In the first week of May, our independent advisors held their second discussion on the impact of the novel coronavirus on the uptake of NHS IT. They argued that a second wave of innovation is now needed; but there is a real risk of trusts “slipping back” unless there is a plan for one. Lyn Whitfield reports.
There is a long way to go before the UK and its health services are through the worst of the coronavirus outbreak. Nevertheless, with intensive care holding and the Nightingale hospitals standing down, attention is starting to turn to what comes next.
In the past week, NHS England has asked trusts to work with its regional offices to resume “at least some” routine activity and the NHS Confederation has launched a “reset, not just recovery” programme to explore which aspects of the Covid-19 response should be retained in the future.
At its second meeting during the outbreak, the Highland Marketing advisory board argued that health tech needs to be part of that debate, to avoid services “slipping back” into old ways of working. And, preferably, to maintain the momentum achieved over the past eight weeks into a second wave of innovation.
Deployment has picked up; now the NHS needs innovation
Cindy Fedell, the chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust, argued that while the NHS and its suppliers have done a sterling job setting up remote working and digital consultations, a second wave is needed.
“Most of what has been done so far has been done by extending existing licences or implementing projects that were more or less ready to go,” she said. “We haven’t been all that creative, so the next step has to be something a bit more innovative than video calling.”
For example, she argued that as routine diagnostic and outpatient work resumes there is a need to create digitally enabled pathways for them. After all, she pointed out, “we know that up to a third of the patients coming into acute [before Covid-19] didn’t need to be there, so we need to create an alternative for them.”
Andy Kinnear, the former director of digital transformation at South, Central and West Commissioning Support Unit, agreed that “we have seen an explosion of low-tech solutions to low-bar challenges” and “now we need something more substantial.”
But he cautioned this will not just happen. “I think people’s willingness to go back to what they know should not be underestimated,” he said. “As soon as outpatient booking clerks get back to the office, they will start sending letters again, because that is what they do. If we don’t want them to do that, we have to make sure there are levers in place to stop it happening.”
Looking for levers to pull
The board argued that organisations at all levels of the NHS will need to find levers to pull. For example, members argued that NHS England / Improvement could build a digitisation into its operating guidance, commissioning models, and payment mechanisms.
They argued that its regional offices could take a bigger hand in co-ordinating the digital efforts of the integrated care services that were emerging from sustainability and transformation partnerships before the outbreak, and which the NHS Confederation has identified as critical to its “reset” concept.
And they argued that medical and organisational regulators could have a role. Or, as Andy Kinnear put it: “Is the CQC going to say ‘this is the minimum level of digitisation that we expect to see’ or is it going to carry on saying ‘you can be an outstanding trust, even if you are at HIMSS EMRAM 2’?”
However, they also agreed that money will be critical; and Andy Kinnear was worried that it would not be forthcoming. “I am worried that, as a country, we will have spent a lot on Covid-19 and the government will say we need another period of austerity to pay for it,” he said.
“If that happens, the money will dry up. Or trusts will have to find it, and I’m not sure that finance departments are there yet. They are used to spending 2-3% a year on technology and I think some reckon we’ve had our money for this year – and probably next year as well.”
Back to basics
While continued innovation will require investment and leadership if it is going to be embedded into a “reset” NHS, there will be other issues to address.
Last week, Sarah Wilkinson, the chief executive of NHS Digital, told digitalhealth.net that some of the changes that have been introduced during the crisis will need to be revisited and put on a stronger legal footing if they are going to continue. That will raise the whole, vexed issue of information governance.
NHSX issued guidance at the start of the coronavirus outbreak that relaxed the basis on which confidential information can be shared and the communications tools that can be used for sharing it. But the guidance won’t hold forever; not least because NHSX’s own contact tracing app has generated a significant level of public debate about surveillance, consent and privacy.
Two further issues that will need attention are infrastructure (which the Covid-19 response has shown to be patchy at best), and the quality of some IT systems. At its first discussion of the health tech impact of Covid-19, the advisory board noted that electronic patient records have not been a focus for attention or innovation during the crisis.
At its second discussion, James Norman said community systems needed work. A family member working as a community nurse had fed back that her trust’s systems were “clunky”, “out of date”, and “not joined up” with acute care (also, that she’d had a ten-week wait for a laptop).
“If we want to change outpatients, we have to sort out community, because that is where a lot of people are going to be cared for and followed-up,” he pointed out. At the same time, the NHS and its suppliers will need to find a way to nurture smaller, more nimbler start-ups with good ideas to add to the mix.
Reset: only a short window of opportunity
With the NHS starting to resume something like normal service, health tech has only a short window of opportunity to help define what normal will look like in the future. Indeed, it has only a short window of opportunity to decide whether to retain or jettison many of the changes that have been made over the past two-months.
Entrepreneur Ravi Kumar pointed out that “there are a lot of three to six-month solutions out there”; even high-profile national offers, such as Microsoft Teams for collaboration and Attend Anywhere for video consultations, have been deployed on time-limited licences.
“After that,” he pointed out, “people are going to have to decide whether to bring these things into enterprise, or say: ‘We tried it, but it didn’t really work, and now we’re going to look for a better solution’ or say: ‘We tried it, and it didn’t really work, and we’re going to go back to doing things the way we did them.”
The advisory board’s concern was that while there is a general conviction that “there is no going back”, some organisations could “slip.” Also, that the organisations that were least digitally advanced going into the crisis are most likely to do so, because they lack the infrastructure, leadership, resources and capacity for innovation of trusts that will be looking to build on recent gains.
Jeremy Nettle said it couldn’t be allowed to happen. “We can’t just go back to the old normal,” he said. “It wouldn’t just be a missed opportunity; we couldn’t afford it. We need to quickly identify the levers to prevent organisations going back to their old ways; and, preferably to move forward in innovative ways instead.
“To adapt the words of Magnus Magnusson, the first Mastermind question master: ‘We have started, so we need to finish’.”