To NHS IT, and beyond?

Health and social care secretary Matt Hancock is setting up an NHSX unit. It’s hardly the first attempt to set up a central body to sort out IT policy and approach. So will it fly, or founder on the launch pad? Lyn Whitfield considers.

When the Health Service Journal broke the news that Matt Hancock was pushing to create his own digital unit, labelled NHSX, the story was greeted with some scepticism.

Surely, said commenters below the line and on Twitter, even a secretary of state as interventionist as Hancock couldn’t think he could just “dabble with the NHS like a kid with a new train set.” Or call his new unit NHSX, with its overtones of Mars shot SpaceX (and, less happily, Elon Musk).

Yet, just a few weeks later, the Department of Health and Social Care has announced that a new unit is, indeed, being set up. And it’s still called NHSX.

What do we know?

The official press release says the unit is needed because the slow pace of change on NHS IT is down to the “responsibility for digital, tech and data” being “split across multiple agencies, teams and organisations.”

“NHSX will change this by bringing together all the levers of policy, implementation and change for the first time,” it says. However, some details have yet to be filled in.

Most obviously, it’s not clear what status the new unit will have; there is no mention of it being given the legal status of, say, a special health authority. Nor is it very clear how it will be resourced or staffed. 

The press release says NHSX will have a chief executive who “will be accountable to the health secretary and chief executives of NHS England and NHS Improvement”.

But it looks as though its other staff will be drawn from Hancock’s own, digital team, and NHS England’s rather more established technology and digital patient leads; who will continue to be employed by their respective organisations. 

In another complication, a lot of its work may need to be executed by third parties including NHS Digital, which the release says will report in to the new unit.

A question mark against NHS Digital

In the medium-term, the establishment of the new unit puts a question mark against the future of NHS Digital, which, on launch day, was putting a brave face on things.

In a quote on the gov.uk website, chief executive Sarah Wilkinson described NHSX as “an important and welcome initiative” and one to which “we are absolutely committed.”

However, in an email to staff quoted by digitalhealth.net, she acknowledged that she expects the unit to “define” NHS Digital’s future and it will have to justify its “privileged position as the prime digital, data and technology delivery partner for the NHS.”

As one chief information officer told Highland Marketing, this “didn’t exactly scream stable future”. On the other hand, he didn’t feel this was a bad thing, as “maybe they are long overdue an overhaul”.

Here we go, again?

That’s not an unusual reaction. But NHSX has been set up to do more than put a boot under NHS Digital.

The gov.uk release says its responsibilities will “include” everything from setting policy and standards and making “source code open by default”, to running its own projects (“agile” ones, naturally) while cracking adoption, reforming procurement, sorting out security, and developing training.

So, the bigger question – and the one NHS organisations and tech suppliers will be asking – is whether it can do all those things. Its chances will depend on several factors; starting with whether Hancock is right, and they all need to be done by one body.

Over the years, various models have been tried for overseeing and delivering technology. The 1998 Information for Health strategy left policy with the Department of Health and what was then the NHS Executive, but set up a single body – the NHS Information Authority – to build infrastructure and run model projects.

When this didn’t work, the 2002 Delivering 21^st Century IT strategy led to the NHSIA being side-lined up in Leeds while the National Programme was set up in London under a ‘director general’, Richard Granger.

When NPfIT started to struggle, the different power-centres morphed into NHS Connecting for Health. In its later years, CfH ran alongside the data-focused NHS Information Centre. Until the 2012 Lansley reforms split policy, commissioning and delivery between the Department of Health, what had become NHS England, and what became NHS Digital.

While this certainly suggests that the NHS can’t decide where to ‘put technology, it doesn’t suggest that it is having one body, or many bodies, for policy, commissioning, delivery and data that make a strategy successful, or otherwise. Other factors, from technology to money to service buy-in, matter.

As if to prove the point, NHS IT has a co-ordinating body at the moment, the national information board. This looked set to become a powerful, national body on the NHSX model when it was controlled by NHS information director, Tim Kelsey.

But it has faded from view since Kelsey left for Australia, the ‘paperless’ agenda he promoted with former health secretary Jeremy Hunt has more or less dropped off the agenda, and NHS England has focused on the global digital exemplar and Empower the Patient programmes.

