A recent HTN Now webinar took an in-depth look at how technology is transforming skin cancer care at the Royal Cornwall Hospitals NHS Trust, exploring successes in reducing two-week wait referral time from 57 days to 12 days, looking at challenges for implementing this approach, and sharing advice to other healthcare organisations looking to implement similar digital pathways.

Sandy Anderson, consultant dermatologist at Royal Cornwall Hospitals Trust, and Gabi Cohen, director of delivery at Isla Health, joined us to share their insight and experience on the project, which won in the HTN Awards category Case Study of the Year, before moving on to take questions from our live audience.

“I’m a locum consultant at Truro, where I’ve been for about 15 years,” Sandy told us, “but before that my background was in general surgery, then general practice, and then dermatology, becoming a consultant through the Portfolio pathway.” His main passion and experience has been in skin cancer diagnosis and complex surgery, he added.

Gabi also introduced herself and her role, stating: “I’m the director of delivery at Isla, and the delivery team is responsible for implementation and evaluation, focused on all of the things that sit behind brilliant projects like these. Our team make sure that at every step of the process, you have that really rigorous implementation and strong clinical leadership, working collaboratively to make things as easy as possible for organisations like Royal Cornwall.”

Innovating skin cancer pathways at Royal Cornwall Hospitals

Sandy then began his presentation on the community lesion imaging clinic initiative, a project he says “began over a year ago” as a means of overcoming the challenge of “escalating skin cancer referral rates and a shrinking workforce”. Whilst 25 percent of consultant dermatology posts in England are unfilled, he shared, the situation is “particularly difficult” in Cornwall due to its remote nature, “and in the last ten years, our skin cancer two-week wait referrals have gone from around 3,500 to 10,00o per year”.

Up until this initiative was introduced, a traditional model has been in use, Sandy went on, “where we didn’t particularly screen two-week wait or suspected cancer referrals – we just saw them all face-to-face”. A key challenge for Cornwall is also that it has “no plastic surgeons”, and less than two whole-time-equivalent substantive consultants, he shared, “for a population of about half a million”.

The model that the trust looked into was a “low cost, high volume, teletriage” approach to suspected skin cancer, according to Sandy, “and from the start we had to make it more efficient for doctor time, it had to work with what we already had in the absence of lots of funding, and it had to be acceptable to patients.”

With the intention of capturing as many of the trust’s two-week wait patients as possible, inclusion was set to cover all adults, with a maximum of 3 lesions noted by the GP to avoid “the risk of imaging the wrong thing”, and excluding genital lesions. Highlighting results from January to May 2024 and the initiative’s first 1,398 patients, Sandy told us how 24.5 percent had been discharged to a GP with advice, 38.9 percent had been added to the day case list for biopsy or excision, 34 percent had been triaged to face-to-face review, 1.3 percent had a follow-up arranged, and 1.4 percent had been referred to a surgical specialty.

“From seeing 100 percent of patients face-to-face, we reduced that to avoid 65 percent of those initial face-to-face reviews,” Sandy shared, “which freed our team up to do the rest of dermatology”.

Sandy highlighted the findings and impact at Royal Cornwall Hospitals, saying: “We think it’s a safe and effective way to operate; it’s reduced our face-to-face appointments by two-thirds, missed cancer rates are similar to our face-to-face work, and as a by-product, we’re building up a big collection of high-quality dermascopic images and metadata which will be ready to contribute to nationwide databases for testing and training AI.”

Implementing the pathway: Things to consider

“We work with a number of teams when implementing this,” said Gabi, “from contracting through to information governance, clinical safety, and to mapping the interoperability required to do this project well – in this context it’s a bidirectional HL7 feed – through to clinical mobilisation and getting everyone trained and confident with the platform, and then into evaluation and business as usual.”

The key is understanding what it is that you’re trying to impact or change, Gabi continued, “as well as the mechanisms that sit behind that, so we can look at the suite of functionality Isla can offer and make sure we’re offering the best of breed pathway”.

“For us, the bottleneck was around the availability of specialist dermatologists,” Sandy considered, “and it’s very difficult to recruit those, whereas it’s quite easy to train nurses to do biopsies and excisions, and the Isla software allows us to mark-up images electronically and complete our standard booking form on the normal hospital system, so when they come back to these day case lists, they’ve got a marked image and that booking form.” Standard surgical questions are also included in the CLIC questionnaire, he went on, “so that’s all present there, too”.

One of the motivations for the initiative for Sandy was “making it as quick and easy for the doctor as possible”, he shared. “If we made this time-consuming and laborious, it wouldn’t be any more efficient; Isla’s been really good for allowing us to see large numbers of patients quickly, and part of the reason is we’ve worked with the team to adapt the product for our needs.” It now takes less than an hour to triage, list and “do all the actions, including letters and things” for a four-hour clinic, he stated, “and the HCAs see 15 patients in clinic, which is a fair sized lesion clinic, and it takes me about 45 minutes to action that on Isla”.

Gabi shared some insight into the impacts around efficiency from a tech perspective, pointing to the importance of being able to “meet patients where they are,” especially in cases with remote populations like Cornwall. “You’re preventing them having to travel for appointments, and inherently there’s a tech need for that, so data can be accessed really securely and safely from these remote locations,” she said, “and having that really clear need made it obvious why this needed to be a digital-driven implementation.”

Offline access has been released this week by Isla, Gabi shared, “and that’s incredible exciting; not just for dermatology, but a lot of our community nursing teams work in rural parts of the country, where there might be no access to the internet”. That allows images to be stored until connectivity is available, before being uploaded onto the platform, she said, “and we don’t require patients to download anything, so the intention there is to make the burden on the patient as minimal as possible.”

Making sure that there is no added clinical burden or overhead has been an important consideration for Isla, Gabi told us, “and another key factor has been in making sure that everyone on the pathway is clear on what their role is, because as Sandy said, we’re leveraging lots of different members, and training is the priority to ensure everyone knows what their pathway looks like, and their place within that.” For this iteration, training was completed with Sandy and other consultants, and videos and user guides were used to create a module for the HCAs, she said.

A lot of work was done on making the pathway as efficient as possible, Sandy shared, “because when we started, we were uploading referral letters by hand into Isla, as I felt the triaging doctor should just be within Isla, and shouldn’t have to have four different systems open, so as much as possible has been kept within Isla, except booking the procedures, although even that is now automated to pull referral letters straight from ERS into the patient’s Isla record when a patient is added to our clinic.”

From a clinician’s perspective, Sandy continued, “within Isla I can have the referral letter there, the questionnaire data, the images, and I fill in a quick review form detailing my opinion and outcomes, and then we just select everything and output it as a PDF back to our EPR.” That has the added benefit of meaning that when admin staff are “outcoming the clinics and doing letters,” they don’t necessarily need to be on Isla, they can choose to stay in the EPR, he added.

Measuring success

Answering some incoming questions from our audience around measuring success, Sandy told us how the team is currently allowing six minutes on average for triaging a single case, with job plans accounting for “90 minutes to triage a four-hour clinic”, which also covers the admin time for processing results.

“When we’re looking to capture the impact of any implementation, we always start off thinking about safety and accessibility,” Gabi considered, “and then we think about clinical productivity and any cash implications”. For this two-week wait pathway, “there are some very specific KPIs like referral to treatment,” she went on, “as well as other efficiencies such as how long it took to action the patients.”

Keeping patients and patient experience at the centre of the model is integral, Gabi said, “and we’re making sure we’re listening to feedback and iterating on the model to make sure we’re really thinking about what that patient experience looks like”. Alongside that, it’s considering the clinical experience and usability, with co-production with clinicians a regular feature and discussions around tweaks that could be made to make the tech “more effective, more efficient” on delivering key outcomes.

Sandy shared some feedback from “a snapshot of between 100 and 200 patients” given feedback questionnaires, acknowledging “coming to the hospital and parking seems to be the biggest barrier to accessing healthcare.” Estimating that it was “about 96 percent positive”, he said: “A lot of the feedback was about being able to be seen locally, feeling listened to, and having everything moved along quite quickly.”

Ensuring successful implementation and adoption 

Having rigorous governance in place when approaching this kind of initiative and assigning clear roles and responsibilities is essential, Gabi noted, “as well as having input from admin and service managers on what standard operating procedures should look like”. It’s normal to “have some anxiety” around a new process, she said, “so we had a regular weekly forum where we discussed any challenges and worked through those in a really methodical way – key to that is having the right people in the room.”

Building acceptance and encouraging adoption is helped along also by ensuring alignment with wider organisational priorities and strategies, Gabi shared, “so we’re articulating the impact something is going to have on patient populations, getting that weekly governance in place, and making sure we can address challenges quickly and effectively.”

“I have found Isla has been very responsive to any challenges we might have,” Sandy agreed, “including in the beginning where we had occasional bumps and glitches – they’ve always been fixed within a day or two, and I think that relationship has been key to the implementation.” Running “dummy clinics” first and testing out things like admin processes and image capture was important, he said, “and we’ve grown it from there, starting with one clinic a week and then adding clinics at different sites.”

Everything that is put into Isla is coded, Sandy told us, “it’s all drop-downs, so there’s no free text, and I can get Excel spreadsheets and CSV files at short notice, either by myself, or via request if it involves big numbers.” That functionality has been “brilliant”, he went on, “and we’ve been able to present and publish a few things so far using that, which is very different to other software I’ve used, and far more reliable than any of the hospital outcome data I’ve encountered before.”

Key takeaways and advice for those considering similar implementations

Moving on to consider what advice they would offer to anyone on the call looking to implement a similar pathway, Sandy said: “There’s no need to reinvent the wheel – get in touch, you can share our processes, share our training packages.” It’s been “a very open and transparent process”, he went on, “and I’ve seen all the costs and the IT security side of it, the data ownership, and so on, so you just need to keep things transparent and honest.”

Planning is key to success, Gabi considered, “and also from our side, it’s having flexibility to tweak things or update them, being open to iterating as we work through the project, learn new things, and review data.”

When considering safety and risk when implementing a pathway like this, Sandy said: “The HCAs have got clear guidance on that if there’s any ambiguity or uncertainty, the procedure should be abandoned and a face-to-face review should be arranged. Similarly, if a patient tells them they have another 12 moles on their back that they would like checking by a doctor, the procedure is abandoned.”

Discussing how the Isla platform can support data security, Gabi pointed to Isla’s focus on ensuring data can be captured and stored in a “really secure way”, before being made ‘immediately accessible to the different teams that need access to that data”. As a cloud-based platform, she said, “the upload process is encrypted, and nothing is stored locally on any device – when using iPads, for example, that information is uploaded straight into the Isla solution”.

The panel also looked at the potential for the images collected and uploaded to Isla to be used for research, with Sandy noting “lots of opportunity” for AI in dermatology and skin cancer diagnosis. “From the start, we’ve asked patients to consent to their images being uploaded to their medical record, but then offered a separate consent for those images to be anonymised and used for teaching and training, including in the training of AI.”

Having collected between 10,000 – 20,000 dermoscopic images of lesions, “we’re now going back and adding their diagnostic tags”, he went on, “and my vision, along with others, is that we end up contributing to an anonymised nationwide research database that we can use to test and train AI products on real world data.”

One key takeaway from an implementation perspective is that “there isn’t one solution that fits every single patient population or every single trust we work with”, Gabi considered, “so getting an idea of how this might look in your organisation and mapping out the problem you’re trying to solve is really important”.

“My key takeaway would be not to be afraid of this being clinician-led,” Sandy said, “because as much as this is about technology, this pathway will be successful if it’s driven by clinicians.”

HTN welcomed Dr Harry Thirkettle and Victoria Foxley-Sayles from Aire Logic, for a HTN Now session focusing on the transformative power of agile in healthcare with practical implementations. As well as talking us through the benefits and challenges around taking an agile approach within the NHS, the pair shared a range of case studies and practical examples, taking questions from a live audience along the way.

For a recent HTN Now webinar, we spoke with John Kosobucki, CEO and founder of OX.DH, to discuss how technology is supporting fertility clinics with patient management, appointment booking, and test results, both in the UK and internationally.

John took us through a demo of the OX. assisted reproduction component, which he describes as “an end-to-end solution for everything that’s needed to operate fertility clinics”, sharing benefits including the streamlining of workflows and ease of use for both clinicians and patients within the familiar Microsoft environment.

