A panel of experts discussed how the NHS needs to get the digital infrastructure right before running advanced software projects
Digital transformation in healthcare is often equated with flashy, large-scale software projects, such as electronic patient records, patient portals, or daily use of artificial intelligence.
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But those only run effectively if the right digital infrastructure is in place. However, this is an area that tends to receive significantly less focus.
There often seems to be a chasm between the emphasis on and excitement around technology that promises to revolutionise ways of working, and the infrastructure and hardware which the NHS has available to run these shiny projects.
An HSJ roundtable, run in association with BT, brought together those working in the NHS, big tech, academics, and thought leaders to look at how the NHS’s digital infrastructure needs to evolve to properly support transformation. The panel addressed some of the current challenges with the way in which the NHS tends to store applications and data, and what changes – such as cloud or other technologies – could make a difference.
Panel
- Tom Allen, head of NHS national bodies – UK healthcare, Amazon Web Services
- Scott Andrew, healthcare and life sciences industry director, Dell
- Tim Cropley, chief information officer, Hampshire Hospitals Foundation Trust
- Corrina Hulkes, chief nursing information officer, London North West University Healthcare Trust
- Dipak Kalra, president, The European Institute for Innovation Through Health Data and professor of health informatics, University College London
- Sultan Mahmud, director of healthcare, BT
- Pritesh Mistry, fellow – digital technologies, The King’s Fund
- Sarah Newcombe, chief nursing information officer, Great Ormond Street Hospital for Children Foundation Trust
- Mick Quinn, healthcare informatician and consultant physician, Queen’s University Belfast and principal clinical consultant, BT
- Claire Read, contributor, HSJ (roundtable chair)
Why is digital infrastructure neglected in the NHS?
Panellists discussed the current challenges with NHS digital infrastructure and how they impact individual organisations
There was strong agreement among panellists that many healthcare organisations are failing to get the digital infrastructure basics right. And while there was consensus around the idea that advanced software systems hold promise for moving the NHS into the future, participants emphasised that without a solid foundation of digital infrastructure, trusts will continue to struggle to even deliver yesterday’s model of care.
Sultan Mahmud, director of healthcare at BT, shared a comment from a consultant in the East Midlands who explained that he had to go outside to make a phone call because of a poor connection: “We’re investing hundreds of millions in really funky stuff, which is great,” relayed Professor Mahmud, “but you wouldn’t put a Japanese bullet train on suboptimal tracks”.
Attendees agreed on a broad definition of digital infrastructure. “It’s not just about the devices and connectivity, but there’s also something about ease of use, reliability, and [being] fit for purpose,” clarified Pritesh Mistry, fellow – digital technologies, The King’s Fund.
And there was frustration around the table that not being up to scratch in all those areas of digital infrastructure – connectivity, devices, and ease of use – is currently holding the NHS back from delivering care to its maximum potential. “I hear all the time Wi-Fi is a problem and then I go to an investment committee and we can’t get investment for the Wi-Fi despite the fact that it is the number one thing,” said Tim Cropley, chief information officer, Hampshire Hospitals Foundation Trust.
Great Ormond Street Hospital for Children Foundation Trust has had an electronic patient record for five years, said Sarah Newcombe, its chief nursing information officer, and “I can count on one hand the amount of times we lost the system, all through infrastructure. Never through the clinical system”.
Corrina Hulkes, chief nursing information officer, London North West University Healthcare Trust, agreed that often the digital infrastructure is insufficient to support the software. “That leads to frustrations from the clinical staff if the computers are too slow and they take too long to load,” she said.
“A lot of the time people do get focussed too much on introducing the whizzy things,” she added. “We do really need to think about getting the basics right first before we then start thinking about AI and machine learning. Because I think people get carried away, and they try to run before they can walk. We need to make it as easy as possible for people to do the right thing, and they need the right kit for the right circumstance.”
Ease of use was a key theme among panellists, who emphasised that it sometimes feels like a “nice to have” rather than an essential piece of the infrastructure jigsaw. “The way you get people to enter data into systems is to make it really, really easy for them to do it,” said Mr Cropley. “What you don’t want to be doing is somebody scribbling on a piece of paper and then having a ‘data entry process’ at the end of their working day, because that does not suit nurses or doctors or other clinicians. And, fundamentally, making it a preferable way of doing it so that people want to be putting the data in in real time.”
“The ease of use of the technology has got to benefit the teams,” noted Scott Andrew, healthcare and life sciences industry director, Dell. “So even if it’s easy, if it’s not [going to] benefit you in the future, it’s not something you’re going to use.”
Mr Andrew’s point resonated with participants, who were enthusiastic about the benefits of getting digital infrastructure right and being clear about why it matters.
“For me, the biggest point is how do we get that on everyone’s agenda, that infrastructure is going to be key to us moving forward for our patients,” said Ms Newcombe.
