation Program, I argued that they should do exactly that - deploy ten thousand or more sensors of whatever variety and concentrate on collecting and analysing the data.   I’m pleased to say that they’ve embraced that approach.

It is a critically important task for anyone who is moving into M2M (and that is essentially what mHealth and smart metering are).  You need to start by understanding your data.  Only when you have done that can you start to decide what value it has and whether a large scale deployment is justified.  That justification might be because it makes your business more efficient, it might be because you can offer additional services to your customer, or gain a competitive advantage, possibly by disrupting the market.  Or it could be because a government pays you to do it; but if they do, will they continue to pay the long term, day-to-day operating cost or working that data?

The problem is that you’re unlikely to know the answer to these questions until a year or more after you’ve deployed your first ten thousand devices and collected and analysed that year’s worth of data.  That’s a large initial expense with no immediate return. 

If the resulting business model is customer oriented, rather than profiting from internal business efficiencies, then it needs to include some compelling feedback if the user is going to want to continue to use it.   That in itself is a new area for both the medical and energy industries.  Neither use a language which the consumer understands, at least until the day the bill arrives.  Instead they stick to scientific jargon with BTUs, kWhrs, systolic and diastolic pressures. 

Consumers are far more interested in comparisons - for them these provide the compelling feedback.  That means simple comparisons such as “are we spending more than we were?”, “more than our neighbours are?”, “are we getting better?”, “should I have eaten that extra doughnut?” need to be developed.  None of these are the type of information that these industries have experience with, but if they are going to provide a compelling service they need to take into account customer psychology.  Even when that is done it may not have the desired effect, as evidenced by the recent report which found that when told they are using less energy than their neighbours, Republicans tend to compensate by increasing their energy usage.

To add another level of complexity, many of these comparisons raise privacy issues that are new to these industries.  Comparisons are normally more persuasive when they’re made with a group of peers, rather than just comparing past performance.  But how many companies are aware of what they are allowed to do in comparing an individual against data from other customers?  How much granularity can you use in comparisons with a neighbour?

Some companies are trying to leapfrog the data learning stage by selling a vision to customers.  A good example is Fitbit, who are using thir initial customers both to build their database and provide feedback.  However, for established businesses, which are those that will be supplying 99% of energy and healthcare users, that’s probably not an option.

Equally difficult is answering the question of how often feedback should be provided?  Should it be realtime - “turn it off now”, or after the event?  Should it affect when you are doing something, i.e. trying to change behaviour now, or retrospectively?  Even before we get to schemes such as energy shedding, which will turn off appliances, we need to know much more about the usage models behind data before bringing further automation into the picture.

These are difficult questions, both for new and established industries.  However, the fundamental order remains unchanged.  First you need to acquire the data.  Then you need to understand what it means.  Only then can you determine what that implies for your business model.  Keep an open mind and be flexible in building those business models.  Whether they be improved efficiency, customer retention, Government mandate, future sales through behavioural modification or company acquisition, they all need a company to take the time to understand the data and develop a consistent model.  Otherwise, you may look back and wish that you’d kept chocolate as a once a year treat, and never entered the chocolate factory.

It has all of the characteristics of the next technical bubble, but with the added benefit that, if we can make it work, it might actually save our healthcare systems from terminal meltdown. We need the disruption that mHealth will bring.  As Clayton Christensen points out in his seminal book - The Innovator’s Prescription, the only way we are going to effect a major change in healthcare is through the introduction of new, parallel business models to challenge those that our current healthcare structure is built on.  That will need new technologies that provide more effective diagnosis of symptoms, as well as devices that encourage personal participation in healthcare by putting monitoring and health records into the hands of patients.  Which are exactly the areas being targeted by the mHealth community.

However, there’s an invisible gorilla in the mHealth room that could consign the whole enterprise to history.  It’s called the FDA.  The FDA has the ability to apply regulations that would choke the development of mHealth.  Like all regulators, the FDA moves slowly - far more slowly than the emerging mHealth technology.  It is important for the industry to engage with it to reset the levels of regulation for mHealth.  What is worrying is that most of the noise around regulation is not about that resetting of expectations, but scare-mongering about the possible reaction of the FDA to an expansion of connected healthcare and new delivery methods.  It’s important that manufacturers understand the barriers that regulation might bring, but we’re at risk of crying “Wolf” to the extent that mHealth may never happen, or else only evolve outside the U.S.

Over the last six months, as the mhealth debate has progressed and new consumer applications have appeared on the market, I have seen a worrying trend for regulators to react to this new technology by making noises about the need for them to enlarge their sphere of regulation.  I’ve already argued that if consumer healthcare is to flourish we need a new patient manifesto that does exactly the opposite.  There are positive things happening - groups like the Continua Health Alliance are helping the FDA to understand the implications of mHealth, but that’s not a message that much of the industry is hearing.

Instead, legal firms and regulatory consultants are increasingly talking up the dangers that may exist within the compass of existing regulation.  Its effect is to reinforce the view that regulators are evil tyrants who may kill your business.  It may be implication and surmise, but it’s sowing exactly the wrong message that we need if we’re going to encourage disruption. 

If you’ve been reading the mHealth blogs or attending conferences, you’ll have come across the excellent articles by Bradley Merrill Thompson.  If you haven’t, you need to join some LinkedIn groups dealing in wireless or healthcare.  I’d urge you to do so, as he speaks a lot of sense and probably knows more about the FDA and its attitude to new technology than anyone else.  As well as being eminently knowledgeable, he’s an enjoyable speaker.  He wowed his audience at the recent Continua Summit and had them shaking in the corridors as they jumped at the imagined sound of FDA bogeymen behind every coffee urn.

