Feature by Highland Marketing 

Health and social care secretary Sajid Javid has announced a new target to complete the digitisation of the acute sector. The Highland Marketing advisory board discussed the approach being developed by NHS England’s transformation directorate, and the challenges to making it work.

In the first week of February, the Health Service Journal reported that it had seen a PowerPoint presentation of the digital plans being drawn-up by NHS England’s transformation directorate, which is absorbing NHSX and NHS Digital.

The magazine revealed that the directorate wants to see the “universal adoption of electronic patient records” as part of its “foundational vision” and that it wants clinical decision support to become “the norm” for all clinicians.

Just a few weeks later, health and social care secretary Sajid Javid delivered a speech at the Royal College of Physicians announcing that he is setting new targets for the adoption of EPRs in England to be rolled out to 90 percent of trusts by December 2023.

A shift in NHS digital policy

This is a significant shift in focus. The Highland Marketing advisory board held a debate on the future of EPRs last year, because it felt as though NHSX wasn’t particularly interested in completing the digitisation of hospitals.

Yet there have been signs that something like this announcement has been coming. In retrospect, the most significant move was made last March, when NHS England announced that it was making Tim Ferris its director of transformation.

NHSX then went on to announce a reboot for the digital aspirant programme that was interesting in two ways. First, Digital Aspirant Plus or DA+ focused on EPRs, and not on the departmental, e-obs, and AI systems that have received digital aspirant funding in recent years.

Second, DA+ comes with central support to procure an EPR and ‘buddying’ support to deploy one. At one level, this looked like a bid to learn the lessons of the global digital exemplar programme, which the National Audit Office has judged a success.

On another, it looked like a bid to give the centre more control over the systems being chosen. Shortly after HSJ reported on Javid’s target, it reported that NHS England has been sending out forms asking integrated care systems about their plans to ‘converge’ local EPRs.

So, twenty years after the National Programme for IT was launched, it looks as though the Department of Health and Social Care and NHS England are going to have another go at getting EPRs into every trust, and that they want to do some market shaping in the process.

How much ‘convergence’?

When the Highland Marketing advisory board met towards the end of February, members debated whether the push would work, and the pros and cons of ‘convergence’.

Chair Jeremy Nettle suggested that it looked as though the centre would still like to see one system used everywhere. “The way things are forming up, with the integration of NHSE, X, and D, and the latest announcements, it looks like they’d like a Henry Ford offer: you can have any colour of EPR you like, as long as it’s black!”

However, the reality on the ground is that the landscape is too messy for this to happen. Nicola Haywood-Alexander, system chief information officer at NHS Lincolnshire, pointed out that EPRs are only used by acute trusts; mental health and community providers have their own systems, as do GPs, and they’re not going to rip them up and take them out.

“We’re all discussing what the definition of ‘convergence’ is going to be, and the utopian answer might be ‘one system’ across an ICS, but the pragmatic answer is going to be ‘data’ and systems that allow data to be exchanged with each other,” she said.

Even in the acute sector, trusts that have achieved a high level of digitisation using a mix of single supplier EPRs and other systems, or ‘best of breed’ approaches, are also unlikely to undo the work they have done. But for the large minority of trusts that are still mostly paper-based, adopting the EPR or approach of another member of an acute group, a neighbour, or the majority of trusts in its ICS area, should make sense.

Andy Kinnear, who retired from the NHS after 30-years and now works for Ethical Consulting, said: “In some areas, trusts have been deliberately difficult with their EPR choices. We can all think of cities in which there are three or four trusts and they’ve refused to use a single instance of an EPR, because they think it will make it harder to merge them.

“Any attempt to tackle that kind of behaviour is going to be a good thing, so we can get on with sharing data to do what we’re meant to be doing, which is creating better services for patients.”

The challenges: deployment

If Whitehall and NHS England do use DA+ and the new EPR target to encourage acute trusts to ‘converge’ on systems at an acute group or ICS level, the NHS will end up with a smaller number of single-system suppliers.

As Matthew Swindells pointed out in a recent Highland Marketing interview, that was one of the intentions of the GDE programme, so recent developments can be seen as taking the health service back to where it was before NHSX arrived on the scene. However, Kinnear pointed out that it won’t be enough to guarantee that NHS trusts will be at HIMSS 5 on target.

“We shouldn’t underestimate how hard it is to deploy,” he said. “Fewer products will make your provider landscape a lot more manageable, but it doesn’t make your trust landscape more manageable. Every trust will have its own way of doing booking, or managing transfers from A&E or whatever, and you have to get into all of that.”

Time and leadership

The advisory board identified two additional challenges to getting the 20% of trusts that are still mostly paper-based over the line: timescales and leadership. As Kinnear pointed out: “No matter how many times we’ve tried to do this in England, we’ve failed, and one reason is that we keep announcing new approaches and failing to see them through.

“As soon as it gets tough, we change the national leadership and start again. I think that if we’d stuck with the NPfIT  – ok, perhaps not NPfIT, but certainly the GDE programme – we’d be there by now.

“I remember talking to the leaders of the GDE programme when it launched [in 2016], and they said: ‘The Treasury won’t give us the money to put EPRs into the entire NHS, because it doesn’t think we’ll manage to deploy. So, we’re going to do a few trusts, to prove that we can do it, and then we’ll go back to the Treasury, and ask for the millions and millions required.

“And they were going along, but then Matt Hancock arrived [as health and social care secretary] and it all changed [as Hancock set up NHSX]. Every IT programme seems to last about three years, but it takes a year to get the programme together, and a year to do the procurement, and at least two years to deploy: so we never see things given enough time to get the job done.”

Targets, money, action?

On the leadership front, the board noted that NHS IT programmes tend to coincide with NHS reorganisations; and NHS reorganisations inevitably end up with good, experienced people leaving the service.

Haywood-Alexander said there are signs that this is happening now, as acute trusts form acute groups or integrated service providers and clinical commissioning groups make way for ICSs, but neither put chief information officers on their boards.

“We all spend a lot of time dealing with the system, and if you’re doing it from a position in which you feel you’re not being valued, it’s very tough,” she said. Again, Kinnear agreed: “I used to work for a shared care record, and I got put into a commissioning support unit [when primary care trusts were abolished in order to set up CCGs].

“But lots of people just gave up and left the NHS at that point, and that contributed to CCGs having a very difficult birth. They just didn’t have the leaders and the experts that they needed to be successful. And now we’re seeing the same thing happening again.”

Entrepreneur Ravi Kumar said this was a real worry. “At the start of the Covid pandemic, there was real progress on IT, and we all hoped that it would be maintained,” he said. “Instead, there seems to be a gap at the top.

“Sajid Javid and Tim Ferris are saying some interesting things, but I wonder if they always agree with each other. Even if they do it will take time for the new relationships between the Department [of Health and Social Care] and NHS England the new transformation directorate to bed in.

“It’s important to have a consistent message, but it looks like we might not get one for twelve months. While that happens, more people will leave the frontline. That’s bad, because all the good things we saw being done during Covid was done by strong people with the drive to make it happen.”

Déjà vu all over again

Nettle drew some positive conclusions from the discussion. Yes, he said, “there is an element of déjà vu about these proposals” but the hope has to be that the NHS’ central bodies, local IT leaders and industry have learned from what has gone before.

If nothing else, he pointed out, in the 20 years since NPfIT was launched, there has been widespread buy-in to the idea that technology matters. “Both healthcare providers and industry have learned so much over two decades, and there is a genuine commitment to the idea that delivering healthcare is dependent on sharing good quality and timely data with those who need it to make operational and clinical decisions.”

However, Kumar summed up some of the board’s concerns about whether current politics and organisational changes could still derail the latest attempt to digitise the NHS. “The danger is we could end up in a situation where there is a target, and money, but there isn’t the strong leadership to make it happen,” he said.

Feature by Susan Venables, founder and client services director at Highland Marketing

The NHS has already made a commitment to become the first net zero health and care system in the world. It’s time for digital health vendors to think about their role – and to be ready to talk about how they are tackling global heating.

Living in the highlands of Scotland, it’s been impossible to miss the build up to Cop26. Glasgow is just an hour and a half away, and it has been preparing for the UN Climate Change Conference of the Parties for months.

Over the weekend, the news has been dominated by the arrival of the ministers who are supposed to agree the next steps on implementing the Paris Agreement and the pressure groups that are seeking to influence them.

For the next two weeks, Glasgow will be a riot of international debate, protest, and trade fair as the world looks on and asks the big question: it is going to be possible to deliver Paris and limit global warming to below 2 and preferably 1.5 degrees Celsius, in comparison with pre-industrial levels?

Climate change and the NHS

It’s a big challenge, and one that matters to the NHS. Partly, that’s because it could see a big increase in demand if temperatures continue to rise. Public Health England reckons 2,500 people died in last year’s heatwave alone.

