The fortnightly newsletter that unpacks system leaders’ priorities for digital technology and the impact they are having on delivering health services. Contact Ben Heather in confidence here.
Finally – after delays, leaks, and much speculation, we have a long-term plan that, among many other things, has plenty to say about digital technology.
This is hardly surprising. Even before the arrival of the digitally enthused health and social care secretary, the NHS IT agenda was well into its rehabilitation post-NPfIT ignominy.
None of the plan’s content is a wild departure from NHS England digital policy developed to date, through the Five Year Forward View, the Wachter review, and, most recently, Matt Hancock’s “tech vision”.
But, taken together, it is more ambitious than the plans that preceded it, positing digital technology as a necessary component to transforming everything from maternity care and diabetes care to appointments, to bringing the whole health and social care edifice together.
Digital technology will be at the centre, or thereabouts, of most conversations about the long-term plan for years to come. Here are a few of the biggest digital talking points from the plan.
Video for all
‘NHS Skype for everyone’, or some variant thereof, was the headline for several national newspapers’ long-term plan coverage on Tuesday. The plan does indeed require the NHS to provide all patients with access to online or video consultations for GP and hospital outpatients appointments within five years.
But what is proposed goes further than showing your GP a nasty rash via smartphone. The plan states that technology that enables remote care, including but not limited to video telehealth, will be used to build a “markedly” different model of care for primary care and outpatient services from the current. This, the plan says, would be based on “tiered escalation depending on need”, with technology used to divert people not requiring care, enable self-care, and, where possible, treat patients remotely. This is a long way from how the NHS currently works and, if implemented, could fundamentally change how care is delivered to millions of patients. It could also, the thinking goes, help address some workforce shortages, by allowing specialists to provide remote care across geographies they could not physically traverse and aggregating underutilised capacity.
Before getting too carried away, it is worth first noting that, to date, there is little firm evidence that video appointments, as popular as they might be with patients, do much to ease pressure on NHS services. So despite a target of universal coverage, the case for remote digital appointments as a safe and efficient use of NHS resources remains to be made.
The NHS also has a history of getting excitable about video telehealth to little effect (David Cameron generated his own ‘NHS Skype’ headlines in 2013). According to NHS Digital figures, even in the areas ahead of the curve, video and online GP consultations account for, at most, 2 per cent of all appointments. They remain dwarfed by telephone and face-to-face. The history of NHS IT is a history of targets for universal coverage being missed, quietly forgotten and occasionally recycled. This could easily happen again.
Digital trusts by 2024
Paperless 2020 is now paperless 2024 and it’s not called being paperless but “fully digitised”. Under the plan, hospital trusts will be fully digitised by 2024. All trusts will be expected to meet a “core level” on digital standards by the same date. Global digital exemplars will remain central to this programme.
There will be “dedicated” money to “accelerate” this process, despite the new target effectively pushing back the trust digitisation project by 12 months. How much and when is not elaborated on, but with current funding committed through to 2020-21, it’s reasonable to expect at least a top-up for the final three years.
The plan does suggest a few ways for this to be done more cheaply than last time the NHS spent billions on upgrading NHS trust’s IT (see National Programme for IT). One is for more trusts to essentially piggyback on neighbouring trust’s IT systems. This is already happening in parts of London and Birmingham and will no doubt expand. Another is to move as much clinical IT onto public cloud services as possible, such as AWS and Azure, reducing trust’s IT infrastructure costs and, theoretically, reducing the pain of deploying software to new trusts.
Sharing is caring
According to the plan, the entire country will be covered in a patchwork of “local health and care records”, essentially regional patient electronic records derived from GPs and other health providers, by 2024. By 2023, summary care records and care plans will be moved to these regional records. For NHS leaders, the records will provide detailed information about millions of people in one place, informing care, planning, and research.
These regional records are not new – the first three “exemplar” sites were announced in May last year – but the plan makes it clear what a crucial building block they are for making NHS patient data useful. In this vision, the records provide a foundation for patient digital services, such as appointment alerts, as well as feeding data into “hubs” for research and development. It will allow local and national NHS leaders to track pressure points in the system, and let a mental health nurse quickly access relevant information from hospital and GP records about a patient presenting in crisis.
While some parts of the country are making good progress, building these records will face huge challenges on several fronts. To name a few: many patient records are still on paper or in siloed IT systems, data quality is poor, and navigating patient consent is perilous. But to achieve even half this task would lead to meaningful and lasting improvements.
A digital fortress
By summer 2021, the NHS will be “100 per cent” compliant with mandated cyber security standards, according to the plan. This is, to put it mildly, wildly ambitious.
The plan does not make it clear what the mandated standard will be but Cyber Essential Plus, devised by the UK national cyber security centre, is the only one previously proposed for the NHS. As of February last year, not one NHS trust has managed to reach this standard and there’s been no indication this figure has shifted substantially since.
Since the WannaCry cyber attack in May 2017, investment in cyber security has increased substantially (about £61m in central funding went to 91 trusts in 2017-18). However, bringing every trust up to the “plus” standard has been estimated at £1bn, money that is unlikely to become available any time soon and may not, according to some NHS officials, be a very good bang for the NHS’ buck. Expect continued investment in cyber security, especially in the wake of another major attack, but many trusts will likely remain vulnerable come 2021.
Saving the NHS
The long-term plan has 10 “priority areas” for doing more with less and five of them rely, at least partially, on a piece of tech.
How to improve the availability and deployment of the clinical workforce? By ensuring that, by 2021, all clinical staff will be managed using e-rostering and e-job plans. How about delivering new diagnostic imaging networks? Investment in digital technology to capture images close to a patient’s home and transmit them to a hub for a quick turnaround is the solution, according to the plan. Rolling out mobile digital devices will make primary, community and mental health services more efficient while machine learning will be used to track patient safety data, creating new insights that will reduce harm.
While new technology can, of course, transform healthcare for better in a myriad of ways, there is a whiff of magical thinking permeating the list. Bob Wachter, among others, warned in his 2016 review on NHS IT against expecting any short, or even medium, term gains in productivity from new technology. A decade is a more realistic time frame, just in time for the next long-term plan.