As a former employee of NHS England, I am sparing a thought for former colleagues in the organisation who are facing yet more disruption.
But looking beyond what will obviously be difficult for NHSE staff, there are undoubtedly some opportunities here for the NHS.
Here’s an interesting test. Can you find anyone out there online or in the news defending the status quo?
I haven’t, and it’s clear why. The disconnect, duplication and chaos that has been generated by the current structure is having a palpable impact on the ability of the NHS to get a grip on its many problems. In addition, there has over the years been a huge concentration of staff at the national level, leaving the wider NHS system that operates on a more local level with insufficient capacity to help make change happen on the ground.
Something had to give, so although seismic, I can see the logic in this decision.
To get it right though, the changes must be delivered with care.
Previous NHSE restructures (and I have been through them myself) have taken a salami-slicing approach – trimming a lump off all teams, so you are still left with a complete mess, albeit a slightly more meagre one. A fundamental reshaping of the organisation needs to take place that leaves the government with a workforce fit to deliver the strategy.
Through this change, the department of health must hold on to their digital skills at all costs. A shift from analogue to digital is not only a key plank of Streeting’s strategy but it also wholly underpins the two other shifts he wants to see – from sickness to prevention and from hospital to home. The digital agenda that NHSE is grappling with, and the criticality of digital to NHS reform, means NHSE can ill afford to lose further digital specialists.
This isn’t just about the use of technology but a different mindset and culture. The NHS is a highly devolved service that needs to be led rather than commanded, as previous efforts, successes and failures illustrate. That’s precisely why taking these opportunities will give the government the best chance of delivering not just evolution but the revolution that will be required to modernise an ailing NHS.
This article originally appeared on LBC news website.
An extraordinary day of news on Monday from NHS England*.
My first thought is with former colleagues and officials in the organisation who have been in almost constant restructuring for the last five years. Just when things were starting to settle, the rug has been pulled again. I am sorry for you, folks.
Looking beyond the personal toll, there are undoubtedly some opportunities in here, as long as the leadership takes the right approach. Here are some thoughts on how to get some positives out of a pretty horrible situation for those involved.
Focus on locally-led change
It’s undeniable that there is a massive concentration of people power in the centre. I don’t think many at NHSE realise just how low the capacity is in some parts of the nationwide system. Last year, I worked with one integrated care board which had a single project manager who was the point person for the entire digital portfolio: NHS App, UEC EPR convergence, e-RS, FDP and others. “Build it and they will come” does not work. A rebalancing of some delivery capacity to focus on locally-led change would be helpful. Note, I’m not suggesting product development skills should be devolved to local – the digital agenda that NHSE is grappling with, and the criticality of digital to NHS reform, means NHSE can ill afford to lose further digital specialists.
NHS as a service organisation
Previous NHSE restructures (and I have been through them myself) have taken a salami-slicing approach – trimming a little off of all teams, so you are still left with a complete mess, a slightly more meagre one. A fundamental reshaping needs to take place that leaves you with a workforce that can deliver the strategy. Within this, there is also an opportunity to fix the overall structure of NHSE. I’ve written about this before (in 2019 gulp), but the way NHSE is structured around priorities, without a consistent taxonomy, results in mass confusion and duplication. It means that everyone, everywhere, is trying to solve the same problem – but from different start points and worldviews. NHSE needs to think of itself as a service organisation i.e. one that organises itself around users and their needs, rather than internal communications structures.
NHSE needs to think of itself as a service organisation; one that organises itself around users and their needs, rather than internal communications structures.
Fix pay and recruitment
I assume it is a legal requirement to freeze hiring, while restructure and consultation takes place; this hiring freeze, however, could be an act of self-destruction. Getting new people into NHSE takes six to nine months. NHSE needs to stay on top of the new skills it will need to deliver against priorities. From a people perspective, NHSE also needs to fix pay consistency across national and local. Talented leaders are disincentivised to go out to the system because, simply, the pay is worse. The restructure must be seen as an opportunity to enhance the value proposition to attract key skills, otherwise it will make a challenging recruitment landscape even more so.
Adopt internet era ways of working
Most critically, NHSE needs to make sure that deep digital and data expertise is at the top table. Driving NHS transformation is not just about technical literacy (although it is a critical part of it) but also internet era ways of working i.e. what it means to operate as a modern organisation. This means adopting, and valuing, inclusive and open ways of working that enable trust, operational transparency, and an efficiency of communications that helps spread knowledge.