Partly, it’s because the health service itself accounts for 4-7% of the UK’s greenhouse gas emissions, depending on whether you look at the carbon generated by its day-to-day operations or the many things associated with them, from food to patient travel.

The NHS is aware of this. In June 2019, Newcastle upon Tyne Hospitals NHS Foundation Trust became the first provider to declare a climate emergency. Since then, others have followed suit, including the mega-trust in Manchester and big name-hospitals in London.

NHS England has also picked up the baton. In October last year, its former chief executive, Sir Simon (now Lord) Stevens issued a report urging the NHS to become “the world’s first carbon net zero national health system” by 2040. That’s in less than twenty years.

Procurement will drive change, ready or not

I think health tech vendors need to sit up and take note of all this. Climate change is on the government and the NHS policy agenda. It’s already flying with influential trusts; and all NHS trusts will have to have a green plan by the end of the year.

The climate and health agenda will get another boost when England’s integrated care systems start work in April, because they have a population health remit and they will be working with local authorities that already have to consider the economic and social impact of their work.

Plus, when you look at the crowds gathering for Cop26, or the audience for net zero sessions at health events, it’s obvious that the climate and health emergency engages a younger, more diverse audience than most government, health or even digital issues do.

That means that health tech vendors need a good story to tell. In the short term, if you have a well-grounded, well-evidenced message, you are going to have a valuable differentiator in the market, and one that will resonate with a new and different audience for what you have to offer.

In the medium to long-term, having that message is going to be essential to protect your reputation and to continue to work with the NHS. From April 2022, every NHS tender will have a 10% net zero and social value weighting.

From April 2023, all NHS tenders worth more £5 million will require bidders to have published a carbon reduction plan, just to be considered. After that, the technical and procurement requirements on the NHS England roadmap only get tougher…

Tips for getting your climate message out

I don’t claim to be an expert on how health tech suppliers can demonstrate their contribution to keeping people well in a warming world, or on how they can calculate their contribution to the NHS carbon footprint, or their own carbon footprint.

The Highland Marketing advisory board is holding a special meeting towards the end of Cop26 to discuss these issues with expert input from David Newell, the head of health at Gemserv. But, as a head’s up: this is not about reducing a few travel miles or planting a few trees!

There are some gnarly things to get into, from thinking about how your data centre is powered, to working out how to provide support in a world where jumping on a plane is no longer an option, to examining the waste and working conditions in your supply chain.

Where I can claim to be an expert is in thinking through how companies need to present themselves to the health and care sector and how to make sure that influencers and customers receive that information in the most effective way possible.

So, as a starting point, here are some basic tips for suppliers that want to start thinking about how they can build net zero into their marketing and public relations:

• Make sure this is on your agenda. Look at the NHS England plan and its subsequent presentations, think about what is being asked of health tech suppliers, and what positive impacts that will have on your business.
• Collect evidence. If you are engaged in a project that has a measurable impact on addressing the health impacts of climate change or reducing the carbon footprint of the NHS, make sure that you are capturing that information.
• Share success. If you’ve done a great piece of work and you can prove it, a compelling press release or case study will raise your profile and demonstrate your credentials to potential customers and their increasingly engaged, increasingly savvy end-users.
• Join the conversation. Cop26 is capturing headlines and NHS net zero plan is getting attention, but there has been relatively little commentary on the role of health tech. So, there’s an opportunity to shape the agenda through blogs, opinion pieces, podcasts and social content.
• Prep for media opportunities. Both the mainstream media and the specialist health and tech press is starting to write about net zero. A well-briefed spokesperson ready to engage at short notice could secure you national press coverage that doesn’t come along all that often.

The moment is now

Cop26 has really focused attention on climate heating. Hearing about the science and seeing the passion of the many young people who are pouring into Glasgow has made me realise that now is the moment for all of us to start thinking about how we can take action.

I want to be completely clear that I am not suggesting to health tech vendors that this is a great bandwagon to jump on or that they should have a friendly green message. Suppliers need to take a good, hard look at the carbon impact of their activities and to make a start on a plan for reducing that.

The other reason that now is the moment is that NHS England has published one of the most ambitious plans in the world for a net zero health and care system and is creating technical and procurement strategies to deliver on it. Companies can seek to influence those plans by showing the change they are making; or get caught up in change that is happening anyway.

Here at Highland Marketing, we always say we are looking for ‘health tech to shout about’. Increasingly, a commitment to net zero and social responsibility is going to be one of the things that health tech vendors are going to need to shout about; and that the NHS and its users will be expecting to hear.

Highland Marketing is an integrated communications, PR and marketing consultancy with an unrivalled reputation for supporting UK and international health tech companies and healthcare providers, built over almost 20 years. Read more analysis and interviews on the Highland Marketing website, follow us on Twitter @Highlandmarketng, or get in touch on: info@highland-marketing.com

Feature by Highland Marketing

Health and social care secretary Matt Hancock has been abruptly replaced by Sajid Javid. The Highland Marketing advisory board consider the huge agenda he is now facing, and what it could – and should – mean for health tech.

Matt Hancock’s downfall as health and social care secretary was swift. On Friday, barely 12-hours after he had delivered the keynote speech to the NHS Confederation’s annual conference, The Sun newspaper published a CCTV grab of him enjoying a “steamy clinch” with an aide.

On Saturday, despite the palpable reluctance of prime minister Boris Johnson to sack him, he was forced to resign (BBC News) as the police started an investigation into whether he had broken the law when he breached his own measures to control the spread of Covid-19.

By the end of the day, Sajid Javid, a former investment banker with Cabinet experience as culture, business, and home secretary and, briefly, chancellor, had been announced as Hancock’s successor (Sky News).

A huge agenda

Confed underlined the huge agenda that is facing health and care over the next five-years, and which is now sitting in Javid’s in-tray. Immediately, the NHS needs a new chief executive to replace Sir Simon Stevens, who is leaving after seven years.

It needs to see the detail of the legislation that will tear up the Lansley reforms of 2012, deliver significant new powers to the Department of Health and Social Care, merge NHS England and NHS Improvement, and create integrated care systems and integrated care providers.

At the frontline, it needs to get through the remainder of the Covid-19 vaccination programme, to navigate another wave of the disease plus flu this winter, to get stuck into a waiting list recovery programme, and to prepare for that shift to integrated care and population health-management.

Meanwhile, social care desperately needs the long-term fix promised by prime minister Boris Johnson as he took office. And both health and social care need to be able to offer something to an exhausted workforce upset at being offered a real-terms pay cut.

Imaging expert Rizwan Malik argued that “workforce planning has got to be central to Javid’s strategy for the NHS” because “we won’t be able to address the waiting list crisis or anything else if we don’t address chronic staff shortages.”

As part of that, he added, the new health and care secretary should stop the attacks on “foreign” staff triggered by would-be NHS England chief executive Dido Harding (The Times), and reign in criticism of general practice, which is struggling to find a balance between face to face and remote working post-pandemic.

Jeremy Nettle, the chair of Highland Marketing’s advisory board, pointed out: “Simon Stevens is leaving in 30 days; it’s going to be quite a handover.”

Start by heading off the looming leadership crisis

Andy Kinnear, a consultant with 30-years of experience in the NHS, felt Javid should start by addressing the imminent leadership crisis that will be caused by Sir Simon’s departure. “This is a leadership challenge,” he said.

“Simon Stevens has done a pretty stellar job in the face of some tough austerity measures, and over the past 18-months we have seen some great leadership from figures like Jonathan Van-Tam [the deputy chief medical officer] and Chris Whitty [his boss]. What they all have in common is a deep commitment to and understanding of the NHS, and we need more of the same.”

A number of political commentators have pointed out that Hancock’s departure could be bad news for Harding, the former Talk Talk executive and Test and Trace leader who has been publicly lobbying for his job – to the disgust of many managers (Health Service Journal) and medical professionals.

But if Javid is going to look beyond Harding and the limited list of other names in the frame, he will need time. Entrepreneur Ravi Kumar suggested Sir Simon might be asked to stay on, or an interim leader asked to step in for six months or a year.

Nicola Haywood-Alexander, group CIO at NHS Lincolnshire, added that transparency in the recruitment process was hugely important. “We need a leader with integrity, who understands what it is like to work at the frontline,” she said.

“People need to have trust in whoever is leading the NHS, and in the appointment process itself, because inevitably questions will be asked and candidates scrutinised. When I am with our health and care staff, you can see and hear who has their fellowship.”

Then stall the legislation?

If he wants to get on top of his in-tray, and then make his own mark on health and care, Javid may also need to stall the legislation required to implement the Integration and Innovation white paper. This will have to come forward soon, if ICSs are going to start work on a statutory basis next April.

But some political correspondents have been reporting that Number 10 is worried about the timing, the size of the changes proposed, and the plans to hand much more control over to ministers (The Independent). If the legislation is delayed, however, it will raise the question of what Javid wants to do with his new brief.

