In 1998, a year after the last Labour landslide, the NHS Executive published ‘Information for Health: An Information Strategy for the Modern NHS 1998-2005’. Among other things it promised lifelong electronic health records for every person in the country, round-the-clock online access to patient records and seamless patient care through GPs, hospitals and community services sharing information.
While the technology at our disposal has changed immeasurably since 1998, the 10 Year Health Plan for the NHS in England, published today by the Department of Health and Social Care, has similarly and necessarily bold ambitions at its heart, including a much-needed shift from analogue to digital. Alongside a commitment to making all hospitals fully AI-enabled and a range of enhancements to the NHS App – including to enable remote mental health support – we also see a familiar commitment to a single patient record for all citizens.
There have been some tremendous successes with respect to digitising the NHS over recent history. The NHS App records over 50 million sessions per month. Platforms like NHS login take the pain out of signing on to multiple consumer systems, alongside the App itself. Some trusts have been paperless for many years, and have been able to optimise pathways for safety and convenience. The OneLondon shared care record and care plan now provides a single digital view of important health and care information supporting faster, safer decision-making.
But one question that remains is: if the goal of a digital NHS has existed for nearly 30 years, a time in which compute and storage has become faster and cheaper beyond comprehension, why can we walk into many NHS trusts around the country and see paper everywhere, double keying, endless logins, endlessly spinning cursors of doom? It’s certainly not for the lack of ambition or strategic attention; every government since 1997 has pinned its hopes on NHS digitalisation. Neither has it been a lack of investment, with countless billions spent on NHS technology in that time.
I have spent years leading digital change and transformation programmes and looking at the lessons of successful and unsuccessful attempts at NHS digitisation. It has made me immovable in my view, and as The Future Governance Forum regularly argues, that the ‘how’ of delivery and execution is as important as the ‘what’, if not more so. The lessons learned from decades of failed technology-enabled change are incredibly well rehearsed. Indeed Public Accounts Committee (PAC) reviews of the aforementioned 1998 strategy document them pretty well.
“End users must be identified before the project commences so that their needs are taken into account fully during design and development of IT projects.” PAC report into An Information Strategy for the Modern NHS 1998-2005.
But these lessons bear repeating often, because the evidence strongly suggests they have still not been widely internalised either by governments or indeed by many other large organisations from around the world. The NHS has seen many high-profile digital failures: just a couple of examples include the imposition on clinicians of ill-suited software under the National Programme for IT, or the data sharing programme care.data.
Here are five things the government needs to do, to successfully deliver the digital commitments in the 10 Year Health Plan:
- Be bold, ambitious and focused on the problem you are trying to solve, but accept that the solutions needed may vary. Building a new piece of technology is not an outcome. The outcome is: better care, thanks to a health worker’s ability to make decisions on the best information, based on having that information at their fingertips. Although technology is important, it’s the culture, process and operating model change that will truly drive this outcome. You will need to spend at least as much on ‘change’ as you do on the technology, even if you design that technology for maximum efficiency of adoption.
- Start small, test and learn, move fast. AI adoption and the move to a single patient record are opportunities to radically rethink the NHS technology approach, moving it to a modern suite of tech suitable for the internet era. But this is a truly massive undertaking. Up-front design based on untested assumptions and a big bang mentality is the pathway to ruin. There are mountains of good work and knowledge out there already to build on. De-risking this should involve letting go of the ‘one system to rule them all’ approach – instead build things which can work well together.
- Fix the basics. There is no point in designing a bullet train if you don’t have railway tracks to run it on. For the NHS to get any benefit from the technology in front of them, the absolute first thing is to have wifi that works in all corners of the estate, computers that don’t take five minutes to boot up, and an operating system that provides half-decent cybersecurity.
- Give equal voice to policy, operations, clinical, technology and design. Policy decisions in the absence of technical advice can create millions of pounds of unnecessary waste. Perfect technology blueprints don’t survive contact with the reality of the mess that is the NHS. The most senior clinician’s view does not represent what patients need practically or emotionally. I’ve seen the effects of all of this up close. The key is to embed true multi-disciplinary working from the top level leadership all the way through to the delivery teams.
- Think long term. Some vendors will have solutions that claim ‘out of the box’ functionality to support the 10 Year Health Plan’s goals. This will appear extremely tempting in the near term especially as the desire for political wins and announceables will be relentless. But in 10 years’ time, who do we want to have custodianship of that data, and how have we made sure that the NHS retains the levers to effect change and set its future direction? This also creates monopoly and oligopoly markets. The lessons of the GP primary care market over recent years ought to be warning enough against this strategy.
People have been trying to solve the challenge of NHS digitisation for more than 30 years. While technology has evolved a lot in that time, the way the NHS thinks about tech – how it builds, buys, manages it – has not always kept pace. While the rest of the world has ridden the wave of digital era technology success, the NHS has often poured endless money into a failed model of technology. To achieve the ambitions of the 10 Year Health Plan, the NHS has to change how it fundamentally thinks about technology, to take advantage of the ability to test, learn and grow successful national scale services.