Mr Mistry reinforced Ms Newcombe’s point of view by highlighting the implications of poor digital infrastructure. “We talk a lot about the potential of cutting edge technology to reduce inefficiencies [and] improve productivity, but we ignore the [basic issues such as] doctors waiting 10-15 minutes to log in. That is a waste of public funds and time [and] impacts people’s care, experience of care, and outcomes.”
Mick Quinn, healthcare informatician and consultant physician, Queen’s University Belfast and principal clinical consultant at BT, highlighted that a digital NHS should be supporting patients on their healthcare journey. “We have to figure out how to get the infrastructure to follow that journey. That will require us to think in a totally different way. We’re still essentially doing Victorian outpatients.”
He added: “We need to start thinking of what we’re trying to do, which is trying to evolve an ecosystem that moves the data related to patient care to the right place at the right time and has all these other auxiliary benefits around research and how we do things better.”
Establishing better digital infrastructure foundations could support the NHS to deliver better care
There were lively discussions around new models of advancing digital infrastructure, while acknowledging some of the potential challenges.
Ms Newcombe liked the idea of being able to rent kit and future proof, because currently organisations install an EPR, “put all [the] kit in, and then a few years down the line, it’s all out of date, not working, [and] the batteries have gone”.
There were also discussions about software as a service (SaaS, in which a vendor provides software online in the cloud rather than as a program that can be installed on a machine). Tom Allen, head of NHS national bodies – UK healthcare, Amazon Web Services, suggested one benefit of such a model is that it shifts many of the infrastructure responsibilities to vendors, so NHS bodies don’t need to “worry about [whether] the machines [are] good enough to run it”.
While Mr Cropley is a fan of SaaS – “look at something like Office 365; it’s revolutionised how we run the organisation” – he warned that staff will call him, not the vendor, when there is an outage. “We need to have some strong guidance around not just what we’re expected to do as internal IT departments but also reflecting that to the vendor market.”
Participants were keen to be forward-looking, but pointed to the splintered understanding in the NHS about the way in which infrastructure can evolve – not least the possible applications of cloud technologies.
“From an academic perspective, people don’t realise that they can capitalise [cloud] in a certain way,” said Dr Quinn. “Some of the research we do is about how you turn off legacy systems by moving them to cloud.”
Professor Mahmud argued that the benefits of cloud for the NHS are not yet fully appreciated. “Cloud has huge implications for all of us. Think about our lives outside of the NHS – quite a lot of it is empowered by cloud. So, it has great application in the NHS and I’m a big proponent.”
There was consensus that the purpose of getting digital infrastructure right is to move forward with healthcare delivery, rather than be content with standing still. Dipak Kalra, president of The European Institute for Innovation Through Health Data and professor of health informatics, University College London, said: “The challenge is [that] the investments that are needed to transform the way we handle and share information, which is really what it’s all about, [don’t] deliver enough if all we try and deliver is yesterday’s model of care. Where do we want to be tomorrow?”
“How do we move forward and look at tomorrow, next week if we’ve not got the infrastructure right?” asked Ms Newcombe. “When we think about things like virtual wards, we still need command centres, we still need to be able to have places for people to report into. How do you move towards [that] care if we [don’t] have infrastructure around us to enable that to happen?”
There was consensus around the table that there is no definition and quantification of the NHS’s digital infrastructure problem
Mr Mistry noted the dearth of published research and evidence on the state of digital infrastructure within the NHS. “That’s very important to acknowledge because it’s a huge black hole in our understanding of how big the challenge is and the implications of that,” he said.
He pointed to some headline statistics that are known. “Approximately 8 per cent of GP time is spent on IT issues, 15 per cent of GPs say their Wi-Fi is inadequate, 30 per cent of GPs say that their computers are inadequate, and one-fifth of doctors say that their computers are insufficient for the work that they need to do.” On top of that, there is anecdotal information around how unreliable the technology can be – how it crashes, and how community-based staff such as district nurses have to juggle between laptops that don’t last all day.
Professor Mahmud agreed that these were fundamental issues and that acknowledging the scale of the issues with NHS infrastructure was central to addressing them. “Having sat on NHS boards for 15 years, the dearth of information that came up around infrastructure is shocking,” he said. “We talked about EPRs, and we talked about the new chat bot, what AI system we’re going to implement, what funky diagnostics we’re going to put in, but the infrastructure was not mentioned.”
That lack of prioritisation is reflected in the funding allocation, with Mr Mistry highlighting that the financial services sector spends approximately 25–50 per cent of their tech budgets on the technology itself, with the remaining 50–75 per cent allocated to the underlying infrastructure, training, skills, education, leadership, processes, and workflow – “all the other things that sit around it. And yet, as we’ve heard from people around the table, [the NHS often has to] cut back on your investment until you’re [only] paying for the software”.
There was also a shared sentiment that when things go wrong with large-scale digital projects in the NHS, it’s often less reported than the successes – which makes it hard for there to be collective learning. “Often people are very quick to tell their story when everything went right, but don’t share that information when things didn’t go quite right,” said Ms Hulkes. “How do we enable that shared learning to be able to solve common problems? Because often we’re all working in silos, yet there’s a similar organisation down the road that’s actually managed to solve the problem that we’re facing. I think we need to look wider [and] communicate better with each other.”
