Following the news that there’s a plan to create an NHS ‘transformation directorate’, Digital Health’s editor-in-chief, Jon Hoeksma reflects on why be believes a new organisation could risk the digital gains made during the pandemic. 

One of the mottos of the technology start-up industry is to ‘fail fast’. Reports predicting that NHSX is to join together with a number of other organisations to create a new transformation directorate, less than 19-months after it was launched, suggests that it may be abiding by this maxim.

In November, Digital Health exclusively reported that the unpublished Laura Wade-Gery Review would recommend a new Digital Transformation unit be established, creating uncertainty over the future of NHSX.

On Monday, a HSJ report suggested a proposal had been made that would see NHSX joining a new ‘transformation directorate’ with the ‘brand’ being retained.

Matthew Gould, CEO of NHSX, gave a briefing to staff at 11.30am on Monday and has since said in a staff bulletin that the organisations work will continue, adding “NHSX will continue to champion digital transformation as a joint unit of DHSC and NHS England, and no functions are transferring out of NHSX or back to the Department.”

Avoiding silos

The role of the new transformation directorate is ostensibly to avoid silos and to embed transformation. The changes come as part of a much wider shake up of the NHS outlined in a new white paper, with minsters taking back direct control in a bid to reverse the devolution of the Lansley reforms.

But if a new transformation directorate is to lead the charge on health and care transformation, it leaves the obvious question of ‘what will even a scaled-back NHSX be left to do?’. Its future looks uncertain at best, particularly for staff who have worked extremely hard throughout the crisis.

Set up 19-months ago, NHSX had only just begun to get going when Covid-19 hit. Arguably, it is being re-organised before it ever got started. Many of the key staff have only just been recruited to its various ‘missions’ and the agency has yet to even publish a full strategy. An alternative strategy would have been to improve NHSX and give it a chance to find its feet.

Leading the transformation

Although it has done a lot of supporting work during the crisis, including key guidance on information governance and fast-tracked procurements to enable remote care and working, it has not been plain-sailing for NHSX.

The false start and repeated delays to the NHS Covid-19 App have been a source of widespread criticism of the organisation, which began work on the app in March 2020 before it was later taken on by NHS Test and Trace.

Monday’s HSJ report suggests that NHSX CEO Matthew Gould, appointed into the role by Matt Hancock, will not head the transformation directorate.

By contrast, NHS Digital is seen to have performed relatively well during the Covid-19 crisis and its continuation was signaled in last week’s white paper on health and care, albeit with a new duty to share data. Similarly, NHSEI will be expected to be in the driving seat on national-level data and analytics on PPE and vaccines during the crisis.

For many NHS IT leaders, the latest changes have been greeted with gallows humour of ‘moving the deckchairs’ variety, as there have been many past re-organisations.

The recurring theme is organisational upheavals, no matter how well-intentioned, inevitably sap time, energy and attention as people work out whether they still have a job. On this occasion it is happening when there is a unique opportunity to build on, and secure, the digital achievements of the crisis.

Getting out of the ground

One of the main criticisms of NHSX from NHS IT leaders was that it took a frustratingly long time to establish itself during a period in which NHS IT policy was in limbo. Past policies on Global Digital Exemplars and Local Health and Care Records were wound down, but nothing was put in their place.

Unfortunately, if NHSX is to be transferred to a new digital transformation agency as part of NHSEI, then the change will almost inevitably carry a high opportunity cost, bringing delays and uncertainty as digital is once again put back into the melting pot.

NHSEI, itself created through the partial merger of two agencies, has a long and mixed track record on IT and digital, often characterised by rivalry with NHS Digital.

Indeed, one of the reasons that NHSX was created by Matt Hancock in 2019 was to break the pattern of sporadic internecine fighting and often paralysing bureaucracy between the various agencies with a hand in digitisation and transformation.

Remarkable achievements

The NHS has unquestionably achieved a remarkable amount on digital in response to the unprecedented public health emergency, particularly in remote care and working.

Yet, arguably, these have primarily been emergency short-term responses crafted by local NHS organisations and communities, not at the centre or its agencies which have served the NHS best when removing blocks. And the uncertainty created by the looming NHS reorganisation will be a major block.

The digital progress of the crisis may yet prove ephemeral and at risk without significant new investment to now go further. The crisis proved that we need plenty of hospitals, but it also proved we need an accompanying investment in digital health infrastructure. The government has pledged to build 40-50 new hospitals, but where is its promise of the investment to build a world-class digital health service?

The challenge of the NHS reset and immediate post-Covid period is surely how to embed the digital changes and systemically sustain the transformation needed. For instance, now moving from remote to virtual and self-care at scale.

National and local leaders have said that the NHS was able to move so quickly in a crisis because the deadening bureaucracy between agencies was lifted for a while. How to sustain this ability to move very fast at scale is perhaps the greatest challenge of NHS digital transformation when the crisis abates.

This is perhaps the greatest challenge for the coming period and where the new white paper offers cause for hope, with its focus on establishing ICSs (integrated care systems) and stronger regional structures.

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