Following on from the publication of a National Audit Office (NAO) report into digital transformation across the NHS, Digital Health’s editor-in-chief, Jon Hoeksma reflects on healthcare IT over the last two decades.
The Government’s ambitious digital transformation goals for the NHS, which underpin service modernisation plans, are extremely unlikely to be met without very significant increases in funding, much stronger governance, and far clearer national priorities and standards.
These were the key messages from May’s National Audit Office report on ‘Digital Transformation in the NHS’, which simply states “the track record for digital transformation in the NHS has been poor” for at least the past two decades.
Surveying the daunting landscape of NHS digital transformation efforts in the decade since NPfIT, the report doesn’t dissect the detail of individual programmes like GDE and LHCRE, but instead paints a broader canvas of the cumulative impact of multiple overlapping digital initiatives and programmes and identifies recurring themes.
The huge challenge of NHS digital transformation
The report bluntly states that digital transformation of the NHS remains a huge challenge.
“The need for large-scale process and behavioural change and for substantial investment in IT systems mean that digital transformation is inherently difficult,” it states.
It also stresses that health remains uniquely challenging: “In the NHS, transformation is further complicated by major challenges including aged (‘legacy’) IT systems, the nature of healthcare information, the large number of stakeholders, complex governance arrangements, and existing commercial arrangements with technology suppliers.”
But even allowing for health being difficult progress has consistently been slow and targets missed. Covering the past five year the report states: “The NHS has not made the expected progress since 2014, including against a headline target to achieve a ‘paperless’ NHS (by 2018).”
In addition, the report also concludes: “Recent investment in digital transformation has not been sufficient to deliver the national ambitions.”
However current plans “are based on very limited cost data and it is uncertain that planned funding will be sufficient”.
Billion pound dilemma
NHSEI expects that the NHS will spend around £8.1 billion to deliver digital ambitions up to 2024, but this includes up to £3 billion expected from trusts for the period up to 2029.
The NAO casts doubt on whether these figures are credible or realistic.
“However, we consider the current estimate to be based on very limited data, and there is a significant risk that trusts will be unwilling or unable to fund the £3 billion expected of them,” the report states.
Citing the self-reported national Digital Maturity Assessments carried out by in 2016 and 2017 the NAO report says “Trust’s digital maturity has improved, although significant challenges remain.”
Falling short of ambition
With much praise rightly given in recent months to the NHS’s significant short-term digital response to Covid-19, the NAO report provides a timely reminder that on wider and deeper digital transformation the English NHS has consistently fallen a long way short of ambitions, and looks certain to continue to do so unless past lessons are learned and systematically applied.
Researched ahead of Covid-19 crisis, the report stresses that deeper long-term systematic digital transformation and accompanying adaptive change of work along with delivering significant productivity gains, remains extremely hard and frustratingly elusive in many parts of the NHS, because past lessons have not been learned and key policies usually abandoned long before reaching conclusion. As a result the NHS is stuck in a Groundhog day like situation of constantly trying to solve the
Need for major change
The report contextualises current digital plans, almost certain to be blown adrift by Covid-19, by persistent and recurring failure to address problems in funding, governance, interoperability and supplier market have resulted in patchy progress, confused polices and plans accompanied by a continued history of often vague and unrealistic targets passing unmet, including ‘a paperless NHS by 2018’.
Without major changes of the kind urged by the NAO, most of which were contained in the 2016 Wachter Review, even the latest vapid target for trusts to be ‘largely digital by 2024’ will also surely prove equally ephemeral.
One of the dramatic illustrations provided of just how far short of aspirations NHS IT continues to fall is the reminder that the 1998 strategy Information for Health (IfH) set an objective for interoperability to be achieved by 2005. Remarkably, despite a consensus of the vital importance of interoperability, fifteen years past the IfH deadline interoperability remains little more than an aspiration, with no clear plan on how to achieve it.
Despite being a high-profile objective, and commitment from Secretary of State Matt Hancock, the report says there remains very limited progress on interoperability and data standards and their adoption, with no clear plan.
The NAO warns that if it sticks on its current course NHSX actually risks making the situation worse.
“In our view, if NHS does not develop and implement a carefully-considered plan then it risks not only failing to take the right steps towards interoperability in the short-to-medium term, but also making it harder to achieve interoperability in the future by adding to the number of standards in use,” the report states.
X marks the spot
The NAO notes that a key part of NHSX’s strategy to overcome fragmentation is the development of abstracted ‘data layers’, but notes “The data layer aspiration does not have clear scope, delivery milestones, schedule or budget, so we cannot assess progress towards it.”
NHSX, which is less than a year old and as yet lacks a statutory basis, also risks compounding problems it was meant to help solve, forming just the latest part of the constantly shifting layers of complex and confusing national governance on digitisation, involving multiple often overlapping agencies, including but not limited to: NHS Digital, NHSEI, Department of Health, the Care Quality Commission, Health Education England.
Complexity and fragmentation are compounded by frequent changes to programmes, plans and experienced leaders. The last being particularly difficult to replace. The NAO observes: “National governance arrangements for digital transformation remain confused, despite attempts to clarify them” and “Arrangements for national oversight of digital transformation at a local level are not in place.”
When added to a backdrop of an NHS undergoing massive change as it shifts to Integrated Care Systems, the governance picture is even more fragmented.
“There is currently no governance mechanism to make existing data and technology compatible with national plans,” the report says.
A further area of major weakness is the near total absence of any cost data on systems and investment requirements.
“NHSX is unclear about the whole-life costs and benefits of the different approaches to digital transformation at a local level,” notes the report.
Learning from the past
If the NHS is to improve on digital transformation the NAO says it must systematically learn and apply the lessons from both its past efforts and from across other parts of the public sector.
“The previous attempt at digital transformation in health was expensive and largely unsuccessful, but we are not convinced that all the lessons are being applied now,” the report states.
The report continues: “While some high-level lessons were identified in the Wachter Review  we have not seen evidence that the lessons of this and other programmes have been captured systematically. In our view significant risks to implementation remain in all areas.”
Small wonder then that maintaining and disseminating “a comprehensive set of lessons for digital transformation from NHS and wider government experience,” covering a range of organisations at different levels of digital maturity, is one of the key recommendations made by the report.
It also calls for investment in skills which are “in short supply” and notes “national bodies have not finalised plans to improve the workforce’s digital skills”.
Pulling the punches
For many working in NHS IT and digital transformation much of report will be familiar — some may even feel it pulls its punches – where it is most useful is as a reminder that while much local progress continues to be made true digital transformation will continue to remain elusive until the familiar litany of key lessons are addressed.
Tackling interoperability, better governance, investing in workforce, consistent strategy, investment and far better data on costs and benefits offer the keys to spreading the benefits of digital to all patients precisely because they are intrinsically hard to do. But as the Covid-19 crisis has shown time and again the NHS consistently achieve truly remarkable things when working together to a clear and common purpose.