An alternative (re)view of NHS Digital and NHSX
- 13 November 2020
In a column for Digital Health News, David Boyd (an alias), provides some suggestions for the upcoming Wade-Gery review of NHS Digital and NHSX.
In July 2018, the NHS tech community widely welcomed the appointment of Matt Hancock as the Secretary of State for Health and Social Care. They saw Mr Hancock as someone who ‘got’ tech and who would prioritise the digital agenda. After all, he not only had his own app but was planning to attend the upcoming Conservative Party Conference as a 3D hologram.
He got off to a rapid start. Within weeks he had ‘axed the fax’, ‘purged the pager’ and published his Tech Vision for Health and Social Care.
In early 2019, as the NHS published its Long Term Plan, Hancock announced his plans for NHSX. This new digital unit would bring together the policy, implementation and change levers in one organisation reporting to both the Secretary of State and NHS England.
On 1 July 2019, NHSX was born. However, rather than simplifying the national landscape in relation to policy and delivery, we have seen organisations jockeying for position, that has created more confusion about the relative roles of NHSX, NHS Digital and the NHS England/Improvement regional teams.
Just one year later, Laura Wade-Gery has been commissioned by the Secretary of State to “determine the critical capabilities and digital operating model across NHSD, NHSX and NHSE/I”. A review that has, so far, spent at least £588,000 with McKinsey and Company.
We are yet to hear the conclusions of the review so, while we are waiting for the official version, I thought I would offer three recommendations of my own for the review team to consider. These focus on Purpose, Structure and Resources.
Purpose
The first-order question for the review must be to clarify the purpose and function of national technology leadership.
Simon Wardley has described the process of innovation as comprising three groups:
- Pioneers – those who create new ideas and ways of doing things;
- Settlers – those who take these ideas and make them useful and applicable; and
- Town Planners – those who industrialise these ideas and move it to ubiquity
In my view, the role of the national digital team is to operate as ‘Digital Town Planners’. They must set out a vision for the future, creating a ‘target architecture’ for a digitally-enabled health ecosystem, setting priorities for action (along with clearly defined outcome measures) and determining the mandatory standards for the service.
Their objective is not to create press moments for the Secretary of State, but to support local health and social care organisations to build a sustainable service model, underpinned by digital tools, that will deliver improved health outcomes for their populations.
There are, of course, nationwide digital services that will be required to enable the NHS to operate effectively as a national service, or that need to be delivered at scale, such as the National Cyber Security Operations Centre, the Spine, national statistics and reporting etc. These should continue to operate nationally under a Service Level Regime accountable to the local NHS via NSHE/I’s regional offices.
Structure
Form follows function. Consequently, there should be a single organisation nationally responsible for the delivery of digital services. NHS Digital and NHSX should be merged to create a single organisation fully accountable to the NHS.
This new organisation should be part of NHS England/Improvement rather than existing as an arms length body under the Department of Health and Social Care, with its leader being a member of the NHSE/I Board – in line with the requirement set out for local organisations in the NHS Long Term Plan. If digital is to be truly at the heart of the NHS’ new operating model, it must, in practice, be a central and integral part of the NHS’ national agenda, not something that sits ‘to one side’ in a technology at arms length body.
The current national arrangements are, in reality, the ongoing legacy of the National Programme for IT (NPfIT). They place digital to one side of the NHS’ operational and strategic agenda, allowing leadership across the NHS to see tech as ‘someone else’s problem’. This review offers the opportunity to make the necessary paradigm shift.
Resources
Resources should, as a matter of course, be devolved from national bodies to Integrated Care Systems (ICSs) via the NHSE/I regional teams. These resources should include both people – some great people are working in NHSX and D today – as well as money.
It is not sensible or appropriate that the national team acts as the gatekeeper of digital investment. This approach creates perverse incentives in the system that delays necessary investment while local boards wait in the hope that national funding will be made available.
Finally, there must be an explicit expectation on the de minimis level of expenditure on technology in the service. The current 2% is woefully inadequate if we are to create the digital infrastructure and underpinning systems and services necessary to enable the service to operate in the new, post-Covid, world. However, any additional local investment must demonstrate a return. This will require a strong focus on the measurement of outcomes and an ongoing focus on service blueprinting and adoption. What matters is what works.
