Big conferences always provide an opportunity to take the temperature of the NHS. At the Health and Care Expo 2018, Matthew Swindells felt it was looking “a little bit peaky.”
NHS England’s deputy chief executive said the service did “incredibly well” last winter. An effort to reduce delayed discharges freed up the beds needed to cope with a flu outbreak; and if flu had not hit “performance would have been the best for some years.”
The problem is that the NHS “has not recovered this year.” A&E performance remains off target and bed capacity is below what will be needed this winter. “We are looking tired,” Swindells said. “We need to get back on the horse and battling.”
Not just for this winter. An ageing population, living with a growing incidence of long-term conditions, means “huge demand” is coming towards the health and care system over the next ten years.
As things stand, it would need to increase capacity by 1,500 to 2,000 beds every year to cope. Or, to put it another way, it would need to build another 30 district general hospitals. Which, as Swindells often points out, is not going to happen.
The new funding settlement of an additional £20 billion a year by 2020 [Reuters] that was announced for NHS70 would not cover building on this scale. And if it did, the NHS, which has 100,000 vacancies [Independent], would not be able to staff it.
Added to which, “creating beds just to fill them” with frail, elderly people who want to be at home and not “detained on our wards” is not good care. “To move forward with the current model of care is just not viable,” Swindells summarised. “We cannot afford it, we can’t staff it, and it’s the wrong model anyway.”
A different response was set out in the Five Year Forward View in October 2014 [NHS England]. It focused on creating new models of integrated care, in which services could ‘channel shift’ out of traditional settings and be delivered ‘closer to home’.
Forty-four sustainability and transformation partnerships were set up to deliver the plan locally; and a handful of integrated care services (accountable care organisations) established to experiment with population-level planning and – eventually – payment.
NHS England chief executive, Simon Stevens, has stressed that this agenda is not going away. At Expo, he said STPs and ICSs would be driven “further and faster.” But it is being refreshed with the development of another ‘long term plan’ that will determine how that £20 billion uplift is spent.
NHS England had useful summary sheets ready for the Expo at Manchester Central. No fewer than 14 workstreams have been set up, covering ‘life course programmes’ (prevention, child and maternal health, long-term conditions and frailty), ‘clinical priorities’ (cancer, heart and lung disease, learning disabilities and mental health), and ‘enablers’ (including workforce and technology).
They will develop ideas in consultation with stakeholders through September and October, before finalising proposals for a plan that must be signed off by the Treasury in time for the Budget in November. After that, an NHS Assembly will be established to “oversee the delivery of the plan’s ambitions going forward.”
The long-term plan’s big challenge will be to balance the need to get the acute sector back in the black and hitting targets with the need to pursue the STP/ICS transformation agenda. This came through clearly in an Expo panel session called to discuss whether it could be both “ambitious and achievable”.
Ian Dalton, the chief executive of NHS Improvement, said that while the plan needed to address outcome and access gaps in its ‘clinical priority’ areas, it also needed to close the funding gap because “the NHS must be a financially sound organisation.”
However, he warned that it could not afford to spend money plugging gaps in its existing model in the hope of starting on reform once this had been done. “We must focus hard in the first five years on how we use the new money, and [any additional boost from] productivity, to build for the second half of the ten-year plan period,” he said. “We cannot get to half way and then start.”
Other panellists called for steps to tackle some of the drivers of demand, as well as planning to meet it within available resources. National medical director Stephen Powis said he wanted to make sure the health inequalities gap “does not widen” and to address life challenges for children and young people, as well as the frail and elderly.
Duncan Selbie, the chief executive of Public Health England, acknowledged the NHS could only do so much to tackle inequality. But he said it could, and should, tackle smoking, obesity, cardio-respiratory diseases and mental health [PHE press release]: working with other agencies through the STPs.
Healthcare IT is a critical enabler of the Forward View agenda. Hospitals need better systems to drive productivity and quality, while integrated care systems need information sharing solutions to enable staff to see and act on key patient details, wherever they are working.
Better analytics and new services for patients have also been on the radar for a decade. Unfortunately, as NHS England is increasingly willing to acknowledge, two failed programmes have impeded progress. First, the National Programme for IT failed on the widespread adoption of electronic patient records.
Then, the care.data programme torpedoed public belief in NHS data collection and use. In his speech, Swindells said some of the commissioning board’s current work in IT is intended to get the health service “out of the PTSD of NPfIT and care.data”.
So, on the one hand it is running a global digital exemplar programme to get “world class” IT into a dozen or so acute and a handful of mental health trusts, and to spread what they have learned to “fast followers.” And on the other it is creating a new data architecture to provide a “single source of truth” for NHS analytics.
At Expo, Swindells insisted that the GDE programme is working. “A few years ago, even the best trusts were mediocre in world terms,” he said, “but I think we are close now to having five organisations accredited to HIMSS 7, and I would expect that to happen in the next six months.
