The big health tech show of the spring took place against the backdrop of an NHS in turmoil, a lack of IT leadership, little or no money, and suppressed row about the role of convergence in the frontline digitisation programme. If there was any advice for CIOs, it was to assess the direction of travel, collaborate locally, and crack on. Lyn Whitfield reports.
“We are 12 months on from Rewired 2022, and it has been a hugely challenging year for the NHS,” Jon Hoeksma, the editor of digitalhealth.net told the opening session of Digital Health Rewired 2023.
“Last year, the hope was that the NHS would have the stability to get into the big agenda on waiting lists and demand. Instead, there has been turmoil. Yet the tide of digital continues to rise and is clearly going to be part of the future of the NHS.”
Tech is the future, but progress is painful
The NHS is certainly in turmoil. As Digital Health Rewired opened at the Business Design Centre in Islington, junior doctors were starting a third day of strike action that put huge pressure on A&E and led to thousands of cancelled operations.
At the same time, other unions were sitting down to discuss a pay offer that would add to financial pressure on the NHS that is already so severe that non-frontline programmes are being slashed. According to the Health Service Journal, that includes half of the £2.2 billion for NHS IT announced in the Autumn Statement.
Which means that just ten trusts out of the 30 that NHS England thinks need investment in electronic patient records are likely to get it. Meanwhile, NHS England is distracted by absorbing NHSX, NHS Digital and Health Education England, while cutting headcount by 30-40%.
As the show started, it had just appointed its second interim chief information officer and its third interim chief clinical information officer in a year (HSJ news story). Unsurprisingly, under the buzz of the exhibition floor, there was a growing sense of frustration with the pace of digitisation.
“The pace of change is so slow,” vented Beverly Bryant, who has worked at a national, supplier, and trust level, in a debate on EPRs and shared care records. The National Programme for IT tried to accelerate things. We all know it failed.
“But since then, we have failed to get traction. Wachter [a major review of NHS IT that led to the shelved global digital exemplar programme] was in 2016, for goodness’ sake. The funding is not there. Interoperability has gone backwards.”
Up the pace
Tim Ferris, the US head of NHS England’s transformation directorate, agreed that the pace of tech adoption is too slow. “The [proportion of the] population of the country [that is] over 60 keeps on growing, and that is the essential problem that is causing capacity issues in the NHS,” he said in his day two keynote (digitalhealth.net coverage).
“It drives everything else. It is not just a linear increase in capacity that is required to keep up: it is logarithmic because of the multiple conditions that tend to be involved. So, the current model of care is not tenable. We do not have the people or funds.
“We need to do things differently, and that means technology. All of you know this. I am not telling you anything new here. The controversial bit is how: how do we pick up the pace?” Part of the answer to that question is deciding what the centre should be doing.
The NHS tends to flip between centralised approaches to IT and more local autonomy. Ferris suggested he is aiming for something of a mix. He said NHS England’s job is to “convene people, collate ideas, and then iterate them.” To back this up, he launched ‘Who Does What’, a document setting out the role of the centre, integrated care systems, and providers in digitising the NHS, with supporting service offers and frameworks.
Who does what?
Yet, on the quiet, NHS England is running quite a big IT programme at the moment – frontline digitisation. This wants to get all trusts up to a basic level of IT maturity while converging core systems. ‘Convergence’ was a big topic at Rewired.
When the idea first came up, it was widely interpreted as an instruction to ICSs to get their providers to move to one, single supplier system. But Dermot Ryan, director of frontline digitisation, put forward a more nuanced picture in a show session on ‘convergence in action’.
“Frontline digitisation is about converging infrastructure and core systems, primarily at ICS level, although it does not have to be,” he said. “When Tim Ferris started talking about it, I think people thought it was an end point and it isn’t – it is a journey.
“There won’t be one, converged system everywhere. It will happen in steps and in response to opportunities, as they present themselves. And it has to make sense locally.”
In a similar vein, Will Goodwin, NHS England’s assistant director of programmes for digital maturity, told another session that the digital maturity assessment commissioned from McKinsey will not be used to create a national “league table.”
Instead, he said measurement against the ‘What Good Looks Like’ framework will provide a “north star” that local organisations can follow when they have “potentially difficult conversations” about how to drive digital maturity.
Convergence: the case for
Even so, the big EPR tenders that are about to hit the market have been put together by two to four neighbouring trusts looking for a single supplier solution. And there were some high-profile sessions that supported this approach.
For example, the leaders of Manchester’s Hive project outlined how an early focus on data migration, clinical engagement, and peer to peer training enabled them to put EPIC live for 34,000 users just one and a half hours later than planned (a drug cabinet that wasn’t receiving data held them up on the day).
