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Special Report: Cloud

The NHS is transitioning to cloud with an estimated 15-21% of trusts now hosting something off-site. The pace of adoption has been slow, but could that be about to change? Vivienne Raper reports

Humber Teaching NHS Foundation Trust is a couple of months off going almost entirely paperless on public cloud.

“[Almost] the only thing we still have on premise is our file server, which we’re getting rid of, because we’re going onto [Microsoft] OneDrive and SharePoint on Office 365,” explains Lee Rickles, chief information officer at the trust.

The trust has most of its systems hosted on Amazon Web Services, says Rickles. Once the file server is gone, the last holdout will be the trust’s access control for the authentication of users.

“There’s no reason not to move [access control] onto cloud,” says Rickles. “But [our technology people] like to control it on premises and we have two more years of support […] until we have to change.”

A growth in cloud

Humber Teaching NHS Foundation Trust is among the 15-21% of NHS trusts which he says are leading the way in hosting some – or most – of their ICT resource in the cloud.

Rickles estimated the 15-20% statistic based on his experience leading on Shared Care Records, but it’s backed up by Alex Green, managing director of Signify Research, a supplier of healthcare market intelligence.

“The trend is definitely towards more increased use of cloud, but I’d say it’s still at a relatively low level of penetration, 15-20% of hospitals,” he explains.

However, despite these low levels, Amy Thompson, research manager at Signify and healthcare IT portfolio lead, believes cloud adoption is set to grow rapidly.

For radiology ICT solutions, such as picture archiving and communication systems (PACS), she believes fully cloud or hybrid will rise from 21% of the UK market in 2022 to 41% by 2027.

“And, I think, when that happens, the US will probably be one of the few [countries] ahead of us,” she says.

Covid as a game changer

Some commentators attributed the growth of cloud to the covid-19 pandemic and the need to support working from home.

For Yusuf Mangera, Technical Architect at Imperial College Healthcare NHS Trust, the improvements to external communications for remote working was a “game changer for IT”.

“We’ve seen a significant amount of connectivity coming inside the organisation for remote access. And that’s fundamentally changed the way we design our network perimeter,” he says.

Having to increase connectivity with the outside world, especially when it’s to specialist providers, rather than through VPNs or via the internet, sets the groundwork for future cloud use.

“To increase the amount of bandwidth we must have sizeable connections to cloud providers directly. And that means you [can] then consume cloud services without constraining your infrastructure,” he explains.

Joining services together

The pandemic may have provided the conditions for cloud but it is no longer the driver behind adoption, according to Chris Scarisbrick, deputy managing director of Sectra.

“I think [remote working] was perhaps a stimulus when local trusts didn’t have the connectivity to support [it], but that’s largely been dealt with now,” he says.

Instead, he attributes an “accelerating” adoption of cloud to – among other forms of joined-up working – the statutory establishment of integrated care systems (ICS) in July last year.

“What’s driving adoption now, I think, is the need to have highly versatile and flexible solutions that can grow and flex [with] these NHS regions.”

Mangera explains how the North West London Integrated Care Board is working to align the electronic patient record (EPR) for four acute hospitals into a single centralised system.

“It enhances the patient record because there’s one system feeding into the main EPR, and the idea is that, once they’re aligned, [it’ll] be cloud native.”

A disparity in adoption

However, cloud is not being adopted uniformly across NHS trusts, according to Green and colleague Thompson. Hospital trusts have generally been slower to uptake on cloud than primary care, they say, due to prior investment in on-premise infrastructure.

“People don’t necessarily want to replace IT they’ve invested in heavily,” Green says. “And that’s acting as a restraint to cloud migration.”

In contrast, Green believes the small, family-owned nature of many GP practices leads more readily to cloud migration.

“[Cloud] is appealing to primary care practices. As relatively small organisations, they don’t want the burden of maintaining their own IT and servers.”

GP surgeries also historically invested less in onsite infrastructure, he argues, which removes barriers to a move into the cloud.

Transferring simpler services

What’s being currently moved into cloud is usually the simpler use cases, argues Kev Hamer, a freelance digital consultant at Advance Digital Limited.

“Everyone has had email and Office 365 [on the cloud] for a few years now as it [requires] virtually no work,” he says.

Most of NHS Humber Teaching Hospital NHS Trust’s services now work remotely, explains Rickles.

His own team moved to a hybrid working model after the pandemic, with team meetings held once a week to keep in contact and a daily subsidy for staff who work from home.

The trust’s board meetings are now on held on Microsoft Teams and posted on YouTube.

Virtual wards – and services that look like them – are also well suited to being in the cloud, explains Hamer.

“NHS organisations don’t tend to have services that face the internet. For obvious reasons, data [has tended] to be secure and locked away,” he says,

As he explains, data was traditionally moved between NHS organisations via the N3 [now HSCN] network, meaning that patient-facing services need specialist provision.

Virtual wards offered on the cloud as software-as-a-service solutions are preferred by NHS procurement, he says, with many stalls now offering them at Digital Health Rewired and other trade shows.

Complex use cases

More complex systems, such as PACS, are taking longer to move onto cloud because of prior investment and the complexity of the systems.

“It’s a major undertaking to move a pathology solution into the cloud,” explains Scarisbrick. “There’s a huge amount of [imaging] data, at the petabyte level.”

Sectra went live with their first public cloud radiology PACS in an NHS trust on 1st July 2023, says Scarisbrick. The deployment, at Homerton Healthcare NHS Trust, is the first for the company, who say they have another major contract in the deployment phase.

“We’re hoping in the not-so-distant future to have [even] more significant wins in public cloud,” he says. “The proof is in the pudding and we’re seeing a strong continued trend towards public cloud as the methodology of choice.”

The case for cloud

For its enthusiasts, cloud has many benefits including freeing-up time spent on cybersecurity.

“IT departments don’t have the bandwidth and expertise to stay ahead of the cybercriminals, whereas the likes of Microsoft and other vendors invest heavily,” says Scarisbrick.

Instead of IT teams spending time “feeding and watering” data centres and servers, Mangera says moving to the cloud means they can spend time creating innovative solutions to improve clinical care.

Another benefit, says Scarisbrick, is in meeting the sustainability agenda increasingly demanded in NHS tenders. “Solutions in cloud are more efficient, in terms of electricity, cooling and heat generation, than duplicating infrastructure [across multiple NHS premises].”

What the future holds

According to Thompson, a major challenge to cloud adoption remains the budgeting model for NHS procurement, which is designed for large-scale capital expenditure. Whereas an on-premise IT upgrade might cost £10 million upfront, cloud might cost a few dollars for each unit of memory, and costs vary dependent on usage.

“It might cost $44,000 one month and $24,000 the next,” she says. “There’s almost a short-term pain of figuring it out and shifting practices.”

Once the revenue model is established, Thompson adds, usage is more predictable, especially as memory-hungry specialisms, such as pathology, get digitised.

“If you have just joined an ICS, an NHS trust might have to find millions to build a data centre – but cloud can scale up and down.”

For Rickles, a major challenge to cloud adoption by NHS trusts remains long-term planning.

“If you’re only planning six months in advance, you don’t know your funding envelope and you’re never going to shift to cloud,” he says. “You’ll just end up fire-fighting.”