The veteran health commentator and the chief executive of NHSX did not agree on much when they met at the King’s Fund, including the direction of health tech policy and whether anything is, in fact, happening. Lyn Whitfield listened in.
Roy Lilley is not impressed with the current state of NHS IT. Which is fair enough. Many people are not impressed with the current state of NHS IT. But the veteran health commentator and newsletter writer thinks health tech has taken a wrong turn in recent years.
He despairs at the sight of the centre pulling back and expecting organisations to invest, since the visible result is a mess of vendor-led systems, DIY efforts, and inaction.
And he has no time for the idea that ‘interoperability’ will improve things, since he doubts anyone knows what ‘interoperability’ means. Or, perhaps, whether companies with a vested interest in selling software will let on if they do. Or whether national bodies, like NHSX, will be able to make them.
All of which promised to make his regular HealthChat with Matthew Gould, the chief executive of NHSX, a lively affair. As usual, however, Lilley started by asking his interviewee, casually attired in one of his trademark jumpers, about his background.
From diplomacy to the DHSC
“What an exciting story you have,” he observed to a man who spent 22 years in the diplomatic service, worked in Washington and Whitehall, and was ambassador to Israel. “Do you actually know anything about IT?”
Gould explained that he became interested in the subject when he was working in Israel and saw the impact of its tech sector on its economy. Also, on its health system. “Israel is very hot on data,” Gould said. “Maccabi [the Israeli healthcare system] has joined up all its records.
“It has an app that allows you to put in your symptoms and a bit of information about yourself and it will give you information such as ‘x percent of people in your demographic with those systems have y condition’. It is very powerful. And it is very simple to do, if you have the right data.”
Gould set up the UK-Israel Tech Hub, before leaving the diplomatic service and becoming the UK government’s director of cyber security and then director general for digital and media policy.
Artificial intelligence: spending stupidity?
Lilley asked if the UK-Israel Tech Hub had tried to pick winners. Gould said not. “I think it was [MP and former Cabinet Office minister] Francis Maude who said you ‘cannot try to pick the winner, put you can try to pick the race’,” he said.
Referring to one of the few, concrete announcements that it has been made about NHSX – that it will invest £250 million in artificial intelligence – he added: “For example, it is clear that AI is going to be a big part of the future. There may be a lot of false starts, and it may cost a lot of money, but making sure that we are in there and ready to make use of it is sensible.”
This just surfaced an early area of disagreement with his interviewer. “Most AI is snake oil, and companies like Microsoft are spending billions looking for the stuff that isn’t,” Lilley retorted. “The NHS’ £250 million won’t buy you the hors d’oeuvres, it won’t buy you the napkins, never mind a seat at the table.
“So why bother? If there’s £250 million going handy, we could have a lot of nurses for that.” Gould disagreed back, arguing that some uses of AI, such as reading scans in radiology, are already working for the health service.
Also, that these examples could be scaled “which is valuable because, increasingly, I think the problem is not innovation but dissemination: there is loads of innovation out there, but what we need to do is disseminate it.”
A fudge, or the third way?
Gould has been using the “it’s not innovation, it’s dissemination” line a lot recently. He ran it out at the NHS Confederation’s annual conference and tried it again at the Healthcare Efficiency Through Technology show in London.
But Lilley pointed out that even if it’s true (when the epithet applied to a lot of core systems is ‘ageing’) it describes rather than addresses a problem. “Surely this is your biggest issue,” he said. “Thanks to the Lansley reforms, you can’t just pull a few levers and watch things happen. Your only tools are persuasion and bungs. And there’s no money for bungs.”
For a moment, Gould almost agreed with him. “This is my reality,” he said, before moving on to claim that when he has met NHS IT people, they are behind the idea of “a diverse environment, in which people can innovate” on “a platform… so that when it happens systems can integrate.”
Lilley flat out disagreed with this. “Look,” he said. “There are two companies out there, Microsoft and Apple. Microsoft is completely open. But when you try and use it, there’s always another bit of kit or another driver to install. We changed over to Apple. It is completely closed. But it just works.”
Gould tried to say that whatever the merits of this argument, it cannot be applied to the NHS because it was badly burned when it tried to use large companies to roll out closed systems in the era of the National Programme for IT. But Lilley argued that underestimated the programme’s achievements.
“I knew [director general of IT] Richard Granger very well,” he said. “And he laid the railroad, with the Spine, and he did it securely.” Admittedly, other areas of the programme, particularly the deployment of electronic patient records to trusts, were less successful.
But Lilley argued this was, in part, because suppliers were not ready. So: “The lesson here is that the government has to manage these relationships.” Gould didn’t feel this was the lesson. “Even if you did that, and you said: ‘Everybody has to use this system’, then it might work at one moment in time, but you are locked in, and there is no challenge, and I do not think any market works well like that.
“So, I think there is a third way…” Lilley: “A fudge.” Gould: “Not a fudge. You let the frontline say: ‘This is what is right for me’ but you set parameters [so people have to work with standards-based systems that interoperate with what others pick].”
Interoperability: does anyone know what it means?
Lilley moved on to that issue of ‘interoperability’. Which, he pointed out, is critical to the third way. Gould agreed, but warned: “It’s going to take time.” Lilley, unusually, agreed with this. Up to a point. “Years,” he said. “It’s going to take years, and we don’t have years.”
“It reminds me of the Middle East peace process,” Gould said. “Everybody says we need peace now, but these things are complicated and take time.” Lilley might have pointed out the peace process has taken so long it is currently going backwards.
Instead, he let Gould tell one of his stories about watching clinicians battle to login and access the records they need before asking how he was going to sort it out.
Gould suggested he thought the answer here was getting “proven technology” in front of the right people. “I have been to trusts and watched junior doctors trying to login for 15 minutes and I have been to trusts where they have a token and it’s all done in seconds.
“So, it’s doable and I think if we come up with proven technology and put some money behind it then it can work. I do not want to say it will happen by x date, because that is just creating a hostage to fortune, but I am absolutely clear that our ability to bring people with us depends on [getting it done].”
No strategy, five missions
Not that sorting out the basics will be enough. “If we want systems that make the best use of data, with proven AI, one of the things you have do to is to provide high quality data for them to work with,” Gould said.
“If you have hospitals that do not have EPRs they are not providing us with the data we need. So, fixing the basics is part of preparing for the future.” So, is the NHS going to have a new IT strategy to lay out what is going to be done? “Say yes,” Lilley urged, “because then I can read it and help to pick it apart.”
Gould said he’d hate to disappoint his interlocutor, but he was going to do so. “I want to avoid big documents and grands projects,” he said. “We need to work out what we are going to do, and then go at it, without constantly pulling up the plant to look at the roots and see how it is doing.”
Lilley was frankly puzzled by this, pointing out that “IT has just fizzled out.” He didn’t list the strategies and projects that are going nowhere, but it’s a long time since anybody mentioned Personalised Health and Care 2020 which is, nominally, the NHS’ current IT strategy.
Or the global digital exemplar programme, which never expanded beyond its first round of trusts and now seems to be struggling to get traction for the blueprints that were supposed to help other organisations follow in its wake.
Or the £412 million that health and social care secretary Matt Hancock announced would be spent by sustainability and transformation partnerships on filling gaps in acute systems and sorting out shared care records.
Gould never mentions any of these initiatives as pointers for the future, even though they all tried to learn from NPfIT and, in the case of the GDEs, have something to show for it. Instead, he said: “Ok, we won’t have a big strategy, but we do have five missions” which, he added in response to a question, he wanted to progress “this year.”
Money be good to me
Lilley had one last go on the money. Gould agreed some would be handy. “Money is at the heart of it. Most sectors spend 4-6% of turnover on IT, and the NHS spends around 1% or perhaps 2%. So, I think there are two issues: how do we best make the case to Treasury that money invested in technology is money well spent? And how do we get trusts to invest?
Unfortunately, he didn’t have an answer to either point before Lilley handed over to Amelia Tickell, the daughter of Shane Tickell, the chief executive of IMS MAXIMS, which sponsors the HealthChats. The industrial cadet and NHS England ambassador asked Gould for his career advice.
In response to which, he warned her against picking a goal and advised her to follow her interests. “Two years ago, I could never have imagined being in charge of NHS IT, and five years ago I could not imagine leaving the diplomatic service,” he said. “So do not stress too much about this stuff.” Health tech, just chill.