“I’m based right outside of Oxford,” John said, “and we have a close association with Oxford University, who are also one of our shareholders.” OX.DH is 100 percent cloud native, he explained, “running Microsoft tenants and installing solutions within Microsoft environments for clients in the UK and Australia”.

Introducing OX. Assistive Reproduction

John talked us through how the journey toward developing OX. assisted reproduction began, saying: “We went out and interviewed people, looked within clinics, and focused on understanding workflows, pain points, frustrations with existing systems, and what we could do to offer the next generation experience.”

Doing this work at the outset allowed John and OX.DH to come up with a set of guiding principles, he went on, covering things like improving patient experience and clinical outcomes, reducing the burden on the workforce, giving people the tools required to access information and services directly, keeping information safe, and improving health and care productivity.

“With healthcare today, there’s often a lot of transcribing, duplication, and information stored on different islands that don’t necessarily tie together,” John said, “but with the right technology, we’re able to give people the tools to access that information quickly and easily, as well as safely and securely.”

How OX. assisted reproduction works  

OX. assisted reproduction works by splitting clinic activity into three broad areas, John told us: onboarding and assessing patients; creating treatments and personalised plans; and ongoing monitoring and care, including pregnancy, outcomes, and regulatory reporting.

Patients can register themselves or be referred from a GP or clinic, John said, “before going on to fill in information about themselves and their partner, which can then be reviewed by a clinician, and which triggers the appropriate HFEA or clinic-specific forms for digital signing, pre-populated with that information”. That may trigger phone or email conversation, he continued, “and all of that is logged on the patient record, including incoming and outgoing communications”.

The next step for patients is usually to have an initial consultation, John shared, “at which it’ll usually be decided what the right treatment path is”, and this is followed up by scheduling the relevant scans, medications and tests, which are all electronically fed back into the OX. assisted reproduction system. One of the features he’s most excited about is the graphical folliculogram, he continued, “and when hormone test results come back in, we’re automatically populating those onto that folliculogram”.

John also shared a success story from Monash IVF in Australia, where the OX. assisted reproduction solution has gone live, automating the patient journey and with the expectation that the platform will eliminate the need for around 50,000 paper forms annually.

How OX.assisted reproduction can help overcome complexities within the fertility journey

“We all know that there can be complexities that happen in fertility treatments,” said John, “and that includes changes in relationships, or the introduction of a new partner. In OX. assisted reproduction, each patient has their own distinct profile, and those are linked together where necessary, and when treatments are scheduled those are linked to those profiles. But should a relationship change, those links can be updated, for example to include new partners.”

The solution also makes keeping track of things like egg sources, sperm sources, and embryos, easier. “We can always have traceability, to track backwards to find the source, to look at who the partner was, and so on,” John said. That also covers donors, he went on, “with search functionality and the ability to link that in to a treatment, record whether that’s anonymous or known, and we can trace that back to the source for the embryo.”

Moving onto the demo, John took us to the OX.ar dashboard, highlighting how “everything is native browser” within OX.DH, making it easily accessible for clinicians and patients. “The great thing about everything being on the Microsoft ecosystem, is that I believe they’re probably the industry leaders in providing cyber security for the data that’s stored in their environments,” he added.

Taking us through navigating the solution, John showed us how the dashboard features an easy-to-use sitemap, and took us directly to the Patient Overview section, using test patient “Irene”. “The system has intelligence built in, and we can see that Irene is currently linked to Sherlock,” John said, “so we can view all of their details, treatments, and so on. Also, if patients are being seen at a satellite clinic, but have treatment scheduled in elsewhere, their information can be shared with another clinic at the click of a button.”

Clicking into the “Treatments” section opens up a patient’s history, and any treatments they may be currently having, along with those they may have already completed, John continued. “Here, we can see storage samples for this patient and their partner, we can view their folliculogram, see any notes on their treatment, and any test results which may have come back.”

There’s also a dedicated document library, John showed us, “where we can drop any documents, and patients can see them immediately, and where patients can also add things like notes from previous treatments, and results from elsewhere.” Documents can also be sent through a shared mailbox, with email templates automatically generated, he said, “and you can embed your own PDFs or links, and even set up workflow emails”.

These activities can then been seen within the patient’s profile, with John noting: “One of the great time savers of this, is that instead of having emails coming and going from individual mailboxes, anything that is sent to and from a patient’s email address will automatically get tracked and logged.”

Linking OX. assisted reproduction to other platforms

Once the demo was complete, John took questions from the audience. First, John was asked if it was possible to link an online booking system with OX. assisted reproduction.

“Absolutely,” John said. “We’ve done that for a number of clinics, including The Male Fertility Clinic, where we were directly pulling through those appointments.” He also went on to explain other options available, including one that allows authorised patients to book their own appointment, and another that allows clinicians to send an individual SMS message with a link that has open appointment slots for a patient to choose from.

John was then asked whether patient registration information can be taken from a website form and populated to create a patient within the OX. assisted reproduction system. “We’re an API company, so all the user interfaces that I’ve shown you have secure APIs underneath them,” John explained. “So we can make this available to embed directly in client websites, starting at our most basic level with just a pure “contact us” functionality. A patient fills in the form, and it creates a new lead record that can then be reviewed by the staff before qualifying those patients.”

Cyber security considerations

Finally, John also highlighted the cyber security measures in place when it comes to all of OX.DH’s solutions, noting: “When we deploy our Microsoft tenants, we’re using something called Microsoft Sentinel which monitors the perimeter. We’ve also created policy that monitors things like impossible logins.” Going into more detail on this, John gave an example: “If someone logs in from right outside Oxford, and then ten minutes later the same account tries to log in from Russia, it will immediately shut down the account.”

And that brings us to the end of the webinar. We’d like to thank John for joining us and delivering this insightful demo. For more information on OX.DH, we’ve included some of the most recent success stories previously covered by HTN.

Monash IVF goes live with OX.DH’s digital patient onboarding platform

Australian fertility service provider Monash IVF partners with health tech start-up OX.DH

The Male Fertility Clinic partners with OX.DH to centralise patient management and streamline bookings

For a recent HTN Now panel discussion we welcomed experts from across health and care, including Sally Mole, digital programme manager at The Dudley Group NHS FT, Fhezan Ashraf, clinical configuration manager at The Dudley Group NHS FT, Stacey Spence, EPR programme manager at Medway NHS FT and Hayley Grafton, CNIO at University Hospitals of Leicester NHS Trust.

The discussion began with wider introductions, where each of our experts gave an overview of their own go-live projects before moving onto post go-live best practices, exploring key learnings and challenges when it comes to engaging the workforce and measuring adoption.

Key learnings and processes 

“This was in the making for many years,” Hayley began as she spoke about the enterprise EPR deployment in her previous role at Royal Marsden Hospital in London. She attributed the “relatively well” go-live to a number of different elements, including “working with a supplier that already had a tried and tested implementation methodology,” while also highlighting the “great endorsement from the leadership team and CEO” as well as “ownership from all areas, not just digital” as instrumental to the success of the project.

Going into further detail about the programme, Hayley explained, “we had operational readiness groups which were jointly chaired by our operational clinical leads,” which included a nursing director and a medical director. During the implementation process, Hayley noted that there was “a lot of planning around business continuity” which led to their bronze, silver and gold group structure, indicating the different stages of the process from operational readiness through to command and control.

Next, Stacey outlined key learnings from their go-live success story at Medway NHS FT, based on their initial EPR deployment back in 2021, which she said was “a pivotal change” for the trust. “It’s not just an IT project,” Stacey added, “it’s a joint shared partnership across the whole organisation.” Giving some background, she explained how Medway was completely hybrid before the EPR deployment, with a “number of independent systems that were in place alongside a lot of paper records,” noting that the transition from paper was “really difficult in those initial conversations.” In order to tackle this, Stacey highlighted how the trust began with a “really strong communication and engagement plan that was clinically and operationally led” and like Hayley’s team, they also had a range of staff members taking on these roles.

The trust ended up going live with their adult inpatients instead of the entire hospital and have since learned a number of lessons from this, with Stacey highlighting one key lesson in particular around sign-in access. “We didn’t have single sign-on in place before our go-live,” she explained, “we had everyone log in through their own windows account which meant that 80 per cent of our issues were around people not being able to get logged on.” Since experiencing this challenge, Stacey noted that the trust has now “implemented a single-sign on tool” which has led to the continued success of other deployments.

Finally, despite having had 88 go-lives since 2022 at The Dudley Group, Sally focused on one in particular, taking us through their EPR upgrade, which she noted as one of their “biggest deployments” over the last six months. This involved five major releases going live at the same time, which included moving infrastructure from on-premise to the cloud with a large focus on “operational management and working with the clinical teams to make sure everything was clinically safe.”

Speaking on the lessons learned, Sally emphasised the importance of letting staff know what they’re getting into, having the same processes and methodology for projects and “engaging with clinical teams, the clinical safety officer, the CNIO, the CCIO and all of the teams on the floor.” From Sally’s perspective, “planning, setting expectations and taking clinical teams on the journey with you” are core elements to success.

Measuring success 

From a configuration perspective, Fhez outlined early end-user engagement as the key success factor within The Dudley Group, which he said was all part of “really understanding and anticipating behaviours” to make sure they didn’t get “too many surprises” when figuring out what needs to change. He noted how this should always be done from the design phase, as “making small changes in any process can have a huge impact if not carefully thought about.”

On measuring this impact, Fhez used pathology as an example, “where we can very easily track the update of a solution just by looking at backend data. Look at how the number of orders placed has increased since making the update and that’s how you can see the impact of change.” As well as quantitative data, he also highlighted qualitative data as a key indicator, allowing you to “really see if a piece of configuration is doing the trick” because “you get to see people using the system and giving good feedback” adding how that is “probably most powerful” when it comes to measuring success.

Benefits of support networks 

Hayley then went on to speak about the benefits of having support in place during and after the go-live stages, stating, “we’re expecting extra issues to come through, so having that back office support is fundamental.” However, Hayley also noted challenges with some of these service desks as being “a bit convoluted when it comes to getting your issue across” because you have to “go through a thousand questions before you can submit your query.” Hayley highlighted how this led to her team “scaling it right back” to one, easy to find phone number for staff to call and then “branching it off” into different categories such as equipment and EPR system fixes etc.

Sally mentioned how her team often do technical go-lives before the systems go live to the user, adding that “you wouldn’t think that it’s so important, but actually it means we can filter out all those user issues and security issues before they go live.” She then asked Hayley if she had the same processes in place within her team, with Hayley stating, “we went live two weeks before the full go-live for our users,” however this meant they were managing appointments on dual systems during that time. Hayley highlighted one key benefit to this though, adding, “it meant that once we went live, everything was up to date” at the time of go-live.

Strategies for engaging the workforce

“We ran a number of face-to-face workshops with our supplier,” Stacey explained, highlighting how difficult this was during COVID but emphasising the importance of bringing the staff along on the journey, stating, “I think the experience wouldn’t have been so positive if we hadn’t brought people along.” She noted how important it was to clearly explain what the EPR system could do for staff, how the transition would work and what it would mean for the day-to-day.

Stacey highlighted the accessibility of the workshops and how they were “open to all staff regardless of whether they were actively involved in patient records or patient care,” allowing them to “see the system and talk about the system design.” This was combined with a multi-phased approach in which Stacey would partner with the clinical leads and attend focused meetings where the doctor would explain the clinical change before Stacey would come in with the “technical side and the reality of going live”.

Expanding on how the face-to-face approach and floor walking gave a “real appreciation” for the clinical perspective, adding, “I’ve worked in digital healthcare for eight years, but I’m not clinical-first, so it’s really important for when I’m managing the project delivery that I understand how the clinicians are working.” For Stacey, this meant getting clinicians involved in the conversation so that she could learn “what their pressure points are, their biggest issues and how an EPR system can actually support that.”

When asked about digital champions, Stacey insisted that “there absolutely is a role for them” when it comes to EPR implementation and that her trust would have “shifts dedicated to staff to be digital champions.” Stacey explained how this was key to the success of the deployment, as it meant they were able to have more “people on the ground supporting our end users.” Stacey also outlined her “work with ward managers for the nursing groups to see who was more confident with clinical systems” as well as looking at those with good leadership skills to become the “dedicated super users of the system” on that ward.  “They work really well,” she added “and we still use them with all our deployments.”