Like his namesake, Bradley likes lobbing bricks to wake his audience up.  His message is that the FDA’s existing charter is so wide that the organisation could, if it wanted, regulate any device with a medical purpose, or indeed any part of that system.  If that seems like make-believe, it’s not.  It is deeply worrying to discover just how wide its remit actually is, and even more so to learn what its aspirations are in terms of increasing its sphere of influence.

For the medical industry we have today, that’s not necessarily considered to be a bad thing.  As with all regulation, the FDA helps to maintain the status quo, not least by providing a barrier to new entrants.  However, at a point where the industry needs disruption, that aversion to change threatens to stifle or deter innovation. 

To change that attitude, we desperately need to attract new entrants into the industry, as they have the most incentive to lobby for regulatory change.  It’s an approach that has risks - it will almost certainly mean that we let in some of the more dubious ends of the medical spectrum.  But the alternative - maintaining, or even increasing the current level of regulation, will inhibit disruption and lead to a system that cannot serve the changing population demographics. 

I’ve argued that if personal healthcare is to move forwards, we need less rather than more regulation.  A level of dodgy, alternative mHealth may be the price we have to pay if we are going to make serious progress.  And regulators will hate it, as not only will it potentially remove some of their powers, it also means that new entrants, who are not part of the established medical club will try to tell them how to do their job.  But to achieve any of this, we need to persuade manufacturers outside the health sector to come and join in and help put pressure on the regulators.

Experts like Bradley are telling the story as it is, warning manufacturers new to the market of the potential issues with regulation.  However, without any firm signs of movement from the FDA, endlessly repeating the warnings of impending doom sends a signal to new entrants to avoid the market, or at least the US market.   As a result, I worry about the number of companies that are should be thinking about entering the healthcare market, but are putting their plans on hold.  Without their voices, it will be slower and more difficult to lobby for regulatory change.

We need to ensure that message gets across, but that message needs to be used to argue for a reduction in regulatory power, rather than putting the fear of God into potential disruptors.  Otherwise we risk stopping investment and innovation.

Patient centric and regulated medicine currently live at diametrically opposed ends of the regulatory scale.  The patient centric end needs more proponents to push its cause.  There is much that the mobile industries can bring to the table, as their business model is firmly based on being user centric.  They need to be encouraged in their new foray into healthcare and taught how to engage with the regulators to find common ground.  Not worried, otherwise they will put their effort into other ventures.

It is, of course, far easier to live with the limitations imposed by a regulator and make good consultancy income from advising companies on how to work around them, rather than getting the regulators to move to meet the market demand.  As Bradley puts it in one of his presentations “Arguing with a lawyer is like mud wrestling with a pig: after a while you realize the pig actually enjoys it.”  But mHealth needs those barriers to be moved, and to achieve that we need to encourage as many companies as possible to come to the table.  It may be hard; it may take time; but if we just stress the difficulties and dangers we may never attain that critical mass, which may endanger the whole future of mHealth.

Of course, those of us involved with healthcare know that this is more than just an election issue.  The changing demographics mean that the NHS, and every other health system in the world is heading for financial meltdown.  Rather than acknowledge it, our politicians (even those who have been pushing through the U.S. Health reform bill) are doing little more than being fitted for their lemming suits and asking for directions to the edge of the cliff.  We cannot afford healthcare in its present form and we’re running out of time to address that inconvenient truth.

One straw that is invariable grasped and brandished is the potential of mHealth (or eHealth, telecare or eCare) to sweep away the costs.  So in the spirit of helping our flailing politicians, I thought it might be an opportune time to review how it’s doing.

The first important thing to realise about mHealth is that it doesn’t need to be complex.  Much of what can be achieved is through better management of resources and improved prevention.  Back in 2005, the Sunday Telegraph reported that missed appointments cost the NHS £575 million every year.  That’s enough to pay for 27,000 nurses or another 8,000 doctors.  Don’t forget those numbers - we’ll come back to them later.

The obvious solution is to send reminders to patient’s phones.  Back in 2005, a large percentage of patients didn’t have mobile phones.  In the intervening five years that’s changed and companies like iPlato have been successfully rolling out a wide range of these text based services.

A further report was commissioned by mobile phone operator Vodafone, with the research carried out by Tanaka Business School, which was published the following year.  It identified additional savings that could be made by using SMS support services for TB and diabetes sufferers.  The report, titled “The Role of Mobile Phones in Increasing Accessibility and Efficiency in Healthcare” was available at www.vodafone.com/healthcare, until last year, when Vodafone announced its new mHealth initiative, at which point the healthcare section of its site mysteriously disappeared.  You can still find it elsewhere on the net, and it’s worth a read.

At the same time, Orange Healthcare announced plans to launch an SMS reminder service in the UK. Their SMS gateway would also allow surgeries, hospitals and clinics to send out appointment reminders as well as to follow up appointments remotely.  So with the pair of them supporting it, that ought to mean we’re saving our first half billion pounds.

Of course, mobile telephony is such a pervasive part of our everyday life that it worms its way into many other areas of the NHS.  Keeping with the worm analogy, one of the more bizarre savings being proposed is the use of maggots to treat wounds.  Believe it or not, 35 of our MPs, back in the heady days of fraudulent expenses, proposed that the NHS could save tens of millions of pounds by using maggots to eat the dead flesh on wounds, helping to prevent the spread of MRSA.  I’m not sure whether maggot therapy can be counted as mHealth, but we’ll add it to the savings bucket.