Participants were passionate about the central role of staff and not making assumptions about capabilities. “The key word of today is infrastructure,” said Professor Kalra. “I would argue that it is not logical or sound to think about an ICT infrastructure without thinking about the people infrastructure, an organisational infrastructure, a buildings infrastructure, [and] an information infrastructure which is different from ICT infrastructure.”
Mr Cropley highlighted his experience: “It’s really dangerous to think that young people know how to use IT. Because I’ve come across young people [who say] ‘I don’t know how to use a mouse’. They know how to use a tablet, they know how to use a phone, they do not use computers.”
He also pointed out that it’s not about training staff to use devices, but rather how to do their job in a digital world. “If you change the training from saying ‘how do I use a piece of technology’ to ‘how do I do this in a digitally enabled world’ that’s a very different place,” he said.
It’s not just the amount of money that matters, the funding model is also crucial
There was a strong sense among panellists that boards do not give infrastructure the priority it deserves, but also that digital advocates need to articulate why it’s important.
“I don’t think just saying ‘I want more Wi-Fi’ is enough,” said Professor Kalra. “We have to say what are the harms to care delivery today, what are the avoidable costs to continuity of care and safety of care that the lack of Wi-Fi is generating. We are probably spending more money on care with avoidable costs than we would improving the Wi-Fi. But where are the economic arguments, where are we proving that what we need now is to change the game even more radically?”
This comment was met with widespread agreement from the industry members, NHS representatives, and thought leaders around the table. Mr Andrew said: “How do you raise the profile of the outcomes you’re going to achieve from these services you’re going to provide [with better infrastructure]? What [are] the business benefits from the clinical perspective and the outcomes you’re looking to achieve?”
“The main point for me is that investment in infrastructure is rarely considered by the NHS,” said Ms Newcombe. “People just think [about putting] in the exciting stuff – we want an EPR, let’s put one in.”
“There’s a conversation to be had with our boards to get people to change their opinion of infrastructure to see it not just as a cost to be avoided, but to see it as an investment,” said Mr Cropley, adding that it is crucial to get “the right funding, down to ICB level” so that “we can take local decisions around those local priorities and what’s right for our patients and clinicians in our geographical area”.
Professor Kalra agreed. “Unless we value health information and unless we value the connectivity between the actors who need to be joined up, we will never regard ICT as a value investment. At the moment it’s a cost.”
Another challenge is that traditional funding structures for digitisation in healthcare don’t necessarily suit the way in which such projects have evolved, or the reality of need on the ground.
Ms Hulkes said: “From the centre, a lot of money is being made available to purchase software. I’ve worked in organisations that have been building up their business case to obtain the funding, and you start off with something that includes hardware requirements and you end up with something that just includes software because you’re told you’ve got to cut back.”
Mr Allen noted that “the NHS often has more capital available for investment of buying things and assets”. But SaaS “tends to be more of a subscription so it comes out of a revenue operations budget because you’re not owning the asset you’re subscribing to”.
Mr Cropley agreed that traditionally in the NHS, IT has largely been funded from a capital pot but “if the IT industry is moving to a revenue subscription based model for everything, we need to change the funding. So it’s not just about the amount of funding, it’s also about how that funding is made available”.
Sultan Mahmud explains the possible benefits of adopting cloud solutions in the NHS.
According to the NHS England Cloud Centre of Excellence, nearly 75 per cent of NHS trusts host the majority of their apps on legacy on-premises infrastructure – an ageing technology that simply isn’t fit to deliver fully-digitised patient care. To rethink patient care, and bring care delivery infrastructure into the 21st century, cloud solutions must be at the heart of digital transformation efforts, embracing the Cloud First policy endorsed by the NHS CCOE.
At BT, we’ve seen first-hand the benefits of cloud infrastructure with our Health Cloud solution, working alongside the NHS to deliver a secure, purpose-built platform that enables collaboration and data sharing across integrated systems. We know one size doesn’t fit all in the NHS, so promoting hybrid cloud solutions where possible, tailored to the unique needs of each trust, is an advantage to infrastructure. This flexibility allows NHS workloads and data to be hosted wherever is most appropriate, be it private or public cloud services, to ensure the best digital care delivery.
Implementing cloud services will mean the health service can move one step closer towards retiring its ageing legacy technology, bringing in a cost-effective infrastructure that is flexible and scalable enough to perform at peak times, and avoiding upfront investments in buying and maintaining additional hardware. New cloud-first infrastructure will help remove the burden placed on IT managers, freeing up valuable time and resource that can be directed towards improving patient outcomes. All this can be done securely and sustainably too, moving healthcare data from on-site servers to energy-efficient datacentres, protected by robust security and compliance protocols.
Professor Sultan Mahmud is director of healthcare, BT