Big bang approach vs modular approach

“I think if I had to choose, I’d pick big bang every day,” Hayley said when asked which approach she’d prefer, however she also recognised that “you need to have the investment to do that. And not just the financial investment, but the resource investment as well” in order to make that approach successful.

“I don’t think there’s a clear-cut answer,” Hayley went onto say, “it all depends on where the organisation is and what you’re trying to achieve.” She then reinforced this by speaking about the more modular approach taking place in her current role at Leicester, stating, “it equally has a lot of benefits. You have the ability to test things out through smaller, incremental deployments” as well as having more “influence on what the system looks like,” which she said “works much better” for the team at Leicester.

Overcoming challenges 

Next, Sally noted adoption as one of the key challenges to going live, outlining how you will “get that anyway with all digital solutions” but that it can be “resolved throughout the project lifecycle as long as the project is delivered correctly.” Echoing what Stacey had to say, Sally touched on workshops as one way to engage the workforce and help with adoption, but also mentioned the need to “create a really good product at the end of it,” which you can only do “with the clinicians that are going to be using it.”

Sally then mentioned future proofing as an essential part of overcoming challenges, stating, “we don’t just look at the digital solution as it stands at the moment, but also what it will look like when it goes live, what we need to do from the perspective of new starters and whether it needs to be included in mandatory trading.” She said the key is to “make sure it’s embedded in processes across the organisation” and to understand that there might be a drop in performance at the go-live point. “We’re not expecting them to start using the system and be absolutely amazing from day one,” Sally said.

Referring back to the discussion on digital champions, Sally highlighted this as key for tackling some of the challenges going forward, noting, “we’ve had lots of great deployments but they could go a lot smoother if we had digital champions across the network.”

Speaking on things that could have gone better, Hayley highlighted how much of an impact digital transformation can have on an organisation, having spoken to members of staff who “didn’t feel like they were ready to take on this technology” and “felt their jobs were at risk because their jobs were changing so much.” In order to address this challenge, Hayley emphasised the value of staff training and awareness, as well as the need to “seek out those people and make sure they’re well supported and recognise that not everyone is going to be as excited about it as we are.”

Stacey echoed this sentiment on staff training, highlighting the importance of getting this up and running sooner rather than later. When looking at what didn’t work well for her team, Stacey explained how they had a “training trajectory based on a numerical value that we had identified early on” however, they ended up being behind this trajectory four weeks before the go-live date. “We did actually hit way over our target by the time we went live,” Stacey said, but highlighted how the slow uptake at the start added “constant operational pressure.” Since then, the team have changed their approach and Stacey noted how this has helped to “improve all of our other deployments.”

We’re like to thank the panel for joining us and sharing their expert thoughts and learning on their go-live experiences.

For a recent HTN Now webinar, we welcomed OX.DH founder John Kosobucki, who shared his insights into best practices around virtual consultations and user adoption, as well as using the national Microsoft tenant, and presenting case studies from OX.DH’s OX. waiting room component.

The webinar began with John outlining how OX.DH has spent a lot of time building up a relationship with NHS England and Microsoft, through the development of different frameworks. He noted how the completion of several implementations of the OX.DH platform has already helped with identifying certain “patterns and lessons learned”, which has allowed the organisation to adapt its approach. From these learnings, John goes on to explain best practices for virtual consultations and virtual waiting rooms.

Lord Darzi report: key takeaways

First, John highlighted some of OX.DH’s key takeaways from the Lord Darzi report, noting: “From our perspective it’s important that people are thinking about that intersection between technology and patient care and looking at how those two things can be married together to give the same type of digital experience that we’ve all grown accustomed to in other aspects of our lives.”

John also expressed a need to “understand there’s a risk if we don’t do anything” and that “things won’t get better and they continue to stagnate”. He went on to suggest that lessons could be learned from large corporations who are already managing staff and sensitive data “to a high degree” and although recognising that “the NHS is different” there are still some areas that “translate well directly into healthcare”.

What do patients and healthcare professionals want? 

Next, John’s focus turned to the differences between patients and healthcare professionals in terms of what they want from a cloud-native solution. From talking with patients, he noted two requirements: “All they want is for it to be simple. Make it an intuitive, modern, easy way to interact with healthcare professionals. And they don’t want to be downloading an app. It should be click and go.”

However, John noted that the requirements are “more complex” for healthcare professionals as this covers everyone from IT, to administration and the people delivering the care. John gave a brief overview of the wants of these professionals: “It starts with making sure it’s intuitive, so it’s easy to adopt. They want to be able to see and engage with their patients with scheduled and ad hoc interactions. And it’s good to bring everything together in one place: video, online, face-to-face and phone consultations, even when that information might be spread across multiple pathways and EPRs.” 

When speaking on what it takes to integrate these systems successfully, John highlighted how, “getting it right is super helpful but often people want to start with a very basic approach and then incrementally start adding in that integration as their broader ecosystem changes”. He noted the importance of making sure this was done in a “secure, scalable and cost effective” way because there can be “so many disjointed systems” within one organisation.

He also highlighted the recent publication of the NHS Cloud Strategy adoption plan. According to the document, a plan has been put in place to “help NHS and healthcare organisations get started with understanding how to adopt cloud solutions and what the impact will be on their server, infrastructure, and applications”.

The OX.waiting room component explained 

One of these OX.DH deliverables is the OX.waiting room component which is a cloud-based solution that manages the patient workflow and can “integrate with existing paths, EPRs and even flat files”. John emphasised that one of the key considerations for implementing any solution of this kind is to “make sure it’s fit for purpose and accessible for people”. As such, OX.waiting room is based on Microsoft Teams, using code that “uses the exact same underlying infrastructure and surface information to create a familiar look and feel for everybody.”

John explained that anyone with an NHS.Net account can take OX.waiting room for a one month “free test drive”. He shared details on how to do this: “It’s installed on the national tenants app source. All you have to do is have one of your admins create a channel, go into the app source and load the Lobby and Admin tabs. Create a test patient or connect for PDS lookup, schedule a test appointment and then start a consultation to see how it works.”

Lessons learned from previous implementation 

John took some questions from the audience. One focused on the lessons learned from the Barnsley Hospital case study in which they partnered with OX.DH to implement video consultations. John noted: “It was very quick getting something up and running to replace what they had. However, what took a lot of time was identifying all the different use cases for the existing systems that they had in place and making sure that they could coordinate and inform people about the transitions that were taking place.”

John and the team also learned that it was good to “identify opportunities to streamline and remove connections that were no longer necessary” and that from a security standpoint “there were many services that were allowing direct access without any patient verification”. John noted how patient verification was “one of the things that our clients have said they really appreciated having because they were often getting randoms queues of people that did not have appointments.”

How can organisations increase the usage of virtual consultations?

Finally, we asked John for his advice on increasing the usage of virtual consultations across healthcare and what some of the best practises were for achieving this. “It’s about making things as straightforward and natural to start using,” John said. “Some systems you have lengthy training material that are time consuming when you introduce those new systems. Ours is pretty straightforward. I log in based on my particular profile and then I see the appointments that I’ve been configured to see. It makes sense.”

We’d like to thank John for his time presenting this demo and sharing his insights.

For a recent HTN Now panel discussion, we spoke to experts from across the healthcare sector on the future of general practice core systems. This included exploring potential opportunities and areas of future growth, considering challenges such as integration and interoperability, and outlining what “good” looks like in this space.

Our panellists were Bex Cottey, business manager for Conisbrough GPs, Emma Stratful, chief operating officer at OX.DH, Dr Sheikh Mateen Ellahi, GP and practice partner at ELM Tree Surgery and South Stockton Primary Care Network and Dr Shanker Vijayadeva, GP lead, digital transformation for the London region at NHS England.

We kicked off the session by asking our panel: what are some of the biggest limitations with current GP systems? Mateen started by highlighting two of the main limitations which he said were the “user experience and the interface itself” as well as “limited analytic and data capabilities”.

Explaining further, Mateen noted three key focus areas when making the move towards a more modern general practice, including equity and access to care, prevention rather than treatment and using a digital triage system. “But how many practices right now are doing this?” Mateen asked. “Not as many as there should be. And that’s what we need to move towards.” He went on to outline how a lack of predictive analysis within clinical systems “often means clinicians are working reactively rather than proactively” and that one of the best ways to tackle this is by having “more capabilities with regards to collecting good data.” Using an example from his own practice, Mateen highlighted how the introduction of a new telephony system helped with reducing call waiting times from three minutes “down to less than a minute across one whole week of 2,500 calls”. In order to continue to see improvements like this, Mateen added, “what we need to aim for is a modern system that uses AI and machine learning to predict patient conditions based on historical, real-time data, to hopefully enable better patient outcomes.”

Next, Bex spoke about making the switch from one clinical system to another, expressing some of the key limitations her practice found. “We were repeatedly having the system fall down and run slow,” she said. “So the options were to either stop complaining about it and get on with it or change the system.” Because of the limitations posed, the practice ultimately chose to make the switch with Bex adding that “since then the stability of the system has been much better”. Speaking on the wider discussion of which system is best, she added, “the two systems have different features and the features that are the same work in slightly different ways. So, it’s about which system suits you and your priorities best”.

From Shanker’s point of view, he noted how “there is no perfect system at the moment,” and that user needs can vary “from the basics of just getting rid of one extra click to the other extreme of implementing a data flow”. To help tackle this, he suggested making everything very simple, adding how “interfaces have to be easy to use and intuitive, yet also be able to manage a huge range of complexity”.

Emma then talked about how OX.DH has entered the core clinical GP system market via the NHS England Tech Innovation Framework, which she noted was all about “bringing new entrants to the GP market in terms of IT solutions”. Emma continued to outline their OX.gp solution, a modern and intuitive primary care solution, empowering new ways of working to streamline processes and workflows for efficient, patient-centred care.   

Aligning with the neighbourhood health model

We then moved on to discuss how primary care systems align with the neighbourhood health model, Mateen noted how “it comes down to population management. You have to look at the neighbourhood as a whole and what their needs are.” To do this, he highlighted the importance of actively engaging with public health while looking at predictive analytics within communities. “It comes down to risk stratification and patient segmentation,” Mateen said, which has reportedly helped to “reduce hospital admissions by 15/20 percent,” according to one study he read. Giving an example, he explained how “some people might be more prone to getting the flu. If you can identify those patients early, you can get them engaged with the flu programme.”

Adding to what Mateen had to say, Emma highlighted her own experience speaking with GPs and how many are “struggling even just to get two screens in a practice or get reliable internet” while being “limited in terms of quality of data and how it’s structured”. In response to this, she highlighted the importance of focusing on the “quality of data” and using tools such as Power BI to run key reports on risk stratification, stating, “if you’re able to analyse and unpick the data that you currently have within your practice, you’re going to be able to better serve your patients at a patient level but also at the local population level.”

Bex echoed the importance of working closely with public health fellows when creating a neighbourhood health model, but also noted a need to consider the voluntary sector and third party “because they are going to be a massive factor in the success of reducing non-medical burden on primary care”. She suggested having a database of “who’s available and where” but also recognised issues with how much of an undertaking this would be, stating, “it’s wonderful to work as a neighbourhood, but I don’t think people quite realise how big that neighbourhood is, even for smaller communities.”

In response to this, Mateen agreed that creating neighbourhood teams would be a “long and difficult project that will take years to properly implement” but also went on to say it was still possible. “Looking at the whole holistic picture is the best way to go forward,” he said, emphasising the importance of using current systems to the best of their abilities in order to help ease the burden. He referenced statistics from the RCGP, saying, “there’s been a 10 to 15 percent increase in appointments from pre Covid to now” and how “more and more GPs are leaving the profession,” so the best thing to do is to continue looking for new solutions and also “find the best way to use current solutions”.

Overcoming barriers to implementing change within systems 

Shanker outlined some of the barriers to changing systems, including the frustrations around retraining and data migration. He noted how clinicians tend to be “really frustrated by our systems but actually a relatively low proportion of us have the capacity to go through the upheaval to make the change.” He added that key motivations to actually making the switch to a different system often come as a result of “system crashes and the level of functionality being offered by current systems”. However, he also said that when it comes down to it, “it’s all about your mindset. Even if you’ve got that backend functionality, if you think it’s not easy to navigate or it’s clunky, there will still be limitations”.