Many commentators believe that the management and bureaucracy of the NHS needs to be reformed.  And who better to do it than patients and doctors?  According to Lloyds Pharmacies, a new generation of internet savvy and iPhone toting mothers are dispensing with doctors altogether, diagnosing their little darlings themselves and dosing them up at the local pharmacy.  In the course of which they’re saving the NHS £825 million a year in prescription costs.

NESTA - the National Endowment for Science, Technology and the Arts, goes further and thinks that the mums and doctors ought to get together to redesign healthcare.  Their rather aggressive report on “Patient Designed Services” reckons that this could lead to savings of £15 - £20 billion over the next few years.

Whilst the doctors are busy at their coffee mornings comparing iPhone apps with the mums, there’s a lot to be said for taking care of the remaining NHS staff who will inevitably end up doing all the work.  Last year, an independent report by Steve Boorman outlined how NHS organisations could tackle staff health and wellbeing and save up to 3.4 million working days currently lost to sickness  - equivalent to 14,900 extra staff or £555 million per year.  Once again, a lot of what is suggested can be accomplished by using mobile phones, text alerts and a new generation of simple, connected health and fitness devices.

Of course, they could start off by walking to work.  Not slow to jump on a bandwagon, the Ordnance Survey revealed that it had calculated the benefit of walking.  By promoting walking, they believe that people could tackle their weight issues, reducing the incidence of early onset diabetes and saving the NHS half a billion pounds a year.  Which is timely, as companies like fitbit and fitlinxx are just starting to sell internet connected pedometers - some of the first consumer mHealth products.

Others prefer to look to the automotive industry. After Gerry Robinson sorted out the NHS, BBC radio suggested that we could learn a lot from Toyota.  Back in 2008, they enthused about Toyota’s production principles, claiming they could be applied to healthcare. Compared with Western systems, Toyota’s approach is tortoise versus hare: rather than seeking efficiency by speeding up individual activities, it focuses on improving the flow throughout the whole system, concentrating rigorously on customer demand. The result: a race-winning combination of higher quality and lower cost.   Of course, that came before the recent Toyota recalls, so some might decide it’s safer to avoid the stuck accelerator of medical management and stay at home instead.

The good news is that you can still save the NHS money by staying at home.  A recent report, ‘Hospital care at home’ by Healthcare at Home Ltd and Dr Foster (not from Gloucester), has shown that the free provision of home-based hospital care could save the NHS £1.2bn.  Most of these services rely on remote sensors - either in the form of assisted living sensors, or more critical connected personal monitors.  So mHealth triumphs again.

Of course, this may be too late.  After all, in January 2007, a report from the British Medical Association said that unless the NHS were to undergoes a major overhaul, the Government will be forced to either cut the services it provides or to introduce a partially private system.  Their prognosis was pretty terminal: that the NHS had only a year in which to be saved and that urgent action was vital.  Incidentally, this is the same BMA who last week halted the Government roll-out of Summary Care Records (SCRs) that could be accessed by patients.  Not to save money to save the NHS, but because it was happening at “break-neck speed”. 

Summing up, I’ve done my sums based on all the saving that I’ve come across. And I reckon that if we can use mHealth to achieve all of those savings that have been promised above, it accounts for about £13.5 billion pounds a year.  Which is more than the NHS spends on drugs.

Of course, you have to question how real the saving actually are?  Back at the beginning we looked at the £575 million every year that could be saved from getting patients to turn up for appointments. That’s the equivalent of 27,000 nurses or 8,000 doctors.  It’s a good solid application that is already out there and working, unlike some of the other more fanciful ones.  But if you keep on employing those 27,000 nurses or 8,000 doctors you don’t realise the savings.  You may have made the system more efficient, but with staff costs accounting for around 70% of the NHS budget, the only real savings will come from reducing staff numbers. mHealth may provide the route to achieve efficiencies that allow this, but by itself mHealth will add cost (because it involves additional new services or hardware).  That’s a lesson that politicians and planners need to understand.

That’s my brief manifesto for mHealth and saving the NHS.  Sadly, it’s probably as detailed as anything I’ll hear from this election campaign.  I’m convinced that mHealth is where we need to go, but as soon as it starts delivering its promise, it will require some unpleasant decisions to be made regarding the number and type of medical staff that are needed.  If the BMA thinks SCRs are a problem, they’ve not even noticed the tip of the iceberg.

At the heart of the problem is the integrity of data that goes into a clinical record.  Until recently, data was only ever entered by members of the medical profession.  The advent of accessible electronic health records means that patients can begin to enter their own data or modify their records.  Whilst I believe that’s the way the world has got to move, it raises important issues.

Take the case of Julia…

Julia is fictional - a healthy twelve year old who I’ve made up to provide an example of the problem.  She’s coming up to her thirteenth birthday.  Last birthday, her parents gave her an iPhone which had a personal ICE medical record on it, which allows users to add and edit data.

Julia, like many kids, like vampires.  She’s just been sitting in her room watching a film where the Transylvanian locals are close to exterminating the last vampires.  To preserve their line, the last two vampires cunningly mutate their blood to the previously unknown AB- group, telling each other, as the stakes go through their hearts, that whenever two AB- parents have a child, then their first issue will be a vampire, preserving the species for ever.  (Don’t ask about the science - it’s Hollywood.)

Not surprisingly, Julia thinks this is rather neat, and that it would be cool to update the health record on her phone from Group “O” to Group “AB-”, so that she can show it to her friends at tomorrow’s party and tell them her first baby’s going to be a vampire.  Her application lets her do it.