As a young minister, he had close links with think-tanks such as the Institute for Economic Affairs, which is associated with calls for a smaller social safety net, smaller state and more private involvement in healthcare, and in his brief stint as chancellor he continued his predecessors’ policies of austerity and public service cuts (The Independent).

Haywood-Alexander mused: “Javid has a good economic background. He’s got Cabinet and finance experience. But health is a tough gig, with huge demand, backlog, and costs, and the well-being of our staff and the ongoing lack of workforce across health and care need tackling.

“Also, where does he stand on privatisation? Or, more importantly, on priority of esteem between physical and mental health? Or social care? Or health inequalities? I’m not so worried about his capacity to do the job of a minister, but I do wonder what direction he will take, and how he will prioritise and tackle investment in these challenges.” 

Refresh the digital agenda     

Hancock tried to put his mark on health and care by focusing on technology and imaging expert Malik argued that his successor needed to do the same. “Don’t just do the typical political thing of reversing stuff your predecessor did, because you didn’t start it,” he advised.

However, many members of the health tech community would argue that Hancock didn’t always focus on the right things. Many hospitals still lack electronic patient records, ICSs have only just been told to get a ‘basic’ shared care record in place, and the NHS and Covid-19 apps have struggled.

In addition, NHSX, the agency that Hancock set-up with considerable fanfare, has failed to find a clear role alongside the policy making activity of the DHSC or NHS England or the delivery functions of NHS Digital, while many NHS digital leaders feel it has distorted local priorities by focusing on headline grabbing initiatives.

Cindy Fedell, an ex-NHS CIO now working in Ontario, argued it is doubtful that X will survive Hancock’s departure. James Norman, former NHS CIO and now healthcare CIO, EMEA, at Dell, agreed. “NHSX was already being consumed by the new transformation directorate at NHS England, and I think this is likely to signal its end in any form.”

Like Malik, Norman argued the challenge for Javid will be to “make sure he does not throw the baby out with the bathwater” but to “make sure the best of NHSX continues” because “the drive to accelerate change with technology was right, it was just the approach of setting up yet another arms length body to deliver it that was flawed.”

By “the best” of NHSX, Norman added that he meant its ability to focus attention on important areas such as interoperability, standards and the use of data. Kinnear agreed there is a “huge opportunity” in open architecture and open systems and in Hancock’s relatively new commitment to “separate data from the applications that use it”.

This is one area in which Javid’s background might be reassuring. Banks invest large sums in IT and the arrival of open banking standards has driven innovation in fin tech. Nettle argued banks also understand “self-service”; or getting users to do some of the work of checking records, carrying out transactions, and booking services themselves.

“It’s not for everybody, and we know we have to keep digital inequalities in mind, but we need a digital front-door for the NHS, and as a banker Javid should understand that,” he said.

Time is ticking  

Unfortunately, the NHS digital and data agenda isn’t in a great place with the public at the moment.

The advisory board argued that Javid would be advised to quietly extend the consultation period on the data strategy, and to put off the planned publication of the new NHS digital strategy, ‘what good looks like’ and ‘who pays for what’. Or, if he wanted to be really radical, to scrap them and give chief information officers the status and space “to get on and do our jobs,” as Fedell put it.

Most of all, though, Javid needs to buy himself time and prioritise that huge agenda; or he’s likely to find himself consumed by it.

Fedell suggested seasoned health and care pros would be on the lookout for other, eye-catching initiatives. “Hancock came in saying he’d run the NHS with an app. We’ll know pretty soon whether that’s Javid’s style. If he takes his time, we’ll know he’s in for the long-haul.”

Summary of key points:

Sitting on top of the NHS in-tray: Deal with the ‘exit wave’ of Covid-19; prepare for a challenging winter; start to address the elective care backlog; prepare for the implementation of the Integration and Innovation reforms.

Additional service priorities: deliver an equitable recovery; ensure parity of esteem between physical and mental health; tackle the deep-seated health inequalities exposed by the pandemic.

Must-dos for the new health and social care secretary: Ensure a transparent process to replace Sir Simon Stevens as chief executive at NHS England; reboot the legislation required to implement Innovation and Integration; bring forward a social care green paper that delivers on prime minister Boris Johnson’s promise to “fix social care once and for all”; head off an NHS pay row and address long-term workforce challenges; go in to bat for his new department in this autumn’s comprehensive spending review.

Some friendly advice, in the form of six health tech dos and don’ts:

Do maintain investment in healthcare technology and don’t “do the political thing of reversing the stuff your predecessor did, just because you didn’t start it” (Rizwan Malik).

Do consider whether it is worth retaining NHSX within NHS England’s transformation directorate but don’t junk the best of what it has achieved – the renewed focus on interoperability, standards, and the use of data (James Norman).

Do push ahead with the NHS data strategy commitment to “separate data from the applications that use it” (Andy Kinnear) but don’t get distracted by every “shiny new app” that wants to use the data (Cindy Fedell).

Don’t forget there is unfinished business in infrastructure, cyber security, single sign-on, shared care records, and modernising GP systems, and do push for investment in social care and addressing the digital divide (Nicola Haywood-Alexander).

Do make sure that procurements are transparent (Ravi Kumar) and don’t forget that public trust is vital – or that it’s just been badly dented by the General Practice Data for Research and Planning extract proposals.

Do think back to your days as a banker; and bring some of banking’s culture of investing in IT, open systems, self-service and innovation to the NHS (Jeremy Nettle).

Highland Marketing’s advisory board is: Jeremy Nettle, former global advisor for Health Sciences, Oracle Corporation; Cindy Fedell, former chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust; Andy Kinnear, former director of digital transformation at NHS South, Central and West Commissioning Support Unit; James Norman, healthcare CIO, EMEA, at Dell Technologies; Ravi Kumar, health tech entrepreneur and chair of ZANEC, and Rizwan Malik, divisional medical director of Bolton NHS Foundation Trust and managing director of South Manchester Radiology

Highland Marketing is an integrated communications, PR and marketing consultancy with a reputation for supporting UK and international health tech companies, built over almost 20 years. Read more analysis and interviews on the Highland Marketing website, follow us on Twitter @Highlandmarketng, or get in touch on: info@highland-marketing.com

By Paul Walker, Chief Technical Officer, Skills for Health

The implementation of a large-scale data collection service from UK GP patient records has been delayed by two months after unions and sector bodies who represent doctors aired concerns over a lack of transparency and public engagement about the right to opt out. 

While welcoming the General Practice Data for Planning and Research (GPDPR) programme deadline extension last week, in a letter¹ sent from NHS Digital and NHSX to health and care organisations, Paul Walker, Chief Technical Officer at Skills for Health, discusses how informed consent is the key to maintaining public trust on how their information is used by GPs and the wider NHS.

Why have GPs voiced concern?

Informed consent is an essential and integral part of patient care, and absolutely key to patient and public trust, not to mention medical ethics and the whole ethos of equitable healthcare.

It is hardly surprising then, that for many patients to learn that their private health records, held by their local GP, are being transferred to a national database with very little warning or opportunity for dissent, has caused concern amongst GPs over its potential impact on the trusted doctor-patient relationship.

Needless to say, the collection of patient data and enabling its use for research purposes is not new. NHS Digital’s safeguarding, privacy and security policies are, and will be, of the upmost stringent standards.

GPs had no more warning than the general public that this was going to become a reality back in May, offering only a six-week window of opportunity for individuals to opt out, with a cut-off date originally of June 23 – now August 23.

While NHS Digital explicitly set forth their guidance on the programme, including a national opt-out policy, these communications were limited to NHS Digital online platforms and distribution to currently relatively unused waiting rooms. Consequently, GP practices felt the onus was on them to inform patients more broadly of the opt out option, at a time of extreme workload pressures and Covid-19 vaccination focus.

Doctor-patient confidentiality is almost sacrosanct, and the only occasions for disclosure of information outside of this relationship is either with the full understanding of the patient, as in the case of referral to external services, or where a patient is at credible risk of causing harm to themselves, or others. Transferring all medical information for all patients to third parties without opt-in consent is a huge contravention of the relationship between patients and medical services.

Confidence and consent

Presumed consent has some precedence in medicine; many of us will remember the cancelled ‘Care-data programme’ back in 2014 and the ensuing controversy surrounding its efforts to centrally collect GP recorded data. The lack of patient awareness and the lack of clarity around options for opting out of the data extraction were well acknowledged as a main cause for its demise, in spite of a national information campaign. Déjà vu?

Yet, on the other hand, the recent change to organ donation policy was met with overall very little protest. Perhaps this seems like a clear case of ‘greater good’ to most people, or perhaps it’s simply that it was well-publicised?

In this case, there was an accessible and achievable course of action for those who do not wish to have their organs considered for donation after death, and the organ donation service were clear that informal choices would still be accepted without question. Meaning that we, or someone acting as our next of kin, can just say no at the point where it becomes a possibility. There is also a clear and legal course for healthcare professionals to make ‘best interest’ decisions for people who are unable to make choices about their care and treatment.