The NHS is a highly devolved service that needs to be led rather than commanded, as previous efforts, successes and failures illustrate. That’s precisely why taking these opportunities will give NHSE the best chance of delivering not just evolution but the revolution that will be required to modernise an ailing NHS.
*Two days after this article was published the UK Government announced the abolition of NHS England.
This post was originally published on the Public Digital website.
Another political administration, another commitment to putting technology at the heart of NHS reform and medical records in the hands of those that need them. If you think you’ve heard this one before, it’s because you have. All of the preceding Conservative Secretaries of State for Health have made similar commitments on NHS digitisation. As did their Coalition and Labour predecessors.
In fact, the story of digital technology reform in the NHS starts all the way back in the 90s with the introduction of the NHS’s first Information Management and Technology strategy. Which said some entirely sensible but eerily familiar things.
“Staff will enter data once and share where needed. Information will be secure and confidential. The NHS will share information using common standards and an NHS-wide computer network.” (Source: Mark Reynolds, 2023, Digital Health in the NHS)
In a complex network of institutions such as the NHS (the NHS is not one single organisation contrary to popular public belief), sharing data about a person to ensure their continuity of care is self-evidently an essential part of delivering a good service – if it was merely a matter of political will, wouldn’t it have been done decades ago?
The real reason that we haven’t achieved this is due to a series of extremely tricky technical, design, commercial and policy challenges all made more difficult to tackle by misaligned incentives.
How the NHS App displays medical records today
The authors led development of many digital products and services within the NHS, including leading on the NHS App, so are both familiar with these problems as well as invested in its success.
The NHS App already does a number of things but this blog post is particularly focused on the access to medical records.
The NHS App uses APIs to connect to GP Systems, of which there are two dominant market leaders in EMIS and TPP. These APIs existed long before the NHS App, indeed without them the App wouldn’t exist.
In some places the NHS App also has integration with providers of secondary care records such as Patients Know Best. Access to these records is highly dependent on which products and services have been procured locally, and therefore it is not uniformly available across the country.
Given that the GP record is intended to contain your entire medical history, and the fact the NHS App is already connected to all GP records in the country, in one sense this is a solved problem.
But it doesn’t feelsolved.
The challenges of the current model
The reason is perhaps that aspects of this solution really don’t work well enough – or they don’t work well enough all of the time.
Firstly, in order to access the full details of your GP record via the NHS App, your GP records needs to have a setting set on the GP’s own system to enable “Detailed Coded Record” access. Without this you will see just a very summarised version of your record in the NHS App. Theoretically from 2023 this setting should be enabled by default, but it’s clear that this isn’t the case with many GPs. To enable this setting on your GP record, you have to contact your GP surgery and ask for it. When we’ve tried to do this for our own records we’ve found that the surgery staff had no idea what we were on about.
There is also a huge usability challenge to overcome. Medical records at their core are designed for professional clinicians and not laypersons. As well as being hard to read due to the technical nomenclature, there are genuine patient safety and usability concerns around presenting uninterpreted data to patients, especially when it comes to diagnoses or test results with significant consequences for patients.
Example of how the Pfizer COVID vaccine shows up in the app.
Furthermore, simply presenting data in lists doesn’t necessarily help a patient understand the journey they are on, or which information is most relevant for their current situation. The same is true for clinicians, who often have to wade through screens of ephemera before finding what they really need.
In the examples above you can see the change in design language when jumping between different systems. This is jarring for users. Joining up user journeys across all the different products sold by different vendors is extremely hard to get right, and requires a muscular approach to shaping the NHS software market that has sadly been lacking.
Under the hood, the interoperability is still not good enough, both in terms of the mechanisms for accessing data, and the modelling of the data itself. The data is pulled into the NHS App via something called IM1, which is a pretty ancient set of API standards that have limited utility.
Better APIs into the core clinical systems do exist, but the vendors charge for access. This is where you run into the politics. EMIS and TPP have their own “patient portals”, and also support an ecosystem of vendor partners that do similar. This is a key part of their business model. So in effect the NHS App is competing with the offers that the 3rd party “patient app / patient portal” suppliers are providing, and many GP surgeries are still using them as their front door and default patient data platform.
In too many cases a ‘let the software market decide’ assumption runs deep within NHSE. Such a posture is in direct opposition to the alignment required to join up patient records.
