The Highland Marketing advisory board held two discussions of the impact of the Covid-19 pandemic on the adoption of healthcare technology in 2020. A year on, it asked whether there was “no going back”; or whether the NHS is, in fact, in danger of slipping back into analogue ways of working.
It feels as if we have reached a critical moment for healthcare IT. This time last year, as England was looking forward to coming out of lockdown for the first time, there was a lot of talk about how there would be “no going back” on the digital advances that had been made in the early weeks of the Covid-19 pandemic.
Now, as the country crosses its fingers that the ‘Indian variant’ won’t hold-up lifting the third set of restrictions, there are signs that the rapid roll-out of remote working technology, virtual clinics and digital-first primary care is stalling or slipping back.
Faced with a record waiting list, trusts are trying to fit in more clinics to tackle the elective backlog. NHS England has bowed to media pressure to ditch its policy of ‘total triage’ and to order GPs to resume face-to-face appointments for patients that want them.
Andy Kinnear, a former NHS CIO and consultant for Ethical Healthcare Consulting, told the Highland Marketing advisory board: “I think we are facing something like a philosophical battle about where we go next.
“There are some comfort zone things going on: there are people saying: ‘We are in a financial black hole, so let’s cut funding for everyone’ or: ‘We need to do recovery, so let’s get everybody back commuting and stick on a load of Saturday clinics’.
“Then, there are the new dawn people saying: ‘Covid gave us an opportunity to do things differently, so let’s keep going’. I think it’s really hard at the moment to say how it is going to play out.”
Shoe-horning digital into analogue processes
At its May meeting, members of the advisory board highlighted three reasons for the current ambivalence towards last year’s health tech adoption.
First: some of the software and apps that were deployed didn’t have the greatest user experience. Entrepreneur Ravi Kumar outlined the frustrating process that he had gone through to book a Covid-19 test using the Covid-19 App.
Second: some of the technology was rolled-out so fast there was no time to adjust workflows to make best use of it. GPs seem to be struggling with the demand that is rushing in through triage and consultation platforms – without changing their appointment booking and consultation processes.
And third: solutions were applied across the board, without being tailored to the specialties and patient groups for which they were best suited. Radiology IT expert Rizwan Malik said: “We deployed the technology that we had to hand, and we shoehorned analogue processes into this digital environment.
“That has caused some problems and at the moment we are beating people up about them. We’re asking GPs why they aren’t doing face to face, when 12-months ago we were asking why they weren’t doing digital. We have to stop doing that.
“We have all this new technology, so we should be asking: how we can use it in a blended approach, so that clinicians see the patients they really need to see, and patients get the service they need?”
Appoint a chief experience officer; and don’t overwhelm the system
To address the usability challenge, Ravi Kumar suggested that the NHS needed a chief experience officer; and that regions, trusts, and regulators should look at experience when they are running projects or assessing software and apps.
Embedding a blended approach to health and care may be harder. When the advisory board discussed the rapid adoption of health tech during the first weeks of the pandemic in April 2020, it identified a number of factors that had galvanized progress.
These included: effective leadership from the NHS’ central and digital bodies; flat decision making and procurement structures at a local level; increased funding thanks to chancellor Rishi Sunak’s promise to give the NHS “whatever it costs” to get through the pandemic; and a supportive supplier base.
However, as early as June 2020, the board was calling for a “second wave of innovation” to start the shift to blended pathways. All of these factors have now changed. NHS leadership is in flux, with chief executive Sir Simon Stevens leaving NHS England, Dr Timothy Ferris joining as director of a transformation directorate that will incorporate NHSX.
The health and care system is still waiting for an IT and a digital strategy, as well as the ‘what good looks like’ and ‘who pays for what’ documents that will support them. NHS Digital losing its chief executive, Sarah Wilkinson, and its analytics functions.
The publication of the NHS white paper, Integration and Innovation, has sparked a debate over the board structure of integrated care systems that, in some areas at least, is distracting attention from how they will join-up care or introduce population health management.
And money is definitely tighter. In his spring Budget, Sunak opted not to maintain pandemic levels of funding for the NHS into the recovery; although health and social care secretary Matt Hancock was subsequently able to announce £6.6 billion for waiting lists and mental health.
This has sent central bodies looking for cash releasing efficiency savings from trusts, while asking them to implement national initiatives, such as community diagnostic hubs, while asking them to bid for funds from programmes such as the recovery ‘accelerator’ project.
James Norman said: “The overload on the service is massive. We’ve still got people in hospital with Covid, A&E is bursting at the seams, people are working 23 hours a day, and we’ve got other people coming along talking about ICSs and accelerators and digital strategies. It’s not sustainable.”
Short term thinking, long term thinking
One way and another, it feels as if the NHS has lost the single, clear goal that it was given when it had to respond to Covid – and it has lost the flat decision-making structures that allowed people at the frontline to come with a solution and secure the resources to deliver it.
As a result, Cindy Fedell argued, the NHS is back to a familiar tension between short and long-term thinking. “Too often, digital is given some money and told to do something – whether that’s roll-out a departmental system or help on a transformation initiative.
“When what it really needs is a strategy and the funding to put the infrastructure in place to do a lot of things in a joined-up way.”
Can things change again? Running through the factors that enabled progress last year, Andy Kinnear found reasons for optimism in the medium to long-term. “Tim Ferris is coming in to drive the idea that transformation has to be digital, and that is a good thing,” he argued.
“We are in for another round of legislative upheaval, but once we are through it there will be new people in place at ICS level. Then, ‘what good looks like’ and ‘who pays for what’ will set out the rules for success in that space, and that’s a good thing. But, in the end, all this comes down to leadership and culture; good people doing good things for their local clinicians and communities.”
Mark Venables, chief executive of Highland Marketing, added that vendors will also play a part, since a “second wave of innovation” is finally arriving in the form of remote monitoring solutions and virtual clinics that address the entire patient pathway from booking to follow-up.
“We are seeing a lot of new vendors coming to us for marketing and sales support – and we are getting a lot of interest in what they have to offer. There are people with solutions and there seems to be appetite in the NHS to procure them,” he said. “If not now, when?”
Seizing the golden thread of change
Advisory board chair Jeremy Nettle agreed – up to a point. “I think we will see that there is a golden thread of change running out of Covid,” he said. “During the pandemic, we saw the art of the possible, and now we are seeing new companies come in to try and deliver that.
“However, I think the question is going to be affordability. Finance directors are going to be looking for savings, so I don’t think this will be about pathways, initially.
“I think it will be about substitution; about swapping scarce resources for technology in areas like pathology and radiology and some clinical specialties. It will be good for some, but the impact will be patchy. It will be a real challenge for IT to pull it altogether; and ICSs may struggle to get the information they need.”