Informed decisions on data sharing

With advance notice, planning, and with plentiful, accessible information about the change, many, even most people might be happy for their data to be used for large-scale public health planning. However, when our data is used without us being explicitly told, the boundaries of consent and confidentiality become blurred.

While for the GPDPR programme there is an online ‘national data opt-out service’² and you can also tell your GP that you do not want your data to be shared, this relegates the responsibility to the individual to be alert and savvy enough to advocate for their own rights. If the ability to opt-out is not accessible and universal, its ethics can be called into question.

There are vast numbers of people who do not or cannot keep abreast of current affairs; who are not digitally literate, do not use the internet, or perhaps have access to the required technology; who live in care facilities or other institutions, or who might have to rely on carers making or acting on these decisions for them.

Data saves lives and fuels innovation

Digitised health data means that we have more information than ever before which can be easily collated, identifying trends, health inequalities, and overall improving public health.

As long as provisions are made for everyone to make decisions about their own data, there is a clear case for data sharing positively informing public health decisions and playing a key role in planning and research, as well as in developing treatments. None more so than what has been evidenced throughout the course of the pandemic and what’s been learnt from the vaccine rollout, and the opportunities it could create for helping treat ‘long-Covid’.

There is no doubt we will all benefit from medical developments drawn from bigger, better cohorts of data. There are more than 60 million people registered with a GP in England³ alone. Large-scale digitised health information has already yielded compelling results, and from some unexpected sources – Fitbit and Strava have contributed information about public health for more people than any clinical trial could hope to accomplish.

Medical innovation based on the largest possible data cohort is undeniably a positive, and if this data can be collected and compiled in a transparent, informed, and consensual way, it is laudable and essential.

At Skills for Health we fully support wider collaboration across healthcare and the use of large cohort health data for public health planning and research, but only with full informed consent or appropriate advocacy for everyone whose data is affected.

NHS Digital’s recognition this week that more is required to prove maintaining patients’ trust is paramount to their efforts is encouraging. Now, the NHS will need to use the next two months to rebuild just that, trust. The success of the programme relies on it, if all groups of society are to be represented, and better care, better treatments and better outcomes are enabled for the UK population.

References:

¹National Data Opt-out – COVID-19 response – Further extension to 30 September 2021

²NHS Digital, National Data Opt-out

³NHS Digital, Patients Registered at a GP Practice – May 2021

Highland Marketing’s advisory board welcomed Jane Brightman, social care lead at Institute of Health and Social Care Management, to discuss the sector and its technology needs. A lot of hope is being pinned on integrated care systems, but when it comes to joining up health and care systems and putting the underpinning IT in place, cultural, structural and funding challenges remain.

The Covid-19 pandemic has shone an unaccustomed light on social care. This has illuminated the commitment of many of those working in the sector and its importance to adults with disabilities, older people, and their families.

More harshly, it has highlighted some of its problems, including the difficulty that many people face in getting the care they need, shortages of funding, staff and technology, and the precarious position of too many care homes.

Ahead of his most recent Budget, think-tanks urged chancellor Rishi Sunak to use the limelight to announce a long-term funding plan for social care. But, in the event, he announced more stop-gap funding, while promising, again, that the sector would see its much-delayed green paper by the end of the year (analysis).

Jane Brightman, who has just been appointed to lead the Institute of Health and Social Care Management’s social care activity (interview), told Highland Marketing’s advisory board that this needed to happen. “I want the social care to have a long-term funding settlement and a ten-year plan like the NHS Plan,” she said.

How integrated will integrated care systems be?

For the moment, social care must carry on; and hope that the arrival of integrated care systems will make a difference. The recent white paper, Integration and Innovation, says they need to join-up both health services and health and social care which is run by councils, rationed by need, and means-tested.

However, while Integration and Innovation spends a lot of time discussing one aspect of ICSs – the NHS body that will be responsible for the shift to population health management and commissioning from provider collaboratives – it spends much less on the other – the health and social care partnership that will draw up an ‘overarching plan’ for public health, health, and social care.

NHS organisations and local authorities will be expected to ‘take note’ of the plan in carrying out their activities; but this isn’t a particularly strong requirement. So, as board member and former ICS chief information officer Cindy Fedell pointed out: “ICSs are an opportunity, but they are very NHS heavy.”

Funding flows (and blockages)

Then, there’s the money. Integration and Innovation makes some provision for strengthening the Better Care Fund and enabling the NHS and local government to pool budgets for joined-up care initiatives.

But, as advisory board chair and Salisbury’s previous mayor Jeremy Nettle pointed out, on the local government side there isn’t much cash around; and councillors may be reluctant to see any money that is available vanish into a system with no democratic accountability that is not at the forefront of voters’ minds.

“In Wiltshire, social care is our biggest expenditure, but we have 3,000 miles of roads and it is roads that people complain about,” he said. “Local authorities have been promised some extra funding for social care this year, but it hasn’t materialised. So, people are talking about pooling funds but there may not be funds to pool.”

When it comes to care homes, Brightman said the Care Quality Commission had determined that just 70 of the 18,000 providers were big enough to be a problem if they failed, while most of the rest are so small they will find it hard to contribute much to the integrated care agenda and the IT required to make it work.

Sitting behind all this, there is also that fundamental challenge that while the NHS component of care will be tax-funded, any social care component should be charged back to the individual. Which just adds a whole new layer of complexity to integrated care discussions.

One NHS and social care system?

Imaging expert Rizwan Malik said it was a shame that, for historical and political reasons, health and social care had ended up on separate tracks. “It just causes huge frustration,” he said. Mark Venables, chief executive of Highland Marketing, asked the board whether one solution would be for the NHS to take over social care.

Brightman said the idea has been floated in the past, but it would be “a huge job”. Labour has proposed creating a national social care service to run alongside the NHS, to provide scale and consistency. But recent governments have shown little interest in the idea.

Entrepreneur Ravi Kumar suggested some of the benefits of a national service might be delivered by creating a “social care brand” for the sector. But Brightman pointed out this had been tried.

Health and social care secretary Matt Hancock backed exactly this initiative when he wore a care lapel pin instead of an NHS pin to a Covid-19 press conference; and was promptly accused of ‘gesture politics’ and ridiculed for having nothing more practical to offer the sector (Independent news story).

Downstream action, upstream savings  

In practice, it is pragmatism that is most likely to drive integrated care. Brightman told the board: “The trick [to getting funding from the NHS] is going to be recognising that social care can do a lot to prevent hospital admissions and to support discharge.”

As an example, she noted that treating a urinary tract infection in the community is much cheaper than treating it in an acute hospital, where patients can deteriorate to the point where they need new care packages and end up as a ‘delayed discharge’.

However, she acknowledged, social care will need status and skills to secure this kind of investment; and deliver on it. This is one of the reasons that the Institute of Healthcare Management rebranded to include social care earlier this year.

The IHSCM is now looking to provide a ‘home’ and a voice for social care leaders and managers and, perhaps, to provide certified training for them (the IHSCM is exploring a partnership with a university that may have a suitable degree programme).

The issue of certification struck a chord with Andy Kinnear who, as an NHS chief information officer, tried to drive forward professionalism in informatics by helping to create FedIP, a membership and registration body. “NHSX is describing 2021 as the year of health and social care professionalism, and it is pushing this agenda hard,” he said.

“So having the IHSCM respond to that will fit with a story that is already playing out in other places. Because we do need to get together, as health and care professionals, to push the agenda forward.”

A sector that needs to be more digitally mature

When it comes to technology, the social care sector has a long way to go. In councils, social care is supported by a handful of small IT suppliers with care records that have been hard to integrate with NHS systems, even in big, national initiatives such as Child Protection – Information Sharing.

The CQC has drawn up a ‘what good looks like’ for digital records in the sector and has similar guidance for care homes. However, last summer, a survey discovered that a fifth of care homes had no wi-fi and that fewer than half of those that did had wi-fi in both communal areas and bedrooms.

During the pandemic, NHSX and NHS Digital worked with leading telecoms companies to address this and make sure care providers could run remote GP consultations, order prescriptions electronically, and enable residents to communicate with family and friends.

The digital agencies also gave care homes NHS mail addresses, which Brightman said had made a huge difference. “I have heard people say that, because they are emailing from an NHS address, clinicians take them much more seriously,” she said. “It’s a great example of why the sector needs to be more digitally mature.”

She added that her priority now is to “help providers understand data and security” and to get them through the Data Security and Protection Toolkit, or DSPT, which, before Covid, was required to get an NHSmail account, and is still required for “the holy grail – shared care records.”

Small steps, big challenges

The advisory board discussed how the structural and funding challenges facing ICSs that want to progress integrated care initiatives are likely to make themselves felt when it comes to deploying the technology needed to make them work.

Nicola Haywood-Alexander, who took up a post as chief information officer of NHS Lincolnshire six months ago, said she would like to integrate the IT teams working on different health and social care systems and fund enhancements to their software.

