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The NHS and the challenge of tech driven reform

12/10/16

Analysis: Achieving a ‘paperless NHS’ is a realistic ambition, but it could still be at least a decade away

The NHS is gearing up for yet another attempt to use the power of IT to increase efficiency and offer convenience to its users. But this time, it really does know how to do it.

Nurses with tablet computerThat’s been the message of NHS IT leaders and stakeholders at two major sector get-togethers in the past five weeks. Now it depends on whether the health service can pull off a complex mixture of retraining, sharing of best practice, a wholesale move to standards - and with a lot less money for new systems than in the previous attempts to computerise the service.

The two events - the NHS’s own two-day Health and Care Expo in Manchester in early September, and an industry event named HETT (the Health Efficiency through Technology show) in London later in that month - presented a combined set of promises and agenda setting by both the Government and the health service.

Policy drivers

A pair of major policy statements from two years ago provided the background: the Department of Health’s commitment to a ‘paperless NHS by 2020’ and the NHS’s own Five Year Forward View. The former is the brainchild of Health Secretary Jeremy Hunt, and the latter of NHS chief executive Simon Stevens, and what links them is the idea that a major tech driven business process redesign could drive out lingering inefficiencies – which are crystalised in the service’s seeming inability to move away from paper as its primary method of information exchange.

Earlier this year, Hunt even put a price on what he could offer to help - £4.2bn. That’s £4.2bn more than the NHS has been offered since the end of the Labour Government’s controversial National Programme for IT (NPfIT) five years ago. But the problem was that until Manchester, no-one was very clear as to what Hunt really wanted it spent on.

The event revealed all. Hunt used the findings of a third party audit of the best way to move use of IT ahead in the NHS. The Wachter Review, led by US ‘digital health guru’ Dr Robert Wachter, a veteran of President Obama’s Meaningful Use programme of IT adoption in US hospitals, has detailed an ambitious programme of reform.

Wachter said the NHS, despite decades of use of IT and NPfIT’s lost billions, is digitally immature, that plans for a paperless NHS by 2020 are out for most institutions by at least three years, and that IT professionals are few in number and do not have any real power or status.

The event saw Hunt take on board Wachter’s advice to reset the paperless target to 2023 at the earliest, to set up ways to boost NHS internal IT competence and put aside money for new programmes.

Bottom up approach

Critically, though, this time around, that money won’t be for central package or outsourcing contracts - an approach now seen as unrealistic and too ‘top down’, given the relative failure of NPfIT’s drives to get common electronic patient records (EPRs) adopted by hospitals. Instead, NHS trusts are being encouraged to go ‘bottom up’, developing local systems that work for their own needs, but which can be opened up to partners - especially in nearby health and social care organisations - for easy sharing of data.

That’s critical, ‘Dr Bob’ said a couple of weeks later in London, because if UK hospitals develop new systems that cannot talk to others it will render a lot of the progress moot.

As he said: “One thing we need to get right from the start in the NHS is interoperability… In the US, we have fantastic levels of technology in hospitals now, but 95% of these systems can’t talk to each other. You need to ensure from the start that any systems you build can talk to not just other systems in your trust, but also when necessary to other hospitals, to GPs’ systems, and non-NHS social care organisations.”

Wachter’s warning was a big feature at the London event, where NHS IT leaders gave their response to his and Hunt’s challenge. But the keystone document for the event was that Five Year Forward View. Two years after publication it is not implemented but, in the words of its ostensible author Simon Stevens, offers the best way to “secure the future that we know is possible”, a future only possible if the NHS changes “substantially”.

What does substantial change look like if you are made up of a million employees and 20,000 organisations? And these numbers can at least double if you factor in the social care teams working in local government or the third sector.

Info routes crucial

Some ideas emerged at HETT. For Andy Williams, chief executive of NHS Digital, substantial change involves using tech to end the paper chase and offer more joined up ways of routing information to support the patient journey through the GP, the clinic, the hospital, out-patient and social services teams.

Williams cited examples such as patients with dementia having needless blood tests because clinicians have no way to accurately record them (and the patient can’t tell them they’ve already had the needle), or others having to keep returning to their doctor for routine prescription renewals, He conveyed the problem as relatively clear: “We have got to get much better as a system when it comes to using the information that we have available to us.”

He ended his speech by warning: “If we don’t do this, we won’t achieve the Five Year Forward View.” But the warnings came thick and fast from the stage, in sharp contrast to the optimism of Manchester. One was from newly appointed NHS England chief clinical information officer Keith McNeil, who declared that: “When it comes to IT in the NHS, we can no longer afford to work at the speed of government.”

So what conclusions can we draw for the immediate future of IT in the NHS? Certainly, there is willingness to try to change, and a recognition that change of some sort is inescapable. But can decades of set practice and addiction to paper based processes really be changed, even by the new target of 2023?

Uneven pace

Wachter said that “substantial” tech-driven change is five to 10 years out, won’t happen at the same pace in every part of the NHS, and even then will take a while to deliver.

“Productivity comes from the complete refiguring of the nature of work after technology is introduced – it’s never an overnight benefit,” he said. “Indeed, it can be the opposite. The tech has to be in place in the NHS first, then the redesign, and only then will the patient, and the clinician, see the improvement.”

The NHS may well change for the better, in other words - but it will take a lot of time. And most observers doubt that extra money equivalent to just 4% of its operational budget of £100 billon-plus per year will really be enough.

Meanwhile, let’s hope we don’t have too bad a winter.

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