NHS England is the independent body, established in the autumn of 2012, to play a key role in delivering the vision of modernising our health service. The primary goal is to secure the best possible healthcare outcomes for patients, by prioritising them in every decision it makes.
The NHS England Business Plan for 2017-2019 sets out the aims as well as the detail of how commissioners can be guided and supported in achieving the best patient outcomes from their valuable resources. The plan lays down an operating model, with clear aims, ways of working and measurement.
The plan does not state explicitly the underlying information technology (IT) dependencies or the criticality of raising the bar on IT services delivery, within the limited funding, to support the achievement of the goals set out.
This paper is aimed at highlighting the crucial link, between the business plan and effective, cost efficient IT services. The analysis and comment is distilled from the experience of studies at several NHS Trusts and organisations.
An appreciation of the goals, the operating model and the measurements proposed by NHS England, suggests a clear and direct linkage between efficient and effective IT services to the achievement and management of outcomes. We consider a few elements of the plan here.
Executives are under pressure to ensure that the clinical departments are in the best position to make informed decisions for patient care.
There are at least three areas in the plan where IT can play a critical role in its success.
To enable informed decisions, easy access to comprehensive and relevant data is crucial. However, that data needs to be easily and securely accessible, and presented in a manner to be of use to make the best informed decisions. Although it could be argued that manual approaches and partial automation are workable alternatives the value to decision making in delivering patient care, using integrated and effective IT systems, cannot be overstated.
Frequently standard reports do not meet the need and therefore “ad hoc” reports are required. Some Trusts are developing the use of business intelligence tools to provide these additional reports to support the decision making process. These reports and additional levels of detail will not be possible without efficient and effective IT.
“If you cannot measure it you cannot improve it” (Lord Kelvin).
Therefore, baseline data and trend information is essential in order to have comprehensive improvement – whatever the type and source of data that is needed within the NHS. This needs data capture, storage, analysis and presentation. The only sensible way to achieving this is using IT as this can ensure accuracy and timeliness in today’s world of information overload.
In order to achieve improvement (in all facets of the NHS – management, clinical, financial etc.) it is necessary to make use of the informatics currently collected and other data that will be needed in the future.
Healthcare reliance on informatics and information management is only going to increase. The ability to automate relevant data collection, cleansing, trend and correlation analysis, and presentation is going to require increasingly sophisticated and integrated IT infrastructure management. The potential for data overload and costly IT complexity could be seriously underestimated.
This scenario applies to IT as much as any other part of the NHS. In which case, Lord Kelvin’s quotation could read “If you don’t measure IT you cannot improve IT”.
However, to achieve this the NHS and Trusts need the most capable CIOs and IT Directors, who can deliver what is required to satisfy the clinical needs.
Although each of the 8 Ways of Working will find some contribution from IT, the key area is “Delivering World Class Service”
The business plan recognises that in order to deliver a world class service, for all the activities, clinical and managerial, and for the scorecard items to succeed – “they need to be able to make use of the latest digital technologies to improve the safety, outcome and experience of care”. Whilst this leans towards digital clinical technologies on first reading it is also applicable for all (digital) technology including IT which will become the backbone for all other aspects of NHS activity in order to share data safely, securely and consistently. This will increasingly happen in real time and in bulk. That is potentially going to drive increased complexity – i.e. cost.
All aspects of the NHS increasingly demand the use of efficient IT from patient records and trust administration to specific clinical systems used for patient care. If the aim is to deliver world class service, this has to start with world class IT!
Furthermore, the NHS is suffering under financial constraints and there are continual statements that the NHS has to transform. Whether this is to simply do the same but in a different way, or to embrace and bring in new clinical systems to improve patient care, the upshot is the same. This will not happen unless there is the capacity and capability within IT to support these endeavours. This is not just a requirement for IT hardware, though this will be important, it is to have the right staff, in the right numbers, with the experience and capability to bring on-board the new approaches with appropriate management if monies are not to be wasted and the future state is to be realised as soon as possible.
Frequently, departments demand that IT accommodates their particular way of working. Whilst IT should recognise the requirements of the users this can give rise to unnecessary expense and inefficiency in IT systems if there are too many variations to achieve the same end – e.g. patient discharge. It could be better to adjust some processes (where this can be done without detriment to patient care) as this would lead to more efficient IT and help with providing capacity and resource within the IT departments for transformation objectives.
