The flurry of digital activity provoked by the first wave of the pandemic often involved decisions made in extreme pressure, and in a belief that any solution was merely a stop gap. But almost two years on, those quick fixes have become business as usual and mean that downsides to rapid digitisation are now being observed. Digital Health brought together a small group for a virtual roundtable, run in association with Virgin Media Business, to discuss that complicated reality. Claire Read reports.
Like colleagues up and down the NHS, Adrian Byrne can easily illustrate just how swiftly digital solutions were implemented during the first weeks of the pandemic.
University Hospital Southampton NHS Foundation Trust, at which he is director of IM&T, had maybe 100 people using Microsoft Teams before March 2020. Within days of lockdown being announced, the solution had been rolled out to 50 times that many.
“We went from 100 people to 5,000 people very quickly,” he remembers. “It was an interesting period, with the accelerated deployment of systems.”
These are the sort of stories that lend credence to the idea that the pandemic has been a catalyst for healthcare digitisation. And they are tales backed by research. A study from the Centre for Economics and Business Research suggests that, since March 2020, the NHS has made the equivalent of four years of progress on digitisation.
Large chunks of this progress will have been made early on, and with the expectation that the solutions being introduced were merely a stop gap. But almost two years on, these temporary solutions remain a fixture. And that reality presents an interesting question: what are the downsides of such rapid digitisation?
It’s a question that was at the centre of a recent Digital Health roundtable. Held in association with Virgin Media Business, it brought together a small panel of experts to consider what challenges might now be emerging from the rapid digital progress made during the early stages of the pandemic.
For Byrne, one of the key issues to emerge is how well solutions that were scaled overnight now sit with pre-existing setups. “One of the challenges, rolling things out quickly like that, is you don’t tend to deal with the integration side of it particularly well,” he said.
It was a point with which Steve Gray was in complete agreement. In fact, he went further. “I’m a sceptic as to whether any of the things that have been spawned as a result of Covid, and the feeding frenzy of certain things that came up in the wake of it, actually constituted improvements,” said Grey, who’s chief information officer at University Hospitals Bristol and Weston NHS Foundation Trust.
“Most of them we were doing already, and it just made us shoehorn some of our costs and a lot of our activity into a shorter space.”
He expressed particular concerns about the impact of what he called the “fragmentation of working practices”, with some people working from home and so distanced from other team members.
“Our clinical colleagues in particular are so much busier than they were before, in a really irregular way, that it’s difficult to get in front of them to do the things that make these transformational things happen,” he said.
In short, one of the ingredients most crucial to successful implementation of clinical software – engagement with the people who will use it – has become as hard to come by as flour was during the first half of 2020.
Said Graham Walsh, chief clinical information officer, Calderdale and Huddersfield NHS Foundation Trust: “Covid forced us to adopt technology because there was no other option. Virtual clinics were all we had, and in a way it’s a false adoption – we forced people into it, but what we didn’t do necessarily is the engagement that we would have normally done to embed that way of working into clinicians’ lives and people’s lives.”
“We had no real user connection,” agreed Tanya Pankhurst, chief clinical information officer at University Hospitals Birmingham NHS Foundation Trust. “We have lots and lots of user groups of doctors, nurses, patients, allied health professions and so on. That was all disbanded or went very quickly during the [first part of] pandemic.”
She feared the patient-facing solutions that had been developed during Covid therefore “tend to suit people who are already very well connected into their healthcare”. Meanwhile those who found the NHS hard to access pre-pandemic may have found things harder still with the increased shift to digital means of communication.
Chris Mulgrew, chief clinical information officer at Royal Devon and Exeter NHS Foundation Trust, summed up the issue by relating the experience he’d had during a recent clinic. “I was asking every patient whether they wanted to get involved with the patient portal,” he said.
“Four of them had a phone that would be compatible with that or had a PC at home and a couple of others had no idea how to do it at all. And that doesn’t necessarily split down demographic lines or age lines.”