They also outlined a number of benefits, including substantial reductions in the cost of handling paper and maintaining legacy systems, and a reduction in medication errors (digitalhealth.net coverage).
Similarly, Kevin Jarrold, chief information officer at Imperial College Healthcare NHS Trust, told the convergence in action session that the 12 hospitals in the provider collaborative in North West London are converging on a single instance of Cerner Millennium.
He also said using one system is enabling the area to get flow issues, while working with Palantir to improve reporting and start generating population-level analysis.
Convergence: why it’s a stupid idea
The counter perspective came from TPP and System C. In a typically robust intervention, Frank Hester, the chief executive of TPP, took a swipe at big US systems that, he argued, are focused on billing rather than patient care, and “are not good value for taxpayer money.”
But then he argued that even if frontline digitisation funds were better directed, convergence would be “stupid” because it is aimed at standardising hospital systems – when “the main transactional load” is not hospital to hospital, but from one part of the system to another.
Attention, he argued, should be focused on “building systems that model the doctor-patient encounter, and can be used across GP surgeries, hospitals and social care settings” (digitalhealth.net coverage).
From a slightly different perspective, Marcus Bolton, who founded System C Healthcare and is a director of Graphnet, told the Tim Ferris session that there should be less focus on EPRs and more on shared care records.
“GPs are not going to take out EMIS and install EPIC. It is just not going to happen,” he said. “If we want to change care, we have to change workflow, and the key to that is data – bringing the hospital and the GP data together, so they can support new ways of working.”
Digitise, connect, transform
Ferris wouldn’t necessarily disagree with this last point. He said NHS England’s mantra on IT is to “digitise, share, and transform”; with the ‘share’ bit covered by shared care records, and ‘transform’ covering some projects that will be run centrally or as programmes for which trusts will have to bid for funding.
He mentioned development of the NHS App as a ‘digital front door’ to the NHS, patient flow or ‘air traffic control’ systems to make the most of available capacity, and improving the usability of systems to drive efficiency, for example by adding voice to text to create “ambient documentation.”
The debate that Beverly Bryant took part in effectively asked whether it’s necessary to digitise, and then connect, and then transform. Speaking against starting with an EPR, Lee Rickles, the CIO at Humber Teaching NHS Foundation Trust, argued that clinical and patient behaviour change are more important.
While Bryant argued that EPRs are foundational because “they collect the data.” Building on this, and making the case against shared care records, she argued that true interoperability between hospital and other systems would be a better way forward.
While Rickles argued that shared care records are essential, as the only way to get data out of the siloed systems in which it is held. Ultimately, Bryant – and the audience – agreed with this, given the slow pace of change. “While I believe in interoperability, for the moment, the shared care record is it. So, let’s see what we can do with it for ten years, and if we suddenly accelerate, we can recalibrate.”
Money’s too tight to mention
At the end of the Ferris session, Jon Hoeksma asked whether there would be anything for the NHS or health tech in the Budget that was taking place on the other side of London. As it turned out, there wasn’t; but if there had been, there might have been a useful debate about how to spend it to “accelerate.”
While NHS England remains wedded to frontline digitisation and headline-grabbing programmes on digital outpatients, virtual wards and – coming this winter – flow, Marcus Bolton thought giving integrated care boards and trusts some cash with “no strings attached” might be one way out of the current hiatus.
“I think that if you gave most people in this room £500,000 with no strings, they would do something good with it. Whereas, with these big programmes, the Treasury’s eyes widen at the cost,” he said.
Collaborate and get on with it
Bolton wasn’t the only one to argue that the best thing health and care organisations can do right now is to engage with the collaborative intent of integrated care systems and crack on as best they can.
Patricia Hewitt, the former health minister who is leading a review of integrated care boards, said one of the best things to come out of the Covid-19 pandemic is “a new focus on collaboration to support the most vulnerable people” and that – rather than tech per se – should be the focus going forward.
In the same session, Paul Jones, the chief technology officer of Leeds Teaching Hospitals NHS Trust, said: “When I was asked by Jon to come down to the show, I thought we could talk about legacy technology, debt, tech funding, where do we find the people… should we all just give up.
“With all respect to the suppliers out there, the answer is not a new IT system, and it is definitely not a bit of cloud, thanks a lot. Instead, it is people, and using them in the right way.”
He argued ICBs and trusts should put CIOs on boards, appoint more clinical IT leaders, and then support them to address local issues. “For me, the answer is local leadership and support,” he said. “You just have to get on with it.”