The Department of Health and Social Care (DHSC) has published the review it commissioned over a year ago into approaches to digital delivery in public health in England.
Led by NHS Digital chair Laura Wade-Gery, the review contains nine recommendations on how to drive transformation centred on data, digital and technology, which health and care secretary Sajid Javid has confirmed will be accepted in full.
The final completion of the report was delayed by the Covid-19 pandemic, Wade-Gery said in her letter to Javid, adding that the crisis had “profoundly changed the context [of the review] and the NHS’s experience of digital and data”. She also noted that the delays allowed time for the implementation of some of the recommendations.
According to Wade-Gery, the review is focused on building on the progress made during the pandemic and ensure that the centre of the NHS can advance its digital transformation, supporting integrated care systems to deliver better services to citizens.
“This is about enabling the centre to have the mindset, operating model, skills, capabilities and processes to provide the right leadership and support to integrated care systems, so that together, the NHS delivers improved citizen and patient outcomes,” she said.
Wade-Gery said the vision for “citizen-centred healthcare” includes the ability for individuals to get health-related questions through a mobile interface and choose to have automated interactions or with a live person. She outlined scenarios in which it could be possible to monitor conditions such as diabetes remotely, with people supported by services such as online prescriptions and the ability to access digital records.
The future tech-enabled healthcare vision set out also includes scenarios such as doctors being alerted about patients’ changes in lifestyle or medications, as well as the ability for citizens to enrol in research studies in exchange for innovative therapies. Also, it focuses on removing the admin burden from NHS staff, with voice-enabled record generation and data used to make suggestions to busy clinicians and inform everyday decisions.
According to Wade-Gery, the need for digital transformation in the NHS is “compelling”. She said: “The NHS faces unprecedented demand and severe operational pressure as we emerge from the pandemic, and it simply won’t work to revert to old models.”
Areas for improvement
The review identified six areas where the current situation regarding digital transformation can be improved. In relation to data and technology, Wade-Gery argued that “the separation of responsibilities for digital strategy and infrastructure results in a lack of clarity on target state data and technology architecture”. This separation also creates friction for data sharing for administrative and planning purposes, she pointed out.
In relation to the actual transformation model, Wade-Gery said the NHS could benefit from greater clarity of roles of national, regional and local teams; also, transformation funding is variably diverted and not always linked to strategy and outcomes. The report also comments on NHS leadership in digital, which has variable levels of experience, commitment and interest, with few individuals able to bridge managerial, clinical and digital needs.
Capability aspects are also approached in the review, which says there is insufficient focus on hiring and recognition levers, leading to limited digital culture development. It also assesses the way in which organisational responsibilities are set, describing this as as unclear and generating duplication of activities.
Recommendations
To tackle the shortcomings listed in the review, Wade-Gery’s recommendations include merging NHSX and NHS Digital into NHS England, announced prior to the publication of the full report.
This integration was described by DHSC as a “recognition of progress” made by both bodies during the pandemic and key to moving to a “more coherent approach” to digital transformation in the NHS. The recommendations for NHS digital transformation set out in the Wade-Gery review are:
1. Commit to patient- and citizen-centred healthcare as a principle
Citizens should expect services and care pathways are designed with them in mind, said the report. This has significant implications for organisational design and technical or data architecture, standards, governance and policy. It requires new system capabilities, as well as data to flow across care settings, with increased data interoperability and common technical standards facilitating a better experience for patients and staff.
2. Tackle digital inequality
Digital approaches should consider individuals who, for example, are immobile, cannot afford to travel, experience anxiety in care settings or want to remain anonymous and not be seen by other patients, said the review.
On the other hand, Wade-Gery noted that digitalisation of services can exacerbate health inequalities, rather than addressing them. To address these risks, NHS England and NHS Improvement (NHSEI) should develop frameworks, guidance and best practice in designing and implementing digital solutions to reduce inequalities and give citizens choice between remote and face-to-face care.
3. Build patient trust in use of data
As data science and tools such as machine learning in health advance alongside data-driven commercial business models, the NHS should focus on citizen trust and acceptance in the use of data to ensure the effective delivery of digitally enabled healthcare transformation.
The review does not consider the technical implications of improving NHS ability to use data and respect data privacy – this is dealt with in the Goldacre review – but Wade-Gery stated the need for clinicians and NHS management to further engage with patients about the benefits of data use for individual patients and for local populations, and the safeguards in place to protect privacy and confidentiality.
