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.
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.
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 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.