Doing technology well involves negotiating multiple hurdles, from sceptical boards to lack of national direction, heard HSJ’s latest roundtable panel. Ingrid Torjesen reports on the event
Technology can play a key role in improving the quality and cost effectiveness of NHS services, but unlocking that potential is easier said than done.
On the eve of the HSJ Provider Summit, held in Northamptonshire in July, senior leaders from a number of trusts met to share their experiences at a roundtable debate run in association with NHS Digital.
Success, they agreed, depends on having the right strategy, commitment and most importantly bold investment and a brave chief executive and board.
Just how big the savings opportunities are was outlined by Tom Denwood, director of provider support and integration at NHS Digital (formerly the Health & Social Care information Centre – HSCIC).
Tom Denwood, director of provider support and integration, NHS Digital (formerly the Health & Social Care Information Centre)
Crispin Dowler, bureau chief, HSJ
Cindy Fedell, director of informatics and IT, Bradford Teaching Hospitals Foundation Trust
Mark Hindle, executive director of operations, Mersey Care Trust
Dr Cathy Kelly, chief clinical information officer, University College London Hospitals Foundation Trust
Kieron Murphy, director of operations, Staffordshire and Stoke on Trent Partnership Trust
Roger Spencer, chief executive, The Christie Foundation Trust
When NHS Digital and Monitor looked at the utilisation of health technology across England in non-specialist acute providers, “we found that without any investment in new tech, just adopting and optimising what we’ve already got, we think there’s a £350m net opportunity.”
Mr Denwood gave some examples of successful adoption that could easily be copied by other trusts. Oxford University Hospitals Foundation Trust, for example, changed the way blood products are managed, so they are not ordered until needed at the bedside.
Royal United Hospitals Bath Foundation Trust has seen an 80 per cent reduction in pressure ulcers since nurses started using clinical decision support software
“They’ve seen a 15 per cent reduction in the need for blood products as an organisation, and that’s given them a half million pound annual saving,” he said. Meanwhile, Royal United Hospitals Bath Foundation Trust has seen an 80 per cent reduction in pressure ulcers since nurses started using clinical decision support software.
Mr Denwood said that while trusts should not expect to find a silver bullet that will achieve 20 per cent efficiency savings, small aggregate gains, each representing 1 to 3 per cent, are achievable and quickly build up. Panel members shared some examples of successful technology deployments from their own organisations.
Mersey Care Foundation Trust – which provides mental health and learning disability care and plans to bring in an £8m surplus this year – uses datasets and coding to record all activity. It then uses that information to size the caseloads of every clinician, to assess what is needed for service delivery, to allocate patients and to encourage timely discharge, said Mark Hindle, the organisation’s executive director of operations.
“When you look at the rest of the NHS, which is struggling everywhere, that is incredible use of technology [and] information about patients,” he said. “The [national cost improvement programme] target was reduced at the end of the last financial year. Mersey Care kept theirs internally at four per cent. I think that’s very impressive, particularly with a capital investment strategy of over £200m.”
Establishing a culture
Kieron Murphy, director of operations at Staffordshire and Stoke on Trent Partnership Trust, emphasised that simply investing in technology is not enough. There also needs to be a culture in which people are willing and able to use it and feel confident in doing so.
There has not necessarily been the most successful strategic approach to technology from an overall NHS point of view
The trust has rolled out laptops to community-based staff, with technology allowing them to have face-to-face meetings remotely. He reported that over the last couple of years that has become culturally accepted, reducing time travelled and associated costs, and freeing up more time for direct care. Ultimately, the trust would like clinicians or care workers to be able to use the technology with service users.
The trust also has a system called e-community, which is able to schedule staff appointments with clients throughout the day according to need and geography.
“That’s been a bridge too far at the moment,” Mr Murphy said. The function hasn’t been switched on because the feedback from staff has been that they prefer to trust their professional judgement.
The e-community system is the enabler for the trust’s reshaping workforce programme, which is looking at skills and how they are deployed to ensure they are used appropriately, and is expected to save £4m.
The deployment of technology at The Christie Foundation Trust always centres on achieving very specific improved outcomes for patients, so is normally clinically led, said Roger Spencer, the organisation’s chief executive.
The trust has deployed advanced technology in medicines optimisation and delivery. As well as having advanced electronic prescribing and robotic dispensing, captured data has enabled efficiencies to be made in the deployment of therapy.
A set of radiotherapy satellite centres now delivers radiotherapy closer to patients, saving patients a combined total of half a million miles in travel. This has been made possible by technology that can plan patients’ radiotherapy and send information digitally between centres in a safe and reliable way.
An electronic patient record system has enabled some sites to go paperless, and use of robotic surgery is cutting patient length of stay. For prostate surgery, average stay is about 1.6 days compared with the usual 7.5.
Mr Spencer argued the real difficulty is that there has not necessarily been the most successful strategic approach to technology from an overall NHS point of view.
