Creating a digital NHS is a national policy priority. It promises to improve the quality of care, reduce duplication, drive efficiencies, empower patients and support joined-up services. The NHS Long Term Plan emphasised national policy’s commitment to the digital agenda and promised fully digitised secondary care services by 2024. This follows a host of other policy and funding initiatives in recent years, totalling national investment of over £4 billion since 2016.
Now the establishment of a new organisation to lead national policy for NHS technology, digital and data has been announced. NHSX will bring together digital leaders from NHS England, NHS Improvement, and the Department of Health and Social Care to lead on setting standards for technology use, championing and developing digital training and ensuring NHS systems can talk to each other across the health and care system. This is a clear sign of continued commitment to creating a digital NHS – including from the Secretary of State.
In this environment, we sought to understand how national policy for digitisation is working from the perspective of acute trusts. We wanted to know:
- How national policy impacted on a trust’s approach to digitisation
- How national policy was helping and hindering digital progress
- What national policy could do differently to better support digitisation on the ground
In order to answer these questions, we spoke to 72 senior digital leaders in national organisations and NHS trusts as well as frontline health care professionals. We used the latest digital maturity assessment (DMA) data to sample trusts based on their digital capability.
This report has a number of suggestions for national bodies. Many of these are likely to be most relevant to NHSX as it is considering how to fulfil its new role to best effect. However, given the uncertainty about how NHSX will operate in practice, we have resisted naming specific organisations. What’s more, given the fast pace of change in this area, we have focused on broad policy lessons rather than recommendations for specific policies or policy instruments. At a time when the organisational approach to national digital policy is being refined, this report provides insight into where energy can most usefully be invested. Below we outline a summary of our key findings, alongside a series of learning points for national organisations.
Key findings and recommendations
Overall policy approach
Most people we spoke to felt the current policy approach was useful in achieving widespread digitisation: it is generally enabling rather than prohibitive, and is notably less prescriptive than the National Programme for IT (NPfIT). However, we consistently heard that the national role could be improved – not least by improving coordination across central bodies.
An important role for national bodies is setting digital standards, particularly to support access to data across the system. The Future of Healthcare – the government’s vision for digitisation – recognises that as a key priority. While there is very positive work to develop these standards collaboratively, the national strategy for implementation is often lacking.
Too often, the implementation of standards is viewed as a technical rather than a technical and adaptive exercise, and frequently falls to technical specialists within trusts. More needs to be done to communicate the purpose of digital standards beyond technical teams – particularly in highlighting the potential benefit they offer the organisation.
- Support the implementation of standards by setting appropriate deadlines, providing clear guidance for local organisations on interpreting and delivering the standard and ensuring comprehensive piloting and testing prior to national roll-out
- Coordinate efforts to support digitisation and data collection across national bodies
Configuring a digital workforce
Trusts were experiencing significant challenges with recruiting and retaining the workforce necessary to support digital change. Many felt that Agenda for Change (AfC) was inappropriate for corporate and technical roles and the structure imposed by AfC was severely hindering the ability of the NHS to compete with the private sector. In addition, a lack of professionalisation and a clear career pathway with accompanying qualifications for digital roles limited opportunities for learning and development.
Many interviewees also felt the need to legitimise the chief clinical information officer (CCIO) role. This extended beyond engagement with boards, and included the need for a clearer career pathway, an accreditation and significant time to dedicate to the role.
- Professionalise digital health roles
- Develop appropriate pay frameworks for the technical workforce
- Allow flexibility for local organisations to determine appropriate governance arrangements for digital programmes, rather than simply mandating board membership
- Provide best practice guidance on clinical informatics workforce configuration, including time allocation
Working with digital suppliers
Whether trusts had one main supplier or many individual systems, managing these supplier relationships was felt to be challenging. Some trusts struggled to engage suppliers in making system upgrades and changes in a timely way, and this was felt to be partly due to lack of supplier resource. Trusts felt there was a greater role that the Centre could play in leveraging the supplier relationship across the whole NHS by providing a stronger system of accountability when suppliers fail to meet trusts’ needs. We also heard about the negative consequences of losing all central digital procurement following the abandonment of NPfIT.
- Proactively engage suppliers about standards and mandates that require software reconfiguration
- Provide trusts with a clear avenue to report issues back to the Centre and hold suppliers to account where necessary
- Consider national procurement of standard, widespread IT systems such as Microsoft software
Across the country, there are examples of providers refusing to engage with local data sharing efforts, often due to concerns about Information Governance (IG). While much of this can be overcome with strong local leadership, there is also room for central bodies to play a much bigger role – not only in supporting with interpreting and applying IG legislation, but perhaps more importantly in providing clear guidance about the benefits and drawbacks of sharing particular data in certain circumstances. • Actively engage with patients and the public around digital, in particular data sharing • Develop analytics capacity by ensuring there is appropriate national and regional leadership and reducing the number of projects that are outsourced • Provide use cases and national guidance on priority areas
Funding and sustainability
The need for ongoing national and local investment to achieve digital maturity cannot be underestimated. This applies for digitally mature organisations hoping to sustain their existing programmes, continue to make the most of new opportunities and spread their learning, as well as for other organisations looking to digitise. Digital transformation can also take a long time, and trusts are unlikely to see sufficient productivity gains to support their significant digital investment in the short term. The Centre needs to be realistic about the likely levels of funding needed to maintain and support Global Digital Exemplars (GDEs) to spread best practice; digitise middling and weaker trusts; and join up digital efforts across the country. It also needs to accommodate a move to, or shift in relative balance between, revenue and capital funding.
- Be realistic about likely funding requirements and accommodate a switch from capital to revenue funding
- Be clear about how different funding initiatives align to deliver digital priorities
- Ensure evaluation is built into funding initiatives for digital transformation
Global Digital Exemplar and Fast Follower programme
The people we interviewed who were involved with the GDE and Fast Follower programme were broadly positive about the programme as a whole, particularly when contrasted with NPfIT. They particularly liked the fact that it fostered a more collaborative environment, focused on sharing best practice and learning rather than individual trusts working in silos. However, people reported challenges with the reporting requirements and felt reporting should be more closely aligned with the programme’s intended benefits. Trusts did not feel that reaching HIMSS level 7 (an internationally recognised measure of digital maturity) was realistic in all cases. While this expectation is just one part of measuring the objectives expected of GDEs, trusts felt a pressure to achieve it quickly. Many outlined challenges with the lack of national infrastructure to support this at the time of the site visits.
- Ensure reporting requirements clearly relate to the articulation of benefits
- Reconsider the focus on HIMSS level 7 and ensure ongoing work on national infrastructure is effectively communicated
- Look beyond blueprints to share best practice
At a time when NHSX is considering its organisational priorities and how national policy to support digitisation can be improved, this report sets out a number of areas that would benefit from national attention. A clear theme across all of the areas is the need for better communication and engagement between national policy makers and NHS providers. Establishing clear avenues for two-way dialogue between all local organisations and central bodies is essential to ensure that national policy is in line with local priorities and effectively supports digital advancement, rather than serves as a hindrance or distraction. This may help central bodies strike the right balance between national direction and giving NHS organisations the space and time to lead their own change.
Castle-Clarke S and Hutchings R (2019) Achieving a digital NHS: Lessons for national policy from the acute sector. Report, Nuffield Trust