The annual two-day conference and exhibition at the NEC in Birmingham heard a lot about national IT strategy and a lot about local initiatives. What it didn’t hear was how they are going to join up. Lyn Whitfield reports.
NHS chief information officer Will Smart outlined four challenges for healthcare IT in England in his keynote speech to EHI Live 2017.
In order: improving digital maturity; improving interoperability; making better use of data; and transforming services for patients. Of these, improving digital maturity has grabbed most headlines over the past couple of years, thanks to the global digital exemplar programme.
Leadership and followership
NHS England launched the GDE programme following US digital doctor Professor Robert Wachter’s review of NHS IT. This concluded, among other things, that any money that was available for NHS IT should be directed first towards those trusts that were best placed to make use of it.
To date, 16 acute GDEs and seven mental health GDEs have been announced, along with 18 acute fast followers. The idea is that they will move quickly to adopt the clinical pathways and technology developed by the GDEs, and help to create blueprints for further trusts to follow.
At EHI Live, Smart acknowledged that the programme has not been universally welcomed, since it rewards those trusts that are already ahead; and the large EPR suppliers they tend to be working with.
However, he argued that while getting the 16 GDEs up to HIMSS Level 7 would be “some” success: “The real success will lie in the 18 trusts coming behind them, if they can implement more easily and cheaply. Success for me is digitisation being driven across the NHS.”
Smart noted that this will require those trusts that are not leaders to embrace being followers. “One thing we need to develop in the service is followership. [The idea that] it may ‘not have been invented here’ but ‘it is still good enough for me’ and ‘I am going to implement it, because it is good enough for me’.”
Over the next 12 months, he added, he wanted to see “progress by spreading the good things that are happening” and much less “reinventing the wheel.”
But he also outlined five more things that need to happen. The centre needs to support “risk taking and innovation by local organisations” and it needs to “communicate better the good things that are going on”.
There needs to be an underpinning architecture that enables good ideas, and systems, to be transferred from one organisation to another, and organisations need to follow through on their deployments: “it is not enough just to switch something on”. Also, there will need to be more money.
The Treasury found £4.2 billion for NHS IT in the last spending review settlement, and Smart estimated that the same will be needed in the next one to “finish the job” of digitising secondary care and creating fully interoperable health and care records [digitalhealth.net coverage].
Architecture and standards
Rob Shaw, the deputy chief executive of NHS Digital, used his speech to EHI Live to discuss aspects of that underpinning architecture.
He acknowledged that, in the past, some of NHS Digital’s programmes have been delivered “in isolation from each other”, that “interoperability has not been on the agenda.” Now, he said, “we need a step forward in this space”.
This is due to be delivered by the NHS target architecture that is being designed to support the Five Year Forward View (the 2014 plan to bridge a £30 billion gap between NHS funding and demand through a mix of efficiency and new ways of working).
The target architecture wants to make sure that IT systems can work together to support accountable care systems (the emerging organisations that will integrate health and care services and find non-competitive ways of funding them) and the 3-5 million population analytics services they will use.
This will require systems to be standards based; which will require suppliers to get on board – although Shaw dangled the carrot of making it easier for them to ‘plug and play’ with the NHS [Computer Weekly coverage].
“We need to make the most of working with suppliers, as we move from HL7 (a messaging standard) to FHIR (an information exchange standard), and from Read Codes (a way of coding clinical information) to SNOMED CT (an international standard for doing the same thing),” he said.
“If we do that, it will do away with the integration challenge that comes with every implementation, and most suppliers will welcome that.”
Think, then invest
Shaw also outlined some of the developments that NHS Digital has been making to its national infrastructure services, such as the Health and Social Care Network that has just replaced N3, and to the national projects that it runs, such as the e-Referral Service and Electronic Prescription Service.
With these up and running, and fully adopted by some organisations, he said, NHS Digital needed to understand the “barriers” that stopped them being adopted by everyone” [GP Online coverage].
At the end of his presentation, though, a clinician in the audience suggested the agency was a bit like BT. It was rolling out the equivalent of a fibre network for the NHS; but that didn’t mean its many local organisations would use it. What, he asked, was going to shift them?
Shaw suggested that the GDE programme and shift to standards would help, by showing what could be done and making it easier to do it. But, ultimately, he said: “We need customers to make strategic decisions and we need them to invest.”
Organisations “need a map for the next three to five years, because if people are on a burning platform, and they only think about getting off it, that is not enough.” They also need to spend, because: “If the local decision is to give the chief clinical information officer a shoestring to deliver on, then we are not going to get anywhere.”
But start with a strategy
The importance of having a strategy came up again at a roundtable for CCIOs and their chief information officer colleagues. Alec Price-Forbes, a consultant rheumatologist and CCIO at University Hospitals Coventry and Warwickshire NHS Trust, said a vision was essential.
“As anybody who knows me already knows, I have been having some home improvements done,” he said. “It has been very difficult, at times, but I had a vision of what our home needed to do, and we built for it to do that.”
Without a vision, he warned, trusts could find themselves doing the equivalent of trying to bold solar panels onto a thatched roof. More specifically, he argued that the ‘best of breed’ strategies and information sharing projects being pursued by many trusts and healthcare communities were just ‘artefacts’ of the way NHS IT has developed.
Areas, he said, needed to be bolder if they were going to equip themselves for the demands of the 21st century. The STP around Coventry and Warwickshire is planning a citizen health record, focused on the patient.
Similarly, David Walliker, the chief information officer of two big Liverpool trusts, outlined how it is planning to spend its GDE money on both a single EPR for its acute trusts and on IT that will start to integrate the “very fragmented” services across the city.
Winter is coming…
Across the two days of the show, however, there was a sense that while there is a lot of good work going on at both national and local level, it is not quite joining up. The acute GDEs and their fast followers are in place, but an awful lot of trusts are still not engaged with the programme, and are stuck in firefighting mode.
The target architecture has been through several iterations, but is still not finalised, never mind implemented. Some suppliers have embraced the interoperability agenda with initiatives like INTEROPen. Other suppliers have yet to be convinced.
Some areas are making enthusiastic use of national services, while some are doing their own thing and others are doing nothing at all.
In short, some of Smart’s enablers are missing; and the big question is whether there are enough drivers in the system to get them into place. While the NHS itself is in flux, there won’t be legislation to smooth the path from the internal market to accountable care systems, and there is absolutely no money.
These issues came to a head in a session organised by techUK to discuss a new paper: Can Technology Help to Avoid a Winter Crisis?
The consensus was that it could – the session heard from companies with analytics, telehealth, and shared care records that could support planning, alternatives to hospital admission, and integrated care pathways.
The question was whether it will be able to. Beverley Bryant, until recently the director of digital technology at NHS England, and now the chief operating officer of System C, summed up the problem.
“Newsflash,” she said. “Winter happens every year. And every year we have this discussion. We got the spending review money a few years ago, to allow the NHS to complete the digitisation of clinical record keeping as the basis for sharing information across health economies.
“That was also supposed to be the basis for risk stratification and population health management and for new patient apps. That’s the Five Year Forward View vision. But if, every September, we raid the technology pot to fund winter, it is never going to happen.
“Investment in winter planning and in transformation need to happen in parallel, because otherwise it is like trying to cover over rising damp with wallpaper. You can keep adding more sheets of wallpaper, but it will always come through. Eventually, you need to tackle the damp.”