Digital advancement in the NHS has been a national priority for years. It is no secret that it has proven extremely challenging, and a number of very expensive initiatives have fallen by the wayside. Now policy-makers seem desperate to digitise by any means, and a myriad of disparate policies and funding initiatives have emerged.
In September 2015, NHS organisations were divided into 84 regions and instructed to draw up plans – Local Digital Roadmaps (LDRs) – to make better use of technology, including a route to providing paperless care by 2020. Just a few months later, the Sustainability and Transformation Plan (STP) was conceived and NHS organisations were divided again, this time into 44 regions. STP areas were told that LDRs should feed into and inform STPs, even though some STPs encompassed more than one.
A year later, in September 2016, the Global Digital Exemplar (GDE) scheme was announced. Twelve ‘digitally advanced’ trusts were to be awarded £100 million to lead the way for other trusts to follow. Since the initial announcement, four more acute trusts have been added to the list and, more recently, six mental health trusts. The sites are set to employ a range of digital solutions, from video links between ambulances and emergency departments to patient monitoring to spot any warning signs of sepsis.
The decision to fund leading organisations came out of the Wachter review, which found that most hospitals won’t be ready to go paperless by 2020. It seemed like a sensible suggestion in the context of varied levels of digitisation and some organisations that seemed to be ahead of the curve. But it is controversial. It prioritises the development of digital hospitals rather than a whole digital system, which seemed to be the driving force behind the LDRs.
It is in this context that the first tranche of GDE sites fear the £100 million they were promised won’t be delivered. To complicate things further, in the Spring Budget, the Chancellor announced £350 million in capital funding (which can fund technological advancement) for the strongest STPs. So now we have (a small amount of) additional funding for ‘star STPs’, the mechanism designed to improve sustainability across a system, as well as ‘star organisations’.
All in all, we’re hedging our bets. But in the context of limited funding, does it make sense to fund various schemes at the same time and prioritise the development of leading organisations over others?
STPs: the only show in town?
The rationale for STPs is sound. They facilitate the planning and delivery of joined-up care, reducing the risk of duplication. They are perhaps the NHS’s best hope of becoming sustainable.
The trouble with the technology component of STPs is that it is at once vague, broad, expensive and lacking a credible plan. They read like a shopping list of technologies on the market, from shared electronic health records, e-prescribing and data analytics to patient-facing tools such as assistive technologies, access to records, wearables and apps. It doesn’t appear that much thought has gone into what to procure or why, which may partly be explained by organisations closely following the LDR guidance checklist, rather than starting from an assessment of what they need.
What’s more, most of them lack plans to meaningfully use technology. For example, virtually all the STPs include a range of patient technologies, including those to facilitate self-care. But few (with some exceptions) set out strategies for NHS staff to actively prescribe, encourage and support the use of digital tools for self-care.
Then there is the money. The funding required to cover the technology costs alone is enormous. North Central London STP, for example, says it will be looking for £159 million to fund its LDR over the next four years, and an additional £21 million in 2020/21. And those that are lagging behind may require even more money to invest not only in new technology, but in new work processes, infrastructure and training. Norfolk and Waveney STP, for example, acknowledges it is starting from a position far below national average when it comes to digital readiness. It also notes it does not have a Clinical Information Officer and will need time to build this capacity, and a backfill cushion in the short term.
Global Digital Exemplars: guiding stars?
Funding those furthest along their digital journey to set examples for others sounds like a good idea in theory. It is not a new idea that those following ‘early adopters’ of innovation often have more successful and cheaper journeys as a result of learning from the trailblazers’ mistakes. And the idea is that advanced trusts will bring less advanced trusts up to speed by 2023.
But in practice there are a few issues with this.
The GDE money was allocated, in large part, based on the Digital Maturity Index (DMI) self-assessments. That means they are subjective, and therefore the shining beacons of technology might not be shining as much as we first hoped (although they also needed to show they were already involved in innovative digital solutions and had a range of initiatives in place).
The organisations have not had to publicly submit feasible plans about how they will eliminate the use of paper by 2020.
They also allow hospitals to develop at the expense of other services in the region. While GDEs may be implementing electronic health systems with data transfer capabilities – which could arguably facilitate joined-up care with primary and community services – it is unlikely they will be compatible with a whole STP area.
So what does this mean?
STPs need significantly more work and resource to create whole-system transformation, and the likelihood of achieving it by 2020 is miniscule. But given that’s the case, perhaps it would make more sense to put any available resource into creating a digitally advanced system rather than achieving digital maturity in individual hospitals – particularly given that those furthest behind are likely to need most support.
Castle-Clarke S (2017) 'Achieving digital maturity: Hedging our bets'. Nuffield Trust comment, 23 March 2017. https://www.nuffieldtrust.org.uk/news-item/achieving-digital-maturity-hedging-our-bets