Walking across the car park to her party, she’s knocked down.  An overstretched hospital believes the information that her distraught mother reads from her phone and forgets the basic pre-transfusion checks…

It’s a rather forced, extreme example, but it illustrates the dilemma of personal health records.  Once individuals can update their records, then the meaning of medical records change.  It’s a fundamental point, but one that tends to get lost.  Patients may do it for perfectly valid as well as more nefarious reasons.  They may want to make changes to affect their insurance, to claim malpractice, to effect a change in their medication, to make their doctor think they are complying more completely with their treatment plan, or simply because they can.  Moreover, the data that comes from connected devices may not be accurate, as it’s unlikely the average person would think about, or even understand the need for calibration.

What’s even less appreciated is that this is only the tip of the iceberg.  Today, it’s a miniscule portion of the population who put data into a health record, or even realise that they can.  That’s about to change.  Consumer medical devices with a wireless link have the ability to push a constant stream of patient measurements into their health records.  It will result in a flow of data that is many orders of magnitude mote than has ever been seen.  And these devices will be freely available in the local mall or internet shop.  How much of the data they generate will be trusted by the medical profession?

The anguish is not just confined to medics who need to act on and have access to medical records.  It’s also affecting groups like the Continua Health Alliance, who were formed to provide an answer to the problem of preserving the integrity of health record data in a connected world.  The core role of Continua is not always well understood.  It came into existence to open up and provide guidelines for the ecosystem of connected medical devices that was starting to appear.  Many people think that its key function is to ensure interoperability between devices from different manufacturers, but that’s just a consequence of what Continua is doing.  Its real job is ensuring the integrity of data as it flows from the measuring device to the ultimate electronic health record.

If we go back to the anxious medics consulting a health record, they need to know that information that has been entered automatically, from an electronic link, is as accurate and reliable as if it had been transcribed by a medical practitioner.  Whilst it might seem natural to think that would be the case, in the connected electronic world that’s not necessarily so.  Whenever a piece of data is sent over an electronic link, particularly if it’s wireless, it may get truncated, compressed or transformed.  If it is accepted by a PC or phone application on the way, it might be converted to different units, averaged, corrected or manipulated in some way.  By the time it has passed through a number of different stages to get to the final medical record, it may have undergone a set of “Chinese whispers“.

The goal of the Continua Health Alliance was to provide an assurance that where each stage of the process conformed to their guidelines, the received data would be unchanged from that produced by the piece of medical equipment.  The Continua logo meant that the path from medical device to medical record was assured.

That is still the bedrock of the Continua promise.  But since Continua was formed, the world of smartphones and apps stores has blossomed.  To trot out an overused cliché, it has changed the paradigm.  Next year, as Bluetooth low energy appears in mobile phones, which enables a mass market of connected health and fitness devices, we’ll see the current trickle turn into a flood. 

Consumer health devices aren’t just changing the volume of data, they’re also changing the way it’s used.  Application developers for smartphone apps are already appreciating this, as they discover that patients have very different display needs to the medic.

Almost every medical device you can buy today displays its results in scientific format, whether that’s blood pressure, temperature or glucose concentration.  They may mean something to many medics - digital displays go well with the white coat image.  But increasingly, consumers are looking for health applications that present results in a manner that relates to their lifestyle.  That may be trends, traffic lights or some other representation, where the original data may not be preserved in its virgin state.  To do that, data is manipulated, and the integrity, precision or accuracy of the original data may be lost.  That doesn’t make this any less valid a health record.  It can be argued, that as it means more to the patient, it’s a better one.  But the question is whether it has the same level of integrity if a medical decision is going to be based on it?

In the coming year, the proliferation of low cost, wirelessly connected, consumer health devices will transform this market.  Much of the data they measure will only ever get as far as a mobile phone, although in time it may get uploaded to patient community sites.  It will generate an explosion in the quantity of patient data that dwarfs anything that exists today.  That makes it a powerful tool for driving evidence based healthcare forwards, if it can be aggregated and mined.

But it may not be, nor need to be accurate. That’s a concept that is very scary to many in the medical profession and medical device industry.

The industry needs to tackle the question of what to how to address this new world, where data may be qualitative rather than quantitative.  It is without doubt a valuable resource, but it is unlikely to sit comfortably in the current medical record mindset.  Continua’s view of end-to-end integrity assured medical record data remains unchanged, but how it will encompass consumer health peripherals for mobile phones.  They have the difficult question of deciding what their logo means on a consumer medical device or application.  Does it imply the gold standard of end-to-end integrity, or a device that connects to any consumer medical application?  Or both?  

The health record keepers within our medical systems face a different question.  They need to consider how to access the value of patient records that may not be derived with the same rigour as they are used to, but which will provide a new order of magnitude of patient data that can help better understand how to manage long term chronic conditions.  It will also be invaluable in driving evidence based medical treatments for them.

Many say the Internet changed the relationship and balance of power between patient and doctor.  That will be insignificant to the change that is coming over the next few years, when patients are able to measure themselves.

Personal fitness featured high in the range of proposals, as illustrated in those from finalists Lisa Durlam and Patrick Coulbourne.  Lisa and her team at Swimovate have come up with a Bluetooth enabled watch for swimmers.  Accelerometers within the watch monitor the swimmer’s movement, and from that calculates their speed, number of strokes, calories burned and distance swum during each session.  At the end of the swim, it connects to the swimmer’s mobile phone an uploads the data to the internet.

