The NHS is one of the largest and most complex organisations in the world, and one that is beloved by the British public. The coronavirus pandemic has placed enormous strain on hospitals and NHS trusts, pushing people and systems to the limit.
Behind the scenes, staff has been working with digital developers to create safe and effective new systems, not only to survive the crisis but for the long term, too.
In September, the New Statesman convened a round-table discussion, sponsored by Fujitsu, to discuss these issues. The conversation focused on a set of questions, including: what lessons can be learned from other organisations and sectors, who needs to be involved and how, and what does the roadmap for this transformation look like?
The chairman, Jon Bernstein, former deputy editor of the New Statesman, opened the discussion by asking: what are the blockers and challenges in the way of digitisation, and what are the enablers?
During the pandemic, HMRC had to complete projects that should have taken 15 months in four weeks. “It was the most ambitious fiscal intervention since the Second World War,” explained Mark Denney, the department’s interim chief digital and information officer. The organisation had to pay out money, rather than take it in, by administering the furlough scheme, the self-employed scheme, the statutory sick pay scheme and the “Eat out to help out” scheme.
HMRC had to move to a very rapid, nimble way of working, Denney explained. He said what saved the day was “ruthless simplicity” and putting the customer at the centre. His team was working in a “very Agile” way, and even the Chancellor was involved. “He didn’t realise it at the time, but he was put into a scrum. And he was part of the Agile delivery,” Denney revealed.
Jamie Whysall, head of UK healthcare at Fujitsu, explained that over the past 12 months, he has been tasked with bringing some of Fujitsu’s global healthcare solutions to the UK market. “I think that the key to success is to bring people on the journey, understanding what the root challenges or some of the problems are that you’re trying to solve, and building them together in a very human-centric way,” he said.
“It’s about a systemic change, it’s about a shift to transforming the system, as opposed to an organisation,” Whysall added. His team has three key phases that it thinks NHS organisations need to consider. The first is to create an environment where you can truly transform, strengthening your digital foundations. Next is looking at how to use technology to increase productivity and the well-being of staff. Phase three is about improving the patient experience and understanding how they come through the healthcare system. In Jamie’s experience, a lot of hospitals approach it the other way around, and that is why transformation fails.
“Covid has done more for digital transformation than any CIO in the last 10 years,” said Stephen Dobson, chief information officer of the Lancashire Teaching Hospitals NHS Foundation Trust. He explained that traditionally the NHS was a place where it was difficult to make a big change, because each member of staff could effectively veto it. The pandemic has changed that.
Sonia Nosheen, operational delivery network project manager of the King’s College Hospital NHS Foundation Trust, talked about how her trust implemented a digitisation strategy that should have taken 18 months in a matter of weeks. This included working with general practices, where the number of consultations by phone and video conferencing has increased exponentially. She feels the “red tape” needs to be looked at again, particularly as health and social care are brought together through integrated care systems.
“Interoperability” is a key concern for Rob Aitchison, chief operations officer of the Airedale NHS Foundation Trust. Providers now need to be able to talk to and work with one another in a more integrated system.
Money is one of the big blocks to transformation, according to Paul Jones, chief digital and information officer of the Leeds Teaching Hospitals NHS Foundation Trust. Having moved to the NHS from the private sector, he has observed that there is less money available in the health service for renewing technology.
Moreover, the ongoing cost of servicing that technology, and a faster rate of depreciation compared with a new building, makes it look less appealing to finance directors when compared with hiring more nurses or investing in hospital estates. Moving patient services to a more resilient cloud-based system would mean paying a monthly charge, and this is not the way IT is financed in the NHS. “We need the funding to catch up; we need those new funding models,” Jones said.
Dobson agreed, saying strong foundations like this would mean there is less worry and pressure elsewhere, but it is challenging to do because of the level of underinvestment. Further, much of the new technology does not directly or immediately relieve the pressures of demand on the NHS.
The challenge of aged infrastructure (or “technical debt”) extends to central government, too, according to Denney. HMRC was able to use its response to Covid-19 to address some of those issues and “lock in” some good practices, he explained. The team put a lot of work into the business case. It emphasised both the need for greater resilience in the system and the issues of technical debt, including the security vulnerabilities and costs created by using aged technology.
The procurement regime was highlighted by Matthew Chase, chief technology officer of UK healthcare for Fujitsu. Reflecting on his previous role as a chief technology officer in the NHS, he said it would take six to 12 months to get something through that system. “I wanted to do things quickly… failing fast or succeeding quickly, in a safe manner,” he said. Chase would like the NHS to have the money and flexibility to bring partners together.
Richard Mitchell, chief executive of the Sherwood Forest Hospitals NHS Foundation Trust, thinks there are specific reasons why the NHS has seen these changes during the pandemic. Covid has brought the necessary focus and real urgency, and money has been easily accessible. “When you’ve got an emergency, you’ve got adrenaline, you’ve got a sense of can-do, and we need to make this work,” he said.
“We often work in a low-trust environment,” Mitchell said. This is both the reticence to learn from elsewhere because “we haven’t invented it here” and the trust between senior leaders to come together in joint projects. He wants to see a focus on “improving patient experience and improving the experience of clinicians” as well as ring-fenced funding for transformation.
Bill Fawcett, chief information officer of the Leeds and York Partnership Foundation Trust, challenged several of the points made. He said the NHS has too many stakeholders to make the type of radical changes or direction that had been talked about. Nor does he believe centralisation would be positive. Fawcett wants to “see change in our middle management” in the way it thinks about funding, how it looks at regions and how it sees the technology in different services linked together.
Richard Wylde, head of improvement and knowledge at the Leeds and York Partnership Foundation Trust, picked up on this theme. He said the missing piece for him is how to work with professionals to help them understand how tech can benefit them and make the most of it. That way, in the future, it will be them coming to ask for the tech they need rather than the IT people.
Aitchison outlined how the Airedale trust has used technology to make sure nurses working in wards have alerts and prompt checks for when they need to do something with a patient and about how they now use tech for electronic blood tracking. He said, “As much as it might be about innovation, I think it’s about consistently getting those basics right across all areas.”
“Balance is key,” said Nosheen. To transform, people from the front line, clinicians and administrators all need to be involved. For Fawcett, the NHS is at a “huge crossroads” because “we have seen what we can do once the reins are off.” While the governance has to come back, he believes that this is still a great opportunity.
Dobson underlined the importance of trust between organisations. “You get trust, you get collaboration, you get collaboration, you get innovation,” he said. “You can get reductions in cost and things speeded up.”
Chase talked about looking from outside the NHS and seeing the willingness to embrace change. For him, the next wave of innovation is about taking that tech and using it to solve a challenge rather than looking for the innovation in isolation. Mitchell, however, said it is important to frame transformation and digital transformation in terms of “providing safe care and make the lives of our colleagues easier”.
“From a citizen perspective, it’s felt as if you’ve achieved a huge amount, and hearing what you’ve been doing today, you have achieved a huge amount,” said Denney. He agreed that Covid-19 has enabled people to push things forward in terms of digital transformation. “We’ve stopped talking about technology at HMRC; we talk about solutions, and we talk about what we can do for the citizen,” he said.