But the local authority and the ICS have made different outsourcing decisions, and it’s hard to secure money unless it can be banked for specific projects. “I’d really like to do more, because there is so much we need to do,” she said. “We need fibre, and satellite broadband, because sometimes on my patch I can’t get 3G or 4G, never mind 5G.

“We need single sign-on so people aren’t having to log-in to so many systems. I want to roll out workflow and productivity tools. I know the argument is that [social care] should help to fund them, but if they can’t that doesn’t help us.”

In the end, it’s down to people

Shared care records illustrate the challenge. ICSs will need shared care records to support teams working on different systems, generate data for population health management, and plug in digital patient services.

They have been told to have a ‘basic’ record in place by September; but it doesn’t follow that social care will be involved in that basic record and there is already evidence that in many areas it won’t be. James Norman, healthcare CIO at Dell Technologies and previous CIO at a large NHS trust, said national IT funds should be directed to ICSs to sort this out.

“I agree about raising the profile of social care and introducing standards, but at the end of the day we need to get money out to the service and into joint working,” he said.

However, Kinnear, who also has considerable experience of driving shared care records from working on Connecting Care in Bristol, argued that it’s mutual respect and goodwill not white papers, structures and funding rounds that will sort things out on the ground.

“In the end, this is about people and people working together to do things for patients and users who are not bothered about whether it is the NHS or social care or someone else entirely who is doing the job,” he said. “It is down to people in the health and care community solving things for the community.”

Highland Marketing’s advisory board is: Jeremy Nettle, former global advisor for Health Sciences, Oracle Corporation; Cindy Fedell, former chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust; Andy Kinnear, former director of digital transformation at NHS South, Central and West Commissioning Support Unit; James Norman, healthcare CIO, EMEA, at DellEMC; Ravi Kumar, health tech entrepreneur and chair of ZANEC, and Rizwan Malik, divisional medical director of Bolton NHS Foundation Trust and managing director of South Manchester Radiology

Highland Marketing is an integrated communications, PR and marketing consultancy with an unrivalled reputation for supporting UK and international health tech companies, built over almost 20 years. Read more analysis and interviews on the Highland Marketing website, follow us on Twitter @Highlandmarketng, or get in touch on: info@highland-marketing.com

Royal Bolton NHS Foundation Trust has been much praised for its deployment of AI in the fight against Covid-19. Rizwan Malik, divisional medical director of the trust and managing director of South Manchester radiology, spoke to the Highland Marketing advisory board about the project and the lessons that other trusts can learn from it.

As the coronavirus spread across Europe in spring 2020, chest imaging became an important tool for diagnosing patients with Covid-19. Clinicians found they could diagnose the disease from a chest x-ray far more quickly than they could confirm it from a blood test, which typically takes 24-hours to turn round.

As part of its Covid-response, Royal Bolton NHS Foundation Trust looked for a way to make it easier for its doctors to use chest x-rays as a primary tool for the diagnosis, without having to wait for a radiologist to become available.

It deployed a decision support tool from Qure.ai to help them interpret scans and calculate the radiographic severity score that indicates whether a patient is deteriorating and so likely to need oxygen support or intensive care.

An entry in the HTN Awards 2020 explained: “Doctors get a very quick interpretation, right at the time of scanning, about whether changes are likely to be Covid-related and, more importantly, whether things are getting worse or, of course, better.

“This has meant more efficient triaging and care of patients, optimised the use of critical care resources, and [made sure] the patient’s journey through the hospital is quick and streamlined.”

A solution for the long-term

Royal Bolton was the first NHS organisation to work with Quire.ai. However, the algorithm used at the trust had been trained on 25 million images to spot the abnormalities associated with TB. The algorithm, which had CE certification for TB, had then been prepped on another 11,000 images to identify the similar changes associated with Covid-19.

In the longer-term, it is the algorithm’s ability to track progression that is likely to be valuable. Royal Bolton’s award entry argued that this could enable medical staff to monitor and make decisions about patients without having to make regular calls on the over-stretched radiology department.

It could also support trainee radiologists and provide a quality check on the work of clinicians across the piece. Dr Gareth Hughes, critical care lead, wrote: “I think a significant benefit will be seen in the post-Covid era [because] it will improve diagnostic accuracy when our junior doctors first assess patients. It should also improve the correct coding and identification of community-acquired pneumonia.”

It was the potential for use beyond Royal Bolton and beyond the immediate crisis that impressed Highland Marketing’s judges, who made it the winner of the awards’ #HealthTechToShoutAbout category. Chair Jeremy Nettle said: “It shows how AI can be used to improve systems and processes, and that should be of great interest to other trusts that want to do the same.”

Challenges in the healthcare AI market  

For its last board meeting of 2020, the board invited Rizwan Malik, the trust’s division medical director, to expand on what he had learned from the Quire.ai deployment, and what other organisations that want to do the same should bear in mind.

Malik started by saying the trust had a bit of a head-start when Covid-19 hit, because it had set up a digital innovation board to discuss AI in response to approaches from companies.

“The board included our chief information officer, and the medical director, who was keen to see what we could do in the field, and a couple of radiologists who were interested in this space,” he said. “That was useful, because I had needed to get buy-in when this came up, I’d only just be getting sign-off now.”

One of the things the board had discovered was that there were hundreds of suppliers in the market, but only a small number had a CE mark – and even fewer had certification to use their algorithm as a diagnostic device.

Also, companies were coming to the trust and asking it to find a use for their products, instead of identifying a problem they could solve. In doing so, many were adopting an approach that focused on cost-saving and doing away with radiologists: “which is like trying to sell mint-sauce to lamb chops.”

Yet, Malik said, they were often “defensive” about their data sources and who would be responsible if a deployment had adverse consequences. To make progress, the digital innovation board had come up with a set of questions to ask:

Where is the data coming from, and is it relevant to the population that the algorithm will be applied to? Who owns the data and who benefits commercially? Are suitable data sharing agreements in place?

How secure is the data, and “if it is squirted into a cloud-based product, what actually happens to it”? Does the product have approval and, if it does, is that approval relevant to the use-case at hand? And: “Why do it, if nobody has done it before?”

Malik said it’s possible to turn this last question around, and say: “Why can’t we do it, just because nobody has done it before?” But there needs to be a good use-case – “a problem to solve, and a way to solve it” – plus good arguments to address clinical concerns, and a decent business case – “because if it just looks expensive, it’s going to be ‘chief executive says no’.”

Ready to address the Covid-19 crisis  

In essence, Royal Bolton was able to move ahead quickly with the Quire.ai algorithm because it could answer these questions. “I can pinpoint the day that this went from an abstract thought to something that we should do,” Malik said.

“It was a day in February, when I was watching a TV report about Italy, where doctors were falling like flies and those remaining were having to make these terrible decisions about who should get ventilator beds. I wondered if we could use AI to make better decisions. I read about this company, Qure.ai, and it seemed to have something presentable to address that.”

Qure.ai could answer the data question. It had a mature product, trained on TB and re-tooled on Covid-19 scans. “So, we knew the data was applicable to what we wanted to do.” When it came to security, Qure.ai had a cloud-based product, but Royal Bolton asked it to install a server within its own firewall. “So even Qure.ai is unable to see it without a timed permission from our IT department.”

Regulation needs regulating  

Things got interesting when it came to regulation. Qure.AI (with the support of the trust)  asked the Medical and Healthcare Products Regulatory Agency to sign-off on the use of the Qure.ai algorithm for Covid-19 for a specific use case using the Derogation route. It not only refused but “told us to shut down” despite the solution already having appropriate CE certification. The team challenged the decision, asking for clarification and won.

In contrast, he said NHSX and the Royal College of Radiologists had been much more receptive. Both had early conversations with the trust and asked it to contribute to a ‘cookbook’ and a ‘guide’ on how to deploy AI and how to integrate it with radiology systems.

Other problems were swept away by the pandemic. On cost, Malik said: “Our medical director got around that by going to the finance director and saying: ‘there is a pandemic on, so you can have no hospital, or you can have this mitigation to help keep the lights on’. And, to be fair to the finance department, they came right on board.”

With clinicians, communication is key

The advisory board were interested in the cultural aspects of the deployment and how Malik and his team had been able to address clinical concerns.

Malik said a lot came down to communication; being clear about who the product was intended to support, and what it could and couldn’t do. At Royal Bolton, the Qure.ai product has not changed the role of radiologists, who remain responsible for reporting.

Instead, it has been deployed to support doctors, but they remain responsible for diagnosing and treating patients. If the product throws up a false positive, for example, they can over-ride it. Otherwise, it provides a useful aid or backup for their skills.

“We were very clear that this was not about replacing people, but about support and quality,” Malik said. “And there was a point at which people went from being sceptical, to being accepting, to seeing the benefits.

“Initially, there was some ‘oh, we’ll humour him and do this to get him to go away’, and then people realised they were not being pushed out, but they were getting things done much faster, and now they want more.

