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.

When HSJ asked NHS England’s deputy chief executive Matthew Swindells about a rumoured new tech unit called “NHSX” in January, he replied that it may or may not happen.

Less than four months later, NHSX is happening. Last week, the unit’s incoming boss, Matthew Gould, assumed the considerable powers over the NHS IT strategy previously held by Mr Swindells. Mr Swindells will leave NHS England in July for a new digital consultancy job (initially with Accenture).

Mr Swindells’ departure will further empower Mr Gould and, by extension, his former and future boss, Matt Hancock. Mr Gould technically doesn’t start for a few months yet, but he has already met with top NHS digital folks within NHS England (or now NHSX) – people whom, until recently, reported to Mr Swindells.

More than anyone, Mr Swindells has influenced the shape and tone of NHS’ digital strategy since he arrived three years ago. As he departs, it’s worth reflecting on what parts of his legacy may endure, and what parts may not.

Mr Swindells has been the driving force behind the (latest) strategy to digitise NHS trusts and it may be this programme which is at greatest risk in his absence.

Based on Bob Wachter’s 2016 review of NHS IT, NHS England’s “global digital exemplar” programme relied on an enhance and spread approach. The original plan was for a handful of digitally advanced(ish) trusts, using a smaller handful of electronic patient record systems, to become even more digitally advanced with central financial support.

These trusts would develop a rigid set of “digital blueprints” that other trusts could use to deploy the same IT systems in roughly the same way. This, in Mr Swindells’ vision, would lead to a fully-digitised NHS dominated by “half a dozen” road-tested EPRs suppliers. At one stage, Mr Swindells said GDE trusts could become digital consultancies to the rest of the service and compete to sell deployment support to less digitally advanced trusts.

That vision has been heavily diluted already and faces a shaky future. GDE trusts and the first wave of “fast followers” have received central money and some are doing impressive digital things.

But the spread bit has faltered. The rigid blueprints Mr Swindells had in mind have been replaced by a vaguer blueprint “library”. Rather than how-to guides for deploying a Cerner or Epic EPR, the blueprints published to date cover narrower tasks like barcoding breast milk or digital engagement with clinicians.

Although no doubt useful, they are not the cookie-cutter plans to spread digitisation that Mr Swindells had in mind. The only GDE trust talking about selling their IT solutions is University Hospitals Birmingham Foundation Trust (in China), and NHS England said GDE trusts are no longer being pushed to sell their blueprints.

The NHS long-term plan commitment that all trusts will reach some vague “core” digital level by 2024 leaves plenty of wiggle room. NHS England has not even invited trusts to bid to become part of the next wave of GDEs, which Mr Hancock announced more than eight months ago. Mr Gould and NHSX may well wind down the GDE programme and shift focus elsewhere.

Open shut, big small

The GDE programme under Mr Swindells also leaned heavily towards large incumbent IT suppliers getting a bigger slice of the expanding NHS IT market (if they could prove their worth). Many of these suppliers are US-based companies and many use proprietary code.

During Mr Swindell’s time in charge, NHS England’s enthusiasm for systems developed in-house by NHS trusts and open source software, previously championed by Beverly Bryant, waned in favour of trying to extract improvements from existing dominant suppliers (with mixed success).

Mr Hancock, on the other hand, frequently criticises the big incumbent NHS IT suppliers. The first group of IT suppliers he met as health and social care secretary were mostly small, young and “disruptive”. He has said he wants to end big/long IT contracts and the NHS should build and run more IT itself rather than buy it from “some big American provider”. Last month, NHSX declared it was an “open source” organisation.

Talk is cheap and a built-in dependency on big IT systems means radical change won’t happen any time soon. But these bigger suppliers are less likely to receive a friendly reception from Mr Gould than his predecessor.

Raising standards

When Mr Swindells gave a speech about NHS IT, the tone was often that of a teacher scolding an errant pupil. He has likened NHS IT to a 1950s bank, called the most digitally advanced trusts “mediocre” compared to their global peers, and named and shamed trusts for failing on “bog-standard IT”.

Reception to Mr Swindells’ direct approach has been mixed. But the message that the NHS needs to raise the floor on IT has been adopted wholeheartedly by Mr Hancock (often in the form of banning obsolete tech). 

Among the many powers collected from other central NHS bodies, NHSX will have sign-off on all major NHS IT projects, all of which will be required to meet some basic standards about security, usability, and interoperability.

Mr Swindells and NHS England’s chief clinical information officer Simon Eccles (now part of NHSX) have been banging on about basic standards for NHS IT since Mr Hancock was still happily killing-off the Leveson inquiry as culture secretary. Mr Swindells can take some credit for this renewed focus and the (albeit modest) improvements to date, notably around cyber security.

NHS know-how

Mr Swindells’ career is steeped in the NHS and health tech, including a stint as a hospital trust chief executive, chief information officer at DH, and stretches in the private sector (most notably with clinical software supplier Cerner). While he has plenty of critics within the NHS, he has detailed knowledge of how the service functions and how it buys IT. That operational knowledge will not easily be replaced.

Mr Gould has extensive experience in public sector tech but no NHS experience. Plenty of people within NHSX will help fill this gap but none have quite Mr Swindells’ experience and skill set.

Mr Swindells’ close working relationship with NHS England chief executive Simon Stevens, who outsourced digital matters to his deputy, will also not easily be replaced. Some may say this is not a bad thing, but it does widen the distance between operational and digital nerve centres. That creates its own risks.