The technology landscape of the UK health care system, the National Health Service (NHS), has had a long shadow cast over it for many years now in the form of the National Program for IT (NPfIT), a £13.7 billion (or thereabouts) vanity project set in motion in the space of an hour by former Prime Minister Tony Blair.
It was during Blair’s Cool Britannia phase - trust me non-UK readers, you really had to be there! - when hanging around with the pop stars du jour and desperately trendy actors was accompanied by a nagging ache to be seen on the bleeding edge of modernity in tech terms.
This was an ambition somewhat undermined by his own stated inability to send his own emails, but hey, a quick chat with Bill Gates and he was ready to embark on a grandiose national push to digitise patient records in the NHS.
No, it really was that simple. Or should I say, simplistic?
But that was the easy part. What followed was over a decade’s worth of incompetent project management, a scandalous waste of tax-payers money, threats of legal action from suppliers to the program and ultimately very little in place when the wretched thing was officially canned shortly after the current Conservative/Liberal Democrat government came to power.
Since then we’ve been waiting to find out what happens next.
While it’s difficult sometimes to communicate to foreign, particularly US, readers just what a political Holy Cow the NHS is, it’s best just to say that any politician foolish enough to tinker with it too much faces electoral oblivion. As such, no politician is ever likely to repeat Blair’s monumental arrogance by setting in motion another NPfIT.
That’s why it’s no surprise that as the government today publishes its long-awaited Personalised health and care 2020 strategy, the first thing that’s of note is how quickly it gets in a pretty significant disclaimer :
This is not a strategy in the conventional sense. It is not a national plan, but a framework for action that will support frontline staff, patients and citizens to take better advantage of the digital opportunity…The proposals in this framework are not comprehensive but they represent the core and immediate priorities for delivery of modern digital health and care services.
In other words, this isn’t another National Program, honest, even if it does look suspiciously like one on first reading!
It’s also one that’s predicated on one big idea: go digital or else!
According to Tim Kelsey, National Information Director Chair at the National Information Board, which was set up by the government to establish the strategic (oops!) priorities for data and technology in health and care:
The urgency of this is increasingly evident: the health and care system faces unprecedented financial constraint at a time of rising demand for its services. Technology can help people use care services less by supporting healthier lives; and it can transform the cost of services when they are needed. It is key to helping our NHS meet the efficiency, as well as quality, challenges it faces.
How that’s going to happen is via a series of high-level proposals, including:
- Citizens to have full access to their care records and access to an expanding set of NHS.
- Accredited health and care apps and digital information services.
- Care professionals and carers to have access to all the data, information and knowledge they need in the form of real-time digital information on a person’s health and care by 2020 for all NHS-funded services, and comprehensive data on the outcomes and value of services to support improvement and sustainability.
- Data transparency in the form of publishing comparative information on all publicly funded health and care services, including the results of treatment and what patients and carers say.
- Ensuring citizens are confident about sharing their data to improve care and health outcomes.
- Making England a leading digital health economy in the world and develop new resources to support research and maximise the benefits of new medicines and treatments.
- Ensuring that all members of the health, care and social care workforce have the knowledge and skills to embrace the opportunities of information technology.
OK, that’s the high-level pitch, but as ever the devil’s going to be in the detail - of which there's actually more than might be expected at this stage.
Drawing from private sector best practice in industries such as travel and banking, the NIB outlines four processes that it says “appear” to underpin wide-scale change driven by technology and data:
- The use of new, non-traditional, smaller suppliers, often working outside structured, planned initiatives, but not losing sight of large traditional suppliers as a source of scalable, resilient developments and for driving dissemination and diffusion at pace.
- Professional behaviour tends to change more slowly than consumer behaviour, challenging the approach taken by existing suppliers, placing a priority on training and retraining. Information is not enough by itself.
- There has to be personalised transactions, leading to consumer control and self-management of end-to-end tasks that deliver tangible benefits and value for individuals.
- The skilling and empowerment of the service user are the result of a skill transfer process, which moves skills from the highly-skilled to the less-skilled and ultimately to the consumer.
The NIB makes a clam that it can already point to growing demand for digital services from the NHS, such as digital information channel NHS Choices, and that there is evidence that better use of data and technology improves patient outcomes and the value of services.
Work from past investments - the NIB can’t quite bring itself to reference NPfIT directly - has resulted in the creation of some useful infrastructure and digital first steps.