“We have just had virtual-RSNA [the conference of the Radiological Society of North America] and two people who really challenged me on this deployment came back from the event and said they’d heard about a couple of things and when could we do them? That gave me a warm glow.”

As a Board Member at Skills for Health, I was thrilled to host their recent digital focussed event, ‘2020: A Catalyst for Rapid NHS Digital Transformation’. Joining panellists from NHS England & Improvement, Health Education England, and Microsoft, we looked to dissect the rapid acceleration of digitalisation in our NHS over the last twelve months, and what this means for our sector and our workforce.

The two hour event hosted over 100 attendees and live-streamed on YouTube, allowing delegates to hear about the key considerations for the impact of a new digital-first way of working.

Looking at the good and the bad from the last twelve months, the panellists shared insight into digital-first training, technology fatigue on the workforce, revolutionary digital approaches from case studies on COVID-19 wards, and much more. However, with recent evidence of the impact of digitalisation on wellbeing and fatigue, not everyone in our NHS and Tech world share a common view on whether digital-only working is the future.

Like many others, I’m currently working almost exclusively from home. Yet, we should remember we’ve all had a significantly different lived experience of digitalisation than those on the front-line in the last 12 months, not just in healthcare, but key workers across many vital sectors. It’s important to appreciate that everyone is having a very individual experience, based on our own unique set of challenges. There is also so much that’s been challenging in 2020, including digital-fatigue, burnout, stress, and anxiety, need for training, lack of feeling connected, home-schooling, digital exclusion.

But it’s not all bad, there is a lot that is good and there are positive changes – for example, better infrastructure, breaking down barriers, better accessibility and an appreciation for some hitherto unappreciated jobs.

And of course, one very positive sign is the recent promising news on vaccines. But even if it does the job, it’s unlikely we’ll go back to the way things were before, but that doesn’t mean we’ll stay as we are now. A combined approach gives us the added benefit of taking the good forward, and leaving the not so good, behind.

One highlight for me, is that we have better infrastructure and capabilities to adapt quickly to a digital-first world than we thought. Digital and workforce transformation in our NHS and health sector is now something we can tackle with courage and ingenuity, sometimes in a matter of days and hours, which may have seemed impossible this time last year.

One important topic associated with digital is the role of learning for our NHS workforce, and Henrietta Mbeah-Bankas, Head of Blended Learning and Digital Literacy at Health Education England, raised some interesting opportunities, challenges, and considerations around digital learning for the workforce:

“Properly defining digital literacy is one of the first vital steps for a digital transformation strategy to succeed, we can’t continue to make assumptions like ‘Millennials are digital-natives’.

“There are three groups we need to consider to properly develop an inclusive digital transformation strategy that will be effective – the digitally engaged, digitally ambivalent, and those that say, ‘I don’t do tech’. For me there’s also a fourth group, those who are actually digitally excluded. Until you understand the barriers these people have and consider how they’ll approach digital solutions, you can’t begin to create an inclusive digital strategy that will ensure everyone comes on the journey with you.

“Learning accessibility is one of the most crucial aspects of a successful digital strategy, and [..] using data to understand how people are learning and accessing learning, gives us information to know how we should be providing learning to staff, in the most accessible and effective way, to improve retention, and provide relevant learning as and when they need it. Intelligent signposting enhances the learning experience for the individual, rather than a ‘one-style-fits all approach’

“Crucially, the conversation needs to change from ‘I don’t do tech’ to ‘What can tech do for me?’

I love that idea of ‘tell me what your problems are, and I’ll help you solve them, it’s not about the tech, it’s about the solution’.

Daniel Langton, Director of Customer and Partner Experience at Microsoft and Skills for Health Board Member, shared some insightful research on the health and wellbeing impact of digital-first and remote working:

“At Microsoft, when the pandemic first hit, we had over five billion ‘meeting minutes’ recorded in a single day across Microsoft Teams. This was unprecedented, and what we realised was that our system had, almost overnight, become critical national infrastructure for the country and the NHS in particular, on a scale we had never seen before.

“What we saw was that the adoption in the NHS at enormous pace was successful, in particular in the exploration of skills and the change in culture. Organisations that already had a strong digital skills strategy and were embracing cultural adoption were the most successful. Secondly, leadership became even more important.

“Now, we’re starting to think about recovery, we’re starting to assess how digital acceleration has impacted us as individuals. Our research at Microsoft has found that stress levels are significantly higher over virtual meetings; and we’re trying to think about that from a technology input by considering how the platforms can give individuals more choice about how they engage over virtual meetings and how they “show up”.

“Certain types of use of the platform can create more fatigue. Some alarming statistics show for example that the volume of meetings is increasing, and 70% of meetings are over-running. Furthermore, 62% said they felt less connected to their teams when working from home.”

Many of us can probably relate to what the research is showing, but at least knowledge is power and by using this data to inform how digital platforms can be enhanced to help, not hinder, we can driver improvements at the ground level as well as for our NHS managers and leaders.

Dr Paul Rice, Regional Digital Transformation Director at NHS England & Improvement joined us from a particularly busy schedule, as he is currently involved in COVID-19 Vaccine development. Paul’s wealth of experience in digital transformation provided some interesting insights about the challenges we face both in a very public way, but also deep within the structure of our NHS.

“One thing we desperately need is a comprehensive approach to digital-first careers in the NHS to attract the next generation of talent who are digitally capable and will ensure we embrace transformation.

“Unfortunately, there’s a narrative in the public eye that the NHS ‘can’t do digital’. That’s simply not true, and contradicts with the immense rapid pace we’ve implemented digital transformation in response to COVID-19.

“There is however a digital divide between those coming into the workforce and those in the existing workforce. We need to ensure we don’t just do digital transformation, but that it’s fully inclusive for all people and roles in the NHS, to be successful.

“The digital aspirations of the sector of course cannot be realised without additional funding. That’s true, it’s always been true, and we are focused on increasing funding for digital innovation. As employers and leaders, we need to find ways to ensure that funding is well utilised and sustainable for the future.”

Adam Causon, Chief Operating Officer at Skills for Health provided some final reflections on the event:

“At Skills for Health, we’re constantly developing our understanding, particularly around quality assurance for our digital solutions such as elearning and workforce management rostering. There’s clearly so much to learn with everything changing so rapidly, and it’s been fantastic to hear from the panellists today with experiences through different lenses from cultural, learning, transformation, wellbeing, and technology. Events like today to share those experiences are absolutely invaluable”

My key take-away from this event was that we need to make sure we continue to embrace rapid digital transformation, use it as a catalyst to get stuff done, improve work, improve lives, and improve patient care. We must use all this data available to us to understand the good and the not so good outcomes from the pandemic to shape initiatives for our new future.

If we get it right, hopefully soon the new normal will surface, one where we’re not stressed and anxious on back-to-back zoom calls, but one where we have better connectivity, balanced with the need to engage with colleagues, teams and patients in the real-world.

This way, we will have our needs met, control of our future and make the most of a rapidly digitalised landscape, whilst retaining this sense of the importance of looking after each other.

A recording of this event is now available to watch on demand here, along with downloadable supportive resources shared by the panellists.

Author: Niamh McKenna, is Chief Information Officer at NHS Resolution, and is currently supporting the development of a major programme to enhance the technology capability of the NHS, whilst ensuring continued delivery of services effectively. Prior to joining NHS Resolution in August 2020, Niamh led Accenture Health UK, supporting the NHS in large scale & innovative programmes such as NHSmail & Secure Boundary.

By Jon Calpin, Programme Manager for the National Record Locator, NHS Digital

NHS Digital’s Programme Manager for the National Record Locator, Jon Calpin, discusses how a pilot with London Ambulance Service has proven that interoperability of NHS systems can be achieved and how this benefits organisations, with Jo Clark from digital care software provider Servelec and Stuart Crichton from the London Ambulance Service.

The NHS is often seen by the public as a single entity that looks after us all from cradle to grave, rather than a myriad network of over 8,000 interconnected organisations all working together to provide the outstanding care that we all rely on.

With this complexity comes the technical challenges we all face in the increasingly digital landscape of health and care.  Each organisation has its own systems and holds its own data on the patients that use its services. There are also a wealth of different data sharing agreements with others, to help patients get the care they need while keeping their personal information secure.

Interoperability is the technical test of our time.  Finding ways to get the right information to the right people at the right time so that patients get the best possible care and clinical decisions when they need it.

The National Record Locator was set up to help meet this challenge.  Rather than being a central store of patient data, it initially provides a way of finding out who has data on a patient.

Authorised clinicians, who need information on a patient for their direct care, can access the National Record Locator using the Summary Care Record application,  see who holds records on the patient and, once the system is mature enough, see the records themselves.

At no point does the record move from one system to another.  It remains with the organisation that holds the data, so there is no need for a central repository.