Bex added that data silos across the NHS were another key barrier, highlighting how “interoperability has to be key” to improving these systems. “We’re not maximising the use of our clinical facilities,” she said, before suggesting how “it may be that we’re not even aware of what’s available to us or that we’re waiting for it be available. Or it’s just so far ahead of the curve that we can’t wrap our heads around it.”

From a supplier perspective, Emma noted how “GPs will utilise existing systems differently, finding workarounds which can affect the quality of data”. To combat this barrier, Emma emphasised the importance of directing GPs “down the same path” and trying to keep systems “simple and consistent so that we’ve actually got something really meaningful to work with to better support patients.”

Using AI to improve systems  

Shanker then brought up the use of AI, noting the “quick wins with workload reduction and clinical decision making” when using AI in these settings. Bex outlined some resistance around this, noting, “half of us are miles ahead thinking how can we use ambient AI to make our clinical systems work better for ourselves. But there’s also this fear that AI is going to make the system even messier rather than more coherent. And I think that’s where we’ll see a lot of resistance in primary care.”

She went on to explain where this hesitation might have come from, adding, “there are practices out there, ours included, still with cupboards and cupboards of paper records. We were told years ago that a system would digitise all those records, but in areas without the funding, that system never materialised”. She highlighted how “the burden of maintenance” seems to always fall on general practice but “we’re not fully supported financially or otherwise to really get on top of that”.

Opportunities for general practice

When discussing some short-term opportunities for general practice, Mateen emphasised the need to enhance the capabilities of current systems. “We always talk about new initiatives and ambient AI etc.,” he said. “But there’s a simple solution, in my opinion: why can’t we clear the space taken up by professional records?” He mentioned how this has already been achieved by many practices in London but that northern practices sometimes get “left behind”.  Mateen also outlined the importance of understanding demand and capacity, enhancing digital access and streamlining the triage and care navigation processes.

For Shanker, it was all about strategy. He noted, “we need a good strategy like we had with electronic prescription services, but we also need to think about those times when we implemented something that was solely driven by addressing a user need”. As an example, Shanker spoke about ambient AI as something that “wasn’t part of a wider strategy but took off because it was agile and fixed a problem”. Shanker also highlighted how “not all clinicians are system thinkers and user experts, so we can’t always communicate our frustrations in a way that will help an IT company work out what the fix should be”. He suggested an opportunity here would be to have a “combination of clinical and user experts to drive some of that change at the bottom end”.

Offering input from the supplier point of view, Emma then explained how OX.DH has been working with a practice in the north of England who have been “very much involved in that UI and that testing,” but also noted how “a GP elsewhere might want something different”. Despite the difficulties of trying to tick every box for each of the seven and a half thousand GP practices, Emma explained how OX.DH instead focuses on building a system that “ticks the majority of boxes and can then be modified to tick other boxes”. She added, “the more insight we get into GP practices and the challenges they face, the more we can make a solution that’s going to be fit for the future”.

Key learnings and areas of focus for the future of digital practice 

Finally, our expert panel spoke about the key learnings from implementing digital solutions in their own practices, with Bex emphasising the importance of time. She explained how it took her practice 12 weeks to switch from one system to another and despite being a “lengthy process,” it was necessary for getting it right. “We needed that time to check every step of the way and even now, a few years on, we’ve not found any gaping holes of incidents which is testament to the process,” she said.

Bex went on to add that finance was also key, at both practice level and ICB level, stating, “it takes a lot of staff and a lot of money to set things up and there’s this insecurity as to whether the funding is going to be recurrent or not.” In order to tackle that insecurity, Bex suggested, having more “long-term investment, not just for this year or even for the next five years, but long into the future”.

Wrapping things up, Mateen expressed his optimism for agile practice as a whole, stating that in his experience, successful integration comes down to three key elements. The first one he outlined was collaboration with key stakeholders, which he said needs to be done “prior to accepting any contracts” and include “everyone who’s going to be using the systems,” otherwise adoption “will not be successful”. The second key area to focus on was effective training on all new tools to “make sure they’re being fully utilised within the practice”. And the last thing Mateen mentioned as being essential for successful adoption was a phased rollout of pilots with continuous celebration of “quick wins” such as patient satisfaction results, staff survey results or just having a good day overall.

We’d like to thank our panel of experts for joining us for this insightful panel discussion. If you’re interested in getting involved in the conversation, check out our upcoming events.

For our latest HTN Now panel discussion on advancing patient engagement with communication tech and patient portals, we were joined by experts including Jothi Vasan-O’Leary, medical information officer and outpatient clinical lead (GIRFT) at University Hospitals of Derby and Burton; Daniel Parkinson, digital IT project manager at Leeds Teaching Hospitals; Sally Mole, senior digital programme manager – digital portfolio delivery team at The Dudley Group; and Emma Stratful, chief operating officer at OX.DH.

Emma also reported on some of the challenges she’s seen working with different trusts and healthcare organisations, including access and “digital equity across patient groups”. Working with Microsoft makes things like translations “an easy fix”, she said, “but if people don’t have devices to start with, that becomes an issue”. She also picked up on Sally’s point around electronic consenting, saying: “It’s a consenting workflow – it’s not just signing a form, it’s assessing all of the risk, the Montgomery principles, how you get that information back into your existing EPR so there’s a digital trail. I think there’s a tendency to underestimate that workflow process, because you can’t just pick up a paper form and translate that to a digital form, because people often scribble their own notes, which are really valuable, and it’s how you structure technology to capture that in a meaningful way.”

Fear of change is another major challenge, Emma continued, “and it’s overcoming that to make digital a more consumer experience, because we do all our banking online, but for healthcare there seems to be an increased sensitivity, when actually, we’ve built our solutions in terms of their security to give patients and staff the confidence that electronic data is secure and accessible to those that need it.” Giving patients access to their own data helps reduce the resource strain on the NHS from things like subject access requests, she said, “and those staff, instead of fearing that their jobs are at risk, will be more likely to embrace it and see how they’re helping patients, as well as how they can use the time that’s freed up to deal with the more complex issues that patients face going forward. That mindset is really key.”

“It’s important to remember that it’s not just about digitisation of consent,” Jothi agreed, “because it’s not a replacement for those quality discussions between clinicians and patients – there is a two-step approach to consenting that I don’t think should be compromised.” Utilisation of the patient portal is “an extension of those discussions”, she went on, “and just because patients have signed, that doesn’t necessarily indicate that they’ve retained that information, so we need to reinforce it and repeat those discussions further down the line.”

“I totally agree,” said Emma, “and I think that’s exactly what we’ve done – we want clinicians to have those meaningful engagements with patients, so they fully understand any risks, and making sure they have the right information. Or recording those conversations so patients can listen back at home, share with their family and friends, and make an informed decision.”

Future directions, future opportunities, and the future state

Daniel shared that his team are currently undertaking prioritisation work to figure out the next steps for their patient portals. “In the longer term, we’re focusing on getting down to one patient engagement portal,” he said, “because we’ve realised that from a patient perspective, they also have to handle various other portals, with a separate one for their GP, the NHS app, and so on. Long term, I’d like to see everything going through the NHS app, including things like patient-initiated follow-ups and video calls.” The trust is also looking at what can be done in terms of proxy access, he said, “which is another major project”.

“At Dudley, we’re focusing on improving engagement with our preoperative platform and expanding that to other areas within surgery, looking at reasons for people not signing up like language barriers, because we’ve got a very diverse community,” Sally said. The trust is also looking at ways to repurpose its hardware, so devices which are no longer in service can be used to help improve access and make an impact in the local area, she reported. “There are a lot of process-driven things we can improve, and improvements to be made in our planning, to try and encompass a more rounded version of what our patients need.”

There’s also a need to consider wider patient access, and whether things like virtual consultations can help deliver services to patients who might not be able to attend clinics, or who might be put off by things like parking, Sally considered. “We’re looking at the actual patient pathways to see whether there are better ways of offering services to our patients, and we’ve just signed a contract for a perioperative support patient portal, which performs a risk stratification on patients. It’s been important for us that clinicians can still make changes to things like questionnaires filled in by patients, because they may not have always understood something correctly, or that might be subject to change, so it’d be really unsafe for us to just take what the patient says without talking it through.”

At an ICB-level, Sally said: “We’re considering how we can work at system-level, rationalising contracts and shared services, upscaling what we already have in place. We need to get to a point where we’re having cross-border referrals and cross-border services, and these patient portals that we’ve all got sporadically across different trusts just don’t really help for data sharing.” Placing the better integration of services into procurement processes, along with things like integration into Shared Care Records, and into the NHS app, has also been important, she continued, “because we need to be able to flow data through those platforms and into our EPR, because that is the one single source of truth for all of our clinicians.” The trust is also evaluating how things like AI and smart notifications can benefit staff and patients, according to Sally, “but realistically, we need to sort out the infrastructure and the accessibility for patients”.

From a supplier perspective, “there’s a backlog with NHSE to get that assurance done” around integration with the NHS app, Emma shared, “and we’ve been on that list for two-and-a-half years for one solution, and that’s still not happened – awarding those contracts might make that seem like more of a priority for NHSE”. Ongoing integration is good, she went on, “but we need to think about what we’re integrating for and what the priority is here”.

“I was having a discussion with one of our patient engagement advisors yesterday,” said Jothi, “and we were talking about ways to improve outpatient letters and how we design those in a patient-friendly way”. A priority for UHDB is implementing two-way messaging as part of a drive to reduce DNA rates, she went on, “but that’s a multifactorial problem – patients should be able to contact the organisation if they need to cancel, and we should be prepared to bring patients in at short notice.” Neighbouring organisations have a DNA prediction tool, according to Jothi, “and we’re exploring that possibility, but we need to have the processes in place to ensure that the information we’re providing to patients is actually accessible for them.”

As an outpatient lead, Jothi told us how there are clear metrics in place as part of the Getting It Right First Time FurtherFaster programme, “and one of the key things is reducing the number of weeks patients are waiting for their first outpatient appointment.” Reducing DNA rates would help create more slots for patients to be seen quicker, she considered. “We’re also focusing on what Daniel mentioned earlier about increasing the patient-initiated follow-up and how best to use remote consultations. But the main thing is around those accessible information standards, because I think it’s really important that we implement those in practice.”

Emma talked about how OX.DH tackles DNAs, saying: “We consume data from existing PAS systems to put appointments into our solutions. Then we can configure text messages, so SMS messages or emails that go out to the patients. And what we found working with a number of trusts is that if you send out that notification upon the confirmation of that booking with a number to contact if they can’t attend that’s specific to the department, and then send out regular reminders letting patients know that they will receive a link to click for their video appointment half an hour before, that works best.”

Those messages can be automatically triggered at set times, Emma continued, “which helps with those regular communications, which can help particularly when referring to secondary care, when there can be a big lull in that communication with patients and it could take weeks for that appointment to come through. A text message letting patients know if their referral has been delayed or where it is on the list would help reduce that burden of patients calling for updates.” It’s about working with trusts to understand their booking systems and PAS, she said, “and how we can integrate across those to make sure that patients are being seen appropriately and that they’re aware of what’s going on.”

Highlighting Emma’s point on referrals from primary to secondary care, Jothi shared how her team has set up a task and finish group looking at clinical pathways, “One of the key components of that is discussions around the primary-secondary care interface,” she said, “and I’ve invited, for example, Derbyshire and Staffordshire GP colleagues to be part of those discussions, and we go to their meetings as well.” Establishing those collaborative working practices is particularly important when it comes to advice and guidance on turnaround times, Jothi went on, “and if you have a good relationship with primary care colleagues, that makes things a lot easier, and we can challenge each other in terms of our practices and improve.”

Moving forward, what Jothi would like to see would be two-way messaging and how those responses could be automated within the PAS system. “That would be fantastic because it would improve oprtational efficiency,” she said, “and if you look at the statistics, 30 percent of operational processes can be automated. But having said that, one of the most recent publications from the Netherlands says that they are aspiring to have 50 percent automation, which is a huge target.” Putting regulatory things in place will be important to allow for this, she considered, “because when we talk about AI and automation, it evokes a sense of fear in people. But we’re not talking about clinical decision making tools. We’re talking about back office functionalities which can automate it.”

