The new chair of four trusts in North West London has had a long career in the NHS and a significant influence on the development of its IT. He talks to Lyn Whitfield about progress on electronic patient records, the importance of virtual wards and population health management, and his ambitions for North West London.
The news that Matthew Swindells had been appointed joint chair of four North West London trusts generated considerably more interest than most chair announcements would have done.
Health Service Journal editor Alastair McLellan put out a tweet saying: “He’s back!” Which neatly conveyed the length of Swindells’ career, the influence that many of his roles have given him, and the bounce-backability that has enabled him to weather more than a few changes of NHS regime.
Along the way, Swindells has made his mark on NHS IT. Indeed, in an era in which NHS England is funding a ‘digital boards’ programme to try and get c-suites interested in technology, it’s interesting that he built his early career in procurement and IT project management.
“My first proper job, after I came out of the NHS supplies management training scheme, was as a procurement manager in South East London,” he says. “Then I became a project manager on the IT strategy for St Thomas’ Hospital, and when Guy’s and St Thomas’ merged, I became what would be called CIO today.
“Our strategy was to get away from our mainframe; but in those days you couldn’t just go out and buy an electronic patient record system, so we created a best of breed set-up that was ahead of its time. It was the early 1990s and I think I put the first ethernet network into the NHS and the first organisation-wide email system.
“We moved moved everybody to PCs (using Microsoft Windows 3.1) and we built a timeline for patient interactions with the hospital. Anybody could see when patients had attended, which consultants they had seen, laboratory results, admissions… there are hospitals in the NHS that still can’t do that today.”
Creating a legacy for NPfIT: twice
The Commons health select committee estimated recently that a fifth of trusts are still paper based. One factor behind that figure is the twenty-year overhang from the National Programme for IT in the NHS.
The programme, which started in 2002, delivered some useful infrastructure and projects. But it failed spectacularly in its bid to digitise providers by splitting England into five regions and appointing a global consultancy (or local service provider) to select and deploy an EPR for each one.
“NPfIT was a good strategy, terribly executed,” Swindells says. “The idea of a competitive environment in which there were four or five EPR vendors was not a million miles away from the global digital exemplar programme, but as the big consultancies grabbed control and then bailed out, we ended up with just two contractors and we lost the plot.”
Swindells has found himself dealing with the aftermath of NPfIT not once, but twice. He explains: “After Guy’s and St Thomas’, I moved into general management and became a trust chief executive. Then, in 2005, I was asked by [prime minister] Tony Blair’s office to be the special policy adviser to [health secretary] Patricia Hewitt.
“As Tony left government, [NHS chief executive] David Nicholson asked me to create the role of NHS chief information officer, and to try and make a legacy for the national programme.” The legacy came in the form of a health informatics review that recommended a shift away from NPfIT’s centralised and ‘rip and replace’ approach.
The NHS priorities and planning guidance for 2010-11 told trusts to retain and add to their existing systems until they had five pieces of functionality that would re-engage clinicians (a patient administration system to generate data, scheduling, order communications, e-prescribing, and letters).
It also called for more interoperable systems, linked into the shared care record of the day, the NHS Summary Care Record. However, when the first NHS CIO post was advertised as a substantive post, Swindells didn’t apply. Instead, he says: “I went to Cerner, and after 18 months they asked me to move to Kansas, where I created their data business and their population health business.
“I was doing that very happily, until Simon Stevens [the chief executive of NHS England] asked me to apply for the job as national director for commissioning operations and information, which later became deputy chief executive.” Swindells joined NHS England just before the Wachter Review of NHS IT reported.
Wachter recommended that scarce IT funding should be spent on the trusts best able to use it, which led to the creation of the global digital exemplar programme. This aimed to get a dozen trusts to the top of the HIMSS EMRAM maturity model, while helping ‘fast followers’ to reach Level 5, and to create procurement frameworks and blueprints for digital aspirants to use in due course.
“One of the problems with NPfIT was that McKesson had decided to exit the NHS IT market, and that put a lot of hospitals on a burning platform,” Swindells says. “So, the programme started with them. And, in retrospect, it was pretty obvious that it should have started with trusts that wanted to be at the leading edge of technology, not those that were on the back burner.”
Which, of course, the GDE programme did. “The other big problem was that there was no local ownership. For the GDE programme, we required match funding from trusts, because we wanted their boards to be involved. We got the idea from the meaningful use programme in the US, which gave organisations an incentive to get a return on their investment.”
Enter and exit NHSX
The National Audit Office recently published a report on the GDE programme that said, in essence, that it worked. However, it was effectively stopped by the arrival of health secretary Matt Hancock, who took IT out of NHS England and handed it over to his own agency, NHSX.
Swindells, who eventually left NHS England himself to become a management consultant, understandably thinks that was a mistake, and is glad to see that under another health secretary, Sajid Javid, NHSX and NHS Digital are being absorbed back into a new transformation directorate.