Paying for itself
This year, Bradford Teaching Hospitals Foundation Trust is also rolling out an EPR system. When Cindy Fedell – the trust’s executive director of informatics and IT – joined three years ago, she found lots of small projects trying to achieve big ambitions.
We really need the clinical team to be the lead of this and get the IT to support the endeavour as opposed to the other way around
“We have made a concerted effort to do something a bit more strategic, so what we have invested in is infrastructure,” she said. “This year we are rolling out the electronic patient record. We’re doing everything at once and the whole reason is because I think if you do it piecemeal, people won’t do it.”
Ms Fedell admitted people are nervous, but asserts that this kind of infrastructure investment is the only way to achieve the change needed. “I did sell the business case to the board on the basis that it is going to pay for itself,” she said.
Savings will come from improved patient safety (such as via prescribing alerts), more efficient use of investigations and tests and fewer bed days, but standardisation of care is expected to have the biggest impact, she explained.
“If we all do it exactly the same way, according to best practice, it should in theory be the right length of stay – not two or three days longer.”
If Staffordshire and Stoke can’t get its nurses to follow scheduling instructions from their computer, will Bradford’s clinicians really be willing to follow instructions guiding patient care, asked HSJ’s Crispin Dowler, who chaired this roundtable debate.
Ms Fedell replied: “So far they’ve agreed to care pathways or protocols, so it’s about monitoring usage.” If a pathway has not been used it would then be taken back as a clinical governance issue, rather than compliance to an IT system, she explained.
Mr Spencer pointed out that most problems that had occurred with technology deployment at his trust had occurred when the initiative had been led by IT. “We really need the clinical team to be the lead of this and get the IT to support the endeavour as opposed to the other way around. If you don’t do it that way around, you will struggle in a big way,” he said.
Ms Fedell said clinicians were very keen, she suspected because there was currently limited technology available to them. “We came to the conclusion we have to do this at some point. We’ve invested now, people are keen, if we stop now they’ll lose interest,” she said.
Another organisation with an EPR project is University College London Hospitals (UCLH) Foundation Trust, which began a procurement last year. Cathy Kelly is the trust’s chief clinical information officer and has responsibility for delivering the digital roadmap for north central London.
It’s not just about what the organisation needs, it’s more about the broader landscape as part of the digital roadmap
She emphasised the importance of taking a strategic view and making the most of the data generated, something she said UCLH has not been good at in the past.
“It’s not just about what the organisation needs, it’s more about the broader landscape as part of the digital roadmap. We’re looking across 22 organisations, including four specialist providers,” she said, so this means working moving towards shared IT services to make savings.
However, three clinical commissioning groups are planning to buy something separately. “As a provider you are trying to share lots of data with them and it is not efficient at all,” she said.
Mr Spencer again stressed the importance of clinical leadership in such situations. Greater Manchester is in the process of procuring a picture archiving and communication system (PACS) for the area because it was thought having everyone using the same system would be more efficient, he said.
“I would argue that the reason that can go well and is going well and that everybody is involved and signed up is because the whole idea of delivering that part of the service started off as clinically led.”
Already an advanced integrated patient record across primary, secondary care and social care in Salford is enabling some fantastic real world studies to be conducted, he added.
“It got there because somebody produced this clinical need for this integrated pathway, as opposed to starting off by saying wouldn’t it be great if Salford PCT and Salford trust had an IT system that was integrated.”
While having a single integrated IT system will mean that care will be more efficient because patients can move around 37 organisations much more easily, he said, “if we start off with that being the end in itself, it will really struggle”.
Historically, big, radical, centrally driven pushes to move everyone over to a new system, such as the national programme for IT, have not been that successful, Mr Dowler pointed out.
Mr Denwood said: “National bodies have learned the lessons – we’ve actually gone back and looked forensically at that particular programme and why it didn’t achieve its promise.”
How do you ensure that change is responsive to clinical need without ending up with sub-optimal pieces of technology that do not link up
He said as a result the emphasis is now on standardisation but no longer with centrally held contracts. It is about encouraging providers to be much more efficient and that should be led locally and supported nationally, so “it’s an adaptive change project, not an IT programme.
Clinically led is one of the best ways of ensuring adaptive change. That’s the only way we can drive those types of change nationally – locally led, and framed as adaptive change.” He added: “We’ve worked with organisations to do their baselines, we supported the creation of local digital roadmaps linked to sustainability and transformation plans, and future central investment will be linked to those roadmaps.”
Mr Dowler said there seemed to be a pretty unified view that change programmes worked better when they developed out of an acknowledged clinical need, but asked about the challenges of clinical autonomy. How do you ensure that change is responsive to clinical need without ending up with sub-optimal pieces of technology that do not link up, he asked.
Dr Kelly said: “It can’t be purely clinically driven in the same way as it can’t be purely IT driven; its development has to be a co-production.”
