What does good look like and who pays for what

The NHS digital agency, NHSX, has published its digital health baseline and funding documents held up by Covid-19 and a change of health and care secretary. Lyn Whitfield looks through them and sums up the initial reaction.

As the health tech community got back to work after the bank holiday weekend, NHSX finally published its much anticipated ‘what does good look like’ and ‘who pays for what’ documents.

The framework and proposals are designed to guide integrated care system and trust leaders on what they should be trying to achieve with digital at a system and at an organisational level, and to address the perennial problem of national funding being chopped up into pots and released late in the year.

However, initial attention is likely to be directed to a new, unified tech fund, which has been set up to roll up and then distribute £680 million of funding between now and next March, when ICSs will be expected to take on the job of drawing up digital plans and funding ‘frontline’ tech.

What good looks like:

WGLL, as NHSX is calling it, is aimed at “NHS leaders” and at making sure that integrated care systems and their “constituent organisations” know what good looks like on the digital front.

Its approach mirrors that taken by the Care Quality Commission in its organisational assessments and is organised around seven “success measures”: well-led, smart foundations, safe practice, support people, empower citizens, improve care, healthy populations.

Each of these “success measures” comes with indicators of how they might be achieved. For instance, well-led starts by saying that an ICS should have a “digital and data strategy that drives ‘levelling up’ [and] is supported by a sustainable financial plan”, that the strategy should have “wide input” and “engage” with “partners, citizens and frontline groups.”

While smart foundations says the strategy should be looking to: include progress towards net-zero; make sure that projects are “cyber secure by design”; simplify architecture; “level up the use and scope of electronic care record systems”; and get a shared care record in place “that adheres to the PRSB core information standard.”

Reaction:

Veteran NHS commentator Roy Lilley used his daily newsletter to describe WGLL as “gobbledegook”. “It claims to ‘provide tools to support your digital transformation journey,” he wrote, “but what journey? It claims to have ‘success measures’ but there are no measurements, no outcomes, no deadline.”

Other commentators were more guarded, while still asking how the document is meant to align with NHSX’s own digital and data strategies. In digitalhealth.net, suppliers lined up to point out that WGLL has nothing to say about the separating data from applications, which is supposed to sit at the heart of ‘data saves lives’.

Nor is it clear what will happen next. In digitalhealth.net, again, Dr James Reed, chair of the CCIO Network, said his question to the centre was: “how do we bring it to life, and make it something that is the way we do things?” He suggested a ‘roadmap’ with specific plans and dates might help.

Other respondents asked how assessment will work and what the impact of assessment will be. CQC assessments lead to ‘star ratings’ and intervention if an organisation ‘needs improvement’ on a sufficient number of criteria. There’s no indication that NHSX is planning anything similar.

In fact, NHSX chief executive Matthew Gould told the Health Service Journal that he wanted a significant element of “peer review” to stop organisations using self-assessment to “game” the system to get funding – which didn’t go down well with the magazine’s readers; who also described the document as “patronising” and “woolly”.

A more fundamental strand of criticism is underneath the process elements (all that “input” and “engagement”) what NHSX thinks good looks like really doesn’t look all that good. NHS England ran a global digital exemplar programme to get a handful of trusts to the top of the HIMMS EMRAM maturity model, with the intention of helping others to follow on.

WGLL talks about “levelling up the scope of EPRs” in terms of “greater clinical functionality and links to diagnostic systems and EPMA”; important, but hardly ground-breaking or likely to inspire trusts well ahead of that game.

Similarly, NHS England ran a LHCRE programme to create sophisticated shared care records that could underpin population health management. But, with its focus on the PRSB core information standard, WGLL is focused on a read-only, hospital to GP link.

Vendors should still read WGLL, however. It’s 94 points will give suppliers plenty of ways to show that they are aligned with its requirements. And it usefully lays out the basic behaviours and core standards that will be expected from SMEs and new entrants to the market.

Who pays for what:

Who pays for what is different to WGLL. It starts by describing a set of problems that NHSX wants to fix.