“I think the creation of NHSX was destabilising,” he says. “It was a distraction; and that’s no slight on the people who were involved. One of the things that I did at NHS England was to bring digital leadership into the operational management of the NHS, so they routinely sat around a table with the regional and national directors, talking about what the operational people needed to do and how the technology could help.
“NHSX broke that. It turned IT inwards on itself and lost the shared responsibility for the performance of the NHS. [Director of transformation] Tim Ferris is bringing IT back into core decision making, and I think that’s good.” Swindells is also keen on the digital aspirant plus programme, which was created by NHSX to provide central procurement support and ‘buddying’ deployment support to trusts at the start of their digital journeys.
“We have solutions that work for the NHS,” he says. “We have Epic, Cerner, InterSystems, Meditech, Allscripts and System C. They all have places that are doing very well on their systems. Ok, they also have places that are not doing so well; but that just underlines the need for good, effective deployment. We have the systems; what we need is a way to spread good practice.”
Health tech is not just EPRs
Having said all that, Swindells points out that health tech is not just EPRs. “We also need better technology in community and mental health and in care: not just in care homes, but in domiciliary care and wellness support for families,” he says. “And we need technology to join up our data for clinical and non-clinical care.
“We need to get to the point where there is a clear view of the whole patient pathway, so if something happens, if A&E getting overwhelmed, for example, we can see what the issue is: whether it’s a spike in demand, or primary care is being over-run, or it is flow through the department, or problems with discharge. That way, we can work out where to intervene.”
He also argues that the most important entry in this year’s operational priorities and planning guidance is the call for every integrated care system to set up 40-50 virtual ward beds for every 100,000 population. Virtual wards have got a lot of technology providers excited, but Swindells says ICSs need to design the right systems and processes.
“The question is not ‘what does the monitoring technology look like?’ it’s ‘what does the support infrastructure look like?’” he says. “We need to focus on the technology that is used by the people who are going in and out of the homes that are connected to those monitoring solutions, so that health and care is joined up around the patients’ needs.”
In fact, he suggests, the question is bigger than that. It’s what are the virtual wards for? “We need to learn from what’s worked in the past and what hasn’t,” he says, talking this time about previous initiatives billed as being about increasing capacity.
“One of the things with walk-in centres [a Blair-era initiative to provide a nurse-led alternative to GP appointments] was that they revealed unmet need and dealt with it. That was great, but it didn’t reduce pressure elsewhere. Whereas urgent treatment centres [an NHS Long Term Plan initiative to provide a GP-led alternative to A&E] did shift demand away from A&Es and reduce hospital admissions.
“We need to make sure that virtual wards don’t just generate new demand – that they don’t end up looking after people that we’re just a bit worried about. We need to make sure they are using analytics and clinical pathways to identify and support the people who are at risk of ending up in hospital, or who could be discharged from hospital sooner with remote monitoring and the right response teams.”
Warming to the theme, he says there’s a similar issue to be addressed with population health management. He worries some ICSs are using the term as a synonym for cool dashboards rather than targeted care that improves people’s health.
One of the many challenges to doing this is digital exclusion, which is another area in which Swindells would like to see more creative thinking. Arguing that “if we digitise care for the most digitally connected” things will be “ok, because there will be more capacity for everybody who is left” is “not acceptable,” he says. It risks exacerbating the ‘inverse care law’ that says those who need the NHS most are least likely to be able to access it.
Nor will “a few training programmes” do the trick. Instead, he argues ICSs should be thinking about how they can work with local authorities to turn libraries and high street stores into health hubs for everyone, and demanding that any technology they procure will “work as well on a pay-as-you-go mobile as it does on an iPhone with an unlimited data contract.”
North West London: “I want it to be among the best in the world”
So, why come back into the NHS, again, this time as joint-chair of Chelsea and Westminster, The Hillingdon Hospitals, Imperial College Healthcare, and North London West University Healthcare NHS trusts?
Swindells says he “thought it was time to get back in the saddle” – but he won’t be getting hands on with the IT. “Kevin Jarrold is one of the most experienced CIOs in the country, and he’s got a great team,” he says. “They’ve already got all four trusts onto a single instance of their electronic medical record (Cerner) and they are adding systems to improve the management of waiting lists, diagnostics and outpatients.
“My role will be to ask questions for staff and patients. Does the board have the data that it needs? Do our staff have access to the full patient record, wherever they are working? If you’re a patient and you need a test, can you see which of our testing centres has the shortest waiting time? Are we delivering the same, high quality to all of our population in all of our facilities?”
Not that he’s thinking small. “I want to shift the ideas of our staff, so they see themselves as a community, delivering for a community,” he says. “And I want North West London to be up there with the very best. I want North West London to be up there with Kaiser Permanente and Johns Hopkins, but within an NHS that is accessible to everyone. And I believe that we can do it. I believe we can be among the very best in the world in care, treatment and research.”
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