But despite not mentioning NPfIT by name, there is a recognition of its damaging legacy:
At times, the health and care system has tried highly centralised national procurements and implementations. When they have failed, due to a lack of local engagement and lack of sensitivity to local circumstances, we have veered to the opposite extreme of ‘letting a thousand flowers bloom’. The result has been systems that don’t talk to each other, and a failure to harness comprehensively the overall benefits that come from interoperable systems.
What’s going to be different this time is a lot of standardization:
We will be tight on standards and definitions, and clear on expectations regarding interoperability, but we will support local decision-making on systems, programmes, interfaces and applications. Some of the key systems needed will remain national responsibilities, such as the sustainable platform – the ‘electronic glue’ – enabling different parts of the health service to work together, and to capitalise on the wider gains of doing so. We will support local health and care communities, respecting their local needs and priorities and acknowledging their relative digital maturity, to decide upon and procure their own solutions, provided they meet nationally specified technical and professional standards.
All of this is all good and well, if a bit ‘we’re going to be having every kind of everything’. We’ll be national, but local; you’ll use standards, but you can do your own thing as well etc etc. Where it starts to get more interesting is in some of the more detailed digital commitments:
- For data and technology to have a major impact on the care system, users should expect access to digital services, and for providers this will be their default delivery channel.
- We will offer citizens a single point of access, through NHS Choices, to common digital transactions, like booking appointments.
- In addition, we will improve easy multi- channel access to NHS-accredited information about health and conditions, comparable information about local services, and access to digital services and apps.
- The national infrastructure that is accessed through NHS Choices will adopt the Government Digital Services identity assurance service (IDA) for citizen access to digital health services, in order to ensure alignment with pan-government services.
- In 2015, all citizens will have online access to their GP records and will be able to view copies of that data through apps and digital platforms of their choice…This framework prioritises comprehensive access – with the ability for individuals to add to their own records – by 2018.
To its credit, the NIB faces up to the stark reality of the digital divide, which in the case of the NHS may well particularly impact key vulnerable groups:
The goal is to make safe accountable ‘digital’ access to care services the norm, where it is appropriate and the service user’s preferred option.We need to ensure that the digital opportunity is inclusive. We currently lack high-quality evidence for how best to support certain key communities with information and services…There will continue to be some citizens who are not able to use or access digital services. We will ensure that we address their needs by developing an accessing digital services programme.
There will clearly be close alignment to existing UK public sector digital work from the likes of the Government Digital Service (GDS), including tapping into existing programs like the G-Cloud:
We will take advantage of the ever-decreasing cost of technology through increased use of commodity technologies and simple, flexible procurement routes, such as G-Cloud and the Digital Services Framework.
Our ambition is to create ‘health-as-a-platform’, using technology to break down silos, join up services and reduce duplication. We will adhere to the government technology code of practice and make use of cloud technology where appropriate.
And the ultimate goal:
By 2020, all care records will be digital real-time and interoperable.
And as importantly for a health care system that sees its running costs escalating as the population ages and expands, 2020’s also the date by which the NIB reckons that digitization will deliver £22 billion worth of efficiencies.
It’s a bold strategy - and that is what it is, never mind all the faffing around! - and one that still begs an awful lot of questions. Most notably, while it’s happy to claim that £22 billion of efficiencies are achievable, it’s not yet revealed how much all of this is going to cost in upfront costs. We’ll be told that in April apparently, one month before the UK electorate goes to the ballot box to choose its next government.
There does seem to have been a welcome recognition that this time around there isn’t the need to have a top-down, centralised approach to a big ticket national program. But equally the document is vague on the extent of private sector engagement in the delivery of its ambitions. something that remains controversial in the UK.
Finally there is a welcome recognition that there’s a major trust issue here, firstly around privacy concerns, but also around the terrible track record of government IT programs in general. The likes of the GDS are helping to make that better, but the NHS is particularly vulnerable here given that the NPfIT remains the single biggest IT disaster in UK public sector history. (Until Universal Credit of course, but that’s a whole other kettle of stinking fish!)
The strategy document is now open to comment and discussion and specific implementation details will hopefully be shaped by a genuinely collaborative approach to decision and policy-making. NPfIT floundered in the 1990s/Noughties at least in part on runaway egos and ‘the centre knows best’ diktats. That’s one mistake at least that can be avoided in our more socially-collaborative world today.