Sharing some of OX.DH’s current tools, Emma talked about having tools that “can read a PDF or clinic letter, identify the patient name, date of birth, and NHS number, and with a degree of certainty say that it belongs to patient X, and then it is automatically filed”. Where a digit may be wrong or there are inconsistencies, “those are flagged for manual checks”, she said, “and whilst that might not be high end AI, it’s really meaningful to those staff that are sifting through all of these letters – I think people are jumping ahead, but let’s start with the basics and see how we can improve efficiency and productivity.”

At Dudley, high-level scoping has been carried out to explore the potential of AI and automation across “multiple parts of our outpatient digitalisation”, Sally told us. Aspects the trust is particularly interested in automating include rescheduling of appointments, she said, “as well as documenting outcomes, clinical coding, and so on – once information is captured digitally, that can be extrapolated and that’s obviously going to be the efficiency saving.” From an AI perspective, there is a working group at ICB-level, she went on, “but there’s a lot of work to be done on regulation, and we’ve got lots of questions about how AI and machine learning work, as well as lots of clinical safety elements to consider, looking at who is monitoring that and how we know whether we’re getting the right outcomes.”

“We’re trying to figure something out around installing a working proxy through the portal,” Daniel said, “and whilst there is apparently something in the pipeline from NHSE, every time I try and track that down it seems to disappear. Eventually I’ll find someone in that area, but I haven’t found them just yet.”

“That’s enabled in our reproductive solutions,” said Emma, “and we’ve also implemented it into our GP solution where you can identify a proxy at your GP practice and that then can be recorded in your GP record, allowing them to see elements or your patient record. It’s a fine balance, but it’s making sure you’ve got those appropriate consents in place.”

We’d like to thank our panel for their time, and for sharing their insights with us on this topic.

We were joined for a recent HTN Now webinar focusing on sharing best practices around cyber security, by an expert panel including Neill Crump, digital strategy director at The Dudley Group NHS Foundation Trust; Nasser Arif, cyber security manager at London North West Healthcare NHS Trust (LNWH) and Hillingdon Hospitals NHS Foundation Trust; and Martin Knight, privileged access management at Imprivata.

The session focused on key considerations for NHS organisations in their approach to cyber security, assessing cyber security maturity, good cyber security practice, the challenges in this area and tips to overcome them.

Nasser kicked off our introductions by explaining how he started out in cyber security five years ago as an analyst, before working his way up to his current role of cyber security manager. From an organisational perspective, “cyber is quite new to us as a separate function”, he shared, “so one of the challenges I’ve had is showing people we exist and what our remit is”. That remit covers day-to-day operations, cyber awareness, and a range of cyber projects across both LNWH and Hillingdon Hospitals. “I love cyber security,” Nasser told us, “and I’m really happy to be here as part of this discussion.”

Neill shared an introduction to say: “We’re in the Black Country, and we provide acute, community, and now primary care services, to a population of just over 450,000.” 25 years of personal experience across the commercial and public sector, in roles touching data, digital, technology, and cyber, has allowed him to gain a variety of certifications, he continued, including becoming a Certified Information Systems Security Professional, which he says “took some doing!”.

At Dudley Group, his role involves the design of the organisation’s digital plan, Neill shared, “which includes architecture, cyber governance, and analytics”. In terms of cyber, “Dudley leads the ICS cyber group”, he went on, “and we’re focused at the moment on forming the ICS cyber strategy”. Within the trust, there’s a focus on “the mantra that cyber is everyone’s responsibility, from the board to the ward, as well as matrix working across the digital, data, technology, and cyber teams.”

Martin told us about his role with Imprivata, focusing on privileged access management and “how we can control and manage that elevated account that’s used both internally and from third-party vendors; reducing some of that risk, and simplifying that process without restricting what users can do”. He shared hopes to contribute to the discussion around cyber security across the health system, “and the way that privileged access management plays a key role in that piece, as well”.

Best practices with measuring cyber security maturity

The first topic our panel tackled was around best practices in measuring cyber security maturity for health and care organisations, with Neill focusing in on pillar one of the National Cyber Strategy: “focus on the greatest risks and harms”. There is so much that organisations can do to improve their posture, he told us, “that you really need to get down to basics and understanding your maturity, so you can understand your readiness against those cyber threats and prioritise your approach in relation to the gaps you discover as part of that maturity evaluation.” 

At Dudley, his team looked first at understanding their approach to risk management, according to Neill, “speaking to the board and getting an understanding of their requirements on oversight of cyber security risks, so we could be clear on roles and responsibilities”. The team at Dudley has also performed a risk quantification review, he shared, using a list of different risk-reducing cyber defence capabilities developed by the national team, “which allows you to quantify risk and then prioritise based on the likelihood of the cyber risk actually happening, or secondly to look at reducing the impact should that occur.” 

A lot of people will currently be focused on the Data Security and Protection Toolkit (DSPT), Neill considered, “especially as this year it’s now linked to the Cyber Assessment Framework“. Those are key areas, he said, “where people are going through and understanding how the bar is actually getting raised”. Dudley has ISO 27001 accreditation, he shared, “and we do an audit every year, focused in different areas such as supply chain and network infrastructure, as well as undertaking regular penetration testing and instant response and resilience exercises”. In summary, there’s “a raft of different ways you can look at your cyber maturity”, he said, “so you can start to prioritise based on the greatest risks and harms.” 

Nasser shared that LNWH and Hillingdon Hospitals have a similar approach, adding: “One of the first things I did when I took on my Cyber Security Manager role was to look at what we already had in place – not just cyber tooling, but also our wider digital tooling, and trying to measure how effective those had been so far, and how we were using them. There’s often a big rush in the NHS to get these shiny new systems in, but the danger we have is when we’re bringing in these complex systems and not utilising them fully.”

That means that when assessing cyber security maturity, “it’s important not only to look at what we’ve got on paper, but also to look at what we’re using in reality”, Nasser shared, “because I don’t think we’re digitally mature if we’re lying to ourselves and just assuming we’re doing everything correctly – we need to be really honest and have that open discussion to check (and verify) we’re actually doing what we say we are”. Whilst those conversations “aren’t always easy”, they’re very effective when it comes to identifying areas for improvement, he said. He also noted how those outside of cyber security can also have important views on “risks we might be unprepared for”, adding: “You should always leave the door open for colleagues outside of cyber to have their say.”

From his perspective with Imprivata, “it’s all about the people”, Martin said. “And for us it’s how we manage the identity that user is tied to, whether that be internal or third-party. A lot of the breaches we’ve seen over the last few years have come from that supply chain or that third-party solution, where you’re giving out elevated accounts to vendors, and then you have no control over who has access to that account, whether it’s being shared; and no full audit trail of what they did when they came in.” It’s about simplifying access for vendors “without giving them the keys to the kingdom”, he considered.

It’s also about ticking boxes across things like CAF and DSPT, and “how we prove there’s a full audit trail in place”, Martin shared, adding: “It can be a complex tool to manage, but if you try and start at person-level first, like with clinical staff, and trying to remove their need for a password, perhaps using fingerprints or facial recognition instead, that’s key. If we can remove the need for users to know passwords, it’s a lot harder then to be phished going forward.”

Basic steps to boost cyber security maturity 

Looking to some of the basic steps that can be taken to increase cyber security maturity across healthcare organisations, Nasser told us how his team “started with the endpoint, which might be your standard trust computer, and just having a look at what damage someone could do on that”. During COVID, one of the issues his trusts faced was the sudden shift to remote working, he said, “and our laptops back then weren’t equipped for that radical shift”

To ensure you’re covering the basics, “you need to look at what harm someone could do with your organisations end user device”, Nasser shared. “It’s about looking at your digital estate and thinking what you would do if you were a threat actor and wanted to cause harm.” For example, stopping people from being able to visit phishing websites “means you’re preventing a lot of potential harms from happening through that attack vector”, he added.

“You’re absolutely right,” Neill agreed, “and I would also add the importance of focusing on identity and access management – I’m not just saying that because Martin’s here – it really is a critical area that Trusts need to look at, understand what their maturity is at the moment, and address it.” Dudley has spent “a lot of time” on privileged access management, he said, “making sure that if we’re letting people access critical assets like servers and endpoints, we’ve got those controls in place”. 

Neill also highlighted two-factor authentication (2FA) as an area needing more attention. “We’ve made some great strides over the last couple of years,” he said, “however, we want to do that over the entirety of the estate.” That also links with the third-party secure remote access aspect of things, according to Neill, “because you absolutely have to have multi-factor authentication (MFA) there, so you’re sensitive to any issues which might be happening”. He also recommended looking to national guidance to help identify potential breaches around an organisation’s perimeter. 

“Neill and Nasser have hit the nail on the head,” Martin said, “because it is about understanding the basics and what’s in front of you – digital identity is really key, because I’ve spoken to trusts in the past where some of their internal staff had four active directory accounts at different levels of elevation, and that’s not simplified for the end user.” The more tools you put in place to advance your security, he went on, “the more people you’re going to have trying to navigate around those, because they want simple access, and they want to do their job”. It’s about balancing simplicity, security, and cost, he considered, “and that is a golden state, because it’s very difficult to get to that point – you’re never going to get to that zero trust network, because the only way you can do that is by giving somebody no access at all.”

Developing cyber security strategy 

Neill shared some details around his involvement in the development of an ICS-wide cyber security strategy, looking at the potential for collaboration under the mantra of “defend as one”. Discussions at the moment are focused around the “what” aspect of the strategy, he told us, before moving on to look at the “how”. The issue with this, he said, “is we need to continue increasing our cyber resilience now, so we need to get on with considering how we can actually get on with doing that”. The ICS has developed “task and finish” groups, he continued, “and we’ve allocated workstream leaders from each of the different providers, so we’ve shared that responsibility to make sure everyone is involved.” 

The vision as it stands has been agreed as “championing a united cyber strategy for patient safety, trust and security, through dependable resilience and collaboration”, Neill shared, “which actually gives us some different strategic objectives: how we enhance our responsiveness and our resilience, how we cultivate a skilled workforce, how we achieve strategic alignment, and how we foster collaboration.” 

Overcoming challenges around legacy systems, infrastructure, and more

One of the main challenges that accompany legacy systems in the NHS include that “many are running software no longer supported or no longer supported by the vendor – sometimes the vendor doesn’t even exist anymore”, Nasser told us. “Sometimes it’s on the network, and you discover it randomly, and you have to ask what it is, what it’s doing, and what it’s talking to. Because it’s legacy, the people who were supporting it, whether that be from the vendor or internally, have often moved on, so you’re left with these systems. There’s nothing wrong with them, they are working, but they’re not compliant with modern cyber standards.”

When tackling this challenge from a technical point of view, Nasser highlighted the importance of investing in “the right kind of systems” that give you visibility over things like medical devices and allow you to pick up from your network “some of these systems that you might not have seen before”, because simply put “if you can’t see them, you won’t know they are there”. The other key step, according to Nasser, is working on relationship-building within the organisation. “I love to talk to people,” he said, “and you find out so much from visiting different departments and just chatting to them – every department tends to have someone fairly technical, who isn’t really IT, but they know enough for the day-to-day fixes and system management. This kind of shadow IT is often frowned upon and seen as a threat, but I think if you identify those people, they can be a real asset for cyber security teams.”

Simply taking these legacy systems off the network “doesn’t take into account what they’re used for”, Nasser told us, “because they’re not being used just for fun – there’s a reason they’re needed, and by working with the clinicians you can figure out what you can do from a cyber security angle, which might include finding a suitable replacement”. His team have “got rid of a lot of legacy systems this way”, he went on, “and I think that’s the best way to deal with those systems, by being honest and having communication around them with the right people.”

Martin agreed with Nasser’s sentiment that “it’s about working with the people”, talking about the value of Imprivata having a clinical-based team who work directly with trusts and perform clinical walkthroughs. “We need to understand what people on the frontline are doing, how they’re using these systems, so you can really see what’s going on,” he said, “and I think a lot of cyber really does start with the person – understanding collectively what everybody’s doing and how they want to do their job. The walkthroughs with teams help to highlight where the gaps can be and how those can be filled, as well as how we can simplify the user experience and save time for clinicians on the frontline whilst also boosting security.”

