What now for the Wachter have-nots?

Mental health and community trusts, and primary care are asking ‘what about us’ following the announcement of the hospital exemplar programme.

Six weeks ago, a bonanza was announced for twelve lucky hospital trusts, each of which has been given access to a £100 million pot to become a ‘global digital centre of excellence’.

That £100 million represents all the central money available to local NHS trusts for IT this year. A review of the £4.2 billion that health secretary Jeremy Hunt announced for the next five years is now underway. So, for everybody else it may be jam tomorrow, or possibly none at all.

Causing uncertainty

It looks as if there will be at least one more round of exemplar trusts. This will presumably take in a few that didn’t make the first cut, such as Cambridge University Hospitals NHS Foundation Trust – a would-be global leader with its Epic implementation that is currently stuck in special measures.

But the centre may well say that it will be up to Sustainability and Transformation Plan areas to set local priorities in future years. And, of course, it has past form on ram-raiding IT funds to help meet deficits or winter pressures.

In 2015, the Treasury carried out an audacious daylight smash and grab on the much vaunted £240 million ‘Integrated Digital Care Technology Fund’ or tech fund 2, slashing it to just £43 million. 

Given the level of uncertainty, it is small wonder that so many have-not hospitals and sectors are thoroughly cheesed off. When finances are so stretched, who’d want to be at the back of the queue for investment funds that may or may not materialise? 

Sending mixed messages

It’s not just about money, although that sure helps. It’s the message that prioritising a handful of hospitals over the rest of the system sends out.

It’s not exactly in line with the joined-up, collaborative, patient-centred care delivered outside hospitals vision of the ‘Five Year Forward View’ plan to close a £30 billion funding gap by 2020-21.

Nor is it much in line with the data-driven, transparent, digital patient agenda of the follow-up IT strategy, ‘Personalised Health and Care 2020’.

When everybody has been busily working away to develop Local Digital Roadmaps to deliver PHaC2020 –  sorry make that STPs to deliver the Forward View – prioritising investment in electronic patient record systems that operate essentially within the walls of a single organisation seems like an odd decision. 

They are important, but so are a lot of other areas crying out for investment. The reason that this has happened, of course, is that Hunt picked up a copy of Dr Bob Wachter’s book ‘The Digital Doctor’.

He then commissioned Dr Wachter to carry out a review of NHS IT and the lessons to be learned from the US experience.

Dr Wachter, a hospital specialist, who is said to have taken on the role only reluctantly, brilliantly did exactly the job asked. The report by the review team that he led provides a really good advice on dos and don’ts for successfully implementing a hospital EPR. 

The full report should be required reading for everyone working on digitising a hospital. But it has little to say about the world outside the hospital walls because that wasn’t what it was asked to look at.

Alternative exemplars: sharing

Delivering the integrated health and care aspirations of the Forward View will require what Digital Health columnist and BCS Health chair Andy Kinnear describes as an end to ‘organisation centric thinking’.

So what could have been done, and what might yet be done, to have a better chance of achieving this joined up, integrated approach?

An alternative programme of exemplars would focus on the world of health and care outside hospitals.  It would centre on a dramatic acceleration and up-scaling of the leading integrated digital care record projects around the country. 

Few of the leading pioneers of shared and integrated records – be they in Hampshire, Bristol, Leeds, Cheshire, Liverpool, London, Birmingham, Manchester or Salford – have reached the scale required to radically alter the way care is planned and delivered.

Targeted, national investment in ‘exemplar’ communities that have worked through the headaches of governance and got local partners to commit could make a very significant difference.

With a major shared records project typically coming in at a few million pounds, even a relatively small pot of money could go a long way. Resources could also be targeted at building new regional structures and organisations required to achieve wider-scale record sharing. 

The models from the US for this would be Regional Information Organisations or Health Information Exchanges. The technology required is secondary to the ability to build a team able to galvanise partners to achieve transformation across a city, county or region.

Alternative exemplars: digital patient services

A second alternative set of exemplars would be in digital patient services, built around personal health records that place patients in control of their data, transactions with health and care services, and personal health advice. 

Again, for all the attention the area has received hardly anyone is doing this at scale.

And there is a world of difference between the technical ability to do something, that has been the focus of so much effort in primary care, and the ability to provide services that are sufficiently compelling to make patients, family and carers clamour to use them.

Just as there are pioneers in shared and integrated records, there are projects to build on here. In the NHS they include the patient records developed by Southampton University Hospitals NHS Foundation Trust and University Hospitals Birmingham NHS Foundation Trust.

There is also a ‘test bed’ programme up and running, backed by NHS England chief executive Simon Stevens, and involving industry groups and suppliers.

(Digital Health reporter Laura Stevens reports this week from Guildford, where Surry and Borders NHS Foundation Trust is doing interesting things with the Internet of Things).

But much expertise also lies with suppliers such as Emis Health and TPP, with platform providers such as Microsoft and Google, and with new entrants such as Patients Know Best. Independent healthcare providers ranging from Nuffield Health to Pharmacy2U and Babylon or Dr Now will also have ideas.

Divide may not mean rule

Right now, there is a stark divide between a small number of haves and a large number of have nots.  But even being an acute exemplar may not turn out to be a bed of roses. 

For a start, each site has to commit match funding, which some may struggle to do without some very deft accounting. The hyperbolic ‘global digital centre of excellence’ moniker is also a little overblown. 

Unfortunately, £10 million only buys so much digitisation in a big hospital trust. Remember Cambridge budgeted £200 million for its eHospital programme, with most of that going on infrastructure and staff.