This is not an easy time to be working in health tech. Andy Kinnear, a former NHS CIO who now works in consulting, summed up some of the contradictions that the sector is facing for the Highland Marketing advisory board.
On the one hand, he said, the government set out some big ambitions in the 10 Year Health Plan. Yet two months on, “there is no delivery plan and no funding” attached to them.
On the ground, NHS England, its regions, and local commissioning bodies are being reorganised. Trusts are being told to cut deficits by delivering multi-million saving programmes, which are leading to “loads of workforce cuts” which will “make it hard to deliver anything” even when plans come through. Morale is “on the floor.”
Lost momentum
Nicola Haywood-Cleverly, a former NHS CIO who now supports trusts as a non-executive director, felt this has “led to a loss of momentum.” Just look at this autumn’s conference agendas, she said, and it’s clear that NHS IT is treading water.
In that context, James Norman, a former NHS CIO who now works on the supplier side, was exasperated that trusts are still talking about electronic patient records. “I am astonished that people are talking about how excited they are to be putting in an EPR or reprocuring an EPR,” he said. “These systems should be bread and butter.”
Where, asked Cindy Fedell, a former NHS CIO who now works in Canada, is the IT for integrated care, or the next generation of innovation? Or, James Norman added, the data and analysis that will allow new NHS structures to get into managing demand and improving population health?
Central policy: stuck in the New Labour era?
Most areas of the NHS would recognise that there is a gap between the government’s rhetoric on reform and what is happening on the ground. But the advisory board felt there are some specific issues that are contributing to the gap where digital health should be.
Firstly, it’s far from clear that the right people are making digital policy. Health and social care secretary Wes Streeting has strengthened his department at the expense of NHS England and its offshoots. But some of his key advisors date from the New Labour era.
New Labour invested heavily in the NHS and in technology, launching the National Programme for IT, which in some respects is only just being completed. But, James Norman mused, “do they really understand the reality of today?”
The plan’s big tech ideas: where’s the plan for them?
Where there is new thinking, it seems to be coming from think-tanks, who can rely on big consultancies and suppliers for funding. Putting aside the hype about AI, there were really only two, solid, tech proposals in the 10 Year Health Plan.
The first was a single patient record, an idea heavily promoted by the Tony Blair Institute for Global Change. Yet supplier events over the summer have suggested it is still in a “definitional” phase, with no clear vision for what it will achieve or how it will be architected.
The second was a big extension of the NHS App. Nicola Haywood-Cleverly said that a single point of entry is very important to patients dealing with the current fragmentation of the NHS.
Yet, she pointed out, the App has been billed as “digital front door” for the NHS for a decade and is still both under-developed and capable of only one, rather than two-way communication with users, because the centre has flipped and flopped on whether to develop it in-house or work with third-party suppliers.
David Hancock, an interoperability expert who has worked for both EPR and shared care record suppliers, said the plan suggests the DHSC – or its contractor – are looking at national development. In which case, “what happens to the suppliers of portals and personal health records?” who can already do a lot of what is proposed.
More EPRs, more FDP
Meantime, NHS England seems to be focused on the programmes it had in hand before the plan came out. Frontline digitisation has nearly run its course, but a new frontline capabilities programme is promised.
This may be where those EPR re-procurements are coming from, but the likely beneficiaries are the big, US firms that still tend to dominate the enterprise IT market. NHS England is also talking about expanding the Federated Data Platform, another project that has, to date, mostly benefited one big US company.
To change this, David Hancock argued that what NHS digital needs is policy: a clear steer on what the government wants to do, and how it wants it to be done. Other members of the board argued it also needs standards, so old systems can interoperate with new ones and generate data for analysis and research.
However, David Hancock argued that standards won’t get traction without use cases. “Vendors have limited resources,” he said. “They need to know they are backing something the NHS will use. The NHS needs to decide what that is. Then we can build the infrastructure to do it.”
Local innovators need suppliers to engage
For the moment, work at a local level has all but ground to a halt. Or, as GP and chief clinical information officer Jason Broch put it, “there are little pockets of stuff going on,” but it’s not joined up or influencing the bigger picture.
Which is very hard on suppliers. Nicola Haywood-Cleverly predicted that many will give up on the NHS and look for easier markets elsewhere. “If they want to persist,” she argued, “the most important thing for suppliers outside the big ticket programmes” is to understand current realities.
“It’s not enough to say: ‘This is our product’,” she warned. “You have to be able to say: ‘This is how it can be delivered in this environment’.”
Where’s the pressure from the frontline?
The advisory board spent some time discussing why there isn’t more upward pressure on digital, or why trusts aren’t pushing for action from the centre on things that matter to them. The relentless focus on deficits and job cuts won’t be helping.
But Andy Kinnear argued that NHS IT leadership is also going through something of a transition, with a generation of CIOs moving on, and a new wave of less experienced CIOs and clinical leads coming into post.
On a positive note, he argued they will find their voice: just as the older generation of CIOs did when NPfIT faltered, and trusts found there was space to break away and buy their own EPRs or set up the first shared care records. It will just take time. “Nobody becomes Che Guevara overnight.”
Reasons to be cheerful
Neil Perry, another former NHS CIO, who now runs his own consultancy, pointed out that some of the “gnarly” leaders are still around.
Also, some leaders who moved into national posts are now going back to big, city trusts that can probably expect to become new-style foundation trusts or integrated health organisations in a year or so, with more freedom to pursue their own agendas.
He was also more optimistic than some of his colleagues about the policy and funding pieces falling into place. There isn’t a 10 Year Health Plan delivery plan, he agreed. But the DHSC has just issued a National Oversight Framework that tells providers what to focus on.
The current financial pain should ease if deficits can be eliminated. Chancellor Rachel Reeves did announce more funding for the NHS in last year’s Budget. As the new financial year comes into view, it should become clearer how it will be allocated.
Growing gaps
So, Neil Perry argued, good trusts “will be able to get on at pace.” The problem, as advisory board chair Jeremy Nettle noted, is that “not all trusts are good trusts” or operating in effective healthcare economies. And that’s one of the dangers of the current hiatus.
In the absence of strong central direction, or a mechanism for sharing best practice, if some trusts invest and others don’t then the gap in digital maturity, effective health service delivery, and health outcomes will grow. Which, in theory at least, is the opposite of what the government and its 10 Year Health Plan want to achieve.