“There’s a big programme of work that needs to happen to transition to modern infrastructure,” Neill said, “but looking at the short-term and things that are achievable in the current financial climate, I think key things are awareness and education, resilience and business continuity, and the supply chain. Those three areas don’t necessarily involve lots of additional financial investment.” Looking to awareness and education, “having a conversation with everyone at the trust about what cyber security is and trying to position it in their everyday life” is key, he shared, “because we can actually give them something that will help them in their personal life, and that in itself will help improve cyber awareness within the organisation.” 

When it comes to improving resilience, Neill pointed to attacks that had been successful in disrupting operations in health and care organisations in the past. “We need people to be confident that when an attack does happen, they know how to recover,” he said, “and I think instant response type exercises, or basic things around understanding policies and procedures or how to prioritise your response, are key areas.” 

For third-parties and the supply chain, whilst “there’s a lot third parties can do to improve an organisation’s overall cyber posture”, Neill recommends: “Ensuring we are having the right conversations, doing the right audits, completing the right service-level agreements; in order for them to recognise how they can better deliver their security, which in turn will provide the short-term improvements we’re looking for.” 

Focusing on awareness and education

Sharing his team’s approach to promoting awareness and education around cyber security, Nasser said: “I felt like the mandatory training wasn’t enough to stop some of the behaviours associated with cyber risks, or to actually educate staff members on their personal lives, which is something I’m quite passionate about. Something I’ve done, especially at LNWH, is tried to humanise cyber. For example, we have an annual staff wellbeing festival, and for the first time ever I had a stand there, which seemed out of place initially, but I was spreading the word about cyber wellbeing and best practice.” For those who fail victim to cyber-attacks in their personal lives, it’s an “awful” feeling, he continued, “and it fits with the idea that with cyber, if you can’t protect yourself, it will be very difficult for you to protect the organisation”. If you can touch someone’s personal life, “that really pays off”, he added.

Activities such as webinars, lunch and learns, holding sessions on safety when online gaming, and launching a cyber champions programme, are just some of the ways Nasser has aimed to increase cyber awareness and education amongst staff at his trusts, he shared. “These are all optional activities,” he said, “but they’re to inspire those who have a little bit of interest in cyber, because once you tackle them, they then pass that knowledge into their teams, so for example if a phishing email comes in, they’ll let me know, but they will also send an email to their whole team to tell them not to click on the link.” That is “way faster” than anything that the cyber security team themselves could do, he considered.

Tips for maintaining cyber security during procurements

Nasser moved on to consider some tips for maintaining cyber security during the procurement process, both within cyber-specific procurements and in general. When you’re looking for a cyber product, it’s important to know the market, he said, “talk to different vendors – even if you’re not planning on procuring certain systems, just maintaining that knowledge of what’s out there is so invaluable”. By learning how certain products work, and building those relationships with vendors early on, “you get a good idea of what works for you”, he went on, “because not every product is fit for every organisation”. Learning from other trust’s experiences is valuable, he considered, “but don’t fully rely on that, because their environment might be totally different”.

The other side of procurement, around clinical systems, is “when risks start to come in”, according to Nasser. “You might have something that’s amazing for your clinicians, and they want that ASAP, which puts you under pressure in cyber to get that across the line,” he said. “One thing I’ve learned is not to be the blocker all the time – if there’s a new system, run it through the usual checks, check it meets the right assurance, and so on, but instead of just shifting all of the ongoing responsibilities to the supplier, I think we need to internally be a bit more proactive.” What that might mean, Nasser continued, “is not assuming that because a supplier has ISO 27001 we can stop following up – we still need to do constant checks on suppliers to see what they’re doing and whether they’re maintaining compliance.”

Balancing innovation with cyber security is challenging, Neill told us, “as we’re in this cycle at the moment where we can really improve patient care using digital methods, and I think the next two to five years could be incredible, so we do need to have good conversations about that, and we also need to ensure we have a lot of rigour, like Nasser said, when it comes to post-procurement.” At the moment, all of this work is being done individually, he continued, “but one of the opportunities within our ICS cyber strategy is to actually collaborate on those activities, which will make it easier for suppliers, because they’re not having to do things for every single trust within our ICS; but it also makes it easier for us, as we can dedicate the time and resource needed to get the outcomes we’re looking for.” 

Once that work is done, Neill said, “we’ll then be able to talk about roadmaps and how third-party suppliers are actually going to improve during the lifecycle of the project, as well – we had that recently, where MFA wasn’t part of the suite, and we talked through the rollout and got that added, so we got the assurance we needed.” That was a “win-win”, according to Neill, “because for the supplier, when they then go to other Trusts, they will already know to have that in place”. When it comes to legacy systems, “we need to start going back through all of our suppliers and checking the risk”, he added, “because that helps you prioritise the digital transformation and drive those conversations with those on the frontline, so we can make the transition to modern applications and infrastructure.” 

Going back to Neill’s point about doing things at an ICS-level, Martin agreed that this would save time from a supplier standpoint, and pointed to the opportunities that this approach offers for knowledge-sharing. “It’s trying to put those best practices in place, because systems and products can often be implemented in so many different ways, and it’s trying to find that balance and simplicity to help meet the limitations around staff time internally, as well, when it comes to managing something or running that,” he said.

Martin also highlighted Nasser and Neill’s points about the constant reviewing of tools and solutions, “because things change, workflows change, people change, businesses change – just because it’s correct today, doesn’t mean it’ll be correct tomorrow, so having that constant evaluation in place is key across the market.”

Where does the NHS need to be in 1-2 years to improve cyber security? 

Answering a broader question, panellists considered where the NHS needs to be in the next 1-2 years to improve cyber security and maturity levels across the board. “In my opinion, cyber security still needs to be fully recognised and understood as a profession within the NHS,” Nasser told us, “because I think the NHS is very aware of the threats we face in the health sector, but we still need to better understand the people within cyber security and the specific roles that are needed and know wherecyber security sits within an organisation.” Tackling that and getting a better understanding of what is needed in terms of the people over the next couple of years, would “put us in a much better place”, he added.

Recruitment and retention is a known issue for cyber, Nasser continued, “and part of NHS England’s strategy is to improve that, but I think one way we can do that is to look internally within our organisations and see where we can bring in that talent, who are already on board and wantto work in cyber, to give those people an opportunity to contribute.” Reporting on his own experience of doing just that, “it’s working quite well”, he observed, “as you never know what you’ll find. I wasn’t always an IT person – it took somebody giving me that chance.”

“One thing that we’re headed towards is more convergence,” said Neill, “so we’ve talked about how we do things better at scale – the same thing is happening across the organisation, like in our operations teams, because they’re setting up elective hubs with multi-provider delivery, and that will mean that we’ll start converging systems like EPR, which itself poses a risk.” Getting the funding in place is essential, he went on, “in order to deliver cyber resilience at scale, including the tools, the skills, and the technical bits.” 

We’re “moving to a different place”, Neill considered, “and we need to work out rapidly how we can get the investment and change our approach to a much larger scale, which we’re going to have to work with the supply chain to achieve”. Suppliers have access to skills that probably aren’t available in the NHS, Neill shared, “and understanding what we have, where the gaps are, and who the people or organisations are who can fill those gaps, is a critical area we need to focus on in the next couple of years.” 

Martin agreed that there’s a need to focus on the education piece for users in the immediate future. “I really like the idea of pointing it back to cyber from a personal standpoint,” he said, “and I see that doing 2FA for my son, who’s five and just starting to use technology. If I can ingrain that into him from such a young age, it’s just going to bring the next generation into it, and helping people bring that back to their personal lives can help them understand that need better.”

Making education “simple yet relatable” for users is key, Martin went on, “and I think that would change the cyber landscape we have”. Starting with the person, then moving on to look at the processes and products, will really help organisations strengthen their cyber posture, he concluded.

Noting the upcoming Cyber Security and Resilience bill, Neill said: “I’m looking for that to make sure the regulators have got the right opportunity to be a bit more robust in laying out the legislation and how people need to behave, even going as far as the penalties that need to be in place. We’re seeing too many supply chain attacks now, where people haven’t necessarily put in the rigour we’d expect, so I’m hoping that will change the landscape and help our partners work better with us in future.”

How can the CCIO and clinical informatics team better support the cyber security function?

Responding to an audience question about how the CCIO and informatics team can better support the cyber security function, Nasser outlined that from a cyber perspective he would benefit from more interaction with those different roles across the organisation, saying that as cyber security manager he “doesn’t often get the opportunity for that interaction”, unless something has happened that means their involvement is required. “Having that openness for your staff to approach you and ask questions would be a massive benefit,” he said.  That interaction would open up the dialogue to begin to discuss different risks, he added, “and I’d probably come to you and pick your brain, after that, about your day-to-day role and what the risks look like.”

“I work with the CIO, CCIO and the safety officer a lot,” said Neill, “and one of the key areas there is around the safety aspect – they’ve got a great understanding of risk and harms, by the very nature of their roles, so I think they’ve got a fantastic amount of insight to provide for cyber.” An example of that might be with medical devices, he shared, “and making sure we understand the risks around that vulnerability to hacking, or what might happen if they are compromised and what the risks are there.” 

Informatics is “an interesting one”, Neill considered, “and reporting could be one element of it”. At Dudley, his team have created a cyber dashboard, he told us, “which is using the Power BI functionality from the informatics team and making insight accessible, using their skills in order to display that information for everyone.” 

We’d like to thank our panellists for taking the time to share these insights with us.

For a recent HTN Now panel discussion, we were joined by a panel of experts from across the health sector to talk about approaches to streamlining patient care, including strategies to reduce follow-ups and increase clinical productivity with targeted technology deployments.

Panellists included Damien Yeo, consultant paediatric ophthalmologist at Alder Hey Children’s Hospital NHS Trust; Rachael Robinson, consultant dermatologist and clinical lead for dermatology at Harrogate and District NHS Foundation Trust; Peter Hansell, CEO and co-founder of Isla Health; and Leila Brown, associate director of digital transformation at Alder Hey Children’s Hospital NHS Trust.

Damien started off our round of introductions, sharing some details about his role as a paediatric ophthalmologist at Alder Hey. “We get referrals from GPs, clinicians and optometrists,” he said, “and we see about 70,000 – 80,000 patients per year in our clinics.” Increasingly, that activity is being moved over to virtual settings, he added, “and ophthalmology is very outpatient heavy, so we’re trying to increase the capacity of patients we can see in existing clinics and also to tackle backlogs of patients on waiting lists”. Optimising clinical decision-making time has been key to that, he went on, “and Isla Health’s solution has given us more digital arms to multitask better and to move consults to a more asynchronous style, which offers flexibility, allows working from home, and enables us to receive information about patients at any time, rather than just in the traditional model of the clinic which is based around one patient at a time”.

Alder Hey is “increasingly digitising a lot of data collection”, according to Damien, “trying to move things onto the EPR, and structuring things that were previously not structured to bring into Isla, like photographs and forms about a patient’s clinical progression”. Historically, the traditional method of relying on contact with a patient to ask how they’ve been doing and note that down hasn’t been that reliable, he told us, “but with Isla, because you’re getting patients to collect data for you at home, without the need for a clinician, you save a lot of time and manpower”. There is regular oversight from clinicians on waiting lists, he said, “and if we require information that can be requested and collected spontaneously, without the need to bring patients into clinics”.

Rachael gave us an introduction to her role as a consultant dermatologist and clinical lead, before detailing how a few years ago she was tasked with improving the department’s image collection process. “As you can imagine, dermatology is a hugely visual specialty,” she said, “and back in those days we were taking images with a normal camera, printing out each one, and then sticking it in the paper notes with some sellotape, so some of those would fall out or get lost, and they weren’t great quality, so I looked at what we could do instead.” Talking about how Isla’s solution offered “exactly what was needed”, she noted its benefits in keeping track of patients, saying: “When patients come to clinic, we take a picture of their skin lesion, which helps us identify the correct site surgery, because we can mark-up the images.”

The realisation came about, however, that Isla’s solution could also be used to communicate with patients, Rachael said, “and this is where things have really improved – whereas patients used to call to say they had concerns about their wound, and we’d tell them to come and see us; now when they call us we can send them a link via text inviting them to send us a picture of their wound, which is then automatically uploaded to the system and linked with our EPR. A nurse can have a look at that, and call them back to let them know everything is fine and not to worry, or to ask them to come in if there looks to be a problem.” That has the effect of streamlining that clinic, she continued, “and it’s especially made a difference for our elderly patients, who do get worried about wounds, because we can offer them that reassurance”.

