Among the many announcements made at the NHS Expo in Manchester this month, one marked a major departure in the bid to deliver a paperless NHS by 2020.

While the government has previously targeted NHS providers with both responsibility and funding for digitising their patient records, attention has now shifted towards commissioners. Suddenly, it is clinical commissioning groups that are supposed to be the driving force behind the ‘information revolution’.

The commissioning board turns to commissioners

The move has a certain logic, in that it fits with the overarching ambition of the latest NHS IT framework, ‘Personalised Health and Care 2020’, to support the ‘Five Year Forward View’.

This plan, issued by NHS England chief executive Simon Stevens last October, calls for additional funding, a new focus on public health, and new models of care delivery to help close a £30 billion funding gap that could otherwise open up by 2020-21.

The new models of care rely on greater integration between care settings, with some ‘vanguard’ projects going further and taking on both commissioning and delivery functions, to integrate health and care budgets.

All of this will need to be underpinned by the interoperability of healthcare records, so staff have access to far more patient information, and planners access to far more sophisticated data, than they have at the moment.

The IT framework promises that: “All patient and care records will be digital, interoperable and real-time by 2020”; with an interim target to deliver paperless working at transitions of care by 2018.

New guidance on delivering this vision says it is CCGs that must decide the steps to be taken in their local area to achieve this.

It says the “seeds were sown” for CCGs to undertake this role in the 2015-16 Planning Guidance, CCG Assurance Framework, and GP IT Operating Model. However, those contacted by Digital Health News say the move came as a surprise.

Tight timescales

Beverley Bryant, director of digital technology at NHS England, explained the decision at the Expo by saying CCGs have been chosen to lead on ‘digital roadmaps’ because they are best placed to manage the health economy and keep the spotlight on interoperability.

England’s 209 CCGs certainly have their work cut out for them over the next six months. The first milestone will be to define their local health economy, and report back to NHS England on “who is in their gang?” – as Bryant put it.

Each group must complete an online template defining the ‘footprint’ of their digital roadmap – the providers covered – by the end of next month. 

By November, CCGs and healthcare organisations will need to tell the centre where they are now in terms of their digital capabilities, which will feed into a new digital maturity index, to be completed in January 2016.

Planning guidance for the digital roadmaps is also due to be published that month and the roadmaps themselves are to be submitted by next April, in time to be published in June 2016.

Chairman of the British Medical Association’s GP committee Dr Chaand Nagpaul believes this is a “very tall order” for CCGs, which are already under considerable strain with the advent of co-commissioning and the need to prepare for winter pressures.

“It’s an extremely ambitious time frame. We are finding that CCGs are having an escalating level of responsibility passed on to them without the commensurate increase in organisational capacity,” he tells Digital Health News.

“We run the risk of CCGs being asked to do too much when they are already struggling. We need a realistic look at the capacity of CCGs and what is able to be achieved.”

William Lumb, NHS Cumbria CCG chief clinical information officer, believes the timetable is achievable, but that delivery could be hampered by the varying competency and capabilities of the country’s CCGs.

There are huge discrepancies between the number of staff employed at CCGs, from single figures up to several hundred, which means many are likely to use either a commissioning support unit or the private sector to help them deliver on target.

Up to the job?

NHS England might not be surprised by this outcome. Indeed, Bryant said at Expo: “We accept some CCGs don’t have the capability to do this, so they might be heavily reliant on their commissioning support unit.

“That is perfectly alright as long as the CCG takes responsibility.”

However, commenters have already expressed concern that with CSUs under pressure as well, it will be consultancies that will be the biggest beneficiaries – with variable results.

Andy Kinnear, the director of informatics and business intelligence at South West CSU recognises the capacity and capability concerns. However, he argues that CCGs are “full of inspirational and visionary clinical leaders, committed to delivering the very best service to their population.”

He adds that CCGs will not be alone in their endeavour to develop digital roadmaps, but will have support from health informatics experts within CSUs, NHS providers and local authorities.

Funding follows the policy  

At the Expo, Bryant also made it clear that CCGs will manage any funding that is made available to support the digital ambition.

No funding has been confirmed, but NHS England has been working on business cases for the Treasury, which is in the final few weeks of the spending review 2015 triggered by Chancellor George Osborne’s ‘emergency budget’ following this year’s general election.

Any money that is approved will be channelled into a “meaningful use technology fund”, to which CCGs will apply in support of their roadmaps. Again, this contrasts with the approach taken by the previous two technology funds, which have been aimed at providers and the implementation of specific systems, such as e-prescribing.

“We expect that for future technology funds, CCGs will be more integral to the process of allocating, awarding and distributing funding,” the roadmaps guidance says.

The guidance also advises commissioners to work “in tandem with local authorities, local providers, local citizens and other local stakeholders” to develop their roadmaps.

While this local approach is generally seen as a welcome change from the National Programme for IT – which was criticised for its top-down, ‘one size fits all’ approach to healthcare IT – experts particularly stress the need for CCGs to involve providers, as that is where much local IT expertise now resides.

Primary care has been almost entirely digitised for some time now, while most acute and mental health trusts are developing or well into delivering on long-term IT plans to meet the paperless target; or their own policy and business objectives.

Siva Anandaciva, head of analysis at NHS Providers – a membership organisation for NHS public provider trusts – says: “Frontline providers of NHS services are the most stable and established part of the health system and work across multiple health and social care boundaries and geographies.

“The NHS provider sector has also shown it has the expertise, scale and experience to develop and deliver digital solutions for patients.”

Balancing national and local

Alongside competency and capacity issues is a question about the varying status of CCGs within their local health economy and their ability to direct the activities of large acute trusts. NHS England has suggested CCGs can use NHS contracts to ensure providers stay in line, but these are notoriously difficult to manage.

Dr Tony Smith, clinical lead for IT and clinical safety officer at Yeovil District Hospital NHS Foundation Trust, also warns that some roadmaps could be superseded by the work of Vanguard sites, which are working at a rapid pace on trialling those new models of care.

“A roadmap written in the context of a conventional NHS structure could be unsuited to an integrated health care system,” he explains.

While local health economies take the lead on delivering a paperless NHS, Smith says the centre has an important role to play in providing an effective way to share success between different areas of the country so that efforts are not repeated and lessons are shared.

 “What could help to overcome the risk of the process slowing down is a level of national guidance on complex issues that are common barriers to progress, such as information governance”, Smith says. “There are use cases that can be shared and replicated rather than inventing everything all over again at each CCG.”