We piloted this over the last two years with staff at the London Ambulance Service, where ambulance clinicians are now able to access the mental health care crisis plans of those they are rushing to help – providing them with often vital information about the patient, ahead of their arrival.

This has enabled cross-border record sharing on a national scale and the opportunities are endless.  It speaks of a system in future that, no matter where a patient presents in the country, they can be secure in the knowledge that the clinician treating them has access to all the information they need to make the right decisions, quickly.

Stuart Crichton is the Chief Clinical Information Officer at London Ambulance Service and a practising paramedic.  He has witnessed first-hand what a difference having information like this at professionals’ fingertips can make to an urgent situation:

“The ability to look at a record using NRL has changed the game for those of us on the front lines.  The National Record Locator has given us timely access to relevant information in a quick and easy to digest format. This means that we can improve our decision making to deliver patient-centred care.

“There are real advantages to this.  We have had cases where, knowing the details on someone’s mental health care plan has meant that we’ve known before we’ve arrived that our presence has led to an escalation in that patient’s stress response. So we’ve been able to take appropriate action, avoid the need for other emergency services to be called and, most importantly, it has meant that the patient hasn’t been distressed unnecessarily.

“Our clinicians don’t have to worry about usernames and passwords to access the information, the security is all taken care of in the background enabling us to focus on patient care. I love it, our staff love it and this technology will change the face of how we access data across the NHS.”

Tech like this usually comes with a hefty price, though, in an organisation’s time and effort to set it up.  This is no different but it’s not as labour-intensive as most.  Servelec’s Head of Business Operations, Jo Clark, explains:

“All you need is an ODS code, a HSCN or N3 connection, the ability to verify NHS numbers through the Spine and an up-to-date Data Security and Protection Toolkit.  Once your Clinical Safety Officer has undertaken their clinical safety assessment, you’re ready to onboard.

“Your supplier will handle most of the onboarding process for you. All you need to do is review the guidance, sign the connection and data-sharing agreements and work with your supplier on integration testing once they’ve built and tested it in NHS Digital’s path-to-live environment. Your supplier will support you through deployment and into live.

“You don’t have to be one of our customers either – while Servelec has led the pilot as the supplier partner, by developing the integration with our Conexes interoperability platform, we want to see other suppliers coming into this marketplace to help their customers to make the most of this technology as well.”

The pilot around mental health crisis plans and ambulance staff has proven itself a resounding success but there’s so much more that this technology can do.  Any type of patient record for any type of service, anywhere in the country.

A truly interoperable system for the NHS, able to share patient data securely and quickly with the professionals who need it, regardless of the IT and record systems involved, fit for the next decade and beyond.

If you think that you could use the NRL, or have records that you think others might need, please contact NRLS@nhs.net.

Industry veteran Jeremy Nettle reflects on a recent debate by the Highland Marketing advisory board on the role of national and local organisations in NHS IT policy, funding and implementation. Twenty-years of switching focus has created confusion and delay, he argues, and it’s time for a new model.

The relationship between national, regional and local leadership of NHS IT is complex, and it has taken a long time for it to become as complex as it has. This May, the National Audit Office pointed out that the health service has been trying to deploy technology for twenty years, and what it has been trying to achieve hasn’t changed all that much.

What has changed is the approach. We’ve gone from ‘let a thousand flowers bloom’ in the 1998 Information for Health strategy, to ‘command and control’ with the National Programme for IT, to attempts to find a ‘third way’, like the global digital exemplar programme, and reverted to central targets.

Some of NHS Digital’s core functions date back to Information for Health, while NHS E/I came up with the GDE programme when Jeremy Hunt was health secretary, and NHSX arrived with his successor, Matt Hancock.

There is no doubt that they can get in the way of each other, and with the work that trusts and integrated care systems are trying to do on the ground. The Highland Marketing advisory board was given some interesting examples by the CIO of an ICS.

First, it was told that it couldn’t let GPs book hospital appointments from within an integrated care pathway, because it must use NHS Digital’s Choose and Book, which was set-up in a very different era of patient choice and acute-sector competition.

Then, it had to put its hospital-diversion projects on hold, to get an NHS E/I ‘talk before you walk’ service in place for A&E this winter; while finding the funds for ‘axe the fax’, which is not an immediate priority, and will eventually be addressed by creative use of an integrated digital care record.

Clarifying responsibilities and roles

If we are going to find a way through this complexity, we are going to need a return to first principles. What is the health and care system trying to do, who does it want to do it, what technology does it need, and who does it want to do that?

Ideally, that would mean clarifying the role of NHS E/I, its regional offices, and health and care systems, and it would mean defining policy and delivery in terms of outcomes, rather than processes or technologies, so organisations could do things in the way that works for them.

That, in itself, would go some way towards addressing the frustrations of our ICS leader, being told to implement a national policy with a specified technology (roll-out ‘talk before you walk’, use NHS 111) that doesn’t align with local priorities (create integrated care pathways, make the most of the developing IDCR).

However, the advisory board felt that it would also be useful to have a new NHS IT strategy, to articulate what kind of technology the health and care system is going to need, and a central body to drive it. Ideally, this body would be strong enough to push back against distracting initiatives (like ‘axe the fax’, again).

Or, at least, it should be able to ask what outcomes such initiatives are meant to achieve, where they sit in the priority list, and how they are going to be funded. Alongside a new NHS IT strategy, we felt the NHS should also revisit the idea of digital maturity.

New models are needed to enable the centre, healthcare economies and individual trusts to prioritise investment, assess progress, identify technology gaps, and work out where support is needed. On the last point, some of the ideas behind the GDE programme could also be revisited, and ‘federated’ models developed to enable trusts to pool budgets, learn from each other, and get a better deal from suppliers.

The x-factor

Our discussion reached a fair degree of consensus on what a more strategic, more stable approach to NHS IT would look like. It would leave policy making at a national level but encourage a focus on outcomes rather than processes or technologies.

It would create a new NHS IT strategy aligned to maturity models that could be used to measure progress and push back against ‘headline-grabbing’ or ‘soundbite’ culture. It would mean a new IT body to set strategy, measure progress, and advise the government. It would mean regional or federated support for local organisations that would otherwise be charged with delivery.

The McKinsey review may have concluded that some of this exists already. Clarifying the role of NHS E/I should be bread and butter to a management consultancy. The NHS E/I regional offices look well placed to take on at least some of the federated co-ordination and support role. ICSs are developing.

So, the big question may be: does the NHS need a new body to set strategy and measure maturity? Or, if this sounds a lot like what NHSX was set up to do: why isn’t it doing it, and how can we make sure that it can do it in the future?

Read a full report of the Highland Marketing advisory board discussion on highland-marketing.com 

 Highland Marketing’s advisory board is: Jeremy Nettle, former global advisor for Health Sciences, Oracle Corporation; Cindy Fedell, former chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust; Andy Kinnear, former director of digital transformation at NHS South, Central and West Commissioning Support Unit; James Norman, healthcare CIO, EMEA, at DellEMC; Ravi Kumar, health tech entrepreneur and chair of ZANEC, and Andrena Logue, consultant, Experiential HealthTech.

Highland Marketing is an integrated communications, PR and marketing consultancy, supporting UK and international health tech companies, built over almost 20 years. Read more analysis and interviews on the Highland Marketing website, follow us on Twitter @Highlandmarketng, or get in touch on: info@highland-marketing.com

As part of the HTN Health Tech Trends Series, Andy Callow, CDIO at Kettering General explores the potential of the Cloud in healthcare and argues why it makes sense.

What is the NHS Waiting For?

In behavioural science there is a concept known as the intention-action gap. This refers to the difference between what people say they plan to do and what they actually do. It would seem to be that when it comes to Cloud and the NHS, there’s a lot of talk and very little action. In 2013, the Government produced a Cloud First policy for all technology decisions, giving public sector organisations the permission they presumably said was holding them back from embracing the potential of the Cloud. And then very little happened. Many organisations then continued to build data centres on premise or even use off-site hosting, and were unable to tackle the barriers of making the jump to the Cloud.

Seven years later, most of the NHS has made little progress. There are of course good stories but they are exceptions rather than a rule. In 2015 I joined NHS Digital as the Head of Technology Delivery for the NHS Website NHS.UK (known as NHS Choices back then). The site had moved out of local hosting in 2014 and we were able to make considerable transformation of the technology stack, staying within the same budget envelope over the next three years. We put a case study together in 2016 showing the cost savings of moving  onto the cloud and the benefits that had been realised in terms of flexibility, availability, site capacity and user-experienced site speed during that time. I remember sharing the case study with numerous people, including with NHS and Local Government colleagues and then watching nothing happen.

There are also some examples of externally hosted web-based systems, but these are generally purchased in that form rather than a dedicated approach to move from on-premise to cloud hosted services. What I’m interested in is a concerted effort to remove or minimise on-premise data centre footprint.

