The government’s previous attempt to modernise the NHS was dubbed by MPs as “one of the worst and most expensive contracting fiascos in the history of the public sector”.
For those unaware, the £13 billion (or there about) National Programme for IT was intended to reform the way that the NHS uses information, but ultimately ended up being a complete failure - with the government having to pay out billions to companies for doing, basically, next to nothing.
And so, as you can imagine, the government and the NHS are overly cautious to make the same mistake again. Currently the digitisation of the NHS is incredibly fragmented, and there have been numerous commitments to speed up progress. The latest being an ambition to make the NHS paperless at point of care by 2020 - which has been allocated £4.2 billion, but has already been dubbed as “likely to fail”.
As such, the challenges facing NHS Digital - the organisation charged with improving information and technology across the NHS - are significant. Speaking at a Westminster eForum this week in London, Director of Digital Transformation, Beverly Bryant, gave us some further insight into the organisation’s future plans for how it sees technology being used across the NHS going forward.
First and foremost, Bryant wanted to make clear that the approach that the National Programme for IT took - whereby a standardised system was set to be implemented across the entire health estate - would not be the approach going forward. Bryant said:
Our vision is to make health and care better by harnessing the power the power of technology. What we really mean there is to partner with the local authorities and the NHS to help them transform care. We’ve been too national, too ivory tower in the past, and now our role is to step out from the centre and help the NHS, help local users, clinicians, to actually do this for themselves.
The Wachter Review in September 2016 effectively said that we need more clinical involvement. It’s alright having it all driven by the new models of care, but if you do not have clinicians at the heart of the decision making, once again we will be imposing new technologies on the health and care system without really bringing the users with us. He also said it will take longer. There is such variation in the level of digitisation across the service, that it will be longer than 2020 before it is able to be delivered.
Bryant said that NHS Digital is in a “very privileged position” and that it has to build the trust of the public in a way that it can deal with their data. Data management is a sore point for NHS at this point in time, after the failure of the ambitious Care.data programme -which intended to use patient data for vital health research, but faced a backlash because the NHS wasn’t clear with patients about its ambitions, ultimately leading to distrust.
We’ve been given responsibility to deliver Paperless 2020 - £4.2 billion that was secured through the spend review, having persuaded Parliament that actually we can do IT in the NHS. It’s time to pull ourselves out of the 1990s.
We have to be agile, we have to be customer focused, we have to respond to the needs of the users. And we need to lead innovation. The trick for us striking that balance. Keeping the trust as the safe haven, but not allowing that to bog us down. The way that we deal with that is to never dilute on safety and trust.
Bryant explained that central to NHS Digital’s plans is to improve patient engagement, empowering people to manage their own care and to look after themselves. Ultimately, it is hoped that this will relieve pressures on the NHS.
Some of the things that have been considered thus far are implementing WiFi across the NHS estate, in an attempt to reduce the isolation of people whilst in care. There is also work happening around creating a single, secure digital identity - to unify the experience online for patients.
Central to all of this is upgrading the current NHS Choices website, which provides citizens with an abundance of health information and is a central resource for many people with questions about their health. The Digital team is looking to upgrade the site to make it more personal, more proactive and a tool to help people better manage their health. It is being rebranded as NHS.UK. Bryant explained:
We are going to have personalised information and guidance. At the moment it’s flat, it’s a flat knowledge base website. Very good, very popular. But we want to be able to personalise it. To give people the option to create an account, send them reminders that they have to re-order their repeat prescription, give them access to tools to manage their prescriptions. And create a framework to assess and recommend wearables and apps that patients might want to download and use as part of managing their own condition.
By giving people more control and an improved understanding of what could work for them through the knowledge and the tools, we think people will be able to make more informed lifestyle choices. If we can’t persuade people to better understand and manage their own healthcare, then we will not be able to respond to the challenges that we are now facing of an ageing population, increased expectations and more and more long-term conditions. What does that mean in practice?
