The NHS Long Term Plan was published at the start of January. The 134-page document sets down how the health service in England will spend the £20.5 billion a year "birthday present" that the government unwrapped for its 70th anniversary last July.
Alongside headline-grabbing initiatives on mental health and primary and community care, the plan lays out an ambitious agenda to return hospitals to financial balance, while progressing the Five Year Forward View’s vision of population-level planning and funding, aligned with more integrated health and social care.
The plan says accountable care organisations - now called 'integrated care services' - will be rolled out across England by 2021, while a new 'service model' is developed to give individuals more 'differentiated' options for treatment, support and advice.
Almost every element of the plan depends on IT and technology gets its own chapter to outline proposals to complete the deployment of electronic patient records in hospitals, develop a new model for integrated care records, abstract and use data, and enable individuals to interact with the NHS through personal health records and apps.
A week after the launch at Alder Hey Hospital in Liverpool, Highland Marketing's advisory board met to discuss the plan and what will need to happen to make it a success. "Was this," askedchair Jeremy Nettle, "the birthday present that the NHS wanted?"
Great, but what about implementation?The consensus was that it probably was, although there is a lot in the plan that is familiar, and implementation will be critical. "It is encouraging, because it is more substantive than the Five Year Forward View, and it is proposing to invest in technology," said James Norman, healthcare CIO, EMEA, DellEMC. "The question is how to do it."
The ideas in the Forward View were supposed to be taken forward by 44 sustainability and transformation partnerships. But most have made only limited progress and just 14 areas of the country are "working towards" ICS status at the moment.
Meanwhile, acute deficits have hit £1 billion a year, and NHS performance against key targets has slipped. The advisory board argued that to make progress this time, board-level leadership will be vital. Also, that where it's missing - or distracted by deficits and day to day pressures - the centre will need new levers to pull.
NHS England is already using the NHS operating framework and financial regime to move towards joint control totals for commissioners and trusts and to push CCGs to merge. But the plan lays out legislative proposals to undo some of the structural and competitive elements of Andrew Lansley's 2012 reforms; and the advisory board felt these would be needed.
"It is hard to believe ICSs will not happen, because NHS England has said so hard that they will happen," said Andy Kinnear, the director of digital transformation at NHS South Central and West Commissioning Support Unit. "But this is a hard agenda, and it will need legislative change."
However it is achieved, the board feltthat consolidation on a 1/7/44 model (a merged NHS England / NHS Improvement, working through seven regions announced just before Christmas, and mapped to 44 STP/ICS footprints) is the right way to go.
Jeremy Nettle, a health tech industry veteran who started his career in the NHS,argued the NHSE/I regions are already "looking a lot like the old regional health authorities” and that this was a good thing, because they had the coherence and authority to drive change in their patches.
Andy Kinnear agreed. "I am missing the old strategic health authorities," he said. "I never thought I would say that, but it is true."
Tech needs leadership and investmentThe board felt similar issues would apply to the technology agenda set out in chapter five. Andy Kinnear said board level leadership would be particularly important for IT and welcomed its call for a chief information officer or chief clinical information officer to be on every board.
He warned, though, that these new CIO and CCIOs would need appropriate skills and training. Money will be required. Both Andy Kinnear and James Norman noted that a lot of money has gone into NHS IT over the past decade and a half.
The National Programme for IT in the NHS had £17.4 billion to spend on national infrastructure, services, and contracts to roll-out EPRs, while former health secretary Jeremy Hunt launched tech funds for ‘paperless’ initiatives, such as e-prescribing.
However, NPfIT mostly failed, and tech fund money was diverted to other uses. So, the board argued, while money is undoubtedly needed, it will need to be spent wisely and its impact will need to be monitored. Also, it will need to be spent at the right level.
"At the moment, there is a lot of duplication," Andy Kinnear pointed out. "Service desks, infrastructure, almost every hospital running its own IT department. There is a lot of money being spent to replicate things, so there are massive savings to be had from working together."
Organising IT at a healthcare community level would also make it easier to get neighbouring hospitals onto the same EPR systems, or to roll-out a consistent architecture for information and data sharing, he suggested.
However, there are no quick fixes. "One of the things I had on my list to talk about was 'patience'," he said. "These things take years. Connecting Care [the integrated care record that NHS SCW CSU runs for Bristol and the surrounding area] has been going since 2012 or 2013, and it is only in the past four or five months that it has become embedded into the system.
"It's taken that long for using it to become normal behaviour; and the plug could have been pulled at any point in the four or five years it wasn't seen to be working."
Getting the basics rightOne reason that tech projects can take so long to make an impact is that they are often not so much tech projects as business process change projects; and changing NHS pathways, processes or working patterns is notoriously difficult.
