The NHS 10 year plan places big bets on digital

Digital is at the heart of the new NHS plan, with big bets on the NHS App and Single Patient Record, but it is let down by significant omissions, no details on implementation and a failure to reflect the “messy reality” of the NHS technology landscape, writes Jon Hoeksma

One year on from taking office the Labour Government has unveiled the long promised 10 year plan for the NHS, with prime minister Sir Keir Starmer promising to “rewire the NHS” through three ambitious shifts: ‘analogue to digital’, ‘hospital to community’ and sickness to preventative care’. 

Digital is utterly central to the 10 year health plan. Pivotal roles are set out for a massively expanded NHS App, imagined as the digital front door and digital service delivery channel,  and a hugely ambitious new single patient record (SPR), pitched as the essential glue required to deliver a patient-centred service.  

The biggest changes relate to how people access NHS services, moving care out of hospitals through the rollout of new Neighbourhood Health Centres and a much greater role for the NHS App.  A national virtual wards procurement is also promised. 

Bizarrely missing, is any serious mention of social care, digital or otherwise, despite the critical role it has in making a shift to community-based services. A separate report is promised to follow on social care. 

The plan blithely scatters promises at every turn, with almost no hint at how they will be delivered

The 160-page plan places huge faith in technology in the shape of digital, data, AI, robotics and genomics, to transform the delivery of health and care, decisively breaking with the hospital-centric model of care that has dominated the health service since its foundation in 1948.   

There is a pledge to introduce single sign-on to systems across the NHS to save staff time. SSO is already widely used technology; it’s not clear why the centre should have alighted on this when investments in infrastructure and hardware would have a greater impact on staff productivity. 

On almost every page turn digital and technology features heavily, indeed it is the leitmotif of a document that is extremely long on aspiration but worryingly light on delivery plans.   

There is almost an embarrassment of riches for digital health professionals or those interested in how digital, and data, can help them do their job better.  And yet there is also a complete abstraction from the current messy reality of today’s brownfield NHS tech landscape.

Where are the ideas on how we sensibly move to this imagined future?   

There is no mention of poor legacy infrastructure, sub-optimal electronic patient records (EPRs), the lack of money to sustain a promising virtual ward programme, suppliers who pay bare lip-service to interoperability, or acknowledgment of the current reality of having to make deep cuts and let go of vital staff with skills and experience that can’t be replaced. 

The promise of a record £10bn investment in digital made in last month’s spending review is barely mentioned, and there is no indication on when it may start to become available or what the priorities will be.    

Speaking to HSJ NHS England chief executive Sir Jim Mackey said the plan was about creating “energy and enthusiasm” and would be followed by detailed proposals developed with local leaders over the summer.  These are to be published before winter. 

Magical thinking 

But without the beginnings of costed, prioritised implementation plans large sections of the 10 year health plan read as extended wish lists and an exercise in digital magical thinking.  

We are told that AI ambient noting will remove the need for GPs to take medical notes.  “All hospitals will be fully AI-enabled within the lifetime of this plan”; and “Make the NHS the most AI-enabled health system in the world”. 

These sound like marketing slogans that ChatGPT might blush at rather than a considered plan that recognises the regulatory complexities and ethical difficulties of introducing AI into the NHS.  

Some of the familiar sloganeering announcing the plan have a rather tired ‘golden oldies’ feel: ‘analogue to digital’, ‘ditch the fax’, and ‘ending the 8.00am scramble for GP appointments’ are all obvious re-treads.   

Time and again there is an almost naïve faith in the transformational power of technology in isolation. There is no recognition that for technology to deliver clinical benefits and productivity gains, it requires matching investments in data modelling, analytics, process change, implementation and optimisation, reimagining clinical work, training and careful evaluation.   

HSJ yesterday made much of the missing chapter 10 on implementation that Alan Milburn was supposed to have written.  But it’s difficult to see how the missing chapter would change the tenor of the document, which disdains to touch on deadlines, priorities, funding or other familiar elements of plans that are intended to be implemented.   

This is less a plan than a lengthy wish list, including a smorgasbord of past policies: PFI is back as Public Private Partnerships and Payment by Results seems to have been smuggled back in too. 

Elsewhere a new national virtual care service or platform is promised in a document that scatters far-reaching policy promises at almost every turn. Why a national service is needed here rather than letting new neighbourhood teams develop locally suitable solutions is not explained.  

In one short paragraph we are told that the National Institute for Health and Care Excellence (NICE) will assess all digital technologies (no mention of the Medicines and Healthcare products Regulatory Agency or Care Quality Commission in this role), and that NICE will also be “given a new role to identify which outdated technologies and therapies can be removed from the NHS to free up resources for investment in more effective ones”. 

This is potentially radical change: are current EPRs to be considered legacy technologies to be ripped out in favour of the new SPR? 

In another we are told that wearables will become “standard in preventative, chronic and post-acute NHS treatment by 2035” and that “All NHS patients will have access to these technologies, which will be part of routine care. We will provide devices for free in areas where health need and deprivation are highest”. They’ll be breaking out the sparkling Kombucha at Apple and Samsung. 

Impossible promises

And still the impossible statements keep coming, including a promise to “Introduce multi-year budgets and require NHS organisations to reserve at least 3% of annual spend for one-time investments in service transformation, to help translate innovations into practice more rapidly”.

We are promised innovation passports to speed-up the adoption of digital technologies. This despite NHSE last month telling trusts to stop implementations of AI scribing due to regulatory worries.

Digital technology is seen as essential to deliver the people-centred, locally delivered preventative health, but also to achieve 2% productivity savings on which the extra spending on the NHS is predicated. This alone requires a detailed 10 year plan of action.

The plan isn’t a plan but a very long aspirational strategy document. It compares poorly to the focus and rigour of the Darzi Review

The new Office for Value for Money recently noted that this level of productivity savings would require trebling the 0.6% annual productivity improvements that were delivered before the Covid-19 pandemic.

Fundamentally, the 10 year health plan isn’t a plan at all but a very long aspirational strategy document. As such it compares poorly to the focus and rigour of the Darzi Review. The government could do a lot worse than to ask Lord Darzi to return and come up with a focused, prioritised and costed delivery plan.

What the 160-page ‘plan’ does point to however, is the fundamental tension between the aspiration to deliver people centred, preventative local care and the political necessity to reduce spiralling hospital waiting lists.

Addressing hospital waiting lists, and pouring investment into hospitals, have always trumped past efforts at reform.

Under the 10 year health plan, the aim is that the majority of outpatient care will happen outside of hospitals by 2035. This will require disinvestment from hospitals meaning hospital mergers and closures. It would be better if the 10 year plan prepared the ground and public for these trade-offs.

The feeble growth of the UK economy and poor public finances mean that the NHS may have to reform and modernise without fresh injections of investment – and that will mean being ruthless in setting priorities. Big unproven new national IT programmes like SPR should not be the priority in this context.

To deliver on the aspirations of the 10 year plan will require more than money or digitisation. It will rely primarily on the efforts and commitment of staff, matched with long-term clear-eyed leadership commitment from politicians of a kind rarely seen in recent years.

Jon Hoeksma is the founder of Digital Health and chief executive of health IT market intelligence and research business Future Health Intelligence.