 Patrick doesn’t like his water wet - he prefers it in its frozen form and has been applying Bluetooth low energy to a range of interactive snowsport equipment.  His company - Flare Snowsport, has made an innovative use of Bluetooth low energy’s advertising capabilities to send geo-positional information, along with trail information as skiers pass by.  The information is captured by a personal clip worn by the skier, which can also capture information from a heart rate, temperature and blood pressure monitor.  At the end of the day, the skier can upload the data to their personal website.

 Moving away from sports, Michael Kohler of Edumotion made the finals with a fertility monitoring device.  The miniature device uses a thermopile to measure a women’s core body temperature, sending the data to be analysed to predict her optimal time for conception.  Such a device needs to be small and lightweight if it is to be comfortable to wear and unobtrusive.  The high level of integration in Bluetooth low energy chips means that personal sensors can be made that are not significantly larger than the coin cell that powers them.

But the ultimate winner was Edward Sazanov of Physical Activity Innovations.  His Fit Companion clips to your shoes and monitors your movement during the day.  It’s bright enough to recognise your posture, as well as whether you’re moving and how fast.  It sends the data to an application on your phone, prompting you whenever it thinks you’re, it moves beyond veering into couch potato territory.  By looking at overall behaviour it move significantly beyond current devices like pedometers to give a broader view of a user’s lifestyle.

This year’s awards were part of an ongoing competition.  If you’ve got a good idea, log onto the participation website and tell the Bluetooth SIG how you can change the world.

The organisers probably weren’t expecting snow, but it didn’t stop the audience turning up en masse to Mobile Monday’s mHealth meeting in Amsterdam last week. The presentations were far from chilling;  mHealth is moving from a position of  relative obscurity a year ago, to something that every network operator feels they need to have.  Vodafone, AT&T and Telefonica have already declared that it’s a key part of their strategy.  The potentially still-born US health reform and accompanying monetary stimulus plans have convinced many more that there’s money to be made from it, and 400 plus attendees were keen to understand where those opportunities may be.

There’s nothing like a church for evangelising, and Mobile Monday had provided the ideal venue in the form of de Duif - a splendid former church on the Prinsengracht in central Amsterdam.  It’s the first conference I’ve ever spoken out that had a live organ to regale the delegates as they came in.  It brought a very civilised touch to the proceedings that others would do well to emulate.

The aim of the conference was to explain what mHealth is, look at what it can do and investigate some of the business models.  First up was Bart Collet of Zogbeheer.com.  Bart runs a care home and writes software to help in the management of such homes.  That makes him a good spokesman for this industry, with practical experience both of developing and using the technology.  Bart set the scene, by examining the five key challenges for healthcare: 

• the increasing size of an aging population,
• the associated increase of chronic diseases,
• a shortage of funds, along with a shortage of medically skilled personnel,
• a change in patient expectations of healthcare, and
• the barrier of rules and regulations.

Bart gave some stats that indicated that 98% of the aging population do not want to move to a care home (I wonder about the 2% that do).  To achieve that we have to take the route of monitoring people at home.  That means more and better deployment of monitoring equipment.  The good news is that the hardware should not be a problem, as small, inexpensive sensors are becoming available.  The anticipated cost savings are estimated to be 64 billion euros in Europe. 

mHealth is already saving money, even using simple services.  I’d argue that it’s only the simple, process based ones that are saving money, but we’ll come to that later.  The classic mHealth cost saving that are always trotted out is the example of using SMS for appointment reminders.  In the UK, no-shows cost the NHS 645 million euros every year.  Simple text reminders have reduced that by 27%. 

Staffing is a more intractable problem.  In most of Europe we have staff shortages, and we don’t have time to train new staff.  Keeping patients out of the medical system should help, but I’m sceptical that this will arrive in time.  And as we get more technology and change, politicians will probably slow deployment by giving us more regulations

Moving to trends, Bart enthused about the use of cellular modems in medical devices, creating great opportunities for mobile operators.  Allegedly 19% of users would upgrade their mobile plans to engage in mobile health, or change provider if they thought it would help.  Hence the rush to the watering hole.  I have more time for that argument, but there are immense barriers to make it compelling.  There are plenty of commentators who look to third world take-up, and suggest that the third world will export eHealth business models to us. Again, I’m less than convinced.

There’s no doubt that fitness and wellness apps will overtake medical ones.  Vital signs are already being monitored, and the line between health and fitness is blurring.  Bart envisages that we will move to the point where the body itself is the ultimate point of care.  It’s a world where we will wear sensors that monitor every moment of our existence.  That’s a message that comes from an observation of the ludicrous speed of sensor development.  The difficulty is in believing that anyone will do anything with that overwhelming quantity of data.  It sounds worryingly like some science fiction storylines, where a population has come to accept a supposedly benevolent medico-dictatorship.

Following on from Bart, I felt the need to play Devil’s advocate and question whether the belief that the world is even ready for mHealth .  I think that the technology side of personal monitoring will get solved in the coming few years, as the new Bluetooth low energy standard makes it cheap and easy to manufacture sensors that push our personal data to the web via our mobile phones.  That’s the easy bit.  The difficult bit is in persuading anyone to wear the sensors.

I disagree with the easy pitches that mHealth will save us money, or that any large constituency actually wants it.  In the long term it may save money, particularly if it helps to establish a broader database for evidence based medicine.  But that’s a long way in the future.  The fundamental fact that no-one dares speak, is that we’ll only make a major dent in health costs when we get rid of half of the current medical staff, as it’s salaries that take up much of the spending.  I don’t know any government minister that would publically say that.  And as more parents push their kids into medical school in the hope of a career that pays the mortgage and gets the pension, things are only going to get worse.  It’s like building more roads.  They just encourage more people to drive.