Ignoring the statutory niceties

Still, NHSX may be something much more straightforward: a land-grab to resolve a good old-fashioned power struggle between Hancock’s new team at the DHSC and the more established set-up at NHS England.

The CIO quoted above certainly saw the move in these terms. “Hancock doesn’t want a whole lot of national agencies running ‘digital’ when he wants to be in charge himself,” he said. This has raised eyebrows in policy circles.

In a thread on Twitter, Harry Aagaard Evans from the King’s Fund noted that “the creation of quangos in response to particular issues is not new” but “they are most often created from the integration or disintegration of existing ones” rather than by “siphoning off” staff and responsibilities from existing ones.

“And that’s significant, because it demonstrates that the independence of NHS England from the DHSC is only really at the pleasure of the secretary of state.” Hunt went along with that. Hancock “is by nature a disruptor.”

The up and the downside a bold innovation

Hancock has been widely welcomed as a breath of fresh air. His focus on interoperability and his impatience with companies that block it have gone down well in NHS IT circles and with suppliers that are on board with the approach.

His headline grabbing statements that trusts should just “axe the fax” or stop sending letters and start sending emails have cut through a lot of rather stale debate about NHS tech. So, the arrival of NHSX, as a startling policy innovation, explicitly designed to drop a bomb into the established world of NHS IT, could make it a radical force that will cut through existing policy entanglements.

Equally, it could severely limit its chances of doing that. Because the flip side of NHSX being created at the behest of the health and social care secretary is that it could be dependent on his patronage. And nobody really knows how long Hancock will be around.

Parking the issue of Brexit, which could still topple the government at almost any moment, he has risen through the ministerial and cabinet ranks by staying for only a few months in any jobs he has had.

Meanwhile, as Ben Heather demonstrated in an opinion piece on the Health Service Journal (£) there are signs that the status quo is quietly fighting back. “An early, proposed version of NHSX would have placed it firmly within the DHSC, with its own director general reporting to Matt Hancock,” he wrote.

But that’s not what happened. Meanwhile, all the organisations involved, which, as Heather notes, includes a bunch of organisations not mentioned in the press release with data or regulatory responsibilities, retain their statutory duties and reporting lines.

And, critically, their budgets. The government may have promised the NHS in England an additional £20.5 billion a year by 2023-24, but for the moment, the only significant sums of money available for NHS IT are tied up in NHS England, NHS Digital, the GDE programme, and sustainability and transformation partnerships – which have already been given the £714 million that Hunt got out of the Treasury for tech in the last spending round.

To do what?

The really big challenge facing NHSX, though, may not be getting things done, but working out what it is meant to be doing. The NHS has an IT strategy, Personalised Health and Care 2020, which was launched to support the Five Year Forward View.

At one point it had more than a dozen workstreams. But of these, only the Empower the Patient programme, which has just lost its leader Juliet Bauer to the private sector, is still visible. PHC2020 looks dead in the water.

The NHS Long Term Plan, which was issued in January to revitalise the Forward View, has a chapter on technology. This focuses on digitising hospitals by extending the GDE programme, creating local health and care records, population health management, and Empower the Patient’s NHS App and NHS Login.

Last year, Hancock launched his own tech vision, extoling the virtues of cloud first, internet first, and app-based technologies. This is at odds with the (mostly) single supplier approach of the GDE programme, and the platform with open APIs approach of the local health and care record exemplars.

Plus, as Roy Lilley pointed out at a recent health chat with Hancock, it’s not really a strategy. The tech vision, for instance, won’t tell trusts what to do once they have axed the fax, on a spectrum from ‘send e-faxes’ to ‘go through the pain of exchanging structured, coded documents via information exchanges’ that will, for the moment at least, rely on proprietary technology. 

Big job or poisoned chalice?

NHSX will need to clarify what NHS IT is meant to be doing, how it is meant to be doing it, and what technologies it should be deploying. A task that has defeated many bodies over the years; even those less closely associated with a single individual and set up on a proper basis with money to spend.

Commenters on the HSJ website, well versed in the art of managerial machinations, noted that a lot will be riding on who gets the chief executive’s job. Will they have the clout and staying power to make sure NHSX gets to fly?