The scorecard is mainly aimed at the clinical services – doctors and nurses – and is underpinned for all items by the need for accurate and timely data.
IT will also play a small part in some of the less probable areas such staff satisfaction. If there is efficient IT, that is easy to use, the staff will be able to achieve results more quickly and be able to devote more time to their jobs which, in turn, will lead to greater staff satisfaction. For medical staff this equates to more time for the patients. All this will contribute to priority items 1 to 9.
Additionally, both current and future clinical systems require IT in terms of IT networks to allow integration with clinical equipment, data storage and processing and thus IT contributes even more to items 3-7.
The main scorecard items where IT will have the highest level of importance are numbers 10 (Becoming an Excellent Organisation) and 11 (High Quality Financial Management).
Item 10 – will require an organisation that learns and communicates success and failure. In order for this to be possible the right data will need to be collected, stored and analysed. As for items 3-7 this needs IT to be both efficient and effective otherwise these important statistics will not be available to support trusts and meet the business plan goals.
Item 11 – definitely requires all aspects of IT to operate in the most efficient way if the financial transactions of trusts and those commissioning medical services are to be correctly handled and budgets monitored properly and expediently so as to avoid the financial problems facing some trusts currently.
ImprovIT has analysed the IT performance and advised several NHS trusts over the last year, and discussed challenges with many more. What follows is a set of perspectives and observations from these activities and research.
Broadly speaking, most trusts have an IT strategy, coupled with a serious commitment to execute on the strategy. However, these were often out of date. They focused on ambitious future goals and often failed to fully take into account an accurate current state and the necessary stepping stones and road-maps to move from the existing infrastructure and legacy applications to a future landscape. The gaps frequently made connecting the current state to the strategic goals rather challenging.
All trusts have faced budget cuts in recent years and in order to preserve the front line services of patient care the cuts handed down to IT (and other “back office” functions) have been large in percentage terms. In order to meet the demand of the cuts imposed, they are often managed in an expedient manner. The immediate impact of the budget cuts has been staff reductions and delays to projects and new investment.
Whilst these actions may have satisfied the immediate budgetary constraint, the limited ability to perform any detailed long term impact analysis on IT budgeting decisions, has made the task of meeting the existing and emerging IT demands more challenging than ever. The staffing cuts in some instances have been to such an extent that “business as usual” is only just achieved by the willingness and keenness of dedicated staff. To address new projects and to operate efficiently would not be possible without the required skills and investment.
All trusts generate significant volumes of IT performance data. However, weak processes, staffing issues, lack of time and pressures mean there is frequently little capacity to convert it into information that could improve the effectiveness and efficiency of the IT services. For instance, at some trusts significant proportion of support requirements by-pass the IT Help Desk when seeking resolution, preferring to deal with individual technicians. This may be because users perceive they will get a quicker solution or the Help Desk process and response times are believed to be inefficient. Whilst this provides a short term fix the issue will most likely not be properly recorded, so trend and workload information becomes inaccurate from the Help Desk statistics and an opportunity to improve service is lost. Equally, targets for service delivery are varied, as are the Key Performance Indicators (KPIs) and measures recorded.
Senior management are focused on overall trust performance and specifically on the clinical departments.
This can impact the overall efficiency of IT operation e.g. discharge data mentioned above. With a stronger voice in the boardroom, IT could provide more efficient services in support of the clinical functions and potentially save money or provide the correct strategic input for new clinical services.
The following represent some of the main areas for change that we’ve identified with NHS Trust clients.
Strategies must always address the three main questions of: “Where Are We Now?”, “Where Are We Going?” and “How Do We Get There?” (all of course in respect of the trust’s business and clinical vision). A useful set of guidance principles for continuous improvement as part of strategic planning form the cyclical acronym GO-ACT or Governance, Organisation, Alignment, Compliance and Transformation.
It is essential that strong IT policies are defined and that these policies are supported by the trust executives. These polices must be designed with close collaboration with the clinical departments. Where close collaboration occurs IT is in a better position to formulate and deliver. Early discussion will reduce the risk of delivering inappropriate equipment or services. This in turn will increase the level of technology commonality as well as set mutual understanding of service levels and expectations.
IT must be given clear targets with consistent means to measure and track alignment and achievement of those targets. The targets should not be seen or used as a threat to resourcing decisions or contracts but rather a means to clearly identify what changes are need to be made in order to improve service. This will lead to improved service management, optimal staffing and better control of budgets.