There are plenty of examples where Trusts refresh their on-premise data centre, without seeming to pause to consider other options. In my own organisation, Kettering General Hospital, a couple of years before I joined, we moved our data centre out from a basement prone to flooding into a shiny container off the car park. There will be hundreds of NHS organisations up and down the country that will have done similar things over the past 7 years without considering anything but on-premise. We desperately need to close the intention-action gap.

Why Public Cloud?

It’s almost embarrassing to even have to make the argument for Public Cloud these days, given 2013 is a long time ago and the hyperscalers have grown massively in this time. For example, platforms for others are now a third of Amazon revenue[i] and Microsoft Azure has grown from a $5.5bn business in Q2 of 2015 to $44bn in Q4 of 2019[ii]. I’m not saying it is easy, by any means. This is a multi-year endeavor, requiring a lot of planning and continual attention, but I’ll be really depressed if I’m looking back in 2027 and collectively across the NHS we’ve not made substantial progress.

Why the Cloud Makes Sense:

• Security – hyperscalers can do security much better than any Trust. They have the scale, expertise and financial incentives to apply the best cyber security practice. No Trust, no matter how good is ever going to come that near.
• Stability – Public cloud offers the ability to provide high availability, with resilience and auto repair with ease
• Scalability – You pay for what you use. Tear down and scale up to meet the needs of the business. The need to get physical tin into a data centre, which only comes out when it has died cannot compare with that level of scale. Are you really happy to be waiting 4 weeks for a server to arrive, installed in your racks and get configured?
• People – This is a biggie for me. Firstly, the availability of skills to manage bare tin will diminish rapidly over the next 10 years, so that means it will cost a lot or you’ll asking people with limited skills to do ever more complex stuff. Plus we are not going to attract the brightest Ops graduates/talent who’ve spent the last three years having never touched physical servers, to on-premise data centre management.
• Technologies – The pace of change in the Public cloud is faster than you can reasonably consume it. The pace of change in a physical data centre is the rate that you can move tin in and out. How many clinical systems does the NHS run that are on old software versions because the overhead of upgrading is just too massive? I shudder to think.
• Cost and Carbon Footprint – Building that data centre in the car park was a considerable investment. In fact the minute it was built it is a considerable liability, and what’s more we have to refresh it every 3 to 5 years just to keep up.
• From an environmental point of view, hyperscalers have much more sophisticated cooling and power arrangements that any one Trust can set up. Just think of the combined net effect of turning off all those individual air con units across the NHS estate.

The Common NHS Barriers

• Funding Models – The NHS runs on an annual capital cycle, which lends itself to physical investments. Moving to a Cloud subscription requires hard-pressed revenue. This is where NHSE/I steered by NHSX could make a massive difference here and help support this change in funding models. However, many people have made the case that the depreciation of the data centre is cost comparator that can be exploited when making the case, which is something we’re looking to use here at Kettering.
• Our Suppliers Aren’t Ready – This is a common plea, but have you considered having a conversation with them about how you can work in partnership in your pursuit of moving to the cloud? Perhaps they are waiting for the first customer to push this?
• Clinical Systems Are Different – There are examples of PAS systems that are externally hosted by some of the larger suppliers. That should tell you that it can be done. But it does rely on the next barrier…
• Our Internet Connection Isn’t Fast Enough – When was the last time you looked at your internet growth forecast? It will be growing massively year on year, so you’ll need to make plans for a resilient internet connection anyway. Once you have that, it will pave the way for your next move regarding cloud.
• We move too much data around, it will cost too much – It is true, if you don’t pay attention to your architecture, you can burn a lot of money by moving data around, but that doesn’t mean it can’t be done. You just need a different mind set, and one that is aware of the cost implications of each decision, which in my view is a better position to be in.
• We won’t have control of our costs – You have very little control of your costs in a physical data centre. You may have done a virtualisation project and improved the utilisation of the servers, but your cost base is now fixed. However, your Ops Engineers will have little or no ideas of how much any one server costs to run per month/year. In my experience with NHS.UK, if you give talented people the information about the cost of the Cloud services and ask them to get the best performance within a cost envelope, they can be incredibly innovative in finding ways to squeeze the best out of each pound.
• We’ve just invested in new physical infrastructure – The good old sunk-cost bias fallacy. That kit is not an asset, it is a growing liability. Plus if you don’t make some plans now, it will be too late to do anything by the time the next hardware refresh date comes around.

Back to Kettering and the search for Clouds on a Sunday Afternoon

As the end of life date of that data centre in the car park at Kettering Hospital starts to figure on forward-look spreadsheets and we start to plan what we need from a re-built hospital as part of the Hospital Infrastructure Programme Wave 2 (HIP2) we needed to start to plan what we were going to do.

One Sunday afternoon in August 2020 I set out to draft a Cloud-First policy for the Trust. My first instinct when doing things like this is to avoid having to think, so I turned to Google. Given that KGH is an acute provider, I looked initially for similar providers. The focus was on finding Trusts who had a cloud-first strategy in place with similar wholescale ambitions as Kettering, rather than those who are using piecemeal pieces of Software as a Service (SaaS), or things like Office 365. I was looking for examples of Trusts who were planning to or already had decommissioned whole chunks of their data centres, and if I was lucky, I hoped see some who had moved their Patient Administration System (PAS) into the cloud.

My first point of call was to look at the 32 Acute Global Digital Exemplars and Fast Followers and search for Cloud strategy or policy or even just their digital strategy. Using Google, I searched against the names of these Trusts and came up with nothing. This was frustrating, but perhaps even more alarming was the absence of a published Digital Strategy for most of these. How can that even be right when we’ve spent something like £300m[iii] on these initiatives?

So Frustrated I Nearly Missed Countryfile

Having spent so much time on that Sunday afternoon trying to search for a policy that I nearly missed Countryfile, I wrote a frustrated blog about my research[iv]. This led to some interesting comments and discussions from various people and a better indication that some Trusts are starting to do something about this. But there was still no sign of a published policy.

If You Want a Job Doing…

So, in the end, we have produced a Cloud-First policy that has been approved by our Digital Hospital Committee and is now available on our website[v]. It’s not perfect, but it is short and out there. I see this as a Statement of Intent; we don’t quite know the detail of how we’re going to get there, or even how long it will take us, but it is really clear to all our technical staff and our current and future suppliers what we intend to do, and I’m really proud that we’ve made this available and enjoyed the conversations it has prompted from a number of sources. In it we’ve declared that we will have no new services in our data centre from July 2021. A Google of “cloud first policy kettering” will get you to it.

Why Are You So Secret?

The conclusion of my few hours of research made me realise how far the NHS has to go in terms of moving with the times. I also concluded that the NHS is terrible at sharing, and that makes me sad. If the purpose of the GDE programme is to exemplify good practice and share it with the rest of the NHS then it is failing at the very basic level of Making Things Open [#9 of the NHS Service Manual Principles[vi]], let along blazed the trail for full on cloud adoption. I’d love for someone to prove me wrong, but even if this is the case, I’d argue that for £300M, the folks running the GDE Programme at the very least ought to make it mandatory for each GDE and Fast follower to have a published Digital Strategy. The next step would be for them to have a published statement, updated every 6 months on progress against the Tech Vision[vii] and finally for funding to be linked to progress into the cloud.

Back to the Intention-Action Gap

Going back to the intention-action gap I mentioned at the start, humans are also greatly affected by their surrounding in terms of decision making. For example, a recent OECD study found that consumers were more willing to purchase sustainable or organic meat products when they thought that others were also doing so[viii]. Kettering General Hospital have published a cloud-first policy. That might just be the nudge you need to publish yours.

Andy Callow is the Chief Digital Information Officer at Kettering General Hospital. He’d love to hear from public sector organisations that take issue with his grumpy views. Andy can be found on Twitter @andy_callow

References:

• [i] https://static1.squarespace.com/static/50363cf324ac8e905e7df861/t/5ed23bd3bdbbdb299cb6aa9f/1590836452410/2020+Benedict+Evans+Shoulders+of+Giants.pdf
• [ii] https://www.statista.com/chart/15910/microsofts-annualized-commercial-cloud-revenue/
• [iii] NHS Digital 2018–19 Annual Accounts and Report states “with £200 million funding announced by the Secretary of State in September 2018”. So an estimate of £300m for the programme to date would be fairly conservative
• [iv] https://andy-callow.medium.com/the-dire-state-of-cloud-first-strategies-in-nhs-trusts-in-2020-773ef98e17f3
• [v] https://www.kgh.nhs.uk/download.cfm?doc=docm93jijm4n2399.pdf&ver=4652
• [vi] https://service-manual.nhs.uk/design-system/design-principles
• [vii] https://www.gov.uk/government/publications/the-future-of-healthcare-our-vision-for-digital-data-and-technology-in-health-and-care
• [viii] K. Vringer, H. R. J. Vollebergh, D. van Soest, E. van der Heijden, and F. Dietz, “Sustainable consumption dilemmas,” no. 84, 2015.