The COVID-19 pandemic has placed huge pressures on the NHS and has forced clinicians to quickly adapt to new ways of working, through the use of digital technologies. The health service's digital unit - NHSX - has been working with Trusts and NHS England to figure out how the momentum that has been established during the pandemic can continue into the future, whilst building trust with the public.
NHSX CEO, Matthew Gould, was speaking at London Tech Week this week, where he shared the lessons learned thus far during the pandemic and pointed to some of the work the organization will be pursuing going forward. It's worth reminding readers that the NHS has historically struggled to coalesce around a digital agenda, given the highly fragmented nature of the organization and the requirement for catering to local needs.
In other words, one size does not fit all when it comes to the NHS.
Gould's ‘fireside chat' was wide-ranging and touched on a number of aligning factors that need to be considered, including cultural change, funding incentives, guidance from the center, as well as adopting complementary digital and in-real-life approaches. However, his opening statement highlighted just how rapidly digital change is occurring. Gould said:
I think we have crammed probably a decade's worth of digital transformation into the last 18 months. And although, in lots of respects, the last 18 months have been completely ghastly in all sorts of ways, this is one of the big silver linings.
So, at scale, we've seen several things happen. We've seen the interactions between clinicians and their patients move, not completely, but to a very large degree at times during the pandemic, online and become remote. And we've been able to see the impact of that and learn lessons about what works and doesn't work.
We've seen a lot of people in the health service, as in any other sector, work remotely themselves. And these two things have had, I think, quite a serious impact together on attitudes. Things that were thought to be impossible actually turned out to be deeply possible.
However, it's the third point that's particularly noteworthy - the NHS's use of data during COVID-19. As we've seen in other areas of public services, particularly local government, organizations have woken up to the impact that effective use of data - and data sharing - can have on delivery of services. Gould added:
At an individual patient level, we made it really much, much easier for patient data to safely move around between clinicians. As often happened during the pandemic, people were seeing patients they hadn't seen before, and could see the sort of key elements of their record, in a way which was really important for patient safety.
Data also flowed for research. So the fact that vaccines were developed at such an incredible pace, the fact that we were able to find out the efficacy of Dexamethasone, was down to the role that data played. The ability to access that data safely and appropriately, but access it to develop various therapies - data for research took a massive boost.
The way the crisis was managed relied on the aggregation of data across the system. One of the very first things my team did with our NHS England colleagues, was to set up the NHS Data Store, which meant that we could see very swiftly, where there were pressure points in the system, where there was a shortage of oxygen, or ventilator beds, and then the same basis was really important during the vaccine rollout.
Gould said that the experience of the pandemic had shifted the NHS's understanding of data use and its impact from ‘theoretical' to ‘impressive use' and showing what the future might look like.
One of the big wins for change using digital during the pandemic has been the willingness of NHS organizations to adopt remote monitoring tools. Gould said that the NHS has been driven by an overriding objective to look after the country during COVID-19, which has "turbocharged" the adoption of such technologies. He added:
If you have somebody with a long term condition, hypertension, or cardiovascular, or whatever it is, you can either have a model where they go in and see their consultant once every six months and have their blood pressure taken and their vitals checked and all the rest of it, which is the old model, or you can give them a device which is digitally connected into their health record and their consultant, which measures blood pressure, or whatever it is, on a continuous basis.
It means they don't have to keep slipping into formal care settings, but it also means that the insight that the clinician gets into the patient is dramatically better.
Gould said the arguments for using remote monitoring are "enormous" and NHSX has since set up a procurement framework that can be used by Trusts across the country to buy remote monitoring technology "confidently", without having to spend months doing the procurement themselves. Gould said:
We set up almost 100 virtual COVID-19 wards. We pushed out a large number of blood pressure monitors for people with hypertension, and it was the start of a really big push that we're doing on remote monitoring technology. It would have happened had it not been for the pandemic, but it definitely gave the programme an enormous shove.
Finding the sweet spot
However, despite the change seen over the past 18 months or so, Gould admits that the "pendulum always swings back a bit". However, the NHS now has an opportunity to find the "sweet spot" for balancing remote/digital care and in-person support. Gould uses the example of GP visits, where he noted that remote consultations should remain or those it is beneficial, whilst also managing in-person visits for those that need them.
However, there is a recognition that the old model of delivery for everything can't be sustained going forward. Gould said:
I think one of the things that's happened over the last couple of years has been a realization from the very top of the health service that we can't continue exactly as we were, with the same model of care being delivered in the same way. We have to, if we want to provide the same level of care, let alone a better level of care, start doing things differently. I think that realisation has really landed and I was really heartened, for example, that the first line of the job description for the new chief executive of NHS England talked about digital transformation.
Gould pointed to the recent guidance that has been issued by NHSX on ‘what good looks like' and ‘who pays for what' as examples of how the center can continue to build on the practices that have been adopted in recent months. He said:
I think for the first time they set out really clearly for health care, for leaders, what they need to be doing in their organizations and their systems. And they'll know that they'll be assessed against that. And secondly, real clarity about what they are expected to pay for out of their own budgets and what they can look to the center to pay for - because that lack of clarity became I think became quite a serious disincentive to proper investment in digital innovation.
I think one of the things, again, that's happened over the last couple of years has been a realization that it's not enough just to say you want to do these things. [It's not enough] to say ‘yes, digital's very important, inclusion is very important'. You actually have to align incentives to make it happen. And we've not always been brilliant at that.
I think we've had a situation for too long, where the aspiration is in one direction, but the incentives are in another [direction]. And I think by integrating the the need for digital transformation, the need for a really clear approach on health inequalities, to be absolutely intertwined with the key planning guidance and the direction that comes out of NHS England, to the system, and the standards and the incentives, and the payment structures - we're starting I think to make some progress.
Bringing people along with you
As was seen with the recently scrapped GP data scrape that was attempted by the NHS, communicating with the public and giving them control over their health (using digital tools) is crucial in driving through necessary change. Gould believes that in order to ensure the public comes along on the journey and is supportive, it's critical to link the problem of health inequality to digital change. Gould said:
I think particularly on the question of inequalities, it's really important, because this whole project will only work if we bring the professionals and the public with us. And I think if we don't have a decent answer for what this is going to do to health inequality, I think it's a sure way to lose public and professional support and trust.
And I think that the key message is that if this is done well, digital can actually be a force for addressing inequality, as it can reach people, provide services to people in different ways, address issues in different ways, and sometimes be more effective than the traditional ways of doing things.
I think making sure that every digital programme is designed with a knowledge of how it will affect different communities, and different parts of the population, and making sure the patient voices heard, making sure that the data sets that we curate and use to develop or verify algorithms, or whatever it is, are representative datasets, and then creating a platform on which innovation can happen, that will allow people to address particular needs.
Finally, Gould is also all too aware that a lot of the challenges facing the NHS going forward have more to do with people change than they do with the adoption of technology. That's front of mind for NHSX over the coming months and years. He said:
I think the main lesson I've learned in this job has been that it's very rarely the technology that's been the issue. Sometimes it is. But actually, for an organization of this size, it's much more about the people, the culture and the systems. But then, because technology is really interesting for people like us and because technologists like doing technology, we say that, and then we tend to devote most of our time to the technology, to the systems, and not to the people side of things.
And I think that constant attention to what messages the leadership give to the wider team around technology, what structures we create, what incentives we create, how you make it easy in a distributed system for frontline leaders to do the right thing, rather than actually make it quite difficult for them to do the right thing. All of those are really key things I think I've learned the last couple of years.