David Hancock on NHS interoperability solutions

The long-standing health and social care IT expert and advocate for interoperability discusses frontline digitisation, shared care records, and standards adoption. Interoperability is closer than we think, he says: what we need are open APIs, and they’re coming…

David Hancock has worked in IT “for something like 40-years”, with 20 of those spent in life sciences and health tech. He worked for Orion Health, where he developed and deployed shared care records “before shared care records were fashionable.”

Then he moved to InterSystems, where he built a strong electronic patient record and health information exchange business. David also represents the health tech industry on the techUK health and social care council and has a long-standing passion for interoperability.

He was part of the founding group for INTEROPen [the organisation set up to define and promote interoperability standards in the UK] and has been its vendor co-chair since 2018 – as well as a member of groups working to develop and promote HL7 FHIR [a standard for healthcare data exchange] in England, Scotland, Wales and Northern Ireland.

“Interoperability is one of the most important things for driving digital transformation,” he says, “and that’s because it enables you to create new pathways. If you can share information across systems, then you can start to change the processes that the people working in them use, and the way that pathways work.”

Digitise – connect and transform?  

Joining up IT systems should be at the forefront of the NHS’ mind, as integrated care systems come on stream. ICSs have a remit to manage health and care economies, streamline workflows, introduce population health management approaches to prevention and public health, and create digital front doors.

And that won’t be delivered unless planners, clinicians and patients have access to the data they need – ideally, in the case of professionals, within the operational systems that they use every day.

Yet NHS England’s transformation directorate, which has just finished absorbing NHSX and NHS Digital, seems more interested in the frontline digitisation programme, which wants to ‘level up’ digital maturity at acute trusts and ‘converge’ infrastructure and core systems in the process.

“NHS England talks about ‘digitise, connect and transform’, but it puts a lot of emphasis on the ‘digitise’ and not enough consideration on the ‘connect’ and ‘transform’,” David muses. He also worries that there are issues with frontline digitisation, even on its own terms.

Frontline digitisation will help – a bit

For a start, he points out that the NHS’ two, big IT programmes of the past 20 years – the National Programme for IT and the global digital exemplar programme – delivered EPRs to just a handful of trusts.

A few organisations have achieved good levels of digital maturity outside these programmes. But they’ve either had the financial resources to deploy a system from a company with a proven (if expensive) deployment model, or they’ve had the IT leadership and resources to buy and build over years.

Frontline digitisation is, in effect, aimed at the rest – which means mostly smaller trusts that may be looking at financial deficits and struggling to fill rotas. The programme does look to have funding for around ten, mid-sized EPRs, and it has defined ‘minimum digital foundations’ to encourage trusts to buy from companies that can deliver them.

However, it’s not clear the programme will be able to help trusts with the resources required to deploy and get to business as usual, while the MDF is very focused on functionality and big-bang go-lives, which may shut all but a small number of (very familiar) companies out of the market.

At the same time, David argues, frontline digitisation is not putting enough emphasis on benefits realisation; and it’s certainly not putting enough emphasis on interoperability. “NHS England is putting a lot of money into frontline digitisation, so it should want to know what it is getting for it,” he says.

“There’s no doubt benefits realisation is difficult, because hospitals are running so hot at the moment that it’s going to be hard enough to get them to deploy and transform. But unless you do it from the start, you don’t know whether you are generating benefits – and if you’re not, you can’t get back on track.”

Aim for interoperability  

When it comes to interoperability, the challenge is the second aim of frontline digitisation – convergence. NHS England would like to see neighbouring trusts using the same IT system; but this addresses only part of the interoperability picture.

“Frontline digitisation is only talking about horizontal integration – between hospital systems,” David says, “whilst integrated care systems have been set up to do vertical integration – between hospitals, GPs, community and mental health – so everybody can work together to deliver better care for less money.”

NHS England seems to be looking to shared care records to do this job, but David is sceptical that they are up to it. “The problem with shared care records is that they are viewing platforms for data,” he says.

“They are hugely useful – put one in front of a clinician, and they always say ‘look at all that data’ – but they don’t allow professionals to work in operational systems that have been set up to re-engineer clinical pathways across and between organisations. To do that, you need interoperable systems – exchanging structured and coded data – and that is what we should be aiming for.”

FHIR started – now fuel APIs  

Unfortunately, the vision of fully interoperable health and care systems can feel as far off as it ever was. Another result of the NPfIT and GDE programmes is that where providers have EPRs, they are proprietary systems, from which data can only be extracted with difficulty, if at all.

Even where systems are ‘interoperable’ they may use different standards and approaches. And suppliers may charge significant sums to extract the data they contain. However, David is far less pessimistic. In fact, he thinks interoperability is “much closer than we think.”

“A lot of work has been done on HL7 FHIR profiles, which define what the content of a message should be. So, we understand what needs to go between systems,” he says. “The big, big thing we are missing is standard APIs [application programming interfaces, or the small pieces of code that sit between, software applications that enables them to ‘talk’ to each other].

“We need to get to the point where there is no need to know what system an API is interacting with, because the same APIs are implemented in every system. We need to be able to say: ‘if you want to do this, then this is the standard API to do it’.

“That way, it doesn’t matter if you want to access Cerner, or EPIC, or a UK provider like Nervecentre, because you can say for all of them: ‘this is what I want to access on your system, this is the request I need to make, and this is how will consume what is provided back’.”

David would like NHS England to put some effort behind this. But as it doesn’t appear to be front of mind, HL7 UK is leading some work on it. So, watch this space.

“This is one of the most important pieces of work that is going to be done in NHS IT, if it is going to support integrated care systems – and patient access to records,” he argues.

“Because that’s the other piece of the puzzle; linking in patient information, so we can do all the virtual ward work, and remote monitoring, and digital front doors that people are talking about – integrated into the relevant operational systems. None of that is going to work, unless we can crack this.”

About David Hancock and Highland Marketing

In October 2022, David Hancock set up New Found Consulting Services to help suppliers to the NHS and social care with go to market and product strategies, benefits realisation, and adopting interoperability standards to help their customers achieve digital transformation.

In April 2023, he became an associate of Highland Marketing, to help clients with market intelligence, strategy, and product development – and to support them in putting forward their ideas, services and products in effective marketing, PR and sales campaigns.