12 Comments
The big problem is Adrian that the IT baggage that will come across with it is NFFP (not fit for purpose. If you see a transcript of Matt’s speech Sept 2018 you will find that little or none has been delivered except prohibition of pagers and faxes. Covid is no excuse. In a battle, if a leader is ‘unavailable’, someone else takes over. I the NHS people live or die by IT and letting it slip is negligence. Matt, if this comes to your attention, I’m available and with 50 years IT experience, have knocked together 2 plans; one for digital transformation which, unlike your 10 year plan (and the 40 that preceded it), mine could work and the other one for that eternal problem, ‘interoperability’.
NHS-IT moving social care into the digital world – your’e having a larf I hope.
Getting its own house in order will be a good start; Leaving it up to ‘them’ to ‘sort-out’ social care IT would be an unprincipled act of faith, based on poor precedent.
At a guess, there’s probably only around of 50% of Adults Social Care activity ‘linked’ to the NHS, and perhaps around 30% of Children’s Social Care similarly. But its nice of ‘them’ to think about us, but i think we are probably ok working it out for ourselves, although it would be nice to have some of your IT money to help us with this, i’m sure we will spend wisely.
I would hope that local Trusts and Industry will be able to contribute to the review and any future options. This will ensure the realities on the ground are fully considered. Input and buy in from Industry will also be critical to make future plans a reality.
Great article ‘David’, be nice to see given a role in creating this optimistic model of a better future for those trying to deliver digital transformation at the frontline 🙂
The problems of the current digital model are exacerbated by the car crash Lansley’s deranged thinking created at local & regional level too so I’d welcome your recommendations alongside the abolition of CCGs and official abandonment of commissioning in favour of formalised ICS model built on culture of collaboration.
Finally a set of expectations on digital leadership that underpin a new true profession where digital leaders are expected to attain and retain a licence to practice just like the medical and nursing and accountancy professionals we work alongside 🙂
2% de minimis level of expenditure on technology is clearly inadequate to create a digital infrastructure, but whatever the right figure, an even bigger % will be needed for implementation and scaling. As always the danger is this will be an afterthought.
Great piece “David Boyd”. To ” purpose , structure and resources” I’d add a 4th key element – culture. The toxic culture of NPfIT is alive and well and thrives in a centre that is the gatekeeper to a staccato funding regime that feels more like patronage than fair distribution to the front line people actually delivering the NHS’s IT systems. The redistribution of central funds and excellent folk to the regions would be a good start.
However, the cultural revolution required wont be complete until you feel you can ditch your pseudonym. If I was your age and still had a mortgage to pay I would also use a nom de plume.
Joe, I think you know I have already ‘written’ my report on this matter in 100 comments across many articles. Each ‘grand plan’ is like the 50 pre- and co-dessessors, which I have documented elsewhere, and in which they promised, in star-gazing detail, NHS nirvana but never delivered. The odds on plan 51 working are small – take the plans to a bookie and ask for odds, then put a grand in them.
It never seems to amaze me how this juggernaut keeps blundering on despite MP brickbats and PAC’s scathing reports (Meg Hiller for e.g.) .
I have a substantial mortgage to pay! I am autistic! I am health technical (not clinical, not managerial and defo not health political) in the field of H&SC the NHS is the very wealthy player – can I say that? iCARE
Yep, the NHS is wealthy but not on the front lines!!! Let us be HONEST together!!!
Joe, what was toxic about the culture of NPFIT? The top-downness? Or the pushiness of R Granger?
To me , a geriatric patient, nothing is more toxic than the bottom-upness which succeeded NPFIT ever since. This bottom-upness has left the four London hospitals which have treated me for two potentally fatal conditions unable to communicate electronically with each other or my GP. (Only in Joe’s kingdom oopnorth can the hospitals talk to each other.)
Expenditure on ‘tech’ is not a measure of success but deliverables are. What did the NHS get for the £12 bn. it blew on NPfIT? No, money should only be assigned when the recipient(S) spells out, in full detail (‘he’ would have to in industry) and offers to fall on ‘his’ sword on failure to deliver. The deliverables should be checked independently for feasibility, granularity, timescale etc. before a single £ is handed over.
I would happily supply the swords (and take part in the checking if asked nicely). Just state how many swords are required.
While agreed with much of the commentary I do worry about what happens to NHSX’s remit to also move Social Care into the digital world.
By having a remit for health and care it provides at least some hope that greater joined up and integrated digital solutions solutions will becone the norm.
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