Digital NHS

Shock treatment: can the pandemic turn the NHS digital?

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Covid-19 transformed NHS services overnight, offering a glimpse of what a digitally transformed health service could look like. How prepared is the health service to change its ways?

Last year, we all experienced the overnight transformation of our lives and the way we work wrought by the pandemic. Every organisation felt the pressure, though none more so than the National Health Service. Not just because it was Britain’s frontline fighting force against Covid-19, but because it had to perform its new and urgent mission while still maintaining the great majority of non-Covid healthcare services. All while it was potentially deadly for a doctor and a patient to be in the same room together.

It also turned out that this challenging mission had an unintended consequence: it forced a health service that has long been sclerotic in its approach to new technology to change how it works.

“Things that would have taken a long time suddenly got adopted within the space of weeks,” says Victoria Betton, a digital health consultant and strategist, who points to how overnight many routine consultations and interactions with patients quickly became phone and video calls instead. This was something only small pockets of the NHS had previously experimented with.

“There was some rapid uptake of technology. But I think probably the more profound thing is that it got over a lot of professional fear or reservation about technology,” she says.

Could this new attitude stick? Could this be the moment when the health service finally catches up with the digital revolution that has touched every other aspect of our lives? Is Britain now firmly on the road towards a modern, digital-savvy NHS?

‘Digital transformation’, to use the jargon, of the NHS has been talked about for a long time. The goal? “Better patient experience, better patient outcomes, a better staff experience of delivering services and more effective and productive services that are of a higher quality,” says Betton. But previous attempts at making it happen have not been entirely successful.

Way back in 2002, plans were announced for a ‘National Programme for IT’, which aimed to fully digitise much of the NHS’s infrastructure, including creating a single electronic care record for each patient. But £10bn and much political embarrassment later, the project was abandoned as incomplete by 2013.

Since then, a more piecemeal approach has been taken to focus on smaller, bottom-up transformation instead of attempting to create a single large, top-down transformation programme. To aid this goal, a special unit called NHSX was created in 2019 which aimed to stimulate innovation across the health service.

Why is this approach necessary? Why is digital transformation so difficult?

“The NHS is not one thing; it’s a very complex system of different organisations working together,” explains Sam Shah, the former director of transformation at NHSX.

In other words, there’s no single organisation or command structure. In just England alone, the name ‘NHS’ encompasses upwards of 30,000 different organisations.

“There is no [singular] ‘NHS’... there is a brand,” says Betton. Each constituent organisation has its own board of directors, with its own objectives and incentives. Some, like GP practices, are privately owned. Others, like hospitals, are publicly owned. So getting the different players to work together can be tricky.

“Someone once said to me that the NHS looks from a distance like a big blue whale. And as you get closer you realise it’s a sea of piranhas all trying to eat each other,” Betton laughs.

However, there are encouraging signs of transformation happening in some parts of the NHS. Shah points to the NHS app, which launched in 2018, as a particularly good example of what the NHS could look like in the future. “It’s a great example of a national platform connected to all the service providers delivering care,” he says.

On the surface, the app appears relatively simple and is very user-friendly: users can check symptoms and book GP appointments. But underlying this is a huge web of complexity: these two core functions are the responsibility of different NHS organisations. And GP booking is not handled centrally. In fact, each of the roughly 9,300 GP surgeries in the UK technically has its own booking system, though in practice three major software providers are used by most to facilitate this.

This meant that NHS Digital, the arm of the service that built the app, had to connect up with three other systems just for booking. All while delivering a simple experience for end users, who shouldn’t need to understand any of this bureaucratic complexity to engage with health services.

Shah also points to the success of the digital version of the NHS’s 111 non-emergency helpline. “Urgent care has always had three needs: it has a clinical need, an emotional need, and a practical need attached to it,” he says. “We had an excess of calls coming into a phone service where you couldn’t just keep on putting in more phone capacity because it was unaffordable.”

Instead, 111 Online acts as a virtual triage, reducing unnecessary trips to the hospital for minor issues, while pointing more serious cases towards physical care services.

The pandemic has, of course, driven some innovations that are likely to stick around. Betton notes how it led to health services scaling up the use of ‘virtual wards’. This is a concept where a patient at home is given, for example, an oximeter to measure their blood oxygen level, and will regularly report back readings to the hospital. The data will then be regularly reviewed by doctors in a virtual ward round, with similar intensity to a patient in a hospital bed. “It’s a way of managing a ward virtually and helping people manage at home rather than having to come into a more risky hospital environment,” Betton explains.

What is standing in the way of other parts of the NHS emulating this success? “We need to look at why innovative ideas don’t get in there in the first place,” says Kevin Monk, the managing director of SARD, a start-up that provides workforce management software to different NHS organisations. He places the blame squarely on the procurement process, which he believes is loaded with perverse incentives.

Stuart Mackintosh, the founder of OpusVL, which builds open-source software for the NHS, says: “There’s a lot of emotion in procurement, which is why people buy based on comfort or based on what other people buy rather than on pure logic of what is the right thing.”

Monk agrees that there is a culture problem with procurement, which leads to risk-averse decision-making – a case of ‘nobody ever got fired for buying IBM’.

“It’s not a case of making the best decision. It’s about making the decision that’s the easiest to defend,” Monk says.

