Will Smart on NHS digital leadership

The former NHS chief information officer is now global director of external relations for Dedalus Group, which last year bought DXC Technology’s healthcare software business. Lyn Whitfield asks him what Dedalus has planned for its NHS installed base and discusses what the future holds for healthcare technology.

The news that global IT firm Dedalus was going to acquire DXC Technology caught the attention of the health tech community when it was announced a year ago.

Analysts wondered what it would mean for the electronic patient record market on the continent, where Dedalus has a strong presence not just in its home country of Italy but in Germany and France, where it has made additional acquisitions in a consolidating market.

Meanwhile, policy makers and trusts wondered what it would mean for the digitisation of healthcare in England, where DXC Technology had a large installed base dating back to its predecessors’ development of the Care Suite EPR (previously Lorenzo) for the National Programme for IT and the deployment of other solutions, such as i.PM and i.CM.

Will Smart, who became Dedalus Group’s global director of external relations in April, after a year at DXC and a long career in the NHS, says a lot of careful thought is going into both questions. “In terms of the UK market, our view is… well, clearly, we will continue to think as a global organisation… but… we are not going to drop our Care Suite EPR for another product,” he says.

“We have other EPRs in the group that work for other markets… So, as part of a broader care suite, our existing EPR will continue to be a key part of our strategy in the UK, and also in Australia and New Zealand.”

From EPRs to system working

Smart doesn’t just want to talk about EPRs, however. He acknowledges there is a certain irony in this, given that he led a high-profile deployment of Cerner Millennium at the Royal Free London NHS Foundation Trust, where he was chief information officer from 2010-16.

Also, that he set up the global digital exemplar programme for NHS England, where he was NHS chief information officer from 2016-19. The GDE programme was a response to the Wachter review of NHS IT, which suggested that central funding should go first to more digitised trusts.

The idea was that they would get to the top of the HIMSS EMRAM maturity model and then develop ‘blueprints’ for others to follow. At the same time, local health and care record exemplar projects were supposed to work out what local shared care records and data services would look like.

The arrival of a new health and care secretary and a new agency, NHSX, effectively stopped the programme, but policy was already shifting around it, as attention focused on addressing the demand caused by an ageing and unequal population through population health management and integrated care.

As Smart puts it: “Deploying an EPR is not digitisation. It is only digitisation of core, enterprise processes. It does not touch the broader system. So, while our Care Suite EPR remains core, we need to broaden out our functionality, particularly as integrated care systems come on stream.

“We need to support working across systems and make sure they have the data the need to plan the system and to transform the user experience.”

Platforms for the future

Dedalus has developed a platform called DC4H, or Digital Connect 4 Health. On its website, the company says this is built on ‘six pillars’ that run from the ‘first’ to ‘last’ mile of a patient pathway, and that integrates and ingests (or cleans and stores) data, before indexing it, combining it with insight services, and using this to inform professionals so they can make the right intervention for an individual.

The platform uses a standards-based (FHIR) open architecture (APIs) to connect systems to the platform and to exchange information between them. One of its flagship installations is the Puglia region of Italy, which has been working on increasingly sophisticated integrated care models since 2004.

It is also being used by UK trusts to exchange information with neighbouring hospitals and as part of their Covid-response. “I have made a pretty bold statement on our Care Suite EPR,” Smart says. “But we are not looking to maintain the status quo. We are looking at this as a moment to do something different.”

Dedalus: rooted in socialised medicine

Smart says he always planned to do the NHS CIO job for three years because “that seemed like enough time to make an impact, without getting too far away from the frontline.” So, he was thinking about new roles when Matt Hancock and NHSX came along and “it felt like the right time” to go.

At Dedalus, he has a global role “working across the interface between software company and its customers” and talking with policy makers and other stakeholders to work out how to support both. He also runs the company’s global advisory board and leads on governance and regulatory issues.

In doing this, he says he keeps in mind Dedalus’s European heritage. “We are one of the big five health tech companies globally, and in terms of electronic medical records we have the largest installed base outside the US,” he says.

“But we are definitely European. We were founded in Italy and we are rooted in socialised medicine systems. That gives us a different perspective to US companies. We start our discussions with the social determinants of health and the complex interactions that influence health outcomes.

“We have systems that reflect that: we do everything from primary care to hospitals and end of life care, because we see health and social as a continuum with the patient at the heart of it, rather than as a set of events. And we are focused on open standards. Our DC4H platform is based on FHIR APIs because our idea is not to create lots of walled gardens but to be open to all systems across that continuum of care.”

The challenge of accepting disruption

In his global role, Smart sees many healthcare systems coming up against similar challenges; but they aren’t all taking the same approach to tackling them. For example, he says one of the coming pressures will be demand from patients to do things differently.

During the Covid-19 pandemic, many countries moved rapidly to deploy remote working, virtual clinic and virtual consultation solutions for their staff and are now looking to build on these to create digital-first pathways and virtual ward set-ups for remote monitoring.

Yet, while there is some push-back from patients who want to see clinicians face to face, this is unlikely to be enough for many citizens. Particularly the digital pioneers and digital natives who already want to know why they can’t use their computers and smartphones to communicate with health services in the way that they communicate with banks, shops and other providers.

“There is a lot of activity at the user-end of the picture,” he muses. “[Digital GP provider] Babylon has just got millions in investment, and [its rival] Livi has just got the first ‘excellent’ rating from the CQC. So, we are seeing the consumerisation of healthcare, and some countries are handling that more proactively than others.

“In the US, where there are lots and lots of patients coming in to do patient support, the insurance model makes it relatively easy to absorb them. Whereas the UK and other countries with socialised medicine have to work out where they fit when most provision is done by the state.”

New health and social care secretary Sajid Javid has just introduced the legislation that will take forward his predecessor’s Innovation and Integration reforms. Overall, Smart thinks this is positive.

“Everybody agrees that you can’t do everything from the DHSC or [NHS England’s London base] Skipton House, and that ICSs are an interesting approach to bringing healthcare closer to the community,” he says.

On the other hand, he notes, the legislation has triggered another round of discussions about NHS structure and organisation, boards and roles. “Other sectors have been disrupted from the outside in,” he says, “and I think the NHS needs to think about how it can be disrupted in the same way.

“How can it work with new actors, including patients, to co-produce these new services? I don’t think there is a healthcare system anywhere that has cracked that, but the NHS needs to be thinking about it, and to try and do something innovative and exciting on the scale that Aneurin Bevan did when he created it in 1948.”

Global health tech, local thinking

If and when it comes, any innovative and exciting solution is going to include technology; and, Smart argues, it is going to include the kind of open architecture that Dedalus is developing. “When I was at the Royal Free, my idea was to bring together clinical systems and give them a common UI,” he says.

“DC4H will finally let that happen. As a clinician, or as a patient, I should be able to say: ‘I want to use this app’ for my work or my cancer treatment, and my wife should be able to say: ‘I want to use this one’ and the system should be able to handle that. The question is how to build the architecture that accommodates all that complexity in the background.”

As a starting point, he says global technology companies, NHS organisations and clinicians need to build on the kind of partnership working that they embraced during the pandemic.

“Sometimes there can be a bit of a Mexican stand-off between us,” he says. “We need to come together to address real-world problems and situations. We need to come up with different forms of service that respond to the demands and needs of patients. And digital has got to be part of that.”