Critics have pointed to the legacy of failed NHS technology programmes and cash shortfalls, plus concerns around patient safety, data security and patient confidentiality.
However, the NHS has seen successful digital transformation such as the introduction of the Electronic Prescription Service, the NHS e-Referral Service. The national roll-out of the NHS App has also begun providing individuals with access to NHS 111 online, their GP record, the ability to book appointments, update data sharing preferences and register for organ donation, all from their computer or smart phone.
We have also seen the benefits of the Global Digital Exemplar (GDE) programme, designed to make our hospitals the most IT advanced and more digitally mature. The Local Health and Care Record Exemplar (LHCRE) programme has started to create integrated care records across GPs, hospitals, community services and social care.
The creation of NHSX, the new joint organisation for digital, data and technology, launched in April and fully operational in October 2019, is intended to spearhead the “digital transformation” in the NHS. Digital innovation hubs are also set to provide an environment reinforcing England’s position at the forefront of life sciences invention and innovation.
Underpinning the Long Term Plan is a recognition that technology will play a central role, helping clinicians use the full range of their skills, reducing bureaucracy, stimulating research and enabling service transformation. However, it is important to recognise that digital advances will require time, infrastructure and the right environment to thrive.
The Long Term Plan: let’s look at the facts
The Long Term Plan builds on some of the broad themes set out in The Future of Healthcare, the Secretary of State for Health and Social Care Matt Hancock’s vision that the NHS will offer a “digital first” approach to enable patients to communicate with clinicians and therapists and use data to develop more sophisticated ways of monitoring patients remotely.
A key focus will have to be on improving the infrastructure to support these aspirations, including the digitisation of all care providers.
The Long Term Plan recognises, rightly, that the starting point for patients and staff is interoperability of data and systems - technology standards will be mandated and rigorously enforced. The Future of Healthcare committed to setting “national open standards for data, interoperability, privacy and confidentiality, real-time data access, cyber security and access rules”. So far, we have a new Code of Conduct for Data-driven Health and Care Technology (February 2019), which promotes the use of open standards when collecting and extracting data from information technology systems.
The new GP IT system, GP IT Futures, the NHS are currently investing in, is supposed to introduce “minimum technical requirements” for systems to be able to “talk to each other securely” and be “continuously upgradable”. However, the current national contract for GP IT signed in 2015 was also meant to encourage the greater sharing of patient data, so it remains to be seen what impact the new contract will have.
The intention was to create a digital NHS “front door” through the NHS App, which would provide advice, check symptoms and connect people with healthcare professionals including through telephone and video consultations. Matthew Gould, the new Chief Executive of NHSX has recently announced however that he does not want to make the NHS App “all-singing and all-dancing”. He would prefer the app to remain a platform “for digital innovation and creating the standards that will allow that innovation to plug in safely”. This will no doubt come as welcome news to the many digital health suppliers who felt they were being pushed out of the market.
While the LTP envisages improvements for workforce, staff will need support to become more digitally literate if the advantages of digital technologies are to be realised. The Topol Review recognises that “Within 20 years, 90% of all jobs in the NHS will requires some element of digital skills” and so “All staff will need digital and genomics literacy.”
Putting digital-first for primary care
The Long Term Plan mandates the right for every patient in England to have a new right to access digital-first primary care by 2023/24, typically to be provided by a patient’s own practice but can be via one of the new digital GP providers. The five year GP contract framework commits to providing all patients with the right to online and video consultation by April 2021. The plan states:
“The hardware to support ‘mobile health’ is already in most people’s pockets – in the form of their smart phone – and the connection software is increasingly available for the NHS to credential from third party provider.”
Concerns have also been raised that a digital first system could restrict some patients, arguably those most at need, as not everyone has access to or the ability to use a smart phone. Researchers working on a Darzi Fellowship project in Kent stressed “The importance of deep public engagement” with “diverse engagement and recognition of patients as individuals, not a generic body” to “ensure that these diverse views form the backbone of future policy and research decision-making”. In that particular case, the team engaged with people living with dementia and found that there is considerable work needed in this group of patients alone.
The Long Term Plan identifies these issues and commits to ensuring that the technologies work for everyone, from the most digitally literate to the most technology averse.
Delivery terms
In order to deliver on this new commitment the NHS will:
- Create a new framework for digital suppliers to offer their platforms to primary care networks on standard NHS terms. NHS England and the BMA General Practitioners Committee are to agree a new standard specification for IT systems within primary care. This will be an important step to ensuring that the drive towards digitising primary care occurs in a relatively consistent manner across the country.
- Ensure that new “digital first” practices are safe and create benefit to the whole NHS, which will include reviewing current out-of-area arrangements and adjusting the GP payment formulae to ensure fair funding without inequitably favouring one type of GP provider over another. The NHS introduced these changes in the new GP contract, sparking objection from some digital providers.
- Review GP regulation and terms and conditions to better support the return to practice and increased participation rates by GPs wanting to work in this way.
Transforming secondary care
The Long Term Plan recognises that the traditional model of outpatients is outdated and unsustainable. The NHS intends to redesign services, introducing digital technology, so that over the next five years patients will be able to avoid up to a third of face-to-face outpatient visits, removing the need for up to 30 million outpatient visits a year – with a predicted saving of £1.1 billion a year.
By 2024, all providers across acute, community and mental health settings will be expected to advance to a core level of digitisation, and by 2020 NHS organisations will no longer use fax machines to communicate with other NHS organisations or patients.
Digital technology will also facilitate service transformation, such as the redesign of outpatient services and reorganisations of pathology and diagnostic imaging services.
When it comes to funding
The Long Term Plan commits dedicated funding to capitalise on these opportunities and the building blocks and milestones for the digital developments are said to be “costed”, although no figures are given:
“Central funding will be made available to trusts (subject to an upper limit) to help them meet mandated standards and technical requirements.”
Under the new GP contract, additional funding for IT will be made available to offer patients “the right to digital-first primary care”, including web and video consultations available to all by April 2021 and the possibility to order repeat prescriptions electronically from April 2019.
Simon Stevens also recently announced proposals to change the way NHS England funds care so that NHS organisations who invest in world-leading technology will be properly rewarded for doing so. Stevens called on tech firms to help the health service become a world leader in the use of artificial intelligence (AI) and machine learning and invited suggestions on how the NHS can best incentivise the use of carefully targeted AI across the NHS from April 2020 and beyond.
What lies ahead?
The Long Term Plan envisages a utopia, with people being cared for and supported using remote monitoring and other digital tools. The Topol Review, which looks to the next 20 years and beyond, makes exciting predictions about how some of the most innovative technologies such as genomics, digital medicine, AI and robotics will improve services.
The intention is that NHSX will take forward the Health Secretary’s tech vision, which underpins the Long Term Plan using experts in technology, digital, data and cyber security. Change has been slow, says the Department, because “responsibility for digital, data and tech has been split across multiple agencies, teams and organisations.” NHSX is set to change this by “bringing together all the levers of policy, implementation and change for the first time”.
Of course, there are risks to these digital ambitions being realised, including funding, infrastructure and workforce, as well as generating the trust of both staff and patients as we move along this journey. As the Chinese proverb says “A journey of a thousand miles begins with a single step” – the sector has certainly taken its first step.
A version of this article first appeared in the journal of Practice Management.