These are: that healthcare funding, with its mix of national and local pots and endless bidding for projects, is “too complex”; that NHS policies and funding mechanisms can impact on digital projects (for example by creating disincentives for trusts to back hospital diversion or remote care initiatives); and that there is no good way to measure what is being spent on digital and what benefits it is delivering.

The document says NHSX will address these problems in two phases: the first running from now until the start of the next NHS financial year, and the second covering the final year of the current Parliament “onwards”.

In 2021-22, it says NHSX will mostly address the funding issue, by creating a unified tech fund; although it will also do some work on benchmarking and spreading best practice.

In 2022 to 2023 and into the next Parliamentary term, the document says ICSs to fund their own tech plans, while it national money is focused on national infrastructure and software, such as Office 365, and national products, like the NHS App.

In addition, NHSX will take “oversight” of ICS plans and make sure they are aligned with WGLL and NHS operational imperatives, which will shift incentives away from contracting and payment by results to ‘system by default’ thinking.

A final section of the document covers off some other things that NHSX will be looking to pay for, including compliance with standards, uptake of established technologies, and new ideas in remote management and AI.

Unified tech fund prospectus:

The prospectus lays out more detail on how the unified technology fund will operate. It says it will bring together “several national technology funds” that add up to £680 million. There is a streamlined bidding process for this money, which will close next March.

The prospectus says the priorities are to: “level up the digital maturity of NHS trusts”, to get a ‘basic’ shared care record in place at all ICSs, to sort out cyber security, to invest in productivity and diagnostic tools, and to support the digitisation of named sectors, such as maternity and child health.

Some high-profile projects with digital components, including the digital pathway transformation and the New Hospital Programme, are excluded.

Commentary:

There has been less reaction to who pays for what than to WGLL, which is surprising because it both clarifies the money available for digital this winter and signals a significant shift in the way health tech will be funded in the future.

None of the money in the unified tech fund is new, but integrated care systems, trusts and vendors have been given a tight timescale for accessing it. That could trigger a scramble to access the cash that IT teams and their suppliers could probably do without as the NHS looks to ‘repair and reset’.

After that, who pays for what is pretty clear that it will “simplify” health tech funding by expecting ICSs to pay for pretty much everything that isn’t national infrastructure, national software, or a national application.

The document’s own list says this includes: cloud services and data centres; electronic patient records; core kit such as laptops and printers; cyber security; IT programme management, training, and service desks; and “system transformation, for example shared care records.”

In some ways, this is a sensible development. Many commentators, including the Highland Marketing advisory board, have argued that national funds, set up in response to ministerial enthusiasms, can distort local priorities, and that ICSs and trusts will be more willing to invest in technology that delivers a clear policy, business or clinical benefit to them.

On the other hand, the list of what will need to be paid for implies a significant level of spending, and we simply don’t know if ICSs will have the funding settlement to do that.

Who pays for what says “ICSs will be expected to fund the delivery of their tech plans from their own budgets, the total envelope available to ICSs and their constituent organisations” – and even with a generous funding settlement there will be a lot of calls on that cash.

It also seems likely that some ICSs and their providers will be more enthusiastic about putting money into digital than others, so the new arrangements could entrench digital variation across the country rather than encourage “levelling up.”

Who pays for what hints that NHSX is aware of this and it is one reason for the agency to have ‘oversight’ of ICS plans and to be able to check them against operational plans, WGLL, new digitisation targets, and new digital benchmarking tools. However, for this to be effective, WGLL will have to become a lot stronger than it is at the moment; not least because the targets and benchmarks have yet to be developed.

In all of this, the bad news for suppliers is that they will still need to influence organisations at a national, ICS and provider level to win business; and there doesn’t seem to be a role for industry in defining the art of the possible, what good looks like, or where the targets and benchmarks should be set.

Who pays for what does give a fillip to the standards agenda, however. It says the use of standards for interoperability and cybersecurity could be enforced by: incorporating them into CQC inspections; excluding vendors that don’t comply from framework contracts; and publicising vendors with good and bad practice – all measures that vendors committed to open standards have been suggesting for years.

Note: NHSX is asking for feedback on the who pays for what proposals, and has provided an email link for thoughts on the document.