The government’s big plan for the 10 Year Health Plan for the NHS laid out a big role for delivery. However, the Highland Marketing advisory board felt the missing implementation plan will have some big issues to address, from addressing the state of NHS IT today, to finding the time and money to deliver on its vision.
The government has published its 10 Year Health Plan, Fit for the Future. Picking up from Lord Darzi’s investigation into the state of the NHS in England, it says the service is “at a historic crossroads” and must “reform or die.”
Its vision for reform is a new model of care that will be achieved through the now-familiar three shifts (from hospital to community, treatment to prevention, and analogue to digital) and delivered by a shake-up of NHS structures, finance, and regulation.
The plan also sets out some big plans for digital, including a single patient record, a massively expanded NHS App, some new, national platforms, and five big “bets” on data, genomics, AI, wearables, and robotics. Overall, the Highland Marketing advisory board was pleasantly surprised by the direction of travel.
“I looked at this from a number of perspectives. Is it a nice story? Does it read well?” said GP and CCIO Jason Broch. “And the answer is ‘yes’. It’s a good story because a lot of it is stuff that we have been saying for years and years. And it reads well because there is buy-in for All across the NHS.”
On the other hand, members agreed that the 10 Year Health Plan is not a plan. “You cannot call something a plan if it has no implementation section,” said entrepreneur Ravi Kumar. This is a vision. But I like the focus on prevention and early intervention.
“If it happens, and if we get the neighbourhood model, things will be very different. Digital innovation with the patient in control: that is a great idea. As a vision, it is a great document.”
Six key issues for health tech:
Sir James Mackey, the transition chief executive of NHS England, has said a delivery plan or plans will be developed this summer. The advisory board felt these will need to address some tensions the plan skips over.
These include where power will sit in the new structures, as integrated care boards are slimmed down, and “reinvented” foundation trusts come on stream. How the tension between the short-term imperative to reduce waiting lists and the long-term ambition to address health inequalities at “place” level will be handled.
How money will flow around the system, while reinventing payment by results and year of care funding are worked out. But when it comes to technology, the advisory board felt there were six, key issues ahead:
NHS IT is not a greenfield site: Analogue to digital is one of the plan’s big themes, but in practice the NHS has been trying to go digital for 30 years. Stop-start investment in big programmes has left the health service with patchy infrastructure, an incomplete roll-out of electronic patient records, and a lot of software that is not as well integrated with them as it could be.
The advisory board argued the plan doesn’t recognise this, but a significant chunk of the £10 billion that the spending review says will be available for NHS IT and transformation over the next three years could be spent on sorting it out.
Cindy Fedell, a former NHS chief information officer who now works in Canada, said: “There’s lots of poor infrastructure, lots of fractured stuff, to address if we’re going to get proper use out of it; and that’s before we start talking about everything that the plan says they want to do.”
Wicked problems can’t be wished away: Because it doesn’t engage with the current IT landscape, the 10 Year Health Plan is curiously silent on some key issues. ‘Cyber security’, for example, doesn’t rate a mention. Nor does ‘interoperability’ or ‘information governance’ or even ‘data quality’.
The plan’s authors may think these issues will be solved by the single patient record, a pet project of the Tony Blair Institute for Global Governance, which the plan says will “bring together all of a patient’s medical records in one place” and “operate as a patient passport” to “seamless” care.
To bring this about, the plan says there will be legislation to require providers to share information. However, the NHS has a poor record on getting clinical and patient buy-in for grand data plans and is still facing a backlash over its decision to award the Federated Data Platform contract to a consortium including Palantir.
Andy Kinnear, who worked for a commissioning support unit that introduced one of the first shared care records, said: “A lot of the rules that are in place are there to protect us and our civil liberties by blocking inappropriate access to sensitive data. It’s all going to get very fraught, once people start engaging with this.”
Too much centralisation could kill innovation: It’s not just the single patient record that suggests the government wants the centre to have a much bigger role in NHS IT. The plan also talks about an expanded NHS App and national platforms, starting with virtual wards and remote monitoring.
David Hancock, a consultant who has worked for both EPR and shared care record vendors, said: “From an industry perspective, this concerns me. If there are systems out there doing these things, what will happen to them? Will they be expected to link to the NHS App, or will this supersede them? And how will new people get into the market? This could kill innovation.”
Mind the app: The plan devotes a whole section to the NHS App, which it says, “will be how we create a truly empowering, digitally enabled NHS.” It promises a My GP tool for advice and access to appointments, a My Choices feature to help patients pick providers, My Specialist and My Consult platform to help them find specialists and consult with them remotely.
It says there will be a My Companion for general health advice and My Medicines, My Vaccines, My Health, My Children and My Carer areas to pool meds, vaccines, test and wearables data, and specialist advice in one place. Yet, Highland Marketing advisory board chair Jeremy Nettle pointed out, the NHS App today is extremely limited and all one-way.
“It pushes information at you, but you cannot push back,” he pointed out. “I can get a text from my GP, but I can’t message them back. That’s not helpful. And lots of other services don’t even use the app. My local hospital still sends letters.” The plan has little to say about how the app will get from A to B; or how this will be paid for.
Photo credit Ivan Samkov/Pexels
Productivity is achievable but won’t fund IT: The digital commitments in the 10-year Health Plan will take far more money than the Treasury has put up. At various points, the plan appears to suggest that some of the missing money will come from cash savings or productivity improvements.
For example, it says outpatient appointments cost £14 billion a year, a lot of which could be saved if pre-op and follow-up assessments were carried out online. The problem is productivity projects require pump-priming for everything from devices to pathway redesign and training.
“The NHS has tried repeatedly to do transformation from within its operating budget, and it doesn’t work,” said Andy Kinnear. “The money you want to release is not there at the start; you get it out down the line.
“It’s not news that there are lots of follow-up outpatient appointments that probably don’t need to happen, but the money’s not been there to stop them happening. It feels like the ambition and the budget are out of alignment.”
Same for consumer tech: The plan also talks about making the NHS as easy to access as online shopping or banking, which have been funded, in part, by transferring work from staff to users.
“The consumerist aspect of the plan is interesting, because it has driven big changes in other areas,” said Andy Kinnear. “We work our own tills. We print our own boarding passes. And we’re happy to do it.”
Equally, it took 50 years for banks to go from the first cashpoints to today’s interoperable apps; and banks are starting to bump up against public opposition to branch closures. The NHS may be able to move faster, but it’s likely to find itself in a bind.
Either, it will find it even harder to shut clinics and surgeries used by elderly and disadvantaged patients, pushing up costs because of joint-running. Or, it will find itself increasing health inequalities by disadvantaging patients who no longer have physical services but cannot use digital ones (another topic on which the 10 Year Health Plan is basically silent).
Where’s the money? Where’s the time?
Overall, the advisory board felt that time and money are the big issues a 10 Year Health Plan delivery plan or, better, a digital roadmap, will have to address.
“There is an over-emphasis on what technology can do in the short term,” said Ravi Kumar. “And I would have liked to see a finger in the air calculation of what a digital first service will cost in the long-term. I think it could be ten or 20 times more than has been mentioned: we might be looking at something like £200 billion.
“At the moment, if I go into hospital, I’ll struggle to get wi-fi on my phone. If we want patient engagement, we need to sort out that kind of issue before we begin – and we won’t be able to do it on the cheap.”
