Mark England on NHS digital change

Bedfordshire, Luton and Dunstable is one of the most advanced sustainability and transformation partnerships in the country. Its chief of staff, Mark England, talks to Lyn Whitfield about what it hopes to achieve as one of the country’s first accountable care systems, and how the Luton and Dunstable global digital exemplar will support it, ahead of this year’s UK Health Show at Olympia London.

Mark England has a job that may be unique. Since September last year, he has been chief of staff for the Bedfordshire, Luton and Milton Keynes sustainability and transformation partnership.

“It’s a job that involves a lot of banging heads together,” he laughs. “As chief of staff, I am responsible for the day to day running of a partnership that involves 16 organisations, that is working to be one of the first eight accountable care systems in the country.

“There’s a senior responsible officer, and a chair, and me, and I work with them to try to keep the ACS on the road.”

From STP to ACS
Before he took up his present job, England was executive director of re-engineering and informatics at Luton and Dunstable NHS Foundation Trust.

In this role, he was heavily involved in the sustainability and transformation plan that the trust led on behalf of those 16 organisations – three clinical commissioning groups, four councils, three acute trusts and six ambulance, mental health and community services.

Forty-four STPs have been drawn up across England to take forward the Five Year Forward View plan to close a £30 billion gap between NHS funding and demand by 2020-21, through a mixture of efficiency savings and new models of care.

The Bedfordshire, Luton and Milton Keynes STP took a data-led approach; appointing Optum to collect and analyse three years’ worth of anonymised data from its partner organisations.

It also brought in actuaries to help it model demand and – with a review of its three acute hospitals already underway – to start shaping plans for integrated care services and initiatives to tackle issues ranging from cancer survival to stroke and suicide rates.

The final submission was one of nine STPs to be judged ‘outstanding’ by NHS England in July. In the meantime, Bedfordshire, Luton and Milton Keynes had become one of the eight ‘pathfinder’ accountable care systems unveiled at the NHS Confederation’s conference this summer.

ACS status has given the area some immediate investment to ‘fast track’ its ideas. Down the line, it could mean a shift to a different funding model, with payment by results replaced by a single, capitated budget to meet the health and care needs of the local population.

The challenge of driving change
Driving change on this scale is not easy. As he was being interviewed, England was driving to a potentially tricky meeting at which the 16 chief executives of the organisations involved in the ACS were going to discuss how to handle this year’s contracting round.

But if he’d been sitting at his desk, he’d have been receiving a steady stream of emails about the transformation agenda. “I have never worked on anything that has generated the same level of emotional resistance,” he says. “I must get ten emails a day saying: ‘We are really worried about this’ or: ‘We cannot do that’.

“One challenge is that we are working without a well-defined legal framework. The ACS is not an entity; it’s a collaboration between 16 organisations. We have aligned some staffing and resources with that; but we don’t have [a big consultancy] in a tower block in the middle of the patch. Instead, we have to work on relationships.”

This tension between the NHS as it is now – organised around commissioners and providers with their own financial, legal and regulatory obligations – and the health and care system as the Forward View would like it to be – with integrated services planned and funded at a population level – has been a subject of growing debate.

It has been a hot topic at conferences since the general election, when the outcome plus Brexit made a health and care bill to support the latest reforms unlikely. Senior figures from NHS England and NHS Improvement have insisted that most of what needs to be done can be done without legislation.

But in the meantime, England jokes that his role is the “collision point – or perhaps the fulcrum – between the Five Year Forward View and the status quo.”

Bringing in the tech, with GDE status
In his old role at Luton and Dunstable NHS Foundation Trust, England was also heavily involved in putting together a bid for digital global exemplar status for its IT.

Unlike many of the trusts that went on to become GDEs, Luton and Dunstable is not running a big, US, electronic patient record. Instead, it has invested in a mix of administrative and clinical systems, while working with Xerox on a major scanning and electronic document management project.

Luton and Dunstable has already named Bedford Hospital NHS Trust as its ‘fast follower’ and will now help the smaller, more financially challenged organisation to improve its IT and get EDM in place. But England stresses that GDE status is not just about acute hospitals.

The STP recognised from the outset that to succeed it would need more IT; including more sophisticated analytics, more information sharing, and more access for patients. So, some of the GDE money will be used to lay the foundations for the ‘digital platform’ for the area.

“If the Forward View is going to be delivered, then we need a digitally innovative system,” England says. “That means we cannot see the GDE as an entity; we have to see it as part of the system.

“One of the things that we want to do is to make sure that when Luton and Dunstable makes a decision about something, its investment can be used beyond Luton and Dunstable.

“For example, we are doing an integration with SystmOne [the IT system used by local GPs]. If we get the integration approach right in Luton and Dunstable, that is a bit of work we will not have to redo elsewhere.

“That really matters, because the marginal cost of rolling something out is much, much less than the cost of starting over. When it comes to IT, we don’t want to do anything for 40,000 patients. We want to do it for 500,000 patients and perhaps 1 million patients.”

Focused on the end goal: better care
This is another “complex bit of choreography.” After he left the chief executives, England was due at another meeting, this time with the IT leads of the 16 organisations involved in the ACS.

This meeting was due to discuss “system interventions, financial governance, transformation, and benefits.” Not easy, when it’s the IT leads and their organisations that still hold most of the budget, can decide what systems to use, and what rules to follow on everything from integration to information governance.

What keeps England working so hard is that potential for change; for creating services that will, for example, make it less likely that an elderly patient will need an emergency hospital admission; or be discharged without the support to stop them being re-admitted almost immediately.

He points to an article about the ACS in the Guardian, which describes how sheltered accommodation with exercise and “gadget classes” is already delivering this kind of outcome for elderly people in Dunstable, as an example of what it should be able to achieve more widely.

“If I didn’t really believe that the new model of care will be better, I wouldn’t be able to keep doing this,” England says. “You have to hang onto that, because inertia is so strong. Sometimes it feels like the biggest force; but you just have to keep looking for ways to overcome it.”