A delayed but eagerly anticipated Digital Health and Care Strategy is expected from the Scottish government in Spring 2018. Matthew D’Arcy asks what it might address.
The latest Scottish government plan to develop services around the citizen, integrate health and care, and drive digital innovation is expected in April.
The new Digital Health and Social Care Strategy, which was originally slated for 2017, will follow a myriad of previous plans that have sought to address aspects of this agenda. Yet big promises are being made for it.
Shona Robison, Scotland’s cabinet secretary for health and sport, told the Digital Health and Care conference held in Edinburgh this February that the new strategy will offer an “opportunity to embark on a shared endeavour, working together towards a more joined-up, integrated and effective service.”
Where health boards have gone before
The foundation for Scotland’s digital health ambitions was laid in 2011, when it published its first eHealth Strategy. This was tightly focused on digital developments within NHS Scotland, but it put some key building blocks in place.
National framework contracts have led many health boards to procure electronic patient record systems, for example, including InterSystems TrakCare.
Concurrently, health boards have deployed portals to provide professionals with more complete medical histories for their patients, and to link information across wider regions, using technology from Orion Health, among others.
More local deployments have focused on specific innovations. NHS Fife, for example, has dramatically reduced cardiac arrests following its implementation of an early warning electronic observations system called Patientrack. The Scottish government has a number of case studies that list what localised innovations have achieved.
At the other end of the scale, it can point to national projects that have gained significant traction. These include access to the Key Information Summary (a far more developed version of England’s NHS Summary Care Record) and the development of telecare and telemedicine.
Planning and promises
An update to the eHealth Strategy, issued in 2014, concluded that NHS Scotland had made “significant progress”, that it was in a good position in comparison to similar health systems, and that delivery had been secured at a “reasonable cost.”
However, it also recognised that there were some significant gaps to fill – starting with e-prescribing in hospitals. Also, that time had moved on and there needed to be a greater focus on working across health and social care, supporting patients, and driving innovation.
A new focus on standards to enable systems to work together, better infrastructure to support access to electronic patient records for staff, a patient portal, and a Digital Health and Care Institute to promote innovation were promised. As these work programmes progressed, another round of policy making got under way.
In 2016, the Scottish government put out a new Health and Social Care Delivery Plan, that was followed a year later by a Digital Strategy for Scotland. With a 2020 vision for eHealth also in the mix, all of these ambitions drove the agenda further towards supporting patient centred, integrated services.
Hence the promise in the Health and Social Care Delivery Plan that the soon to be published strategy will help to create “a digitally-active population, a digitally-enabled workforce, health and social care integration, whole-system intelligence and sustainable care delivery.”
A shift in national mindset
So where is healthcare IT in Scotland, really, and what will need to be done to deliver the latest ambitions? The Scottish Parliament released its scathing conclusions in February this year.
A report on technology and innovation in health and social care from the Health and Sport Committee said its members had been expecting to hear about exciting new ideas. Instead, they were told about systems that didn’t join up, barriers to innovation and a reluctance to work in new ways.
The committee criticised what, it said, had become a “board by board” approach to technology adoption, and called on the Scottish government to take ownership. It echoed calls for the Scottish government to mandate digital change, shifting from enabling boards to take up new ideas to requiring them to do so – or explain why not.
As NHS Scotland chief executive Paul Gray told the Edinburgh conference, which was sponsored by InterSystems, there is a need to “let go the determination to implement locally developed digital applications that only nine people can use”.
Leadership would be key to achieving this, he added. “Some people would wish you [you being the person directing change] would die rather than accept systems that are demonstrably better,” he said. “As leaders in this field we need to persuade people to do things that don’t seem immediately attractive, or immediately beneficial.”
A digital maturity index for Scotland?
The Scottish government will play close attention to whether the strategy is delivering on its ambitions. As part of that, it could commission a digital maturity index for Scotland.
Discussion in Edinburgh suggested this would differ to digital maturity measures in England, which have included the adoption of the US HIMSS EMRAM model and the Clinical Digital Maturity Index promoted by Digitalhealth.net and NHS England.
It will also be necessary to run more projects at scale. Scotland has been diagnosed by some as suffering from a case of “pilotitis”. The vision for the new strategy has said Scotland will “build on what we have” and focus on “spreading what works”.
Organisations like the Digital Health and Care Institute, and the broader cross public sector CivTech initiative, may be given a bigger role; but vendors will want to know their solutions will be picked up widely.
With a population of around 5 million people, the market is already comparatively small on a global scale. As the Health and Sport committee pointed out in its report, a “once for Scotland” approach will be needed; and it will need to be enforced. The new strategy must make clear how this will happen.
Focusing on users
Then, there is that focus on the public. “Digital must first serve the public,” said Paul Gray, urging his audience to shift their focus from their organisations to the people they serve. “Above all see this from the perspective of the people we need to serve, not to make systems in service of the institution, but rather in service of the people.”
A shift of mindset may encourage organisations to work more closely together; and even adopt ideas that were “not developed here”, but it could go further.
A resistance to co-design was cited in the Health and Sport committee’s February report. But Scotland has already seen an example of the kind of success that can be achieved when users are effectively engaged in the creation of digital services.
NHS24’s Angiolina Foster told the conference that Scotland’s NHS inform service had undergone a fundamental redesign with users, and had seen users pick up from 100,000 per month to 1.3 million per month as a result. As she put it, it’s time to “start redesigning together”.
Work around engagement and clinical acceptance
Usability is now one of the hottest topics in healthcare IT. Christopher Wroath, director of digital transformation at NHS Education Scotland, reminded developers they cannot expect clinicians to use technology unless they are completely clear about what they are doing and what the effect will be.
Purchasing the wrong train ticket online may have minimal impact, he pointed out; the risk is much greater if a system used by a clinician to help treat a patient leads to a slip. Will user-engagement in technology design and implementation feature in the coming strategy? It will be interesting to see.
Sorting out standards, engaging with IG
The strategy is also likely to find that it’s time to go back to that standards work. It will have an opportunity to advise technology providers of the standards it expects them to work with going forward, so that their systems interoperate and are open to smaller vendors with good ideas.
But just as important, and arguably more difficult, it will need to revisit the issue of data sharing. Many of those attending the conference felt there was a real need for national leadership on this issue, to prevent local interpretations of the rules.
For example, it was claimed from the floor that one board did not permit the use of Google Chrome as a web browser; preventing staff from engaging with services that its neighbouring health boards were able to deliver.
And there were many concerns raised about local information governance procedures and data sharing agreements. It was even suggested that a single Caldicott Guardian for Scotland might be needed, to help to ensure greater clarity.
Citizens owning data
A bolder idea, and one that could feature in the strategy, is to let citizens own their own data. To make this happen, a single online identity would be needed for all online transactions, George Crooks, CEO of the Digital Health and Care Institute told the conference.
“Big brother is watching you today, but we will never be able to find out because our systems are so dispersed,” he said. “In a single online identity, it becomes much more transparent. But that needs leadership at the top, and it needs courage.” Who knows, it might also need blockchain technology – an idea much discussed in Edinburgh.
Your ideas – ‘we’re listening’
The Scottish government has been developing its strategy in consultation with the public and wider healthcare community. A website has allowed people to submit their own ideas. Suggestions have included everything from free broadband for people over 70, through to text and email reminders for appointments. How much this will inform the end product in reality will soon be revealed, but people at the top say they are listening, and listening beyond the NHS. “There is a tendency to say health and ‘comma’, social care, as if it was an after-thought,” said Gray. Perhaps the new strategy, which the minister says is informed by hundreds of responses and thousands of comments, will change this.