What will be the impact of the latest changes at the top of NHS IT, and the decision to merge NHSX and NHS Digital into a new NHS England transformation directorate? The Highland Marketing advisory board held a call to canvass views…

In the middle of November, health and social care secretary Sajid Javid gave a speech to the NHS Providers annual conference. He looked beyond the Covid-19 pandemic and demand pressures to the importance of reform and the role of leadership in delivering it.

In doing so, he took time out to say that he found the split of national responsibilities for NHS IT “odd”. It sounded as if something was afoot, and a week later the Health Service Journal reported that NHS England will absorb NHSX and NHS Digital.

Merging digital bodies is ‘the right direction of travel’

The members of the Highland Marketing advisory board were unanimous that this is the right direction of travel, given that the current set up is not just “odd” but the outcome of a series of historical accidents.

Back in 2011, the Conservative-Lib Dem coalition government abolished the National Programme for IT and set up NHS Digital to run what was left of its national infrastructure. Then, former health secretary Andrew Lansley published his reform proposals, which made NHS England a ‘purchaser’ for NHS Digital’s services.

Lansley’s successor, Jeremy Hunt, secured funding for digital from the Treasury, leading NHS England set up a new digital team to create a strategy and programmes to spend it. Only for Hunt’s successor, Matt Hancock, to arrive and set up his own agency, NHSX.

Advisory board member Andy Kinnear, a consultant who worked in the NHS for 30-years, said: “Letting NHS Digital emerge from the smoldering embers of the national programme was a mistake, and NHSX was the wrong organisation, created by the wrong man, in the wrong way, at the wrong time. Undoing all that has to be good, but it shouldn’t have been done in the first place.”

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Merging them into NHS England’s transformation directorate has benefits…

Having said that, NHS England is not planning to create a new digital directorate. Instead, it is going to bring NHSX and NHSD into its emerging transformation directorate.

This will be led by transformation director Tim Ferris, with the support of NHS Digital chief executive Simon Bolton, who is moving into an (interim) chief information officer role (there is no word, as yet, on the future of NHSX chief executive Matthew Gould).

Members of the advisory board could see the rationale for this decision. Ravi Kumar, an entrepreneur who started his career in health tech in the 1990s, felt the new set-up had some of the hallmarks of a period.

“The Department of Health and the NHS were very tightly aligned; there wasn’t the same gap between policy and delivery,” he said. “That meant we could run short programmes of work, with the funding aligned to benefits at the local level.”

Imaging expert Rizwan Malik said he hoped the new directorate would recreate that dynamic, given the pressing need for the NHS to tackle the waiting list backlog while getting back into the NHS Long Term Plan’s reform agenda.

“Technology should be an integral part of transforming healthcare, not a bolt on,” he said. “So, from that point of view, I can see that these changes made sense. The digital strands have had time to do what they needed to do, and now we need to incorporate them into the changes that we all want to see.”

… but could have drawbacks

However, there could be drawbacks. Cindy Fedell, a former NHS chief information officer who is now working in Ontario, wondered whether the nature of the change would “damage the reputation of health tech” since it would be taken as evidence that “NHSX has been a failure.”

A quick look at the comments on the Health Service Journal’s story shows there is, indeed, little love lost for NHSX or, indeed, much respect for NHS IT, among its readers. And there’s a clear danger that health tech could lose further prestige, if it comes to be seen as just another way of ‘doing’ transformation, rather than as a source of innovation in itself.

More immediately, Fedell was also concerned that the transformation directorate would be more interested in developing transformation ideas than in the roll-out methodologies and technology underpinnings that would be required to make them work on the ground.

For example, she noted “lots of trusts still don’t have core IT systems in place”; but will an NHS England transformation directorate see its first job as sorting out electronic patient records? Or, for that matter, building on the ‘basic’, view-only shared care records that ICSs were told to set up this year?

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Taking the strengths of the old into the new

Nicola Haywood-Alexander, the system chief information officer at NHS Lincolnshire, suggested that if it is going to succeed, the new directorate will need the organisations moving into it to bring their strengths to the party, and to counter their weaknesses.

She recalled conversations with CIO colleagues who felt NHSX’s strengths have been that it has recruited people with a vison for how digital can bring about transformation, and that they have genuinely looked to engage with the frontline and to work peer to peer.

However, it hasn’t always had a solid understanding of how ideas can be realised technically across systems. Meanwhile, she said, those conversations suggested that NHS Digital’s strength has been the provision of high-quality infrastructure and the availability of staff with real, technical prowess.

But its approach hasn’t always been as accommodating and agile as it might have been when it came to working with the frontline on real-world challenges.

