Advisory board debate: national and local control

There is a tension between national and local control of NHS IT, and when one clashes with another it can be costly and disruptive. How could we create a more defined environment that is more conducive to long-term progress? That was the subject of Highland Marketing’s latest advisory board debate: Lyn Whitfield listened in.

At its September 2020 meeting, the Highland Marketing advisory board discussed the tension between national and local control of NHS IT that has developed over twenty years, as strategies have swung between one and the other.

Cindy Fedell, the executive chief information officer of West Yorkshire and Harrogate integrated care system and Bradford Teaching Hospitals and Airedale Hospital NHS trusts, discussed some recent examples of the issues the tension can cause.

The board then explored some specific aspects of the tensions, and how they might be resolved with more clarity on aims, roles, and responsibilities. A central organisation to set IT strategy, monitor progress, organise support, and push back against ‘soundbite culture’ might be needed… does that sound like a job for NHSX? 

Setting the background scene  

Flipping between ‘a thousand flowers’ and ‘command and control’

There is an ongoing tension between the NHS’ central and local bodies over who should be taking the lead on policy, operational issues and healthcare technology.  

In the IT space, this has been evident since the 1998 strategy, Information for Health. It created a national body, the NHS Information Authority, to create infrastructure (the N3 network) services (including NHS Direct, the NHS Summary Care Record and Choose and Book), and electronic patient record demonstrator projects.

But left it to trusts to procure their own EPRs. Two years later, another strategy, 21^st Century IT, left much of this programme in place but argued, in the face of company lobbying and a lack of investment by trusts, that a centrally directed, regional approach to EPR was required.

This triggered the National Programme for IT, led by NHS Connecting for Health, which mostly failed to deliver EPRs except, belatedly, in London. Since then, health tech policy has swung between a focus on specific, political imperatives and attempts to address more strategic issues.

And when the focus has been on strategy, the aim has been to strike a balance between national and local control. So, the coalition government elected in 2010 focused initially on ‘transparency’ initiatives to bolster NHS competition (including ‘star ratings’ for trusts and comment sites for GPs).

It wasn’t until 2014, when the NHS Five Year Forward View was published, that the NHS got a new IT strategy, Personalised Health and Care 2020. This broke into a proliferation of national workstreams on everything from standards to consent but left the local IT space largely untouched.

A year later, a Forward View into Action paper stepped in and told sustainability and transformation plan areas to draw up local digital roadmaps. Since the publication of the FYFV, the focus of NHS policy has been to evolve STPs into integrated care systems to focus on population health management.

Yet, the roadmaps vanished in the face of a lack of funding and another NHS IT regime change, as NHS England took an interest in IT that would improve operational efficiency and streamline data collection. Against this background, the 2016 Wachter Review of NHS IT switched attention back to hospitals.

Wachter recommended that any national funding that was available should go to more digitally advanced organisations. The result was the global digital exemplar programme, which aimed to take a dozen trusts to HIMSS Level 7, their ‘fast followers’ to HIMSS Level 5, and to create ‘blueprints’ for others to follow.

With the GDEs up and running, health secretary Jeremy Hunt announced another national initiative for NHS70, the NHS App, and a set of local health and care record exemplars to work on integrated care systems and patient engagement.

However, Hunt’s successor, Matt Hancock, has had little to say about the GDEs or the LHCREs, which have failed to expand beyond their initial waves. Nor has there been much discussion about the standards that Hancock initially talked up as an alternative solution to the NHS’ interoperability challenges.

Some standards work has been done at NHS Digital, which is also responsible for keeping the lights on at the successors to the NHSIA’s infrastructure and national services (the HCN network, NHSmail, Microsoft Teams, NHS 111).

But the current health and social care secretary has tended to focus on headline grabbing initiatives (lose the letters, “purge the pager”, “axe the fax”); while the latest organisation to be asked to ‘do’ NHS IT, NHSX, has become engulfed in the saga surrounding the Covid-19 contract tracing app.

Three examples of national/local tensions

These constant shifts of focus have not helped to progress NHS IT. As the National Audit Office pointed out recently, they make it hard to work out what the health and care system is looking to achieve with any investment that it makes in technology, what has been delivered, and whether that is value for money.