Another thing Rachael’s team have looked at is automation, she went on, which has been effective in their two-week-wait clinic, as patients can be sent a link prior to their appointment to upload an image of their skin lesion, along with a form to be filled in that has been designed to cover all of the information needed to inform their care. “That has meant the clinic can run quicker,” she shared, “and when they come in we already know what it is we’re looking at, and a bit about the history.” It has also allowed the department to increase its capacity, according to Rachael, “because we can easily see ten percent more patients, and we’re looking to increase that even more”. She also shared that feedback from registrars has been positive, and that the solution has helped facilitate MDT working by allowing images uploaded to the system to be shared during MDT meetings. “The automation for our two-week-waits has worked so well that we’re now looking to move that into our acne clinics,” she concluded.

We also heard from Leila, who shared with us some of her insights into the use of the Isla platform at Alder Hey from a digital transformation perspective. “I look after the projects and programmes team, as well as the systems team,” she said, “so we do a lot around keeping the lights on and keeping our current systems going, but also trying to introduce new technologies to bring benefits to our staff, our patients, and our families.” Taking us through a slightly different use case to those already talked about by Rachael and Damien, Leila shared details of an ongoing project at Alder Hey focusing on waiting lists. “We’re contacting people on our waiting lists, and validating through Isla whether they still need an appointment,” she said, “which helps us fulfil the requirement to contact patients every twelve weeks.”

Alder Hey also worked with Isla on a pilot within surgery, Leila went on, “to do this validation work, to reach out to patients and families on the waiting list to check whether they still needed their appointment, and we’ve seen really positive results”. According to the latest data, she shared, “we had over 200 families get in touch to say their appointments were no longer needed, and that worked the other way as well, as we had those who stressed their need for an appointment, so it helped us prioritise”. Along with benefits in clinical time saving from the released appointments, Leila also pointed to the benefits for patients and families, in not having to travel to unnecessary appointments. “It’s been a really positive pilot so far, and is now being replicated across surgery, with tongue tie being next on the list; being brave with that has been necessary to help us get to where we need to be in terms of national targets,” she finished.

And finally, we heard from Peter, who talked to us about Isla Health’s development and the technology perspective, as well as where the company started, and its motivations in the health and care space. “I’m an engineer by training,” he said, “but I find working to improve the health system much more personally fulfilling, so I’ve spent the majority of my career in various roles covering tech and transformation across the NHS.” Five years ago he founded Isla, Peter went on, “with the intention of optimising the way we receive information from patients, preventing them having to keep coming in for appointments to track their conditions, and to pick up on deteriorations earlier”. The overarching aim, he shared, “is we want to modernise this process and move to a system where we have much more regular input from patients in to the clinical team, and offer that empowerment and ownership for patients to submit information about their condition”.

Applying that model to a large cohort of patients highlights that some will require much more regular follow-up than others, Peter continued, and also some who won’t require as much face-to-face input with a clinician. “The key thing is to understand who those people are in both categories,” he considered, “and the real key value is that through the information we collect in images, videos, sound recordings, and PROMs; we can go a long way toward providing quite a complete summary of how a patient’s condition is changing.” Starting in dermatology made sense, as so much of that relies on visuals, he said, “so if we can create a longitudinal understanding of the way something is visually changing, that can help in making the right clinical decisions”.

Key outcomes: patient outcomes, feedback, impact, and more 

Peter shared details from other case studies where Isla has been making an observable impact, including work with burns teams in Nottingham University Hospitals and Chelsea and Westminster. “Chelsea and Westminster is a regional burns centre, so they cover quite a large area,” he said, “and an external evaluation there showed a decrease in average waiting times from 67 days to 24 days post-implementation.”

“We’re seeing patients quicker,” Damien agreed, “and there are many benefits to that – families have important lives, kids have to go to school; the less disruptive we can be to that, the better.” In general, feedback has been that families find the technology relatively easy to use, he said, “and where they have any difficulties or where they’re not comfortable, we have an easy way to revert back to the traditional model, so it’s very forgiving”. Whilst finding a solution which can meet the needs of different specialties can often be difficult, he continued, “Isla is very fluid and very open to change – you can create bespoke functions, and the forms are all customised based on your specialty, so the experience has been very good with regard to the families”.

Looking to clinical outcomes, Damien talked about Isla’s potential to help make improvements to the triaging process, ensuring patients are seen in the right clinic, at the right time. “Before Isla, patients would sit on a waiting list before coming into clinic, and at that point we’d realise maybe they had a squint that we’d missed. With Isla, we can use a photograph to differentiate between patients that have a real squint versus those who don’t – the picture makes that easy to identify, so we can bring those who need it to clinic much sooner.” Referrals from other consultants or departments can also be dealt with faster, he said, “because we can get lots of information about a patient in a very quick manner, in order to triage them properly”.

Overcoming misconceptions and concerns around clinical safety 

“I think user resistance is always a concern,” Leila told us, “because there’s always the danger that you’ll roll something out and people won’t want to use it, or they will rebel against it. If you get it right in terms of starting small and proving the concept, showcasing the benefits and assessing that against the impact it’ll have on people day-to-day, that helps.” Although resistance hasn’t directly been an issue with the Isla solution, “you’ve got to be mindful”, she said, “and I think it comes back to integration – we prioritised our integration with the community EPR, working closely with Isla to get our inpatient EPR integrated too”. In general, “people can see what it can do for patients and staff”, she went on, “so with Isla it’s been more about those who can’t onboard onto the platform”.

Having that problem identified first, and then demonstrating how Isla can help to overcome that has been central to the project’s success, Leila observed, “rather than doing it the other way around and finding that solution first before looking for problems it could solve”. Ensuring things like the PROMs questionnaires are clinically-led has also been important, she went on, “and at the moment, we decide what we want those to look like, and then send them over to Isla for the Isla team to put that in place for us”. Having an “open and honest relationship” between the trust and the supplier has helped, she considered, “and the transparency around what the process has involved has helped keep our staff happy with the solution”.

Key learnings and takeaways

Leila talked about some of the lessons it’s been possible to take away from her experience of Isla’s implementation at Alder Hey. “There are a few things that I think made it a success,” she said, “like having the involvement of all of our MDT teams right from the beginning – clinical, digital, operational teams; buy-in from our execs, and so on. Doing it together and understanding what the benefits were together was so important, and we’ve all leant on each other and learned things along the way which will inform our future projects.” Leaning on those clinicians with enthusiasm for the project and relying on them to help identify any teething problems prior to taking it further is also important, she continued. “You need to go step-by-step, choosing specialties where it’s been proven in other organisations, working with clinicians who are good at this kind of thing or who want to be advocates for this kind of solution, getting your data and then presenting it to others in the organisation who might be more nervous about using this type of tool, so they can see that it works”.

The amount of enthusiasm amongst clinical teams for Isla once Alder Hey had done this engagement work “meant that everybody wanted it”, Leila shared, “and what we ended up doing was listening to whoever was loudest; what we could have done in hindsight was a bit more around where the real benefits are, and where we could see the biggest impact, so we could have started with those specialties first.” Now that the solution is “trust-wide” across “numerous specialties”, all of that has come together successfully, she considered, “but if we were to do that again, that’s probably what we’d do differently”.

In Harrogate, Rachael noted the time taken at the beginning, working through governance and making sure all of the functions required for the dermatology department are available within the solution. “We spent a lot of time discussing that, outlining potential benefits, and running through the governance piece,” Rachael said, “so we had weekly meetings, and it took several months to get everything set up, but it was very worth it when we did.” The team is now working on blueprinting for NHS England, she continued, “doing a blueprint-on-a-page for Isla in dermatology, which should be helpful for people to look at who might be wanting to implement the solution in their own trust”.

Damien shared his perspective, saying: “Adopting tech in healthcare can be very difficult and notoriously slow; the systems here do not like to be disrupted, and the NHS in general does not like disruption because it doesn’t like taking risks, essentially. It requires lots of information gathering, as well as enthusiastic individuals who can see the potential of a solution and the impact it could have on our patients.” Getting the buy-in from managers and administrative staff to support a project like this is key, he said, “but when patient and clinician experiences are good, the solution will naturally be taken on more and more”.

Damien also highlighted the Isla team’s ability to make changes rapidly and understand how to overcome challenges that might occur during implementation. “They have the talent and the skills to make rapid changes to systems to cater to the needs of different specialties,” he said, “and I think that fluidity has been really key in achieving success.”

The technical bit: Isla’s integration with clinical systems 

Peter explained Isla’s integration with clinical systems, “typically it’s possible to have a bi-directional interface whereby we can pull all patients automatically into Isla, and push any information we collect about them back in”. There are also instances where Isla can be embedded into systems such as Cerner, “to avoid clinicians having to jump between different screens and platforms in order to get the information they need”. Referring to that as the “gold standard”, Peter said: “We’ve built those interfaces with SystmOne, EMIS, Cerner, MEDITECH; we’re working on that with Epic, and we’re integrating with Rio at the moment.”

From a supplier perspective, “the consequences of getting it wrong are significant for a lot of people”, Peter considered, “but I think the more we work with people like Damien, Rachael and Leila, the more our confidence grows to be able to challenge the underlying model and do this at an increasingly large scale – we’ve proven the concept works, and now we’re looking to deliver that fundamentally different model of care.”

We’d like to thank our panellists for taking the time to share these insights with us.

For a HTN Now panel discussion, we were joined by expert panellists including Dr Penny Kechagioglou, CCIO and deputy CMO at University Hospitals Coventry and Warwickshire NHS Trust (UHCW); Stuart Dures, digital skills development manager at Greater Manchester Mental Health (GMMH); Dan Chilcott, client enablement director at Patchwork Health; and Sally Mole, senior digital programme manager – digital portfolio delivery team at The Dudley Group.

Our panellists considered some of the key determinants of successful NHS workforce transformation, looking at how best to drive buy-in and support the workforce, and noting challenges and barriers to transformation.

Starting out by offering a brief introduction, Penny shared some details of her background as a consultant clinical oncologist, along with her role as CCIO and deputy CMO at UHCW. Talking about UHCW’s recent EPR deployment, she said: “One of our biggest assets during that programme has been the development of our workforce, and for me, it’s important that workforce development aligns with digital transformation. We’ve focused on building capacity and created a clinical informatics team which oversees that, to make sure we’re not just going live with a clinical system, but we’re also optimising that and thinking about how we automate workflows, embed patient portals, and engage with our patients and citizens better. Without our workforce talent, and training our workforce in digital skills, all of those innovations would never have happened, so we need to keep focusing on how we can evolve that to enable further digital transformation.”

Sally highlighted her role heading-up The Dudley Group’s project management office for the digital portfolio delivery team, as well as her work representing the Clinical Safety Board at ICB level. “My work with the NHS began in pharmacy, before I moved into a digital role about seven years ago,” she said. “Now, I’m responsible for leading our digital portfolio, which has 61 projects in flight, 34 of which are active. The project management office didn’t exist when I started this role in 2022, so we’ve created that from scratch, with a whole new process to implement and a whole new team to onboard. We’ve done a lot in terms of transformation, and then really trying to embed that into our engagement within the organisation.”

Offering a slightly different perspective as a supplier, Dan talked about his experience of working in the NHS as a workforce leader, travelling up and down the country to support different organisations with workforce transformation, and how that has helped him get to grips with his current role as client enablement director with Patchwork Health. “I now support our onboarding of new customers and the ongoing development of our technology suite,” he said, “which is predominantly focused on providing the tools to help organisations deliver workforce transformation projects, ranging from temporary staffing to rostering solutions.” The company’s recent acquisition of L2P has helped incorporate job planning and helped Patchwork create “a seamless journey of workforce delivery”, he added.

Stuart discussed his past work in health records and patient pathway processes, leading a range of projects “on paper”, before following the transformation to digital and EPR, clinical systems and applications. “I’ve trained and led on projects throughout my career,” he shared, “and in my current role I was brought in to start the electronic prescribing process, which we introduced using a gamified approach to training. In general, I help support frontline staff in everything they do, and we’re working on a digital skills self-assessment at the moment to assess staff’s ability across Microsoft products and clinical EPRs, to give us a baseline understanding of where we stand and how to get to where we want to be using targeted training based on where identified gaps are.”