“Now, we are moving the focus from individual organisations to how we bring together systems across STPs and ICSs, and the next £421 million of investment will be going to them; so we can say: ‘As a system, where do we need to invest?’”
That £412 million of investment was confirmed by Matt Hancock in his first speech as health and social care secretary. At Expo, he added another £200 million of spending to an expansion of the GDE programme, which will be taken out to community trusts for the first time [digitalhealth.net].
NHS England has also been developing new, digital services for patients. In a panel session at Expo, Juliet Bauer, the commissioning board’s chief digital officer, said the NHS Choices website had been re-platformed as nhs.uk.
NHS Choices was designed to put consumer pressure on trusts, by enabling patients to compare the performance of NHS organisations and leave comments. The new site is all about helping people to “take control of [their] health and wellbeing”.
Bauer said progress is also being made on the NHS Apps Library, which has now received 500,000 visits and 50,000 downloads, and the NHS App that was announced by former secretary of state Jeremy Hunt at Expo last year.
In his keynote this year, his successor announced that from October the app will be piloted in five areas (Liverpool, Hastings, Bristol, Staffordshire and South Worcestershire) ahead of a national roll-out in December [BBC].
Previews of the app [Gizmodo] suggest that it will replicate a lot of functionality that already exists, for example in GP booking apps and repeat prescription services.
But Bauer defended this. “I have rather changed my mind on this,” she admitted in response to a question. “When I arrived I was all about ‘let’s build an ecosystem and let a thousand flowers bloom’ but I have come to realise that there is value in the NHS building its own services.”
As well as driving innovation, she pointed out, NHS services were more likely to be trusted by the public, which retains huge confidence in the NHS brand.
Swindells was in an unusually upbeat mood at Expo, and finished his speech with a vision of where all these developments could be going. He talked about having his entire health record “including genomic data” on his phone, and about this information being constantly analysed in the cloud, so that if he was eligible for a trial or a new drug, his GP could just email about it overnight.
By contrast, Hancock was in a mood to be completely blunt about the failings that he’d seen on a nightshift in London and that he’d been told about in meetings with industry disruptors. “The NHS has too many systems that do not talk to each other,” he said. “Systems crashing is a regular occurrence.
“The NHS is one of the biggest buyers of faxes on the planet. And it’s clunky, clunky, clunky. In many NHS trusts, people have two screens, not because they are working in a cutting-edge City trading desk, but because they have two computer systems running side by side.
“Systems that fail to reconcile accounts and identities and rely on expensive, out-of-date and badly manged contracts with low-grade suppliers that don’t understand the core business they are intending to support.”
This last point was greeted by applause, suggesting many Expo attendees have little love for established IT companies. However, the secretary of state also laid blame on trusts, and boards in particular, for learning the wrong lessons from NPfIT and shying away from technology-driven transformation.
Hancock didn’t just come to Expo with a list of problems. He also had a six-point plan to move forward. Step one: focus on interoperable, open systems.
“We will publish robust standards in the coming weeks that IT systems must meet if they are going to be bought by anyone in the NHS,” Hancock said. “Existing systems will have to be upgraded” and suppliers that do not comply “won’t be supplying IT to the NHS.”
Two: make sure NHS organisations can “buy the right stuff”, by improving procurement capacity and splitting up contracts to encourage an “agile, iterative approach” to deployments [HSJ]. Three and four: support smaller suppliers and in-house innovation, to encourage a more diverse market.
Five: develop a new skillset, so that technical skills are better spread across the whole health and care system, and six: encourage a culture change, so ideas can be tried, adopted or dropped faster.
Despite his harsh words for NHS IT suppliers and boards, Hancock insisted he was “not looking for people to blame” for the current state of affairs, but for “people to lead” change.
In this context, it was interesting that when he announced a HealthTech Advisory Board, chaired by Dr Ben Goldacre [National Health Executive], the first things he said it would do would be to “identify where change needs to happen” and “where best practice is not being applied.” Acting as an “ideas hub” for transformation came third on his list.
Hancock’s speech went down well in the ‘Future NHS stage’ in Manchester. But veteran NHS IT watcher Phil Booth told Wired magazine there was nothing in it that would help the NHS perk up for this winter.
Also, the idea of a data-driven NHS is nothing new. Since the 1980s, all that’s changed is the approach to getting there. The 1998 Information for Health strategy relied on national infrastructure and local procurement of EPRs.
When trusts spent ‘ring-fenced’ IT money on other priorities, NPfIT was brought in to do procurement and deployment for them. When it failed, trusts were left to their own devices. Now, the NHS is trying national standards and stern talking to boards.
But, a “senior NHS clinical CTO” told Wired: “The internet doesn’t work because standards are enforced; it works because there is a commercial and social advantage to sharing data.” In the world of commissioners, trusts and local authorities, organisations have incentives to hold onto their own data.
In the world of integrated care systems, they should have incentives to share it. But then they’ll need the technical and financial systems to do it. Squaring that circle might be achieved by telling everybody to work harder; but it’s more likely to be one of the critical challenges for the long-term plan.
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