Our studies show that broadly speaking NHS trusts IT efficiency compares favourably to the wider business and industry peers. Nonetheless, in keeping with a wider group of peers, trusts were also subject to the same opportunities to improve in specific IT service delivery areas. As well as these discrete opportunities there was the potential for up to a further 15-25% savings by more effective process adoption, technology adoption including virtualisation and complimentary governance frameworks to encourage managed and aligned IT service design, implementation and delivery.
Focussing on improving inter-departmental communication is a surprising common means of delivering improvement. Often IT departments operate in relatively closed environments, with little visibility or positive interaction with others. The IT department can be backward at coming forward with their successes and failures. This in turn does not give the other trust departments the opportunity to learn what might be possible in IT terms and of benefit to them. Correspondingly, the IT department is unable to learn about the day-to-day requirements of clinical departments or areas that can improve. Thus IT can find it more difficult to help drive the technology agenda.
The senior management and executives are rightly focused on the care outcomes of the trust. This means clinical outcomes within budget, in the main. However, rarely is IT a voice in the boardrooms of trusts other than via one executive who has picked up a responsibility for IT, usually the Finance Director. This may lead to a lack of visibility of IT capabilities, as mentioned in previous sections, its constraints, capabilities, capacity etc. In addition, IT is unable to comment on and temper the goal set, road map, the speed and ideal state, at an early stage.
Before any journey can begin, the first critical need is a clear unambiguous understanding of the “You Are Here” on the road map. The rate of change outside is faster than before, and continues to accelerate. The transformation journey has begun whether by design or a natural organic response to business pressures. It is therefore, never too early to baseline the present state, so enabling the design of the transformation path and plan. A perfect starting point for this is a detailed analysis and benchmark of key services metrics of the IT estate, including all services towers, people, processes and technology. This helps establish recognition of the start point, of “where you are now”, a baseline which enables the charting of the transformation journey.
The next step is to develop an updated IT strategy, in close synchronisation with the business strategy and goals. This needs to include the context interdependent issues of desired business outcomes (within constraints of capital investment and operational budgets, in-house capabilities and customer satisfaction needs). The IT strategy, developed closely with the business, not only defines clear objectives, policies and governance, but also guides the development of the most appropriate IT services, infrastructure and application solutions, mapped closely to business needs. It provides guidelines for the regular assessment and management of technical and financial risks in IT, measurement and reporting of service quality, operational process compliance and measuring the business impact of IT.
With an unambiguous baseline and a guiding strategy that fits the business needs, the next step is to develop a transformation plan, a journey planner to get to the desired destination. Transformation planning calls upon additional disciplines and specialist skills, such as Enterprise Architecture, Application Portfolio Analysis, Technology Evaluation as well as Transition Management, Knowledge Management, Capacity Planning, Service Design and Sourcing. In addition to these strategic skills, there is often the need to model “what if?” scenarios, to help with decision making, which may have high impact in meeting business expectations and financial constraints.
The ability to effectively manage the change, including IT and its impact on the business, requires a robust project and change management process. For on-going measurement, management, goal setting and continuous improvement, the identification of and reporting on the most suitable key performance indicators (KPIs) is about as critical as the role of headlights when driving near the cliffs in the dark. Regular service and quality reporting, while sharing of successes and achieved milestones with the business is an advised practice, often ignored by the best run IT organisations. People and cultural change are an important aspect of any transformational journey.
The NHS England business plan has an ambitious agenda to drive a renewed focus on clinical outcomes for the patients. Effective IT will be a crucial component if the NHS is to achieve that goal whilst introducing new clinical services within tight budgets.
In the right collaborative environment, IT has the potential to become “smarter”, truly motivated, and a highly efficient and effective partner in the delivery of the new agenda. By adopting the recommendations above, trusts can transform and deliver collaborative environments and services.
ImprovIT is a UK-based, internationally recognised independent business technology consultancy specialising in metrics-driven analysis (MDA) and peer benchmarking of IT costs, performance and quality using a rigorous methodology that measures like-for-like hardware, software, service and workflow components. With this data, ImprovIT helps enterprise customers and IT outsourcers baseline their IT operations towards improvement and optimisation, advise on price and performance, service scope, sourcing strategies, staffing, procurement strategies, modernisation and GO-ACT (Governance, Optimisation, Alignment, Compliance and Transformation) programmes. ImprovIT’s client list includes Tier 1 organisations in the commercial and public sector markets including utilities, higher education, healthcare and government.
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