Meanwhile, the general medical profession is less than keen on mHealth.  Whilst a few may embrace it, for most it threatens their professional status and careers.  Nor do most patients want it.  The sad fact is that most people like to ignore their health until it goes wrong.  Which is why we have an increasing issue of obesity and similar illnesses. 

The corollary from that is that we need to find solutions to easy problems that we can persuade people to use.  To get the debate going I threw up four possible business plans:

• Engage the open source community and patient groups to design their own applications for those with long term chronic conditions.  I call that model “the Wisdom of Sick Crowds.”.
• Target the guilty, selling dieting plans or similar,
• Don’t forget alternative medicine.  There no reason that mHomeopathy shouldn’t be just as profitable as mHealth (although I hope it’s not.)  However, alternative medicine has fewer barriers than traditional healthcare and may well innovate faster.  In the same way that the porn industry drove internet development, alternative medicine may drive mHealth.
• Use personal monitoring to sell generic (and alternative) drugs directly to the patient.  On average, we digest around 54,000 pills each over our lifetime.  It’s got to make commercial sense to find a better way of prescribing and dispensing them.

And if all else fails, don’t forget to look at schemes that monitor your kids and pets.  A copy of the slide set is available here.

Bringing us back to reality, Jeana Frost talked about her experience with Patients like me.  The medical experience that most people have is very much a top down one, Companies like Patients like me are trying to change that.  Jeana recalled how, as a student, she had been influenced by discovering that patients become more involved with the healthcare decisions when they were able to take a greater part in the treatment process.  Patients like me has taken that into reality.  It allows patients to enter their data, which is then aggregated, allowing groups to see how others live with the same disease.  Today they have over 50,000 patients in 9 different condition groups.  They’re working on how to provide meaning out of the information they aggregate, particularly in the form of mood charts, which members can use to compare themselves with each other,  it’s an interesting take on feedback and a good example of where mHealth data manipulation needs to go.

The community is also proving useful for researching treatments.  Patients find it useul in learning about their symptoms; from there, improving the way they record them and in turn reporting them to their doctor.  In a warning shot to the pharmaceutical industry, the database is beginning to bring up a range of side effects and reactions to drugs that can be sharply at variance to those reported in clinical trials.  That’s because it’s coming from patients that have become comfortable with their conditions and have started to describe them honestly as a part of their life.  It’s another sign of how mHealth could dramatically increase the evidence base behind modern pharmacology.

Robert Houtenbos, from Dutch insurer Univé-VGZ-IZA-Trias provided an overview of mHealth in Holland, and the issues faced in trying to attain the Holy Grail of mHealth.  From an insurer’s viewpoint, everything must be based on trust - their business model is predicated in a trusted relationship between insurer, patient and doctor.  To move forward, he believes that they need to open up APIs, so that multiple sources can share information.  It means changing their perception from Big Brother to Big Sister (although what she’d place in Room 101 wasn’t explained).

It’s not just about technology.  3G doctor is a service that lets patients use their phones to have a video consultation with a doctor.  It might be 3G, but it’s not about technology - the phone is just the vehicle in your pocket.  The core concept is simple.  But, as Dave Doherty explained, the reality of delivering the service is very different.  In order to be able to launch the solution, it required every segment of the medical profession to be convinced that the patient is not compromised.  They needed to persuade the authorities that data would not be lost, that patient’s records would be continuous and integrated and that the information offered met professional requirements.

It illustrated the issues (and benefits) of working within the system.  It took prodigious effort for the medical profession to accept it.  As a sideline, 3G doctor also offer vast amounts of reference materials to doctors via their phones, which the doctors love, as it reinforces their status as knowledgeable Gods.  So having got there, it’s win-win.  It’s a good example of how mHealth can work when you scratch the back of the medical profession, and hence a perfectly valid business model.  But I’m not convinced that it’s the sledgehammer that we need to change the current way we deliver healthcare.  For that we need something far more disruptive.

That only took us to the break. The presentations should available soon on the Mobile Monday site. Next week, I’ll cover the second half…

I don’t think anybody would argue against the need for reducing the cost of healthcare.  There are obviously many efficiencies that can be brought into the system, whatever and wherever that system may be.  But most agree that increasing the individual’s focus on wellness is an important foundation to that cost reduction.  To make that happen we need to make personal health devices cheaper and more accessible.

That’s where this bill betrays itself.  Hidden amongst the headline grabbing stuff are two clauses that may well help to slow the speed at which these devices come to market - a tax on each and every device, and a proposal for the FDA or similar body to administer an Orwellian control over what comes to market, potentially stifling innovation.  If this really is a bill for reforming healthcare, that’s a strange route to take.

When a company designs a medical product they quite rightly need to take it through a range of qualifications and certifications to ensure that it works and does no harm.  The newer and more innovative that product is, the more important that is.  But the level of these tests is getting onerous.

For any electronic products there’s CE or FCC requirements to make sure it meets basic safety levels.  If it includes a wireless connection, like Bluetooth or Wi-Fi, it needs to pass the qualification requirements set by those bodies, plus additional RF testing.  Most designers of medical products are now using the Continua Alliance guidelines, which mean that products from different manufacturers will provide compatible data.  That’s another certification and another cost.  To sell it in the U.S.A. it needs to be certified by the FDA.  Which is a considerable additional cost.  In fact we’re reaching the point where these costs can come close to the cost of designing the product.  Guess who pays?  In one form or another, the consumer.   And now the Senate has slapped on a device tax of 2.5% to every product to help make it less affordable to those who need it most.

