In many ways, the National Health Service (NHS) is a victim of its own success. Founded almost seventy years ago, many of the diseases that would have killed us then have been cured, and as a result our population has a higher proportion of older people than ever before. The healthcare needs of this growing population, combined with modern lifestyle factors and coupled with growing public expectations of what a health service should provide have resulted in the financial crisis the service faces today.
At the same time, the NHS is going through a period of fundamental technology-enabled change in the way patient care is delivered. As a result, funding – always a hot topic in the NHS – is now more constrained than ever. A five-year funding allocation was made available by the government in 2016 for Information Technology. About half of this money was earmarked for existing programmes or renewals, such as N3, NHS Mail and GP systems, and the other half was available for new programmes in the Personalised Health and Care 2020 strategy. However, a number of unplanned factors such as the urgent response to cyber security have made calls on this money, and the allocation is also subject to the same reductions related to productivity assumptions as all other parts of the public sector.
In our work with various Trusts we have observed that these government “digital” funds can come with some difficult strings attached. In a number of cases the funds are only made available for new business cases, e.g. a paperless prescription system. The funds cannot be used to replace underlying infrastructure nor provide resources for ongoing support, but are permitted to be used purely for the purchase and implementation of the new system. As a result, a number of NHS innovations are being built on archaic foundations with new system functionality limited by the old, often crumbling infrastructure below it.
Connecting the old to the new can also be unexpectedly difficult for some. Integrating a patchwork of currently disparate clinical systems is essential for NHS to fully adopt digital. A complicating factor is that local NHS IT departments often do not control or maintain all the technology needs within the Trust, making the management of change very difficult. Local NHS IT departments sometimes face challenges from clinical departments wedded to their stand-alone systems and often paper-heavy workflows. Whether legacy COTS black boxes or award winning in-house developments, these technology islands pose an obstacle to digitally connecting the NHS. They are also often ferociously defended by people (often high-ranking clinicians) who are used to working with them, have little appetite for change and see re-training as wasting time that could otherwise be spent caring for patients.
Against this complex and challenging backdrop, IT organisations are asked to deliver core digital platforms that enable significant enhancements to patient care. In our experience, those NHS Trusts most successful at advancing their digital agenda are taking a holistic view of their IT function. Rather than undertaking discrete initiatives they are taking a broad, comprehensive view of how best to meet the needs of all core clinical functions. Streamlining day-to-day IT operations to release the scarce resources (both people and financial) required to build the digital future is essential.
A number of the NHS Trusts we work with have outsourced their IT functions. Typically this is a decision taken many years ago, and primarily one taken for reasons of cost savings. To their credit, most service providers work hard to deliver value to the Trusts. However, all service providers come with one fatal flaw: a congenital inability to recommend any service or solution they cannot provide. There are, we believe, a lot of good reasons for Trusts that outsource their IT to review their current sourcing arrangements. We know this because our recent studies at a number of Trusts identified significant savings opportunities within existing sourcing contracts. Equally, those Trusts that kept their IT in-house don’t always employ the most efficient methods to manage their resources, and often lag behind best-in-class techniques. What was a good price a few years ago is not necessarily a good price today. The difference between what you are paying and what you should be paying can be a very useful contribution to the digital transformation budget.
Pure budget issues aside, many IT organisations are approaching digital through a dual IT strategy. In the commercial world this dual approach focuses simultaneously on efficiency and stability for traditional services and on innovation and speed for the new digital opportunities. Within the NHS we see less of a focus on speed and (understandably) more of a focus on quality and getting it right first time. This dual approach – sometimes labelled “bi-modal” – is increasingly being implemented as an organisational structure within the IT departments of commercial enterprises, though we have not seen this yet within any of the NHS Trusts that we work with. This is perhaps not surprising as there is some degree of overlapping and resultant overhead in bi-modal structures and most Trusts are rightly keen on keeping organisational overheads to an absolute minimum. Notwithstanding this, some Trusts are finding effective ways of managing the current while also enabling the future.
The key is to address three very specific needs while not over engineering the organisational structure. These needs are:
Deliver patient care systems: This is clearly a basic requirement and is essentially the IT functions that support key clinical services day-to-day. Here the management focus is typically on availability and reliability (both of which have a significant impact on patient care) and also cost efficiency.
Help the Trust improve its performance: Those IT elements and applications that enable the Trust to improve its productivity and also improve the quality of the service it delivers. Here the management focus is one of balancing the benefits of the outcomes with the resources needed.
Deliver innovation: For most Trusts today, this is where digital fits in. How does the digital strategy translate into innovative patient care solutions and how does the IT organisation within the Trust best enable this? Here the management focus needs to be on skills; the right people doing the right things. Innovation cannot be at the expense of impacting current services, and a carefully crafted vision that takes the best from “bi-modal” without the expensive overheads is the way forward for many in the healthcare sector.
Four Pillars of Digital NHS
As ever, there is no magic trick to solving a complex task. We have identified four key areas – our “Four Pillars” – that we believe are essential areas of focus for all IT functions within Healthcare:
Funding is, it goes without saying, a key enabler. You can’t invest if you don’t have the money and without appropriate funding there is little hope of achieving a coherent and functioning digital future. Maximising the value of current spend is a must, and this may also result in a useful addition to existing budgets.
Organisation is the foundation for governance within any Trust. With the onset of digital, change will not be a transitory phase but rather a continual state. Effective change is always preceded by effective planning. The most effective IT organisations are those that are flexible and designed to adapt. IT managers who recognise changes earliest and build strategies and organisational structures to meet them will be the most successful.
People can be the Achilles heel of an organisation. Without the right skills there can be significant delays in projects, or at the more extreme end of the scale there can be failed projects. For many, a lack of skills is a limiting factor, every bit as serious as a lack of funding. For many Trusts, the ability to attract and retain the right skills is a critical success factor.
Technology has the capability to deliver integrated patient care solutions that can truly transform the quality of healthcare for many people across our nation, while at the same time delivering significant productivity and efficiency gains. Indeed, without these innovative solutions it is difficult to imagine how the NHS will cope with the ever growing demand for its services. Getting the right technology implemented in the right way is far from easy.
Let me leave you with what I believe are the key questions every NHS Executive should be asking in relation to the digital journey and the “Four Pillars”:
Pillar 1: Funding
Q1: Have we optimised the delivery of our IT services and is the funding level appropriate?
Q2: Are we maximising the value of our existing sourcing contracts?
Q3: Does IT deliver Value for Money, now and in the future
Pillar 2: Organisation
Q1: Are our operational processes effective and lean
Q2: Is the structure appropriate and does it allow us to exploit new technology innovations?
Q3: Should we deliver IT internally or work with partners? Which areas should be retained?
Pillar 3: People
Q1: Do we have the right people with the right skills and are they deployed in an optimum way?
Q2: What should be the size and skill mix of the retained team?
Q3: What skills will we need in the future and how will we retain them and their knowledge?
Pillar 4: Technology
Q1: Are we exploiting new technologies and are we making the best use of what digital has to offer?
Q2: What is the best way to move towards an E-Hospital?
Q3: How do I develop a business case to fund future technology enabled healthcare initiatives?