In his view, NHS tenders are too driven by specification rather than outcome. They specify how a task must be carried out, instead of simply outlining the ultimate goal, and leaving it for bidders to innovate and discover new and better ways of working. This means that start-ups that take new approaches could be frozen out of the bidding process from the beginning.

“It never takes into account the things that make you different,” says Monk, “If you presuppose a solution to your problem, you’re not going to get any innovators in.”

Mackintosh adds: “We shouldn’t be buying software, we should be buying outcomes”.

Shah thinks the challenges run even deeper. “Most of the NHS gets its funding for seeing people. Whether you see them in person, or speak to them on the phone, or do some surgery, most of the funding is based on seeing people. There isn’t any special ring-fenced funding that is just for digital transformation,” he says.

“Unfortunately the combination of the culture, the policy, the procurement process, and the resources available create an environment which means that not much change happens,“ he laments.

He also argues that the funding model used by the NHS is still too centralised. National NHS bodies create or commission new IT systems that are handed down to providers, such as hospitals, to use, which in principle sounds great as hospitals may have access to a new system or tool without having to dip into their own local funding. But this also skews procurement decisions.

“Imagine clinicians on the ground have got used to using [a system],” he says. “Patients have got used to using it. The hospital has designed its infrastructure around this thing that is effectively a free gift given to it from the centre. So now all their systems and processes are aligned around this thing. The contract then comes to an end, and they’ve got to make a choice: do they go through a big procurement exercise and find another supplier?

“They’re not getting any extra money [...] so they just carry on with the supply they’ve got because it’s the least burdensome change. It’s the easiest thing to do, which is just carry on with it. It has distorted the market,” he comments.

‘Unfortunately the combination of the culture, the policy, the procurement process, and the resources available create an environment which means that not much change happens’.

Sam Shah, former Director of Transformation at NHSX

There are other problems with the funding model, too. The way NHS IT contracts tend to work is based on handing out multi-year fixed contracts to big providers, but many of the most innovative providers operate on a software-as-a-service (SaaS) business model, where costs scale with usage.

“A lot of IT spend is through capital budgets. Capital budgets lend themselves to buying kit, whereas most digital is like a SaaS model, so it’s really hard to buy software from start-ups and small providers,” Betton explains.

Betton has seen vivid examples of the human pressures that cause the inertia: “I’ve done interviews with clinicians who are just crushed. They’re [working] on their weekends, in their evenings. They feel like they’re trying to fight procurement, they’re trying to fight the system”.

“A lot of CIOs [chief information officers] don’t have the headspace,” says Betton. “They’re running these legacy systems that are very time-consuming. Nobody wins by taking a big risk; there’s very little incentive for people to take big risks. You’re trying to fix the engine while it’s still running”.

If one thing is clear, it is that transforming the NHS is going to be a slog - but it is ultimately something that will need to be done. Where can policymakers and managers look to make a start?

Mackintosh, speaking from a supplier’s point of view, says “the solution would be standards”. If the NHS were to define open data standards that providers plugging into its systems must use, then it will make exchanging data between systems easier, and would make it easier for new, more innovative solutions to problems to be plugged into the NHS, because developers would simply need to make sure their system exchanges data in this common way.

“Just imagine if your blood pressure was stored in a standard way across every system in the industry,” he says. “Any system could access that piece of data. It means wherever you went – GP, hospital, dentist – [...] to be able to observe that as they’re doing their standard checks and have that in your patient record would be great.

“Technology is not the limiting factor. It’s not that tech isn’t there,” he says. “That’s the bit that we’re missing. It’s very boring, just doing the plumbing of what’s obvious.”

There are also plenty of low-hanging fruit, as exposed by the pandemic. Betton gives the example of a junior doctor she spoke to working on an outpatient support service, which previously required patients to come in for a check-up every six months. Now the service just phones them – a tiny act, which has proven revolutionary for how consultations are performed.

“I think we need to really focus on optimising the most basic of technologies that are ubiquitous among the population,” says Betton, “So using text messaging, using the telephone, and to a lesser extent, video consultations, to enable people to transact and interact with services, using the tools that they use every day.”

Why not a focus on video? “The heaviest and most regular users of NHS services tend to be older, and from more socioeconomically deprived backgrounds,” she explains. “Text messaging and phone calls are ubiquitous, whereas even being able to use video consultations is not.”

Can the NHS sort out the plumbing? One sign that worries Mackintosh and Shah is that NHSX could end up being distracted by shiny baubles. In 2019, the unit launched a £250m ‘AI lab’, which aims to solve “some of healthcare’s toughest challenges”, such as improving cancer diagnosis, with cutting-edge technology.

“I think we need an NHS that focuses on the problems that clinicians and citizens, more importantly, are facing today and into the short-term future,” says Shah. “That means you need to really think carefully about whether or not now is the right time to fund some of these other things like an AI lab, which is going to cost absolute millions relative to solving some other problems that will serve a lot more people in the short term.”

“We’ll find out soon whether they are funding the plumbing, the core stuff that needs to happen, or whether they’re funding the shinies, and that will be the measure as to whether we make progress or not,” says Mackintosh, who adds dryly: “The problem with AI is it’s like a microwave oven. It’s a cool thing, but go back 150 years where you didn’t have stable power and it’s limited in its use.”

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