Where will the money come from to connect the NHS?

Guest Blog by 2020health Consultant Director, John Cruickshank

Published in November 2014, ‘Personalised Health and Care 2020’ sets out a framework for action around the exploitation and adoption of digital healthcare.   The document has been prepared by the National Information Board, which now represents all the major national stakeholders in the English health and care system.
Over the course of my 30+ years in the sector, some half dozen of these national strategies for IT in the NHS have been published.  The better ones have been forward thinking on vision, short on platitudes, clear on expectations and what will be ‘done once’ nationally to enable progress, with evident funding policies and a structure that enables  – and measures – delivery.  How does this paper face up to these challenges?
The good news is that this document is above average and has much to commend it, not least the explicit focus on improving the care and experience of patients and citizens. It is well worth reading and in places inspiring.  Its three key themes of collaboration, transparency and participation all make good sense and are threaded through the document.
The document was originally due out much earlier in 2014, so was it worth the wait?  Rather like the ‘Pantomime Horse’, it suffers from design by committee (perhaps why it took so long to appear) with some recommendations rather convoluted and opaque.  But unlike our dear Horse, it is stronger and more appealing in its middle sections than its front and back.
Strangely for a major government report, the Executive Summary is so short as to give almost no clues to the depth of consideration and recommendations in the meat of the report.  And in then painting a picture in chapters 2-4 of the need and current status, it is sketchy.  It contrasts the uptake of digital in health with other industries in a way which is nothing new.  The paper apparently airbrushes out ten years’ of huge investment and some progress enabled by the National Programme for IT in the NHS (NPfIT).
And at the back end (chapter 12), while commendable in terms of commitments to specific dates, the action plan is long on promise about future roadmaps and the like, but short on clear deliverables, roles and responsibilities.   For example, it is widely known that one of the reasons for inaction has been the lack of clarity of roles between the Department of Health, NHS England and the Health & Social Care Information Centre (HSCIC) around digital, and where funding and accountability lies.  This paper hints at some progress but does not inspire one with much confidence.  And with many of the due dates lying after the next Election, one also wonders whether they are remotely deliverable given the likelihood of political change.
The meat of the report (chapters 5-11) has good analysis and many welcome recommendations.  The more eye catching ones include:
•    NHS Choices as a single point of access to common digital transactions, integrated with 111.
•    National accreditation and kitemarking of apps (one hopes this does not stifle innovation).
•    Piloting digital care accounts for patients with a personal budget.
•    National ‘experiment’ of a mobile care record under the control of patients.
•    Use of the Digital Maturity Index to track effective use of IT in the acute sector and beyond.
•    Dame Fiona Caldicott as National Data Guardian of health and care.
•     A new National Tariff that supports and rewards new models of care, enabled by technology.
•    Leadership support to exec and non-exec directors in the development of digital strategies.
So what are its limitations and gaps?  I would highlight the following:
•    How is the document expected to be used?  Would a Trust CEO or indeed an ICT Director know what to do next?
•    Throughout 2013, the promise was the NHS would be ‘paperless by 2018’.  Although laudable, this was a false promise in that the aim should be more streamlined care not the removal of paper. And it was not remotely deliverable. The ‘paperless’ term has been quietly dropped in this paper, with a new commitment ‘all patient and care records being digital by 2020’.  Why ‘all’ and how is this deliverable?
•    The commitment to greater standardisation is welcome but this is a familiar theme – ten years ago, the mantra of NPfIT was ‘ruthless standardisation’. What’s different this time?
•    What is the national technology architecture within which national infrastructure and systems will operate?  Who is responsible for developing it?
•    How will the hints on funding policy (e.g. around future Tech Funds) be developed to give longer term clarity about national investment policies? Nothing was mentioned in the Autumn Statement about funding this essential infrastructure.
•    In my opinion, some element of systems coordination around the common development of digital and health records are essential to corral health communities to deliver joined up care to their local population.  How will this report enable this to be achieved, particularly with NHS England rationalising its local informatics support?
Finally, many NHS organisations around the country (and particularly those in the north, midlands and east) face a cliff edge in July 2016 when their NPfIT patient record contracts will expire and national funding for their systems cease.  The paper is entirely silent on this. Can local commissioners and providers afford the new arrangements, do they have robust plans in place, and how will patients be assured that their care will not be put at risk?

About Julia Manning

Julia is a social pioneer, writer and campaigner. She studied visual science at City University and became a member of the College of Optometrists in 1991, later specialising in visual impairment and diabetes. During her career in optometry, she lectured at City University, was a visiting clinician at the Royal Free Hospital and worked with Primary Care Trusts. She ran a domiciliary practice across south London and was a Director of the UK Institute of Optometry. Julia formed 20/20Health in 2006. Becoming an expert in digital health solutions, she led on the NHS–USA Veterans’ Health Digital Health Exchange Programme and was co-founder of the Health Tech and You Awards with Axa PPP and the Design Museum. Her research interests are now in harnessing digital to improve personal health, and she is a PhD candidate in Human Computer Interaction (HCI) at UCL. She is also dedicated to creating a sustainable Whole School Wellbeing Community model for schools that builds relationships, discovers assets and develops life skills. She is a member of the Royal Society of Medicine’s Digital Health Council. Julia has shared 2020health's research widely in the media (BBC News, ITV, Channel 5 News, BBC 1′s The Big Questions & Victoria Derbyshire, BBC Radio 4 Today, PM and Woman's Hour, LBC) and has taken part in debates and contributed to BBC’s Newsnight, Panorama, You and Yours and ITV’s The Week.
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