In future, Haywood-Alexander argued: “We need NHSX’s leadership and ability to engage with the frontline to stand-up strategy and policy. And we need NHS Digital’s solid, technical expertise to design, build and supply sustainable national services.

“Then, we need both to think about how all their different programmes come together when they land at the frontline, to make sure that they all connect and none of them contradict each other.”

Plus, she added, looping back to the earlier point about the need to underpin transformation thinking with solid foundations for delivery: “We need the new organisation to support us with project management and delivery skills, because we need those resources to get traction.”

But how will the ‘transformation factory’ operate?

For the moment, it’s hard to predict how the latest round of changes will pan out, because there are too many unknowns. The decision to merge NHSX and NHS Digital into NHS England’s transformation directorate was made following the much-delayed publication of Laura Wade Gery’s review of data, digital and tech.

This makes six observations about the current position and effectively argues that the NHS also needs to change its transformation model, create consistent funding streams that align capital and revenue and avoid pinging backwards and forwards between “monolithic programmes or small-scale initiatives”, and find more “soft levers” for change.

But there is no organisational chart for the new body (it’s not just Matthew Gould’s future that is unclear, there is no word on where most of NHSX and D’s senior leaders will fit in the transformation directorate, if anywhere) and there is no operating model.

The closest the Wade Gery Review comes to the latter is a section that talks about creating a ‘transformation factory’ that will bring together operational, clinical and digital teams to run ‘agile’, benefits focused projects.

Jeremy Nettle, chair of the advisory board, suggested this meant the directorate will be looking to adopt some of the approaches adopted during the Covid-19 pandemic; identify a problem, come up with a solution, and place a limited number of contracts to deliver it.

“I think we will see them prototyping ideas and then putting out a blueprint with a national contract or framework that trusts can use to implement it,” he said. “If trusts want to do something else, there will be an extra cost, so trusts will be expected to work with their suppliers to show that it’s worth it.”

James Norman, a former acute trust finance director and CIO who now works in the health tech industry, agreed and felt the changes would be positive.

“They are talking about taking out boards and duplicated senior management jobs. That should reduce costs at the centre. I hope that funding will go down to the frontline, so there is more support and more technology funding for the ICSs. Not immediately, but in the next six to 12 months. Then we’ll see what they can do.”

Even long-term gains will mean short-term disruption

However the new organisation pans out, its formation is bound to be disruptive. Immediate reaction from NHS IT leaders and the industry focused on the danger of a long hiatus, as redundancies are made, and people are recruited into new positions.

In digitalhealth.net, the leaders of the Digital Health CIO, CCIO and CNIO networks worried that in the process momentum could be lost on some of the positive things that NHSX has done recently: like set up the unified tech fund, reboot the digital aspirant programme, and issue the ‘what good looks like’ and ‘who pays for what’ document for ICSs.

Andy Kinnear shared these concerns. From long experience, he said: “We all know that these reorganisations take at least a year to organise and bed in; and the NHS doesn’t have a year. It needs to be making digital decisions now.”

Ravi Kumar agreed and said digital needs to stay visible if it wants to stay relevant: “If I was a trust chief executive or an ICS chief executive, what I’d want to know is how this is going to affect me. Because I’m not thinking about transformation. I’m thinking about ambulance queues, or waiting lists, or the levelling-up agenda.”

Jeremy Nettle also felt the real test will be whether the new directorate can cut through at that level. “In the end, that is how you do transformation,” he said. “If you come up with something that solves those problems, and get it rolled out, you do it. That is what changes the dynamic.”

Summary and advice:

In summary, the Highland Marketing advisory board felt the decision to merge the digital policy making, funding and delivery responsibilities of NHS England, NHSX and NHS Digital makes sense, and corrects the “odd” split that has evolved over the past ten-years.

But it also felt there are pros and cons to the decision to move digital into NHS England’s transformation directorate. On the plus side, this should make it easier to align NHS policy and challenges with digital solutions.

The potential downside is that the new organisation could become focused on big transformation ideas, rather than on the change management and digital foundations required to deliver them. Digital could also lose prestige in the longer-term, which will not help innovation.

To achieve its potential, members felt the directorate will need to: stay visible and relevant during the inevitable disruption that will be caused by its formation; keep up the momentum on important digital initiatives that are already in flight; create an organisational structure that plays to the strengths of its constituent bodies; clarify the idea of a ‘transformation factory’ and explain how suppliers and NHS organisations will engage with it; align funding streams; highlight the need for rapid transformation and focus on supporting trusts and integrated care systems to deliver it; and recognise the good work done by local teams to deliver on the ground.  

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