As Russell Tilsed put it, “if I’m a patient trying to access services through a technology, then that [technology] should be easy for me to use”. That it’s not equally easy for all patients means some in the NHS have major concerns that rapid digitisation has served to further compound inequalities.
As a consultant psychiatrist at Hertfordshire Partnership University NHS Foundation working with people with neurodevelopmental disabilities, Paul Bradley worries about that inequality in a patient access sense. And the organisation’s chief clinical information officer, he always worries about disparities between trusts.
“Although there were national implementations of systems, whether they were adopted, how they were adopted, how they were implemented [varied across the country],” he pointed out.
“Video consultation is a big part of that, but it could be said of remote working, of shared care records.” That meant, he argued, that the gap between big centres which were already digitally advanced pre-pandemic and those organisations that had already been struggling on digitisation has increased further still.
Part of the issue is that the immediate demands of Covid naturally meant longer term digital transformation programmes had to be put on the backburner. Michael Lumb, who recently retired as a consultant obstetrician and chief clinical information officer at North West Anglia NHS Foundation Trust, gave a specific example.
“We didn’t have a full EHR for our inpatients but there’d been a bit of development work going on the year before the pandemic to allow some clinical noting.
“That was actually pushed out very, very fast to all the medical wards right at the start of the pandemic but it’s not sustainable in the long term because it’s not capable of future development,” he explained. “People are going to have to backtrack from that to go towards procuring a fully-featured EHR.”
These are the visible digital challenges that have flowed from the pandemic. But Daniel Ray pointed out there was also a huge quantity of less prominent but no less critical work that has also complicated matters.
“The frequency of alerts that have come out from NCSC [the National Cyber Security Centre] has absolutely rocketed. So on top of all the stuff that the organisation sees – kit that’s being rolled out, application development, etc – there’s also a load of what I call hidden work, thankless work, that’s also gone through the roof.”
Ray, who’s chief technology officer at Birmingham Women’s and Children’s NHS Foundation Trust, said his organisation has had to relaunch mandatory cybersecurity training in response. “We also took the brave step that if you get to a point where you’ve not done your cyber training we will lock your account until you do.”
The fundamental question, then, is how to reconcile continuing pandemic-related IT issues with previous priorities. Byrne suggested the time was right for organisations to “re-strategise” on digital.
“Covid and the things that we did [in response] will have affected the strategies that we were implementing, but that doesn’t mean that the old strategy was in any way invalid. We’ve still got quite a tough job actually in terms of going forward and delivering that strategy.”
But as teams steel themselves for that mission, Tamara Everington said it was important to recognise and acknowledge the progress that has been made, both before and during the pandemic.
“I sat down with my chairman and one of our non-executive directors in my consulting room, in front of my computer screen, with the chief nurse for IT. I said: ‘Look, this is how we are working now,’ and [talked about] how we were working three years ago exclusively on paper,” said the chief clinical information officer, Hampshire Hospitals NHS Foundation Trust. “Things have improved massively.”
Or as Martin McFadyen, head of public sector at Virgin Media Business, put it: “What we have to do, having been through so much in the last 18 months, is reflect on just how far we have come.”
- Paul Bradley, chief clinical information officer, Hertfordshire Partnership University NHS Foundation Trust
- Adrian Byrne, director of IM&T, University Hospital Southampton NHS Foundation Trust
- Tamara Everington, chief clinical information officer, Hampshire Hospitals NHS Foundation Trust
- Steve Gray, chief information officer, University Hospitals Bristol and Weston NHS Foundation Trust
- Michael Lumb, retired consultant obstetrician and chief clinical information officer
- Martin McFadyen, head of public sector, Virgin Media Business
- Chris Mulgrew, chief clinical information officer, Royal Devon and Exeter NHS Foundation Trust
- Tanya Pankhurst, chief clinical information officer, University Hospitals Birmingham NHS Foundation Trust
- Daniel Ray, chief technology officer, Birmingham Women’s and Children’s NHS Foundation Trust
- Russell Tilsed, senior director – public sector, 8×8
- Graham Walsh, chief clinical information officer, Calderdale and Huddersfield NHS Foundation Trust