Adding complexity to a complex system

Also, they often overlap and, at worst, get in the way of each other. The NHS Summary Care Record has never been scrapped – in fact, an enhanced SCR was rolled out during the Covid-19 emergency. Yet the first aim of many LHCREs is to develop a core integrated digital care record with more or less the same data points.

This feels like a wasteful duplication of effort. However, one reason LHCREs and other shared care record projects want to do this is so they can create their own foundation for integrated care services. Yet, Cindy Fedell said her local health system has just been told that it can’t let GPs book hospital appointments from their own systems at appropriate points on the integrated care pathways it is developing.

Instead, they must use the updated version of Choose and Book, the e-Referral Service. Why? Because it supports ‘choice’ – even though driving the internal market is no longer a priority and patients are asked if they are happy with the provider offered.

Similarly, shared care records lay the foundation for the population health management services that are supposed to keep patients out of hospital whenever possible. Yet NHS England / Improvement has just told ICSs to create ‘talk before you walk’ to A&E services by December, as part of its Covid second wave/winter planning.

Like most ICSs, West Yorkshire and Harrogate ICS will have some hospitals that are able to execute its roadmap by then and some that won’t, so it will have to find a work around to meet the deadline. While, nationally, NHS 111 may be involved, but not the nhs.uk website or the NHS App, both of which have been promoted as a ‘digital front door’ to the public.

Many actors in search of a role

“The bottom line is that nobody is sure what their role is,” Fedell said. “’Axe the fax’ is a particularly good example. It is eye catching. It makes headlines. But there are good reasons to retain faxes, which are often part of disaster recovery planning.

“So, removing faxes from pathways is something to do, but you need to do it in a planned way, when you have good alternatives in place. Instead, we are hearing that a lot of people are switching from physical faxes to software faxes to meet the deadline.” Fedell says Bradford Teaching Hospitals NHS Foundation Trust did not go down that route; but removing faxes diverted yet more attention, time and resources from other priorities.

Opening up the broader discussion

Articulating the problem

Andy Kinnear, the former director of digital transformation at NHS South Central and West Commissioning Support Unit, identified three reasons for the confusion over roles and responsibilities that has emerged from the past two decades of trying to digitalise healthcare.

First, he said, most systems are procured and implemented at an organisational level, but the shift towards STPs and ICSs implies that systems should be built at health economy level. So, “there is a disconnect between the model that people want to operate and the model that they find themselves in.”

Second, there is the “soundbite political culture” that generated ‘axe the fax’. And third there is the ‘alphabet soup’ of national organisations with health tech responsibilities – “NHSE/I, D, X” – which rub-up against each other and, sometimes, everybody else.

Other advisory board members raised additional complications. For example, Fedell argued that while many large trusts and the better developed ICSs were keen to progress their own digital strategies, some smaller organisations with non-board level IT leads wanted more central direction, not less.

James Norman, healthcare CIO, EMEA, at DellEMC, noted that one reason is that trusts in this position lack the funds to pay for digital initiatives without central funding. Although, ironically, they are also most likely to be overwhelmed by the big projects with onerous oversight commitments that tend to attract it.

Looking for solutions

To find a way forward,Andrena Logue, founder and principal at Experiential HealthTech,argued there should be a return to first principles: what is the health and care system trying to do and who does it want to do it?

“At the moment, the operational side of the NHS is wandering between national control and another bowl of alphabet soup, full of STPs, ICSs, and the rest – so it’s no surprise that IT is doing the same,” she said. “You need to know what you want to do, so you can get IT to support that. You need to do the technology in tandem with the policy and the organisation.”

Focus on outcomes

To support that, the advisory board agreed that new policy should set out the outcome required, rather than the process or the technology for doing it, so healthcare economies or trusts could achieve the outcome in the way that worked for them.

Also, that reasonable timescales should be put on implementation, to allow time for IT procurement, development, and deployment. Advisory board chair Jeremy Nettle argued this would address some of the issues raised by ‘talk before you walk’, since ICSs could build the development of an appropriate solution into their roadmaps.

Think strategically

Allied to this, the board felt that the NHS could do with a new IT strategy, both to articulate what it wants technology to achieve and to create scope for ‘push back’ against distracting initiatives. “A lot of what ‘axe the fax’ is looking to achieve would be achieved if everybody had a good EPR and used it to create effective workflows,” Fedell pointed out.