We need to make our NHS.UK information more accessible, regardless of the digital skills or health experience. This has been a major strength of NHS Trust. But we’ve got to make that information clearer. Some of the ways that modern websites and apps work today, it’s much clearer and much more accessible. We need to make it relevant, that means useful on a first visit. Most people hit NHS Trust through Google search, get into what they need, then leave again. But if we can use more personal type cookies and history to provide content to people, then it’s likely to be more relevant to visitors and they’re likely to come back and get information. And if they’re registered, it’s likely to become even more personalised.
Bryant is also aware that NHS Digital can’t leave anybody behind - with six million citizens in England not online and with 12 million with low literacy, she said that this is an important consideration. Bryant wants to ensure that the NHS offers skills to the hard to reach people, so that they can build their capabilities around digital.
She added that all of the plans for NHS.UK are based on a consent model, where the individual opts in and decides that they would like to interact with the digital tools. Bryant said that there is “no question” about citizens having anything done to them, or for them, without their explicit consent.
However, personalisation is the key. Bryant said:
Once we make it relevant, once we’ve persuaded them to register, that’s when we can make it personal. So that they get a single aggregated view of their health. Last time they came, what was the information they asked for? A record of the appointments they’ve got, a history, a reminder - don’t forget to take your prescription, appointment reminders, referral management etc. The information presented to them is really relevant to them.
This all feels quite bold for the NHS at the moment, which is still struggling to join the records across primary and secondary care. Where the information about you, you often have to repeat again and again and again, as you go from one part of the system to the next. We are actually ten years behind other industries.
Potential of the Internet-of-Things
With the explosion in wearables, home sensors and data driven applications, the Internet-of-Things
potentially provides a real opportunity for the NHS to further help people manage their health. This is an opportunity that NHS Digital is actively considering.
Bryant said that whilst the NHS is still “catching up” when it comes to technology, this doesn’t mean that it can’t start looking at new technologies for the future.
I’ve been looking at and studying the Internet-of-Things. This has a huge potential for patients, for front line staff and for the system. We could reduce hospital stays, where people are only staying in for supervision. We could reduce drug events, which improve safety. And again, drug compliance is a huge way in which we could use the Internet-of-Things to help optimise our processes for drug adherence.
But I do think that the greatest benefit here could be in patient self management. The governance around liability for the data and the decisions based on the Internet-of-Things, if we start to prescribe some of these apps and wearables, is very, very complicated. So, why can’t we have a discussion around the future potential technology? But at the same time making sure that we are doing this in a safe way, with consent, so that individuals and clinicians know what they’re getting into.
The fact is though, if people are generating information and they’re interacting with their own health data, the fact is that they’re more likely to be involved in managing their own health. So this should be encouraged. And in the young population, it is absolutely silly for us to ignore it and carry on trying to do what we did in the 1990s. We owe it to them to embrace this and face it, so that we can actually get it right.
However, NHS Digital is also all too aware of overloading GPs and clinicians with additional information, when they’re struggling to manage the current demand for services with limited resources. Bryant suggested that whilst the Internet-of-Things should be encouraged, it needs to be managed carefully. She said:
My view is that the GPs will not have the capacity to deal with the uncoordinated upload of information from patient generated health data. It would be wrong for us to say to patients, here, have an app, have a FitBit, monitor your condition and load it all up to your GP. We absolutely cannot do that. There is sensor data, device data, sensors, wearable data - so we need to make sure that we don’t overload our clinicians. Our GPs are already under pressure.
But what I do think we could do is have patients pulling their medical information down and mixing that with the available literature about how conditions could be managed, to help them control and manage. So that it changes the relationship between the GP and patient. We must make the behaviour change of the individual - and that’s the hard bit.
We absolutely do not need another disaster like the National Programme for IT. That could ruin the reputation of technology in the NHS for good.
The challenge is that - and this is why the NPfIT failed - is that the NHS is an incredibly diverse organisation with a wide variety of local needs. This is going to be a long-game for NHS Digital. It will be centred around getting clinicians and local organisations to drive the change they need, and getting them to think differently about technology use.
At present, GP systems in particularly, are dominated by a select few vendors and buyers are used to doing things a certain way. Encouraging a culture of innovation is going to be challenging, particularly when those that need to drive it are under so much pressure already.
However, NHS Digital is making the right noises - focusing on where it can make a difference. This is going to be an interesting one to watch.