But the more worrying feature of the bill is the proposal to institute a national registry of medical devices.  This seeks to list the serial number of every product that is sold.  The rationale is that it allows more effective recall of faulty products.  But it has the prospect of creating a bureaucratic monster that could potentially try to track every download of every iPhone medical application.

The recently published white paper form Triple Tree raises the spectre of the damage that the FDA could do, asking “If an iPod includes an application for diabetes tracking or another medical use, does Apple need FDA approval before selling an iPod?”  According to the letter of the law, the answer is yes.  Today’s bill potentially grants it even more draconian powers.

I’ve previously highlighted this issue and argued that we need the FDA and other regulators to step backwards.  There is no question that critical and new products need to be checked and regulated.  But if we want to encourage innovation, then we need to decide which categories of medical devices can be exempted to allow users to innovate.  I’ve suggested that Consumer Healthcare needs its own Manifesto to free it from the embrace of unnecessary regulation.  After today, that seems even more important, but sadly, further away than ever.

Today the device tax only applies to the more clinically focussed Type II and Type III FDA devices.  But taxes like this have a nasty habit of spreading.  As soon as personal healthcare takes off in volume, there’s a real risk that tax hungy legislators will see that as another source of income.  That’s a slide which must be resisited.

Despite all of its headline appeal, it feels that the details of today’s bill don’t understand the needs of the consumer.  Whilst welcoming the number of those it brings into healthcare, I’m worried that it will do nothing to help tens of millions more take more control over their own health.

It’s not a new message, albeit it has been revitalised by the prospect of the Obama billions.  The physicians believe that they can heal themselves, or at least the system they work in.  So it came as a breath of fresh air to see a posting that popped into my inbox from Joe Macaluso on Real Health Reform.  It argues that the only way we will see any real reform is if it’s done by patients, without the support of Congress or the medical industry.

Over in Europe, the EU is running a debate on Consumers and Health, asking for contributions to a seminar in Brussels at the end of the month.  I’d been thinking about this for some time and had come to the conclusion that the most useful thing that the EU commission could do would be to look at how to change the regulatory playing field.  That’s necessary to let patient-based groups start to take healthcare and even prescribing into their own hands.  To achieve that I think we need a Manifesto for Consumer Health, that provides a safe environment for disruptive developments.  By coincidence I’d just finished writing my thoughts on that, which I was posting to the EU Consumers and Health site as Joe’s mail came in.  After reading Joe’s post, I’ve added a poll asking “Whether you believe that healthcare reform needs to be driven by patients, rather than medics or legislators?”  Please go and vote - I’ll post the result in a later blog.

So why do I think we need a manifesto..? 

Over the last decade we have heard proposal after proposal to “solve” the demographic problems that increasingly challenge our health systems.  Billions of dollars and Euros have been poured into research that only ever appears to act as a basis for yet another research project.  As a result, rather than containing the cost of healthcare and improving patient expectations, the health industry continues to roll along largely unchanged.  Everyone continues to point out that the health system we have is broken.  But it is happy to remain so, as long as it makes money for all involved.               

A major reason for that is that governments persist in asking the health industry to reform itself.  They persist in believing in the old maxim of “physician heal thyself”.  All of the evidence is that whilst they are making a comfortable living, they have little incentive for fundamental change.  Instead their comprehensive hold on the health system serves as a barrier to stifle the more disruptive patient led initiatives.

If we are to take cost out of healthcare, there is a fundamental corollary - we need to take expensive medical staff out of our future health system.  eHealth or Telecare solutions will not offer savings if we still need the same number of health professionals to deliver our healthcare.  Instead we need to look at ways in which patients can self-manage their health, using the medical profession only when they need major medical intervention.  

That is why I believe we need a Manifesto for Consumer Healthcare and Wellness.  Today the system and regulatory procedures throughout European member states work against patient groups developing their own care structures.  Instead they support the maintenance of the status quo.  We are about to see the emergence of a new generation of low cost, connected medical monitors, such as weighing scales, blood pressure meters, blood glucose meters and pulse oximeters.  These will let patients measure their own health trends, often using the convenience of their mobile phones to transmit data, and save them to their own personal health records.  It opens up the ability for patients to begin to measure their own wellness and trends. 

If we are to persuade our citizens to embrace these developments and begin to use them for society’s mutual benefit, they need to have compelling reasons to do so.  All of the evidence suggests that this will not come from medical companies or state health systems - they are too set in their ways.  Rather, we need to encourage new, disruptive approaches that address their own quality of life.  Already we are seeing the growth of special interest groups of patients who share information on their diseases.  That’s eminently sensible, as they have the hour by hour experience of living with their chronic conditions.  They know what influences their daily life and how best to manage it.  This is where change and compelling applications are likely to come from.

As low cost diagnostic monitors become available, the next step is for these groups to work out how to share their data, and the way they manage their disease, working towards medication or lifestyle regimes that give them the best possible quality of life.  From that, the obvious progression is to give them access to prescribe their own medication, independently of the current gatekeepers.

This will be resisted by the current medical hierarchy.  Whilst there are valid arguments for continued regulation to preventing damage and charlatanism, they need to be modified to encourage innovation.  As vested interests will attempt to deny this progress, we need an EU wide approach to enable a disruptive approach by providing a framework that removes barriers at the same time as trying to include appropriate patient safeguards.

To enable innovation to happen as quickly as possible, it is important to provide a environment that is conducive for development.  That needs guidelines and possible support to let patient based groups pursue models which the established medical establishment may see as disruptive or threatening.   For that reason I propose that the EU implements a Manifesto to enable an atmosphere which allows patients to build these new structures.

