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.

With the health secretary announcing the next big thing in health tech every other week, you might assume the funding has followed the rhetoric.

But despite Matt Hancock’s digital excitability, there has been no meaningful boost in NHS IT funding since his appointment last year.

Mr Hancock’s tech funding announcements have all been drawn from the five-year £1.3bn settlement agreed between his predecessor Jeremy Hunt and the Treasury back in 2016 or other legacy tech pots.

The gap between the government’s NHS tech commitments and the money to pay for them is widening. Many of the NHS long-term plan’s ambitions rely on a new piece of tech but, for the next two years at least, NHS England has made it clear that extra tech funding is unlikely.

The money may come later but, in the meantime, something will have to give.

Murky money

Central NHS tech spending is difficult to track but, based on recent history, a good rule of thumb is that less money flows into the real NHS economy than promised.

The past three NHS tech funds have all been cut. Last year, HSJ revealed that in the first year of Mr Hunt’s tech fund (then the “paperless 2020” fund now the “digital transformation” fund) £256m less was spent than budgeted. The Department of Health and Social Care said the money instead went to “offset pressures in other parts of the system”.

DHSC has refused to disclose any overall figures for the digital transformation programme in the two years since. Cobbling together fragments of public information, we can say spending on cybersecurity, shared electronic care records, electronic prescribing and GP online consultations have almost certainly risen. But it is less clear where spending has fallen and what projects have been quietly shelved.

Less money (for some)

There are, however, some clear areas of stress.

NHS Digital is nominally responsible for delivering digital transformation nationally, but over the next two years its income will drop by nearly a fifth. As part of the “belt-tightening”, the agency expects to reduce its headcount by 500 (a sixth of total workforce) by the end of the year.

Some might applaud a little quango trimming but there’s no evidence the cuts equate to a commensurate increase in tech funding for frontline NHS services. Apart from a few targeted funds – for electronic prescribing or cybersecurity – central funding on “provider digitisation” has been less than budgeted for at least two of the past three years (spending for 2018-19 is yet to be disclosed).

While some NHS trusts, particularly those of the global digital exemplar programme, have seen a bump in cash from the centre, others are struggling to secure central approval for any major investment in new IT, partly because the money is not there.

Silly money

And then there’s the long-term plan.

A £13bn-never-going-to-happen investment in NHS IT was posited early in the planning process. But even paring that figure back to a more reasonable sum, the long-term plan is teeming with tech solutions for everything from pathology to staff rostering and outpatient appointments. The money left in Mr Hunt’s tech fund (estimates vary) can’t cover existing commitments, let alone new bells and whistles.

NHS Digital’s experience again proves instructive. The organisation spent the latter half of 2018 “re-baselining” which national digital projects it could afford, and which ones would have to be shelved or scaled back for now. Projects “reassessed” include some data collection and digitising urgent care.

In February this year, NHS Digital started the process all over again to accommodate the new long-term plan commitments.

Some tech spending to support the long-term plan may pop up in other places, such as money set aside for cancer or stroke services, rather than a dedicated IT pot.

Broadly, moving away from treating IT projects as discrete from the services they support is a good thing. But in a stressed system, if money isn’t ring-fenced for technology, it is often spent on other, more immediate, priorities.

“It’s not about the money”

There is also a view that the problem with NHS IT is the culture and structure rather than the money.

In January, NHS England deputy chief executive Mathew Swindells told HSJ the problem wasn’t “how fast we can get money out the door”, but how fast services can be transformed. For all his enthusiasm, Mr Hancock’s focus has been more of tech oversight than growing the funding pot (think NHSX, mandatory IT standards, banning faxes). Even his support for Babylon’s GP at Hand is financially cost neutral for the NHS overall (although not for its constituent parts).

NHS trust CCIOs and CIOs have told HSJ that Mr Hancock’s tech enthusiasm has already helped shift the culture for the better, particularly in getting boards to pay more attention to IT. And having a digitally literate board, the right IT standards, and healthy competition among IT suppliers are all necessary conditions for digital transformation in the NHS. But they are not sufficient.

Building new IT kit inescapably costs money, more than is currently available. One review found that bringing the NHS up to “the minimum bar” on cybersecurity would cost £1bn. The NHS has committed less than £200m to cybersecurity since WannaCry. In 2016, Bob Wachter estimated to digitise all NHS acute trusts (putting aside the rest of the service), would cost more than £3bn. That is more than twice the amount committed in Hunt’s tech fund for digitising all providers through till 2020-21.

More money may yet arrive, but until it does the NHS tech revolution is on a slow burn.