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.

Last week, NHS Digital published the clearest picture yet of how billions allocated to improve and maintain NHS digital technology have been spent (to peruse these figures in detail see the attached spreadsheet).

The picture is not quite complete. NHS England says it is missing some very important projects that, when included, happen to make the bottom line look far more favourable for the national commissioning body. But it does account for most central IT spending and gives a detailed view of which projects are received the lion’s share of funding last year and which are not.

With the new boss of NHS IT, NHSX chief executive Matthew Gould, hinting at changes in how the remaining £1.4bn or so of central tech money will be spent by April 2021, it is worth reflecting on where tech money has gone to date and where it could go in the future.

A few caveats

Accurately tracking central spending on NHS IT is difficult because central agencies have not published comprehensive figures for several years. Any picture we have is, therefore, partial.

While NHS Digital’s latest figures are accurate, they don’t cover all central IT spending and the agency has refused to say what exactly it doesn’t cover. NHS England has said £465.6m of IT spending last year alone (nearly half) isn’t covered by NHS Digital’s figures but haven’t explained how its own expanded figure has been reached. The national commissioning board says some of the extra money went on Microsoft licenses, on the local health and care record exemplars and some on running “live services”. NHS England has not explained how its figures helpfully reduce the underspend for NHS IT last year from £131m to £30m.

The last time the Department of Health and Social Care released overall digital spending figures (for 2016-17) it showed an overall £250m underspend and, since HSJ published those figures, it has released only partial numbers for subsequent years. NHS Digitals’ disclosure is the best available picture for recent years, but the future spending projections should be treated with caution, not least because NHSX is currently reviewing all NHS IT spending.

Short-changing trusts

So, what do the NHS Digital figures show?

First off, trusts have been given far less money to improve their IT systems than promised. The figures show £62.2m less than planned was spent on “provider digitisation” in 2018-19, equating to a 26 per cent shortfall. Cobbling together figures from previous disclosures show even bigger shortfalls in money provided to trusts to “digitise” in the previous two years, equating to cumulative underspend of about £260m over three years. This means trusts have received just over half the money promised to date (about £300m).

NHS trusts desperately need that other half. Outside those involved in the global digital exemplar programme, many providers have made few IT improvements since 2016. Back then, the Wachter review found about half of all hospital trusts were still reliant on paper and badly outdated IT systems. It is widely acknowledged, then and since, that money the government had allocated to digitise trusts (about £1.3bn at the time) was inadequate. Now even less is being spent.

A sharp drop in cyber security funding last year to £22.9m (down from £72.3m the year before and £34.3m below budget) adds to these concerns. Most of that shortfall would have gone to making trusts’ IT systems more secure.

NHS England has said that the money for trust IT has been merely delayed, not cut, and the difference will be made up by April 2021, if not before.

But time is running out. To hit budget, the centre will have to give trusts £695m by the end of next year. Given that it has taken three years to get less than half that sum out the door, funding delays will likely morph into real cuts in digital technology investment over the next two years. 

Pennies for patients

While digital patient services, such as health apps and personal health records, have attracted plenty of headlines, central health agencies are still spending relatively little on these areas.

Over the past three years, just £2.2m has been spent on “widening digital participation”, £7.5m on increasing uptake and assessing health apps, and £1.5m on personal health records.

Biggest areas of spending on things patients use include revamping the NHS Choices website (£33.3m) and the NHS App (£14.1m), although it appears that NHSX has already decided the app will receive little to no support in the future.

Overall, an additional £100m is expected to be spent on digital patient services of all types through till April 2021. More money is expected to be spent on developing a new NHS network over the same period.

Training a digital NHS workforce, identified by the Nuffield Trust as one of the biggest impediments to digitising the NHS last month, is another area that has received little financial attention, receiving £6.6m over the last three years. Social care in its entirety has received just £9.9m to improve its digital technology.

Where to now?

According to the NHS Digital figures, there is another £1.4bn left of central funding (as of February 2019) for digital technology through to April 2021, perhaps more if we include however much NHS England wants to tack on the end.

In reality, the money that is actually spent by the centre on digital technology this year and next is likely to be far lower. Every NHS tech fund announced in the recent past has been cut, raided, or otherwise reduced and this one has already faced delays in its first three years. However, looking at where the money is projected to go is still a good rough guide of where the centre will prioritise spending.

Despite delays and fears that NHSX might dump critical parts of the programme, the NHS Digital figures show spending on digitising trusts is still expected to account for about half of all central digital spending until April 2021 (£695.1m). Other areas where substantial funding remains include cyber security (£136.2m), the health and social care network (£147.6m) and GP clinical IT (£192.7m).

What is striking about these areas is the common focus of getting the IT basics right. While the overall figures for all these areas will change in the final tally (almost certainly shrinking), and NHSX may shake-up exactly how spending is released, all four areas are likely to remain a focus for central investment through until 2021 and probably beyond.