4. Make NHSEI accountable for digital transformation in the NHS
As part of reorienting the focus on the centre in transforming care through digital, NHSEI should have overall accountability for the process. Clarity should be provided around the role of the centre, with a clear enterprise architecture aligned with the integrated care service operating model. Wade-Gery recommended the development of a national framework articulating the conditions under which certain tech-enabled transformation should be done.
5. Implement a new operating model for digital delivery
Here, Wade-Gery argued that the NHS needs a joined-up centre driving a digital and data transformation operating model. She outlined the problems relating to responsibilities split across the teams at NHSEI, NHSX and NHSD, together with the fragmented and uneven technology capability in the wider service to justify the recommended changes. On the other hand, she said “significant change” is required to the aggregate business and technology operating model if the centre is to achieve its digital transformation aims.
The operating model proposed by Wade-Gery has four layers: system leadership, whereby the business and technology capability requirements of integrated care systems and the centre, with the roadmaps to realise these, are set out; a transformation factory approach, which will see digital and transformation tools and techniques such as agile development utilised to adopt a user-, patient- and citizen-centred approach; technology strategy, infrastructure and operations, which will have overall responsibility for the technology architecture, standards and policies adopted by the central and wider NHS system; and the creation of a data and analytics capability for NHSEI and the wider healthcare system.
6. Realign organisational responsibilities
In this recommendation, Wade-Gery advises the DHSC to create a new transformation directorate, with NHSX integrating into the wider technology and transformation teams. She said the digital delivery unit “no longer needs a separate identity, and can become a key, integrated driver of the new approach to transformation”.
Here, Wade-Gery advises that NHS Digital is embedded into NHSEI as its tech function and as the NHS centre of excellence for technology, “with an intent to merge legally once legislation enables this”. Among the changes introduced by this reorganisation, NHS Digital chief executive Simon Bolton is appointed chief information officer for NHSEI, and becomes a member of its executive committee. Other recommendations include the creation of a chief data and analytics officer function for the NHS.
7. Build and nurture skills to support digital transformation
The creation and retention of skills to drive the digital ambitions for the NHS is also set out as one of the recommendations of the review. Among the points made, Wade-Gery argues that NHSEI “should be responsible for developing the right curriculum and that competency frameworks be updated to include levels of data and digital literacy”. She also argues that NHSEI should work with the Chief Digital and Data Office in the Cabinet Office to “make the case for appropriate career structures and pay arrangements”. Recommendations made in the skills pillar include the development and recruitment of “leaders who can lead integrated teams that combine managerial, clinical, operational and digital and data experience”.
Another point made in the review involves fostering a more agile and flexible workplace, focused on meeting user needs. According to Wade-Gery, the cell structures and joint programme teams with short lines of command and rapid decision-making introduced for half of NHSEI during the pandemic needs to be rolled out permanently.
8. Revise financial arrangements
Wade-Gary advises a review of the revenue funding for digital transformation and live services within NHSEI and between NHSEI and DHSC. She said: “All revenue funding from DHSC for NHS digital activity should be routed from DHSC to NHSEI, via the NHSEI chief financial officer, and remain ring-fenced to ensure no diversion for other activities”.
Among the points made, Wade-Gery also noted that by adopting the approach taken by the Government Digital Service and HM Treasury, the NHS should use a more agile approach to business case development and approval.
9. Reprioritise NHSEI digital spend and assess technical debt
In this recommendation, Wade-Gery advises a re-prioritisation of NHSEI spend to lift the quantum devoted to digitally enabled system transformation. She urged the organisation to “determine the levels of spend on IT across the wider system and seek to re-prioritise spend from within the wider NHSE budget to support accelerated digital transformation”.
She also recommends that NHSEI updates the estimate of the likely costs and work, with DHSC to make the case for additional funds to address the risk associated with the large legacy IT estate across the wider NHS, which creates “significant additional cyber and operational resilience risks to the NHS as a whole”.
Challenges ahead
Wade-Gery emphasised that the extent of the changes proposed should not be underestimated, and said implementation of the changes “will fail unless the accompanying enablers for change are not followed through”.
She said the change management effort is significant and will require full-time resource and the determined sponsorship and commitment of Amanda Pritchard, the new chief executive of NHSEI, and Simon Bolton, chief executive of NHS Digital, and their wider executive team and boards. She noted that so far, both organisations had demonstrated “strong support for the proposed changes”.
“The time for action is now,” said Wade-Gery in the review’s concluding remarks. “The need is enormous. The NHS faces unprecedented demand and severe operational pressure as we emerge from the pandemic. Now is the moment to put data, digital and technology at the heart of how we transform health services for the benefit of citizens, patients and NHS staff.”