“So, we need someone to be able to step in and say: ‘we should do this, but we need to do it the right way, and this is the way we have agreed to do it, so we should keep going.” However, board members felt that if an IT strategy was to be effective, it would be important to keep going; and not to abandon yet another plan as soon as things got hard or expensive or there was another round of change at the top.

As Nicola Haywood-Alexander, an experienced health CIO,put it: “We are very good at fanfare and despair. If you look at well-established change models, like the Kotter model, it seems that we constantly do the first steps. Everybody is excited, and then we find it difficult, people resist and instead of doing the next steps, we give up, when we should support people to get past the bottom of the change curve and keep going through to adoption.”

Measure to manage

Nettle suggested that one way to encourage this would be to revisit the idea of digital maturity, and to develop new models that would enable organisations and healthcare economies to assess their progress and prioritise their investments.

“We need to set a direction of travel and then work out how far along the road organisations are,” he said. Kinnear agreed with this: “I was looking at the model set out by Information for Health the other day, and it was good enough,” he said. “If we had stuck with it, we would have been much further along than we are.

“Of course, it would have morphed over time, but if we had done the essentials we would have a lot of good stuff to work with. So, we need that culture of measurement so we can demonstrate progress and push back against new people coming along and saying: ‘Let’s rip it all up and do something different’.”

Federated models of support

Another reason for measuring digital maturity consistently would be to identify trusts that are struggling; and to provide them with support. Logue argued the NHS had “missed a golden opportunity” in this space by apparently deciding not to persist with the global digital exemplar programme.

“The GDE programme was trying to say: ‘This is what a good trust looks like’. And yes, there were challenges, and yes, it took ages to get the blueprints out, but there was an opportunity there to say: ‘These are the things that are fundamental to any organisation, so you should go and do them’ and: ‘Here is the support to do it’.”

Logue added that she is encouraged that there are some signs that this could happen, with work underway to resurrect the blueprint template to support digitally immature organisations and to gear tech specific advice to NHS teams.

However, she argued that this would still be more effective in a ‘federated model’ for NHS IT, in which organisations worked together to reach agreed levels of digital maturity. This could also address some of the budget challenges identified by Norman, by creating a pool of funding to do it “instead of everybody just saying ‘I need an EPR’.”

Other advisory board members argued that this kind of co-ordination and support might be the job of the new regional offices of NHS England/Improvement. Whoever does the job, the board also felt that there should be investment in leadership and change management models at all levels.

And Logue argued CIOs need to work together. “One of the things we have not talked about so far is vendors,” she said. “I think that if there was more collaboration between CIOs it would be easier for them to scrutinise vendors, what they have achieved, and how much it has cost.”

Haywood-Alexander said local authorities had moved in this direction; and taken a lot of managed services back in-house as a result. Local government also makes better use of progressive procurement frameworks and contracts than the NHS, she noted.

The X factor

The discussion achieved a fair degree of consensus on what a more strategic, more stable approach to NHS IT might look like. It would leave policy making at a national level; but encourage a focus on outcomes not process and on reasonable timescales for delivery.

It would mean creating a new IT strategy for health and care that could be used to measure progress and to push back against ‘soundbite culture’. It would give a role to NHSE/Is regional offices to support local organisations. It would involve investment in leadership and change management skills, and it would encourage collaboration between local organisations to improve the transparency of the supplier market.

However, this implies that an organisation is needed to provide health tech policy advice and write and monitor a matching strategy. Does the NHS need a new organisation to do this, should NHSE/I, D or X take on the job, or, to put it another way, if this sounds like the job that NHSX was set up to do, why isn’t it doing it?

Board members had lots of thoughts on the last point, ranging from X’s over-close association with Matt Hancock, to its fractious relationship with bodies like NHS Digital, to the very expensive, very public distraction of trying to develop the NHS Contact Tracing App during the Covid-19 emergency. However, it could yet come good.

“For me, this is all about defining roles and responsibilities,” Fedell concluded. “What is the role of the DHSC, of NHSE/I, of X, of the ICSs, of trusts? Who gets to say what gets done and who says ‘no’, or ‘not now’? If it can find a way to do it, this could be X’s core job: to cut through this very messy landscape for us.”