Ravi Kumar, the chair of Zanec Software Technologies who was chief technology officer at iSOFT, argued that the NHS will need to get better at going faster. "The whole point of the ICSs is to make structural change, but the question is how they will do this," he said.
"Technology is an enabler, but that is going to be the bigger question." Advisory board members felt the NHS would need to make a big investment in Lean and other industrial improvement methodologies to shift the dial.
Yet Cindy Fedell, chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust, stressed that even if it did this, it would need to make sure technology was pulling in the same direction. "Sorting out clinical pathways is a huge focus for work at the ICS level," she said. "But something we talk about a lot is how we make that happen when all our IT is set up to work within organisational boundaries. “How can we make sure that a district nurse, who is being sent out to work differently on behalf of three organisations, can do that without using three logins to three different systems?"
Naturally, Andy Kinnear agreed. The plan may focus on creating integrated care records, but at a local level, he argued, the real need is for integrated infrastructure. "The plan can't talk about that, because it sounds too boring and not transformational enough, but we need to get the low-level stuff right, because if we do it will make the rest a whole lot easier."
Exit the SCR and enter the PHRWhen it comes to integrated care records, the plan seems to envisage turning the old Summary Care Record plus a care plan into a basic record, rolling this out at local health and care record exemplar level, and then abstracting data for population health management, research and other uses.
The advisory board had few problems with the idea: the old NHS Summary Care Record struggled to become established and still exists in only the most basic form, while the more advanced LHCREs, like Bristol, are finally seeing information shared to support both services and planning.
Andy Kinnear pointed out that the plan seems to think that LHCREs will need to be bigger than most of the information sharing projects that exist at the moment, and that they will need to work within a consistent architecture to realise NHS England's data ambitions.
But he was more interested in the personal health record aspects of the plan, which both envisages that patients will interact with their care plans, and access booking, clinic, and advice services through the NHS App and an ecosystem of third-party apps using its NHS Login.
"I talk to a lot of CIOs who think that their job is to build a PHR for their organisation, and I don’t think that is right," he said. "I think the job is to create a vendor neutral platform that makes data available from the clinical record to apps that share it back with the patient and their health team."
Cindy Fedell said she agreed and wondered if those who didn't had "misunderstood the use case." "This is not just about data, it is about managing the plan for health and wellness," she said.
Beware the disruptorsSome organisations have already got this. Andy Kinnear praised University Hospital Southampton NHS Foundation Trust for building a PHR that has improved efficiency (a prostate cancer app delivers routine test results, cutting outpatient appointments) while delivering unexpected benefits (the same app has been used to organise support and social events).
But he argued that if the NHS as a whole didn’t move in this direction, it would find itself under pressure from disruptive new entrants. Primary care, he pointed out, has already been rocked by the GP at Hand service that has so impressed Matt Hancock and by Livi, which has just employed NHS App developer Juliet Bauer.
Ravi Kumar suggested that ICSs might even use services to do the disrupting; breaking up the traditional GP practice to create, for example, "digital first" packages for working people and dedicated visiting services for care homes. Jeremy Nettle suggested the real need is for policy makers, commissioners and providers to think differently.
"At the start of this discussion, we were talking about how the challenge facing the NHS Long Term Plan was going to be implementation," he said, "but now I think it is empowerment. The key insight is that people will need to be empowered to take its ideas and drive change."
- The NHS Long Term Plan is welcome as a comprehensive document that recognises the importance of technology. The challenge will be implementation.
- Board level leadership will be essential. Legislation may also be needed to create regional bodies with the authority to drive change within integrated care services, when these are established.
- More investment will be needed to deliver the proposals in chapter five to complete the digitisation of hospitals, create integrated care records, make better use of data, and roll-out personal health records and apps.
- However, costs could be avoided, and savings could be made if more health and care organisations shared IT services; and bought the same systems.
- Many technology projects are business process change projects, and the NHS will have to make more consistent use of Lean and other techniques to deliver the plan. But even if it does, it will need to make sure it has the infrastructure in place to support new pathways and processes.
- The development of personal health records and apps linked to the NHS App are a major opportunity for the health service to develop new services for patients. If it fails to grasp it, it could see disruption by new entrants.
- The key to the success of the plan may be empowerment: people need to be empowered to take up ideas and the potential of new technology to drive change.
Highland Marketing advisory board members:
- Jeremy Nettle, chairman, and past chair of the techUK healthcare group and former European director for Oracle Corporation Healthcare.
- Cindy Fedell, chief digital and information officer at Bradford Teaching Hospitals NHS Foundation Trust.
- Andy Kinnear, the director of digital transformation at NHS South Central and West Commissioning Support Unit.
- James Norman, Healthcare CIO EMEA, DellEMC
- Ravi Kumar, chairman ZANEC Software Technologies.