How to solve these problems
A foundational question in all this, which was the source of some debate on X this week, is “is it possible to solve these problems without fundamentally ripping up the core technical infrastructure at the heart of the NHS and starting again?”
Is it better to work with the model we have, an archipelago of medical data with a central shared view pulling data in from the multiple sources, or is it better to do something radically different where we re-engineer the existing model and create a new national record infrastructure based on data being pushed into a consolidated record which is made available through dedicated API services?
Both models need more analysis, and those analyses should be published so the public can appropriately scrutinise the hundreds of millions that will need to be spent in either context. They must also include a hard look at the existing significant investments in NHS data infrastructure and technology, and resolve any duplicative or conflicting approaches.
Regardless of the technology approach, this challenge won’t be solved through the creation of the perfect architectural diagram.
Whichever route you take there are some other fundamentals that also need addressing:
Embedding deep experience and technical knowledge in the Centre of the NHS, particularly at the very top table driving commissioning and strategy conversations. This is lacking at present.
Committing to a long term plan (no, not that one) that remains consistent and is inoculated from political change and cabinet reshuffles.
Radically reshaping vendor markets. NHSE has too often let the market decide. Enough of that.
Properly funding and taking a coherent approach to data and open information standards, with a coordinated approach to working with vendors.
Publishing a clear strategy and roadmap, explicitly linking strategic aims, the work that will contribute to them, and the aligned incentives that will support their success.
Once we see the announcements that will achieve these fundamentals we can look beyond the headlines and get some real hope that things may just be different, this time.
Cowritten with Matt Stibbs and originally published on the Public Digital website.
In the wake of reports linking IT flaws to deaths of patients and the recent cyber attack on pathology services in south east London, Chris Fleming calls for radical change to make digital safer and more effective
Digital technologies and ways of working have huge potential to transform our healthcare system and alleviate some of the pressures facing the NHS. But only if we do it right.
So how are we getting on? Last month, the BBC reported on IT system failures that have been linked to the deaths of three patients. And in the last fortnight a pathology system supporting some of our biggest hospitals has been taken offline, and an entire healthcare system’s digital infrastructure was reported to have collapsed.
We need to change. We need to improve the products we ask our staff and patients to use, insist that the market modernises alongside us, and recognise that digital is not the same as IT – it changes the way healthcare is delivered. It is essential to get this right, to tackle the risks of digital systems and prevent patient harm.
Reshape the market
It’s tempting to bury the reasons for this failure behind issues of complexity. And in fairness to my colleagues working in the sector, the federated nature of the NHS, and the inherent complexity of medical data and medical practice, are undoubtedly contributing factors.
But the complexity is not a sufficient excuse.
There are three things we can and must do now to mitigate future patient harm and make sure we are leading digital change in the most effective way we can.
Firstly, we must take market shaping seriously to drive drastic improvements in the products we use every day in the NHS. We need to act on rent-seeking behaviours and give new players who are shaping the market in a positive way a boost. Given the general failure of the market to respond to this design challenge (with a few exceptions) we might, as Digital Health’s editor-in-chief Jon Hoeksma points out, be rather better off building some of our own systems.
Secondly, we need to take the development, coordination, and enforcement of open standards in interoperability and cross-institutional communications seriously and underpin it with the resources that reflect its importance. It is an unglamorous topic, but this plumbing is vital for the future of the NHS. The Data Protection and Digital Information Bill, which had provisions for interoperability between vendors, fell down in the wash-up period after the general election was called. If they win the election, as looks likely, Labour should revive the provisions in the Bill, to give the NHS teeth to force interoperability without being scared of the response of the market.
Thirdly, we need to recognise across the NHS that digital health is not about funding ‘IT projects’ but a fundamental rewiring of the way healthcare is delivered, requiring requisite buy-in from the whole organisation both at national and provider level.
Digital at the top table
All of which will require a well-informed and muscular centre playing a servant leadership role with the system. Digital and technology experience should be at the very top table of NHS England. Clear architecture and commercial strategies should be developed in conjunction with the wider NHS CIO community.
NHS England needs to focus on a long-term approach to funding and should build (or fund the scaling of) world leading open platforms that are designed for adoption that can take pain away from the system and prevent the front line from having to constantly reinvent the wheel.
The Wade-Gery review recommended “Putting data, digital and tech at the heart of transforming the NHS”. I know many fantastic people in the local and central NHS who get it and are succeeding, in spite of the challenges. We need to break down the barriers, unblock things for them, and let them deliver.
The complexity of the digitisation of the NHS and social care is such that it is not an area where major systemic change can happen over the short term. This has been proven many times in the past. Any incoming administration would be advised not to underestimate how hard it will be to deliver their technology commitments – especially those involving patient data, as the operational changes are huge.
But if we do not at least start with a radical rethink of how to go about these challenges, history will be doomed to repeat itself.
If I were a new Secretary of State arriving at the Department of Health and Social Care (DHSC), one question I’d be asking is why is it so difficult to have a single patient record. That is to say: a single source of health information about a person that is available to any health practitioner helping them.
The reasons for this are legion but fundamentally it’s down to two things. Complexity and culture.
The NHS, despite the name, is not one single service. It’s a huge collection of different organisations funded in different ways under different conditions, delivering possibly millions of different services. This is underpinned by a huge mix of software systems both national and local, making the NHS the brownest of brownfield environments for digital change.
As well as institutional complexity, there is also data complexity. Picture a cradle-to-grave data model that minutely describes the human body and its systems, the things that can go wrong, and the treatments available. Add in the fact this data is also highly personal. The technical security and political sensitivity questions are formidable.
Beyond the environmental factors, there are some self-inflicted moves that have slowed progress too. Lurches in NHS technology policy from the top down / outsourced model of NPfIT to thousands of blooming flowers (although flowers is perhaps a generous metaphor in many cases).
From interoperability to convergence and back. Completely different commercial approaches in primary, secondary, or urgent care. And more digital and data strategies than you can shake a stick at. This confused and confusing picture is exacerbated by piecemeal funding cycles driven by announceables that don’t allow for long term planning or foundational enabling work.
But it can be done. It arguably has been, if you look at the success of shared care records like Connecting Care or One London. In the long term many, including me, believe that the best way to deliver this requires a new model where comprehensive health records are organised around patients rather than institutions, based on open data standards. Such models are emerging in some regions and countries, such as Slovenia.
I would ideally like to tell the new Secretary of State to simply swerve the question as elegantly as possible. A single health record is hugely complex, fraught and littered with elephant traps. But on the basis that isn’t politically feasible, here’s what I would say is needed:
Clear consistent long term strategy accompanied by a credible delivery plan
Sustainable and predictable funding supporting the development of long standing expert teams
Bold local and national leadership
Starting small and iterating, and scaling what’s effective
More active management of the vendor market in secondary care
Increased investment in the “plumbing” activities supporting development and adoption of data and interoperability standards
Because no matter how hard it is, there are reasons for optimism. Like many things in the NHS, the future is perhaps here; it’s just unevenly distributed. And because the prize is so big, it really is worth the effort.
This post was originally published on the Public Digital website.
The news broke last week that Tim Ferris, Director of Transformation at NHSE is leaving. I was quite surprised about how relatively quiet the Twitterverse seemed about it, but change fatigue is a forgivable response. The news reminded me of Joe McDonald’s excellent lava lamp analogy to describe the NHS’ constant pattern of reorganisation.
The plans and timeline for appointing Tim’s replacement haven’t been made public yet. Assuming there will be a like-for-like role to step into, the new appointee will have a full in-tray.
Here are six suggestions for what I’d put on the top of their to-do list.
Exemplify the NHS England ambition to adopt a collaborative, servant-leadership posture, and establish what the system will solve at the centre, what it will not, and why. Contrary to what you might hear from some quarters, the NHS doesn’t need fewer managers. It needs a different leadership approach, one that strengthens the feedback loop between the system and national teams.
Publish and keep updated a single roadmap for national products and services that describe the relevant team’s future approach, the rationale for any major product decisions (e.g. why particular features have been prioritised above others), and how they relate to each other. That roadmap needs to give systems and suppliers confidence in what’s coming, and what they can rely on.
Stop the Federated Data Platform procurement until there’s a good answer to the questions posed in the very sensible UKFCI paper. Start working in the open so that people can be brought on the journey and be confident about what’s going to happen with their data.
Step into shaping the software market for health. Make this an explicit mission of the transformation directorate, and take a 10-year view. Quietly ditch the EPR convergence mandate, make space for interoperability approaches, and remove the barriers to entry faced by challenger suppliers that are taking iterative, design-led, open standards based approaches.
Do less, better. System digital leaders are bombarded with pots of cash, priority requests, exacerbated by end-of-financial year “spend it or lose it” moments. No cash for “innovation” until organisations have put an end to 10 minute login times. Work with wider NHSE and ministers to agree a smaller set of key priorities, and stop doing other things.
Give the next administration a plan to allow the long term funding of teams, not projects. Prepare this so it’s in the in-tray of the new administration on Day One.
What would you do?
I’d love to hear your ideas.
And for those in the trenches trying to get the work done – keep going.
This post was originally published on the Public Digital website.
The Department of Health and Social Care announced yesterday that NHS Digital and NHSX will be folded into NHS England. We have seen these kinds of reorganisations many times before, including in the NHS. All too often they are distracting, dispiriting and don’t deliver the intended benefits.
But that doesn’t have to be the case – providing you get off on the right foot. The reorganisation is not the story. What you do afterwards is.
We don’t know all the internal mechanics of the NHS. But based on what we do know, here are our suggestions for using this transition to build trust and continue the momentum gained during the pandemic.
Work in the open by default. Start by publishing the names of who’s in charge, and what they’re responsible for.
Make an unambiguous, technically literate statement explaining what this means for patient data.
Deploy expert multidisciplinary teams (design, technology, clinical, operations) at all levels of decision making and delivery. Make the most of NHS Digital’s specialist capability in design and technology.
Explain which platforms are needed across the NHS, based on a thorough look at what exists now.
Show how this organisation change is meaningful by delivering something quick, visible and helpful to the system as a truly joint team. Such as an MVP platform for ICS websites, or new clinical calculation APIs, by next April.
Use the practice of working in the open to manage dependencies and duplication, instead of relying on spreadsheets held by Programme Management Offices. Get senior leaders to publish weeknotes.
Fix corporate basics to reduce friction for staff: make the website clear, put everyone on the same email system and directory, modernise the most important internal tools.
Do less so you can deliver more. Use the change to stop doing what is no longer needed or isn’t delivering value.
Most important of all – don’t let this distract from the core mission of making the NHS better for everyone. We need it, especially this winter.
This post was originally published on the Public Digital website.
As part of our work with NHS Providers (supported by HEE and NHSX) on running digital board sessions for trusts, we often get asked, “Can you tell us what good looks like?”. So it was great to see that NHSX is working on this very question, and even better talking about it openly on social media.
When Trust leaders ask us this question they usually are coming from a place of “tell us what the latest technology is” or “paint us a picture of the modern digital hospital”. My response is always the same. We could do that, but is that really what you need?
Historically, digital advancement in health settings has been taken through a predominantly technological lens. The most obvious example of this is HIMMS. But I worry this approach has been pretty unhelpful overall, because as anyone with experience at the sharp end of digital transformation will tell you, it’s not just the technology but the culture, processes and operating model you need to worry about if you want to genuinely change. The risk of painting the picture of an internet-era clinic is that you are not giving a trust any tools to help them get there.
With that in mind, here are some thoughts about what good looks like
Having a clear mission everyone understands. Digital strategies that are 40pages of shopping lists are hard to remember. Make it clear to people what you are trying to do, or they wont come on the journey with you.
Relentlessly focus on your users’ needs. If you aren’t actively focussed on understanding and addressing the clinical, practical, or emotional needs (Ht Janet) of either patients, clinicians, or other staff people won’t use your services and you will never see any benefit.
Talk about services not projects. Services start at go live, projects end at go live. Your digital services should be seen in the same way as any other service you offer- to be supported ongoing, iterated, improved. The NHS Service Standardhas all the advice you need.
Invest in skilled teams – with internet era capability covering not only engineering but product and design, and pair these with clinical and operational staff. Work together, don’t chuck requirements over the fence. And please please try not to design things without some design expertise!
Use modern cloud based technology. Don’t lock into long contracts. Work with suppliers who want to collaborate with you as one team. Stop putting tin in the basement.
Be agile. Focus on the minimum viable product based on valued delivered and iterate when you learn more. Minimum viable governance that is proportionate to the need. Show the thing, don’t hide meaning in 2″ inch-thick board packs.
As a board, be servant leaders. Take collective responsibility for your digital transformation, put it at the top of your agenda. Ensure you have the right technical knowledge in the room where it happens. Unblock things for your teams. Move authority to information not information to authority.
The title of this blog post is ‘What good looks like for digital transformation in health’ but the same principles apply in every sector. None of this is news. It’s all already in the Public Digital book, blog, and in other places like the digital maturity scale my colleagues developed with Harvard Kennedy School. Many of myformercolleaguesand others all around in the health and care system have been saying similar things.
A common picture for what good looks like is beginning to emerge across the NHS. In some places, it is already more than just words – you can see it, and so can patients. But that’s not true everywhere. What comes next must be the harder discussion about what makes good so difficult to achieve, and so hard to scale. Because the answers are likely to be rooted in the topics that all too often fall into the ‘too hard to fix’ category: money and power, legislation and legacy, the rules and tools of the game.
If you’re interested in this work and want to continue this conversation you can find me @e17chrisfleming.
This post was originally published on the Public Digital website.
For the uninitiated, this is the policy response to a challenge teams are navigating up and down the country. Some responsibilities for health and care fall to the NHS, and some things are done by local councils. This can create a mess of misaligned incentives, duplication, and fragmentation.Enter the Integrated Care System (or ICS for short) to help straighten things out.
“In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS care, and improving the health of the population they serve.”
NHSE/I.
NHSE’s proposal aims to formalise the model, putting the ICS reforms on a statutory footing and give them responsibility for planning and buying services. This is an oversimplification, but the move would seemingly repeal aspects of the Health & Social Care Act 2012. For further reading NHS Providers has released a helpful primer.
What the paper says about digital
There are quite a few references to digital in the NHSE/I 40-pager. I’ve extracted them to save you a job.
Starting from the off, there’s a clear strategic intent to put digital & data at the heart of the change. It’s one of a handful of key themes.
“…we will need to devolve more functions and resources from national and regional levels to local systems, to develop effective models for joined-up working at “place”, ensure we are taking advantage of the transformative potential of digital and data, and to embed a central role for providers collaborating across bigger footprints for better and more efficient outcomes. The aim is a progressively deepening relationship between the NHS and local authorities, including on health improvement and wellbeing.”
In addition to this broad strategic intent there are more specific points on digital that are set out as follows:
ICS’s will have an SRO for digital on their boards.
ICS’s will need a digital transformation plan.
There is a responsibility to build digital and data literacy of the whole workforce “as well as specific digital skills such as user research and service design”. And can we just pause for a round of applause for whichever official managed to squeeze that latter clause in. 👏
Introduce shared contracts and platforms including shared EPRs.
Develop or join a shared care record joining data safely across all health.
Build the tools to allow collaborative working and frictionless movement of staff across organisational boundaries, including shared booking and referral management, task sharing, radiology reporting and pathology networks.
Follow nationally defined standards for digital and data to enable integration and interoperability.
Use digital to transform care pathways.
Develop shared cross-system intelligence and analytical functions.
Ensure transparency of information about interventions and the outcomes they produce.
Develop a roadmap for citizen-centred digital channels. NB Not sure why this would be different to the digital transformation plan referenced above, but nevermind.
Roll out remote monitoring to allow citizens to stay safe at home for longer.
What does that mean for local digital capability?
So far so lofty. But what does the team look like that has to be put in place to deliver all of this?
The challenge of doing cross-institution service design in health and care has long been a bugbear of mine and many others. How can you possibly design great services across such a fragmented system? The NHS must be the largest manifestation of Conway’s Law on the planet. So on the face of it I think this reform is A Good Thing. But it will only solve the digital mess if there is also investment in capability at the ICS level to be able to deliver it. The types of people you need to deliver all of the above amounts to really rather a lot of specialist skills. And there are, assuming the website is up to date, 21 ICS’s currently.
Individual trusts, councils, and others will also have their own digital and technology teams. Institutional fiefdoms will still need to be managed, so how to ensure all the relevant organisations have skin in the game and that the whole is greater than the sum of its parts? This will all also need to be executed in the context of national agencies delivering platforms, framework agreements, and inevitable ministerial pet projects.
What should an ICS Digital Team look like?
I guess a lot of this will need working out and no doubt people are on the case as we speak. But my starting points for an ICS digital transformation team would be the following:
Multidisciplinary: it would contain designers (service, interaction, content); transformation experts; product and delivery people, user research; interoperability gurus; data scientists; IG experts (the ones that enable not block); and experts in the management of commercial IT contracts. It would also definitely have some technical architects (not armchair architects, ones that can still write code) and developers.
Empowered, within some well understood and enforced guardrails delivery teams need to have clarity of purpose but freedom to act. There needs to be an agreed patch for sensible service design, and this feels most achievable at the ICS level. Teams should be autonomous to work within that. But there should also be some rules around what gets built or bought, based on the NHS design standard and use of common NHS platforms.
Networked: the teams across the country should all be talking to each other. One of the most brilliant but little-talked-about innovations of the central government digital transformation movement was the cross-government Slack instance. All digital professions in the civil service across the country could instantaneously reach tens of thousands of other experts. A question like “does anyone have experience of translating services into Welsh” would attract multiple offers of help within seconds. Building on the curated communities that already exist like Digital Health Networks need to be turbocharged.
That’s my view at least. I am sure others will have alternatives and I’d really love to hear them.
This post was originally published on Medium on 10 December 2020.
There is a wide and occasionally bewildering array of software used by patients and clinicians in the NHS. This is a short, introductory reference guide to illustrate the range. It is by no means comprehensive so any critique or additions are well received. I hope it’s useful to some.
Clinical system: If you are new to healthcare, one of the immediate things you encounter is the primacy of the clinician and the concept of clinical safety. A clinician is someone with a medical qualification who treats people i.e. a doctor, nurse, paramedic, dentist, pharmacist, or midwife. ‘Clinical system’ is a broad term that is used to refer to the software that supports clinical activity i.e. the act of treating patients in a healthcare setting. When software is considered to be clinical it means it is subject to legislation such as clinical safety standards (as defined under the Health and Social Care Act 2012) or the Medical Device Regulations. This means clinical systems must be able to evidence their safety through testing and by explaining their approach to clinical risk management.
Clinical systems are the bread and butter of healthcare and this is where most of the health IT money goes. They can range from specific standalone systems for a specific purpose like a Radiology Information System/Picture Archiving and Communication System, to care pathway-specific dealing with, say, cancer. A care provider chooses these based on its needs then often integrates them into a core enterprise system, more on which below. There could be over 100 in a given hospital.
Patient administration system (PAS): used in hospitals, this describes the software that manages administration of patient interactions. This includes things like: the hospital’s patient index with patient demographic details, appointment booking functionality, checking patients in and out, scheduling and workflow type stuff, referral management, payments. Notably, PAS’s are distinct from being clinical i.e. they do not typically store or process clinical information about patients. Pretty much every care setting has something akin to a PAS, it’s just that the term is synonymous with hospitals. Because of the way PAS’s in acute settings have evolved to meet very specific NHS-y needs such as national data returns or payment processing, it makes it a niche market with higher barriers to entry.
Electronic Patient Record (EPR): self-explanatory in some respects, as this refers to the digital manifestation of the patient’s healthcare record. EPRs are everywhere, although the term itself is most closely associated with hospitals. This is mainly because in hospitals there is a historic distinction between the care record and the PAS, and because other care settings have EPRs that are already called other things. These days EPR systems often do heavy lifting for both the patient record and various jobs previously undertaken by the PAS, as part of the trend to enterprise approach. EPRs can also go by the name EHR, or EMR. The market leaders in the UK are Cerner and Epic. It is apparently not cheap to install an EPR. Leeds Teaching Hospitals built their own, starting in 2003. Many sensible people on all sides of the political divide think that the patient data layer should be separated from the enterprise applications, and more who suggest it should be nationally owned. This is not going to be easy.
GP IT Systems: these are the main software systems used by GPs, and are really an EPR for the GP setting. They have a whole range of features from appointment booking and management, prescription management, to generation of letters and storage of data. Crucially, they store your GP medical record, allowing GPs to code entries and enter free text information regarding your consultations, conditions or medications. The GP record is particularly important in NHS terms because the way the NHS is structured means it is de facto the main record for your healthcare. It stores correspondence between your GP and hospital or other provider. The systems also automatically pump data to NHS Digital for aggregate, statistical use. There are 4 GP system suppliers in England which are TPP, EMIS, Vision and Microtest.
Clinical decision support system: commonly abbreviated to CDSS, this is a tool that is often embedded as a feature within types of clinical systems. It typically forms a series of questions that can be asked of a patient in order to help a healthcare professional (either clinically trained or not) assess the patient’s condition. You can see a CDSS in action on 111.nhs.uk in which patients themselves access the NHS Pathways CDSS. Pathways’ underlying clinical information makes a risk assessment based on the combination of answers provided. It’s essentially a corpus of medical knowledge with the “one thing per page” design principle applied. CDSS’s can be either for diagnostics or triage. Diagnostics is where the tool is actively trying to suggest possible illnesses whereas triage simply assigns a level of risk to direct a patient to the appropriate clinician or care setting. The former is governed by stricter regulations, but this is a bit of a false distinction in my view as a triage system is still making some guess at what the problem might be, in order to assign a risk score. As well as online, CDSS is used by phone operators e.g. on 111, or at the front door of emergency departments. Very specific CDSS can also exist to support clinicians in highly specialist settings e.g. to help doctors select the right chemo dosage in cancer treatment.
Online consultation systems: these are relatively new on the scene, and are systems in primary care to enable GP-patient interaction to happen remotely. They comprise a number of features that support this. Online consultation is often conflated with video consultation. While the former does encompass video consultation, the terms are not wholly interchangeable because online consultation also encompasses things like form-based triage (i.e. the patient fills in a questionnaire about their symptoms and this is sent to the practice); 2-way messaging between the practice and patient; and symptom checking using a CDSS. Examples are eConsult, Ask my GP, Engage Consult.
Personal healthcare record (PHR): PHR isan umbrella term for a digital healthcare record that is owned and administered by the patient themselves. It’s not clear to me yet how much this term is understood beyond a core group of wonkish types like me who work in digital healthcare delivery and policy. A PHR may combine clinical information from various sources, but crucially they also allow the patient to submit information themselves either through manual data entry or via wearables. NHS Digital maintain a working definition of a PHR on their website. Some examples are Tiny Medical Apps, Patient Knows Best or Apple Health.
Computer Aided Dispatch (CAD): This is the system that supports 999 control centres in the management of telephone calls into the service and the coordination of staff and vehicles in support of the calls. It also supports CDSS modules to help triage calls. Ambulance services will also often have a separate EPR for their patients. As the urgent and emergency care sector evolved as its own sector through the advent of the 111 service, so too did the case management tooling. So now equivalent products are available in 111 to queue and manage calls, undertake referrals, update records and perform triage. And some are used across both 999 and 111. In NHSD we have broadly referred to these as Encounter Management Systems but this is not a widely used term. Examples are Cleric, Adastra.
Internet pharmacies: also known as ‘distance selling’ pharmacies in commissioner language. These are pharmacy services that fulfil prescriptions by delivering them to your house as opposed to requiring you to go to the pharmacist. They tend to have web or native apps that enable you to manage prescriptions accordingly. Examples are Echo, Pharmacy2U.
Patient portals: as much as it pains me to write this heading, this is nonetheless still a term that is oft used in the NHS. It refers to any application either browser-based progressive web app or native app that enables a patient to interact with an underlying clinical system. Usually this is so the patient can see their records, book and manage appointments, and manage their medication. There are a ton of these for both primary and secondary care.
Wellbeing: there is a massive market for wellbeing apps which support everything from diet, mental wellbeing, sleep. For a browse of some examples it’s worth a look at the NHS Apps library. I’ve not really given them the full treatment here because I know little about them and they aren’t typically transactional in the same way the other examples are.
Having set all of this out, a few thoughts on healthcare products.
The boundaries around the different types of products are very fuzzy. e.g you will get PHRs that have some features of online consultation tools; or EPRs that do the work of a PAS. This sometimes makes it hard to know what to buy, and exacerbates the challenge of ensuring interoperability between systems. i.e. it’s a bit confused, in a similar manner to the organisation of our health institutions as I have blogged before.
Somewhat unlike central government departments (in my experience at least) the NHS and its staff are entirely comfortable with the concept of ‘services’. The clue is in the name I suppose. But there is very little discussion of services in the context of digital delivery, except at the national level with things like PDS and e-RS. You rarely hear the term ‘product’ compared to say ‘system’ or ‘tool’, and the closest you get to service is probably ‘digital care pathway’ which is kind of getting there but can miss the real fundamentals.
This proliferation of product types means there are lots of places that patient data can be held, hence the massive focus on interoperability in the NHS, and the importance of point 6 in the Future of Healthcare.
Hopefully this is helpful to digital healthcare workers new and existing. As above, I welcome any additions or comments.
The views expressed here are all mine and not those of my employer. Thanks to Kate Gill for her fact checking and examples.This was originally published on Medium on 1 May 2020.
