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Growing Pains—the NHS’s Long Journey to Digital Maturity

September 2021 saw the release of a new set of digital guidelines for NHS Trusts. Published by NHSX, the NHS’s central digital unit, they are designed to help both Integrated Care Systems and individual organisations know ‘what good looks like’, (WGLL). The Digital Agenda, mentioned in many of the health service’s future planning documents, touches almost every area of NHS life. Few can doubt its importance­­­—from digitising traditional forms of communication like the outpatient letter, to remote consultations, and the harnessing of vast pools of Big Data to allow smarter and faster decision making, digital is here to stay.

The WGLL framework has 7 success measures, each defined from the perspective of how they should look at both ICS (Integrated Care System) level and organisational level. The main aims are as follows:

  • Well led: at ICS level, this means a digital and data levelling-up plan with Board accountability, regular engagement with clinical representatives, patients and front-line groups. At organisation level, this means having a CIO role, creating a Board to review digital strategy and cyber-security, and linking it all to ICS strategy.
  • Ensure smart foundations: at ICS level this involves striving for net zero carbon, meeting Sustainable ICT and Digital Services Strategy (2020 to 2025) objectives, investing in modern infrastructure, and levelling up the use of electronic care record systems. At organisational level, this involves all of the ICS goals as well as moving to cloud data hosting, removing fax and pagers, and contribute data to the ICS-wide shared care record.
  • Safe practice: ICS level requires investment in systems for robust ICS-wide cyber security, using national cyber services provided by NHS Digital, having a clear system-wide process for reviewing and responding to relevant safety recommendations and alerts. Organisations should plan to get off and stay off unsupported systems, ensure cyber-security is adequately resourced, fully use national cyber services provided by NHS Digital, and have an adequately resourced clinical safety function, with a named Clinical Safety Officer, to oversee digital development.
  • Support people: ICSs should promote digital systems and tools, create ICS-wide professional development and front-line skills development and generally ensure staff are digitally literate and innovative. Organisations must also share these goals, as well as providing access to digital support services 24 hours per day, and supporting staff to work flexibly and remotely.
  • Empower citizens: ICSs should develop a single, coherent ICS-wide strategy for citizen engagement and citizen-facing digital services, and take an ICS-wide approach to access to care plans, test results, medications, history, appointment management, screening alerts. Organisations should also ensure that services are designed with citizens at their heart, and have access to a standard set of digital services that suit all literacy needs. Citizens should be able to access and contribute actively to their healthcare information.
  • Improve care: ICSs should transform care pathways using digital and data, reduce unwarranted variation and improve health and wellbeing. They should redesign care pathways across organisational boundaries, ensure organisations use EPMA and bar coding, and collaborate on multidisciplinary care planning, using digital tools and services. Organisations also share these goals, as well as providing decision support and other tools to help clinicians follow best practice and eliminate unwarranted variation across the entire care pathway, providing remote consultations, monitoring and care services, and promoting patient choice.
  • Healthy populations: ICSs should develop an ICS-wide intelligence platform with a fully linked, longitudinal data-set (including primary, secondary, mental health, social care and community data). They should use data and analytics to redesign care pathways, and ensure that local ICS and place-based decision making forums, including PCN multi-disciplinary teams, have access to timely population health insight. Organisations should use data to inform their own care planning and support the development and adoption of innovative ICS-led, population-based, digitally-driven models of care.

 

It’s well understood that the NHS does not have a good track record of large-scale tech implementation; it was only in 2018 that then health secretary Matt Hancock banned the NHS from buying fax machines and set a deadline for them to be phased out by April 2020. Monitoring is therefore crucial. But how are we to measure our progress? What would ‘good’ look like, and would we know it if we saw it? And who will pay for it all? The challenges, unsurprisingly, are numerous. But the prize, should we achieve these ambitious goals, is enormous.

Challenge 1: we need an engaged workforce. You can have the best data and the most up to date systems in the world, but if staff are not on board, engaged, and capable of using it then there will not be significant success at scale in digital transformation.

Challenge 2: we need agreement on what to measure. Many commentators have already warned that there needs to be common agreement on how and what should be benchmarked, and the data used must be clear and trustworthy, and be meaningful at the point of care. We also need to leave room for those at a local level to cater for local needs and chart their own course, rather than trying to impose top-down, national frameworks. In other countries, such as Denmark, the most successful digital strategies have been those that come from local initiatives.

Challenge 3: our digital transformation needs a broad focus at ICS-level. As with all transformative processes, this agenda needs buy-in from ICS Boards and Trusts who drive it and take responsibility. Local IT support teams can’t make this change alone.

Challenge 4: we need to prevent digital maturity scores being used to ‘game the system’. The risk is that some organisations fabricate low scores to access more central funding than would otherwise be available. Self-scoring and benchmarking also needs to be easy, transparent, and not be too demanding on already-stretched staff and resources.

Challenge 5: we need to know who pays for what and that sufficient money is available: as well as the guidelines on ‘what good looks like’, the NHSX has also published proposals on Who Pays for What. These state that, in 2021 to 2022, national funding for transformational tech projects will be consolidated into a single fund and steps taken to support ICSs to make better investments. From 2022 to 2023, NHSX propose to start moving away from central funding of frontline tech, and ICSs will increasingly be given control over the resources with which to deliver their tech plans.

The pandemic, as horrendous and costly as it was (and continues to be), nonetheless allowed us to achieve levels of digital transformation with great purpose and speed, not something the NHS has managed in ‘normal’ times. Whether we can maintain that momentum, and take everyone with us on the journey to a fully digital NHS, is one of the great challenges of our generation.


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