Key factors of successful workforce transformation 

Penny kicked us off with some key factors for successful workforce transformation, including having a strong vision in place to help the workforce keep pace with digital transformation. “For me, it’s thinking about the creation of new roles, training, building capacity in existing roles, learning from other organisations and providers, and building not just the technical skills but also the soft skills which cover change management, transforming, challenging the status quo, and improving.”

Success also relies on looking at the ways technology can be used to support staff and support transformation, Penny continued, giving an example of how UHCW has used AI to streamline routine tasks like answering calls and responding to queries for its HR staff. “It’s about how can we ensure that we don’t use highly skilled staff to do mundane tasks.” she said, “so we can ensure our workforce works at the top of their scope of practice.”

Stuart highlighted the importance of “the context that’s used to transform the staff”, saying that engagement should “always be kept contextual to what they’re learning and where they want to get to, what they’re going to get out of it, and the benefits realisation”. The main question staff have relating to transformation is “why?”, he went on, “and they want to know why we’re getting in the way of their current practices to change a system that they believe works perfectly well”.

Sally agreed with Stuart’s point about ensuring the value is outlined within transformation work, adding: “I think the biggest factor in resistance to change is around the communication – as an organisation we need to be clearly communicating why we’re making these changes and how we’re going to do it.” Sometimes the end point can “seem so far away”, she considered, “that you do get a lot of resistance and skepticism around the changes you’re trying to implement”. Changing the communication style to reflect the needs of different audiences is also important, she told us, “so you do need to have that information in lots of different formats”.

Moving on to discuss the skills gap, Sally shared that at Dudley they baseline staff against the SFIA Framework, which she says “helps pinpoint current skill profiles and identify our people’s skills we might not be using”. Talking about the emergence of things like AI and automation, she said: “It’s important to know whether we have the skills in-house to be able to do things like that and transform the workforce, so we can implement these digital solutions effectively, with the right staff.”

“Everything mentioned so far rings absolutely true for us,” Dan said, “because when we start working with a new customer these are things we want to address: what is that vision, what are the skill gaps, and what are the outputs we’re trying to achieve.” Understanding the different problems that different stakeholders are going to have is key, he went on, “because the problem that the finance director is going to have, versus the problem the clinician is going to have, might be very different”. Bringing a “full range of those voices” to the table to help make some of those really key decisions is integral, he noted, “because nobody likes having change forced upon them, but when they know there’s a problem that’s going to be resolved, they’re much more likely to come on that change journey with you”.

Overcoming challenges around workforce transformation

Penny cited four challenges around workforce transformation: the change itself, and how that can be “daunting” for some people, along with the fear of failure, and how it’s important to allow people to “fail and retry”; the perception that transformation projects will take people away from their clinical duties, and the need to focus on job planning to “make sure that people have the capacity to devote time to that change”; the lack of trust in technology and its use to replace routine tasks, and having to focus on building that confidence with staff around clinical safety; and digital literacy, with organisations needing to expose staff to digital training to ensure they can use technology effectively.

Dan reflected on his work with NHS organisations across the country, noting that “everyone is different, and everyone’s at a different stage of their digital journey”. For Patchwork, that often means having to integrate with existing solutions or meet differing requirements, with legacy system integration in itself becoming “quite a challenge”, he said. By focusing on that interoperability and integration, Patchwork has managed to help “achieve that flow and minimise duplication of data entry when using technology”, he continued, “and that’s a challenge we need to take on early on, so we can put development work in to meet those needs”.

Another challenge lies with financial constraints, Dan shared, “especially when people are replacing a paper-based system, and there’s no existing line on someone’s budget statement for technology – being able to prove ROI from digitising things can be quite challenging, but when you start to drill out efficiencies these things are possible”. Again, that’s something that Patchwork like to tackle early on, he said, “because then we can move on to the other challenges that Penny mentioned around things like resistance to change”.

Thinking back on her experience in the project management office to date, Sally told us how the biggest learning has probably been around communication and the need to set expectations, “not only for what improvements the digital solution is going to bring, but also for what the clear process is to get us through the delivery”. She also echoed Stuart’s comments on the importance of baselining current position, saying: “You can only understand where those risks and concerns informing resistance to change come from by going on that journey and having that conversation with people.”

At Dudley, there’s a portfolio delivery checklist which “standardises project delivery from end-to-end”, according to Sally. “We’ve also got terms of reference for product owners, so if a request comes through for a digital solution, we have to have clinical buy-in from the top down; a product owner with clear terms of reference about what their role is around engagement; and making sure we have the right subject matter experts involved, so when we come to do things like clinical safety we know we’ve followed the right process.” Quite often, during current state process mapping, “we realise there are lots of other problems we can also solve as part of this transformation”, she went on, “and there are other opportunities for us to improve the services so it’s not just like-for-like”.

Securing buy-in on transformation projects

When considering how best to secure buy-in around transformation projects, Stuart stressed the importance of maintaining that honesty with staff and “keeping the human touch when engaging – don’t do everything by email or SharePoint”. Keeping your communications simple, but ensuring the right level of information so that staff have the details they need is key, he went on, “and it all comes from strong leadership – the engagement practices, the plans, keeping service leads involved at all times so they can cascade and disseminate information, so you get a communication trail flowing”.

Stuart also shared some details about a project using gamified training to help introduce electronic prescribing. “It was a challenge to introduce that at a trust which only used paper because of the safety aspect of it,” he said, “and the trust was also going with a new gamified training methodology provided by a company called Attensi. That wasn’t like the traditional tick-box exercise – it’s a game and a test all of the way through, so you use process steps like you’re using the system in real life, but you answer questions as you’re going.” Depending what the training is, the platform allows users to interact with patients and other members of staff, according to Stuart, “and whilst that’s just for ePMA at the moment, the opportunities there for workforce transformation are endless”.

“Communication is so important for securing buy-in, but it’s doing it at the right time, as well,” said Dan. During the procurement process, he went on, there are going to be people on the panel making decisions, but there are also potentially “thousands of users not on that panel that you still need to take on that journey with you”. An approach that Patchwork recently tried with an NHS organisation was putting in place an open forum for users to ask questions about their temporary staffing solution that was being implemented, and Dan told us how this helped his team understand the problems users were encountering with their paper-based processes, allowing them to demonstrate how the solution would tackle those.

“Having that constant feedback loop in place allows us as an organisation to keep evolving,” Dan said, “and we work to ensure we can really deliver ongoing improvements to our products in a way that encourages people to continue to buy-in, even after the project has been delivered.”

“One size does not fit all in terms of engagement,” Penny considered, “and we need to be able to use different methodologies to deliver the same message.” Agreeing with Dan’s point about engagement and buy-in needing to be continuous, she continued: “We need to be constantly looking at what our goal is, where we are currently, and how we can support each other – I’ve found in my experience that it works best when our engagement is incorporated into existing structures and frameworks, rather than creating new meetings, which can often add more workload.” Examples of what has worked at UHCW include regular workshops, blending the organisation’s staff with industry staff to get different perspectives, and regular check-ins to focus on problems and how tech can be used to solve those, she shared.

Ensuring sustainable workforce transformation

Responding to a question from our live audience about how we can be sure that workforce transformation projects are sustainable and do not simply end up “landing in someone’s lap” or creating extra work going forward, Stuart highlighted that “the BAU (business as usual) teams, who run everything as the project gets going, sometimes end up on the back end of it, because the funding dries up, the staffing that was supposed to remain in place to allow a project to continue falls flat, and that leaves them to have to deal with it”. That’s why the sustainability of a project should be seen as “the main aspect” of the project moving forward, he said, “and it’s important to look at that when it comes to funding, and to get everyone involved with those conversations about how this is going to keep performing for a long time, not just for now”.

Sally picked up on the topic of financial and staffing challenges, pointing out issues around managing starters and leavers, and “achieving that consistency across services” as the project continues. “As part of our BAU service desk, we look at issues that might arise as the project moves forward,” she said, “as well as scalability and shared services – we should be looking to procure at an ICB level to get better value”. What often happens, she considered, is that interoperability and integration takes a lot of time and resource, “and if you can buy something where those services are already shared, and you are rolling out on a much wider scale, that’s much more financially sustainable”.

From the perspective of a supplier, Dan noted how these financial challenges make it all the more important that the solutions being delivered enable NHS organisations to achieve a return on their investment. “Whenever we support customers, we’re always looking at what the savings to come out of the project will be,” he said, “and over the past few years, we’ve saved the NHS millions of pounds in agency avoidance by enabling these systems to run.” Building in features like rate controls within temporary staffing solutions also allows for further savings, he said, “and we’re constantly committed to driving workforce costs down where possible, whilst still maintaining that ability for organisations to deliver safe and effective care”.

“For me, it’s about how we can leverage big transformation programmes to ensure maintenance training for our staff is right,” Penny said. “Stuart is right – you get a number of agency staff, and then when they leave you’ve got a gap, and you’re left with a couple of people to deliver a big change.” Looking at ongoing training and how that is delivered in order to keep up with that is key, she went on, “and there are lots of online courses we can use to support that as well”. Then there’s how technology can support productivity, she continued, “and what the outcomes are when it comes to saving time for our staff to improve productivity”. Aligning workforce transformation strategy with digital transformation strategy would be an area to focus on for the future, she considered, “because there might be roles that are now redundant as a result of new technology, and there might be new needs that need to be met by workforce to keep pace with that technology”.

Sally told us how her team at The Dudley Group have been doing “a lot of sharing” around roadmaps and lessons learned, as well as sharing their build for the maternity department with Bolton. “We spent nearly two years doing that, and they’ve been able to implement it within a four-month period,” she said, “so I think there’s something to be said there for canvassing the area and where we’ve got the same demographics and the same standardised build, looking to share the digital innovation work we’re doing, so we’re not reinventing the wheel all the time.”

Going into more detail about what the maternity build involved, Sally talked about how Dudley took a blueprint “which equated to roughly 40 line items”. The scale of the implementation from getting that blueprint to working in all of the necessary regulations around maternity care, and “making the solution fit for purpose across the whole pathway”, meant that this increased to 160 line items. “We employed a digital midwife specifically for that project,” Sally told us, “and a lot of that work was going on on the floor, with the midwives, consultants, obstetricians; to go through their processes, because there was lots of paper, lots of risk – labour and delivery was probably the biggest eye-opener for me – and from a digital perspective we wanted to try and stop people having to put things into the EPR which had already been captured.” Midwives were spending “about four hours” after a delivery writing up their notes, Sally continued, “which was instantaneous at the point of the episode, so they saved a lot of time”.

“We’ve already got an excellent workforce with a very high level of skills,” Stuart said, “and I think it’s important to focus on the upskilling of those people in a proactive sense, rather than just on demand.” That approach would save money for future projects as a whole, he noted. Stuart also mentioned consistent underspending of apprenticeship levies, adding: “They offer so many courses on things like data, digital, AI; we should be looking to actively use those, because we just lose them in April, every time.” What good would look like for the future would be promoting self-learning, he continued, “so part of our staff’s objectives is to upskill themselves, and we’re giving them the digital tools to support that”.

As a supplier, Dan shared how his team go about looking at the capacity that’s available to NHS organisations from within their digital teams before looking at how they can support that. “Some have got resource available to them,” he said, “and it’s whether you can tap into that, but also where you can scale your implementation offer to support smaller organisations who perhaps don’t have those skills or that capacity available to them.” Going back to Stuart’s point about self-learning, Dan also told us that Patchwork Health has “invested heavily” in online learning and some elements of gamification to help make their solutions accessible and easy-to-use, so people are engaged. “That also helps us communicate with users about any new updates to our system or new features which may be available, and we’ve done that in a really innovative way, too.”

The direction of workforce transformation away from a single organisation out to the ICB, has meant Patchwork Health is increasingly spending time on “helping organisations find a safer and more effective way to deploy staff to multiple organisations, like by using digital passporting and relevant credentials,” Dan shared. “That’s a really interesting concept we’re looking to explore with our customer base”. Another area of focus is on smarter staff scheduling, he said, “so we can look at activity and see how many staff members we need to have on a certain day to ensure safety for patients”.

We’d like to thank our panellists for taking the time to share these insights with us.