Clinicians are good at articulating need and they are good at defining the solution they think they want, but that solution might not necessarily be what they need, she explained.
She said good collaboration between clinical leadership teams and IT departments was the most effective driver for change, which meant digital needed to be “recognised at an executive level as having some ability to drive and lead change”.
She added: “At board level there needs to be a dramatic shift in how they see digital technology,” and suggested having non-executive directors with a background in the digital technology industry helps.
Ms Fedell, who is one of the few executive heads of IT, said being an executive certainly helps, because it means she can articulate to the board what needs to be done and the value it can bring, and ultimately get things done faster.
Mr Murphy agreed a collaborative approach was best. When Staffordshire and Stoke on Trent Partnership Trust put in place a new service line management system it was driven by IT and that “was a big turnoff for clinicians and teams”, he said.
“They didn’t engage with that process, so we took a decision strategically at board level that I would take responsibility for it, not because I knew the technical stuff, but because I would be able to bring to the table the views of what teams wanted to see in front of them.”
This “One View” system has just launched and shows exactly the types of information that users, clinical team leaders, said they wanted. This was achieved by collaboration, he said. “I don’t think we would have got there if we had done an either or.”
The difficulty in securing investment for technology was flagged as a massive problem area, and several panellists highlighted banking as a service industry from which the NHS could learn a lot.
Banks do not baulk at investing in infrastructure such as cash machines and internet banking as an enabler for strategic direction without evidence of return on investment
Banks do not baulk at investing in infrastructure such as cash machines and internet banking as an enabler for strategic direction without evidence of return on investment, Mr Hindle pointed out. “If you went to most boards and said we want to invest two or three million in mobile technology, laptops, iPads, whatever for our community staff, they’d said well show me the return on investment. I think that is a major barrier for organisations.”
Providing evidence of ROI is difficult, he said, because while some of the change is cash-releasing within an organisation, a lot of it is not and instead delivers efficiencies elsewhere in a system. Mr Hindle agreed. He said banks will take a long term view of investment and consider it a business risk.
“The NHS is still on one year planning cycles largely and is risk averse,” he added. In a situation where we can’t deliver financial targets, a decision in an NHS organisation to invest, particularly revenue, “is a brave decision”.
Something else that could be borrowed from the banking world, Mr Murphy suggested, was investing money in supporting clients to use new technology. Banks are investing time and money in helping people understand how to use internet banking, he explained, so they are less reliant on branches.
The analogy for health is social isolation in communities of older people, he pointed out. “That drives admissions because they have not got a network of support. Where are we in that kind of engagement in our community, helping older people learn how to Skype each other?”
Mr Dowler asked whether there was any value in having national levers to encourage uptake of technology initiatives.
Dr Kelly said it wasn’t a question of lack of levers. “People are desperate to do things,” she said. “The challenge is the huge investment. How do you justify £60m or £70m of capital investment when return on investment is going to be in five to 10 years? It’s not going to be their first priority.”
When Mr Dowler suggested national targets might make it more of a priority, Dr Kelly replied: “But you need the money to do it, because you have to make more and more savings.”
How do you justify £60m or £70m of capital investment when return on investment is going to be in five to 10 years?
Ms Fedell said the financial climate meant that much of the investment that did take place was “reactionary”. “We are just all running around trying to do everything and we just end up spending more money in the long run because we haven’t made long term investment choices,” she said.
Mr Spencer acknowledged that something was only likely to become a priority after a “top-down suggestion” that it should be done. “That is not because nobody believes in it, it’s just because of the circumstances that we’re in at the moment; it’s got to take its place.” Mr Denwood added: “It takes a very brave chief executive to start a programme that will lead to high short term risk, but medium to long-term success.”
Mr Murphy agreed, pointing out that many chief executives won’t be in post for that long in any case. Sooner or later the centre has to behave like the centre used to and actually say: “Sort this out in your STP process. If that’s a system then don’t try to do it as 30 different organisations, because that’s doomed to failure.”
Mr Hindle agreed, saying: “If investment in infrastructure had the same profile as the A&E four hour target, and it had had it for the last 20 years, the NHS would be in a dramatically different state from now.”
He added: “I would probably advocate having some centrally driven targets around how much money we invest in what infrastructure. I can’t see what else is going to drive this systematically across the NHS. If we don’t do it, I fear for the NHS because I don’t think we can deliver efficiencies.”
- Acute care
- BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST
- Mersey Care NHS Foundation Trust
- NHS Digital (HSCIC)
- Oxford University Hospitals NHS Foundation Trust
- Patient safety
- Primary care
- ROYAL UNITED HOSPITAL BATH NHS FOUNDATION TRUST
- SALFORD PCT
- Social care
- Staffordshire and Stoke-on-Trent Partnership NHS Trust
- Sustainability and transformation plans (STPs)
- Technology and innovation
- The Christie NHS Foundation Trust
- UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST