Advisory board round table: NHSX

Ninety days on from the publication of the NHS Long Term Plan, the health service has seen some structural and legislative changes – and the announcement of NHSX. At its April meeting, Highland Marketing’s advisory board discussed its potential impact.

The NHS Long Term Plan was published on 7 January, with a chapter devoted to IT. Just over a month later, the Department of Health and Social Care followed-up with a tech announcement. Not a strategy to implement chapter five, or more funding; but the creation of a new body – NHSX.

The DHSC’s official announcement, issued on 19 February, described NHSX as “a new joint unit” with its own chief executive that would report to health and social care secretary Matt Hancock and the chief executive/leader of NHS England/Improvement, Simon Stevens.

It also set out a wide range of responsibilities for the new organisation, including: “setting national policy”; “developing, agreeing and mandating standards”; making sure technologies like the NHS App “are designed so trusts and surgeries don’t have to reinvent the wheel”; making “source code open by default”; and reforming or developing industry relations, procurement, security and training.

Another body to do NHS IT?

Despite this, Andy Kinnear, director of digital transformation at NHS South, Central and West Commissioning Support Unit, told Highland Marketing’s April advisory board meeting that its remit may boil down to something simpler.

“Hadley Beeman [Matt Hancock’s chief technology advisor] has said there are two drivers,” he said. “At the moment, decision making is too fragmented and the speed at which the NHS can access innovation is too slow.” If NHSX could “make progress” with those two issues, he added, “we should be fairly pleased” with it.

NHSX may have its work cut out. Its only appointment so far is Matthew Gould, a former ambassador turned digital tsar at Hancock’s former department of Digital, Culture, Media and Sport, who became chief executive-designate at the start of April.

However, Will Smart, Simon Eccles and Tara Donnelly, the CIO, CCIO and interim CDO of NHS England respectively, are expected to transfer to the new unit when it becomes operational in July. That would seem to put the DHSC and NHSE/I on the front foot, and to raise a question mark about the future of NHS Digital.

Except that NHS Digital runs a load of critical infrastructure, has led on NHS standards work to date, and is recruiting like mad to open source initiatives; which suggests it is going nowhere fast (at Digital Health Rewired, Beeman said its future was “solid”).

Nor is NHS Digital the only organisation that has been tasked with ‘doing’ NHS IT and then parked when things got tough; there are plenty more bodies with tech responsibilities hanging on out there. NHSX will have to be powerful and adroit to cut through the noise without adding to it.

Or, as Kinnear put it: “The question is whether Matthew Gould will get this slick, new organisation – or find himself bashing his head against the same-old dysfunctional organisation, poor culture, legacy stuff.”

Also, Kinnear pointed out, there are at least four engines that should drive health tech. The NHS central bodies, and organisations like NHSX are just two of them. Local organisations, from commissioning support units to trust IT departments, are also important, as are innovators and vendors. “If NHSX could orchestrate all of these, it would do a useful job,” Kinnear said.

“But it would mean asking some difficult questions; like why so much money goes on national projects, or why there is so much variation in capability and approach at a local level, or why vendors come up with great stuff and then find it impossible to sell into the NHS.”

Flying the flag for standards

Since his first days in the job, Hancock has asked a different question: why don’t NHS IT systems talk to each other? And he has given a consistent answer: they don’t use “interoperable data standards.”

NHSX will pick-up on this by ‘mandating’ standards for use in NHS IT systems. However, the NHS has been trying to get the NHS Number used as the primary identifier in its IT systems for twenty years; and mandating this or, indeed, writing it into law, has not done the trick.

As advisory board chair Jeremy Nettle pointed out in the Health Tech Newspaper shortly after the meeting, the issue is compliance. And it’s not just suppliers that need to comply, however often Hancock and his advisors imply it by saying companies that don’t get with their programme will not be doing business with the health service in the future.

If anything, Nettle pointed out: “A lot of effort has taken place within the supplier community, with the formation of INTEROPen and the development of HL7’s FHIR standard [and] that has been supported by NHS Digital and some clinical bodies.” What is missing is “demand from the health and care system itself.”

“Attempts have been made to mandate interoperability in many health IT procurements,” he added, “but, sadly, without any conditional payment incentives the exercise becomes more of a tick-box than a mandatory requirement that is then qualified in testing.”

Finding a baseline for the local engine to run on   

At its meeting, the advisory board felt that one thing NHSX could do to make a difference would be to baseline digital maturity at both trusts and healthcare communities.

Cindy Fedell, the chief digital information officer of Bradford Teaching Hospitals NHS Foundation Trust, argued that this would identify organisations and areas that had made progress; identify those that were struggling or had gaps, and enable issues to be addressed through a combination of support, blueprinting, and targeted procurements.

“We have all been discussing NHSX as if it is going to be another, stand-alone IT body, and that is the problem with NHS Digital – it sits apart from the rest of the NHS,” she said. “We need to get it aligned with day-to-day business, and with the transformation and integration agendas.”

When Hancock’s predecessor, Jeremy Hunt, secured Treasury-backing for his ‘paperless’ vision, NHS England tried to run its own digital maturity assessment of trusts to support investment decisions and “knowledge sharing” between organisations facing similar challenges.

The local digital roadmaps that sustainability and transformation footprints were subsequently asked to draw up were supposed to use the assessments to agree local tech priorities, while getting into information sharing and the new digital services piece.

Fedell argued that neither initiative had got far, because neither had been repeated, and neither had adopted a recognised methodology. Since then, she pointed, out, HIMSS EMRAM has been adopted by the global digital exemplar programme and become far more familiar to NHS trusts generally.

Kinnear added that HIMSS is now working on a Continuity of Care Model, to measure the digital maturity of health systems and to support co-ordinated care; and at least one English city is about to trial it. “This stuff can be measured, so we should be measuring it,” he argued.

“If I was leading NHSX, I would ring up HIMSS and KLAS Research [which measures satisfaction with vendors and systems] and get them to assess everybody every couple of years. Then we’d have a benchmark. Then NHSX, or NHSE/I, or the new regional directors, could sit down to talk digital and have something to talk about.”

Managing for change

Since the NHS Long Term Plan was published, there have been some structural and legislative changes to the health service that are designed to drive its implementation. Since April, NHS England and NHS Improvement have been “working as one organisation”, with a single chief executive/leader in Simon Stevens.

The regional directorates established before Christmas have been bolstered with additional appointments; and Stevens has confirmed that he wants to see integrated care services set up on the same footprint as clinical commissioning groups.

However, there are some uncertainties, such as whether the regional directorates and ICSs will be ‘outposts’ of NHSE/I or have some local autonomy – possibly as statutory bodies in their own right.

Stevens and outgoing NHS Improvement chief executive Ian Dalton told the Commons health and social care committee that they were reluctant to go down this route, because they wanted to avoid another ‘top-down’ reorganisation of the NHS – and there is no Parliamentary time for one.  

But the advisory board felt the sheer fragmentation caused by the Lansley reforms couldn’t be left unaddressed. Also, that NHSX and its agenda need to be plugged into an effective national and regional management structure.

As Andrena Logue, the founder of Experiential Health Tech, which has just formed an alliance with Highland Marketing to offer analysis and consultancy services, said: “Doesn’t this all come down to power? If a trust or a healthcare community is struggling with digital, then who is going to sort that out?”

Or, as Kinnear put it: “In the days when a regional director could give you a roasting for something, you’d sort it.” And: “We probably need to get back there. But we need to make [any IT interventions] evidence-based.” Hence something like HIMSS EMRAM.

Logue argued there was also a developmental aspect. “This is also about investing in trusts and their people,” she said. “If another organisation has done something good, then the question is: how can we help you to do the same?” Nettle argued this is where the GDE and LHCRE footprints should come in.

“They are meant to be about how a trust has implemented and demonstrated the benefits to patient care,” he pointed out. “So why shouldn’t another trust be proud to pick up on that, and not replicate any pitfalls in doing so?”

One x, many whys

Overall, the 90 days following the launch of the NHS Long Term Plan have felt positive. As Kinnear said, even if there have been few concrete developments so far, “there has been a mood change” and local organisations are starting to engage with the plan’s agenda.

In the healthcare IT space, the announcement of NHSX is a bold move that has caused considerable interest. But the board felt that if it is going to have an impact, it will need to align itself with that mood change and work out how to get IT embedded into NHS structures and processes.

To date, Hancock and his advisors have focused on innovation (Hadley Beeman has suggested it could set up its own ‘skunkworks’ and ‘regulatory sandpit’) and interoperability through ‘mandated’ standards. But the NHS already has innovators and standards bodies.

What they need is a mechanism to drive tech down to trusts, out into healthcare communities, and onto the front line. Hence the suggestion that it should focus on base-lining digital maturity, using recognised, international models, and aligning with emerging national and regional structures to focus attention on digital laggards.

Fedell suggested this might mean a stronger focus on IT at regulators such as the CQC, as well as at the new regional directorates. “Our whole way of doing digital in the NHS is not mirrored in our central and regional bodies,” she said. “We are going to have NHSX, but I think we need regional chief information officers.

“Trusts are being told to put IT people on their boards; the regional directorates need to do the same. Then, they need good evidence, so they can go out and challenge trusts in a constructive way. That means using something like the HIMSS model, because you can’t fudge HIMSS. Put all that together, and you might see some real change.”  

Key points:

• The NHS Long Term Plan was published on 7 January and has been followed up with structural changes to NHS England / NHS Improvement and its regional directorates and legislative proposals to undo elements of the Lansley reforms.
• The Department of Health and Social Care has also announced the creation of a new unit, NHSX, to report into the DHSC and NHSE/I on health tech, and to streamline policy making, standards setting, innovation, industry relations, procurement, training and cyber security.
• Hadley Beeman, the strategic technology advisor to health and social care secretary Matt Hancock, has indicated that NHSX’s first priority will be to ‘mandate’ standards. However, the advisory board noted that this approach has been tried before, with limited success.
• The board also argued that one of the barriers to adopting standards compliant systems – or IT systems of any kind – is demand from NHS organisations. It suggested NHSX should stimulate demand by using international maturity models to baseline local IT, so gaps and weaknesses can be addressed through targeted procurement and support.
• To make this approach effective, the board also argued that NHSX will need to align itself with the emerging national and regional structures of the NHS. Also, that they will need effective chief information officers to hold constructive discussions on IT developments.