There are other benefits from this approach.  The development of these groups and self regulated measurement of patient conditions provide a unique opportunity to build a database of evidence for different treatment plans.  Encouraging open source development of such databases could provide a more valuable source of evidence based treatment than anything that has come from previous medical trials.  It may even be able to use this to feed back into the conventional medical system.

Manifesto for Consumer Health and Wellness

The EU should work to provide an environment to stimulate the development of patient centric healthcare initiatives.  This concentrates on removing restrictive barriers and providing a framework for a radically new approach for healthcare development, led by patients.  It should help to protect such groups from regulatory discrimination, encourage innovation, communication and dissemination of information and provide access to sources of appropriate medication.

Key points are:

• Encourage patient based development
• Remove regulatory barriers to group self-treatment
• Review prescribing barriers, allowing groups to work directly with pharmaceutical suppliers.  This may need to be limited to a defined list of generics, and be dependent on the open availability of anonymised patient data.
• Encourage and share best practice in the development of “trust” strategies for patient groups
• Provide a directory of innovation and promote the most compelling applications.
• Provide a forum for dissemination of data
• Optionally provide an EU personal health data storage facility, based on open source standards, for use by patient groups.
• Extend wellness and personal health from the personal group to occupational health, without the need for traditional medical involvement.

That’s just a starting point.  It’s a debate that we need to start now, so that those who start to develop new applications can concentrate in innovation and not fighting regulation.  If you’ve any other suggestions, please let me know.

Scotland is an interesting country in terms of health, as it contains a number of anomalies.  At one end of the spectrum it boasts some of the best examples of Telecare and Assisted Living practice anywhere in the world.  In the middle are some excellent preventative initiatives.  And at the other end it has issues with lifestyle and diet that are propelling its population towards an increasingly unhealthy future

The issue of diet is a long-standing one that starts at an early age.  Whereas England is embracing chefs like Jamie Oliver who are leading high profile campaigns to improve the quality of school meals, Scotland largely ignores them.  If you’re in Scotland at lunch time, you’ll see queues of school kids outside the local chippies and bakers downing their daily intake of carbohydrates as they start on the route to weight related health problems.  For most, lunchtime means a trip to the local obesiary, which is typically Greggs - the chain of bakers who feed a large percentage of the population. 

Festival time and the influx of non-Scots appetites don’t have a noticeable effect on the traditional catering preferences.  When you’re eating in Edinburgh, it’s Chips with everything (which was sadly not being performed this year).  Try and order something without chips and you’ll be met with a stare of incredulity.  Even if they take the order, the chance is that your plate will still arrive with at least half of its surface concealed with a pile of deep fried potato.

What I hadn’t noticed before was an observation made by Marcus Brigstocke during his excellent rumination on his God shaped hole, which is that the local Fish and Chip shop (chippy) next to the flat he was living in also sold Rennies.  I don’t know whether Rennies are an international brand, but for those unfamiliar with them, they’re the UK’s best known indigestion remedy.  There’s a rather inevitable irony abut the coupling.  Instead of reducing their portion sizes, the local fast food takeaways take the approach of selling you the next product you’ll need.  It was an observation that started me looking at each chippy I passed and sure enough, each one had a shelf of indigestion tablets.  The obvious next step would be for them to start selling blood glucose test strips as well, but I didn’t manage to spot any that had made that connection.

More detail on the intricacies and etiquette of this most essential part of the Scots food chain came in a wonderful little event at the West Port Book festival.  Peter Burnett has devoted a year of his life to listing everything he has eaten and published it along with comments in The Supper Book, which I would recommend to anyone studying the Scots diet.  (Or anyone interested in the trivia of food, such as the fact that the inventor of the Pringles tube left instructions for his ashes to be buried in one.)  The chapter on chippies enlightens us further with another strange Scots custom.  If you order a single fish it will result in your being served two.  It also explains that Supper is an adjective that ensures you have chips with everything.  For those with more exotic tastes, that extends to the Deep Fried battered pineapple supper.

At the extreme end of the carbohydrate spectrum, Scotland is the home of the deep fried Mars bar, that pinnacle of calorie laden culinary excellence.  It’s become such an emblem of the Scots lifestyle, that you’ll see chippies with standardised adverts for it.  Which is more than you’ll see for the better known, but possible less eaten speciality - haggis.  By coincidence, at the same time as the Festival, a meeting of the Royal Society of Chemistry in Glasgow was being presented with a paper by Georgina Rayner who had performed an analysis of the this quintessentially Scottish fare.  Packing a coronary inducing 600 calories, it apparently provides a combination of the major food groups we need in our diet, containing carbohydrates, protein and fats.  The only thing lacking is salt.  So for anyone on a low salt diet, head down to your local chippy for a healthy deep fried mars bar.

During the last few weeks the local papers have been bemoaning the increase in obesity in the Scots population, including a report that personal perception of size is lessening, making it easier for people to eat without worrying about how they look.  A few pages further on in the Business section, the same paper was happily reporting the growth in Greggs’ profits, with the prospect of them opening further shops.  At a recent healthcare conference when the panel I was sitting on was asked “what would be the one thing you’d suggest to improve Scotland’s health?” I glibly answered “Ban under eighteens from Greggs”.  After a few weeks in Edinburgh I’m not sure that is such a bad idea. 

Scotland needs to find a better way to promote healthy eating.  On being presented with another pub meal replete with unwanted chips I may have one alternative answer - don’t eat them, play Jenga with them.  I’m not sure the cook appreciated the stack of chips being sent back to the kitchen, but it’s one small step for sanity in the land of the deep fried diet.