COVID-19, the NHS digital health revolution and lessons from the past
The relationship between the NHS and information technology has been a long and drawn out affair.
In September 1998, the department of health’s (DoH) strategy information for health was published with the goal of modernising the NHS with a national strategy for local implementation. This commited to electronic health records, round-the-clock online access to health records and information; and the ability to share information and services.
The Wanless report “Securing our future health: Taking a long term view” (April 2002) examined the long term trends affecting the health service. This identifed a need to double ICT spending, setting national standards for data and IT; implementation of a national programme and a vision to provide a service designed around the patient.
In June 2002, “Delivering 21st century IT support for the NHS — A national strategic programme” was published by the DoH and lay the foundations for the National Programme for IT (NPfIT) and the subsequent formation of NHS Connecting for Health agency.
“This saga is one of the worst and most expensive contracting fiascos in the history of the public sector” — Richard Bacon MP, member of the Committee of Public Accounts in 2013
By September 2011, it was announced that the national programme would be dismantled but with component parts in place under separate management and accountability structures. While NPfIT was widely considered to be a failure, substantial achievements include the spine, N3 network, NHSmail, Choose and Book, Electronic Prescription Service and Picture Archiving and Communications Service (PACS).
Acquire new knowledge whilst thinking over the old, and you may become a teacher of others — Confucius
In 2013, Jeremy Hunt MP challenged the NHS to go paperless by 2018 citing that better use of IT could save more than £4 billion and free up professionals’ time. This was expanded further in the NHS five year forward view (2014) by looking at improving health technology and transformational change by exploiting the information revolution.
In late 2015, the National Advisory Group on Health Information Technology in England was formed which in 2016 led to the publication of the so called Wachter review — “Making IT work: Harnessing the Power of Health Information to Improve Care in England” citing a £4.2 billion investment to support digitisation of the NHS. Health IT in UK general practice, NPfIT, US and secondary care sector provided the lessons of the past. In the same year, Lord Carter presented a report on how to improve operational productivity and performance in NHS acute hospitals citing innovation and the need for digital technology and information systems to managing quality and efficiency across care pathways. This subsequently led to the creation of Global Digital Exemplar (GDE) whose purpose was to share their learning and experience and to partner “fast followers” and who will spread best practice and innovation.
Published in January 2019, the vision of the NHS long term plan was that digitally enabled care would go mainstream across the NHS by empowering people, supporting health and care professionals, supporting clinical care, improving population health and improving clinical efficiency and safety.
This was soon followed by publication of the Topol review which examined the impact of technology on the skills and education the workforce required.
The recently formed NHSX brought together of teams from the Department of Health and Social Care, NHS England and NHS improvement and a renewed vision to drive the digital transformation of care.
The initial outputs from NHSX have included the shifting of funding from GDE to a new digital aspirant programme, NHS app, AI lab and digital blueprints.
COVID-19 pandemic declared
The World Health Organisation (WHO) declared COVID-19 a international public health concern on 30th January and then pandemic on 11th March 2020. The UK death toll had reached 335 when strict new curbs on non-essential travel, in effect a lockdown, were introduced by the Prime Minister Boris Johnson on the 24th March 2020.
This led to a dramatic impact on NHS emergency department attendance and emergency admissions with falls of 29% and 23% respectively in March alone. For the first time, there had been more 111 calls than emergency department visits.
As part of measures to increase emergency bed capacity, elective operations were cancelled in a move last occurring in January 2018 to prepare for the winter pressures.
Rapid changes were necessary to coordinate and deliver emergency and non-emergency healthcare to patients. This has included the providing over 20,000 laptops for primary care to enable video and online consultations, £20,000 of capital funding to secondary care providers using video consulting to purchase any hardware, guidelines and blueprints to enable implementation of video conferencing; and issuing new guidance on information governance to enable sharing of patient information to support the COVID-19 response.
Digital engagement by healthcare professionals since COVID-19 has been high. NHS Digital has reported the number of care providers signing up to centrally-funded email service NHSmail has more than doubled in six weeks.
Tara Donnelly, the Chief Digital Officer of NHSX reported that over 75% of GP practices in England ran video consultations compared to less than 10% prior and Health Education England’s COVID-19 e-learning programme had been viewed more than 650,000 times.
Digital engagement by patients has similarly increased.
According to NHS Digital figures, in March there was a 111% increase in NHS app registration, 97% increase use of the app for repeat prescription requests, more than 50 time increase in NHS 111 usage and more than 1.25 million nominations up from 304,000 on the electronic prescribing service (EPS).
The availability of timely data and its analysis has been of vital strategic importance. A recent Public Health England (PHE) blog on COVID-19 has detailed the need for surveillance in community, primary and secondary care; and the role of a data dashboard as part of the strategy for tracking the virus.
Data has similarly been used by the Imperial College COVID-19 response team for modelling the pandemic and greatly influenced the UK government strategy to prevent the deaths of up to 250,000 people. Working on behalf of NHSE and NHSX with collaborations including ICNARC, the OpenSAFELY group have analysed more than 24 million patients’ full pseudoanoymised primary care records to deliver answers to key clinical and public health questions during the COVID-19 emergency.
Public access datasets such as the those from Public Health England, the European Centre for Disease Prevention and Control and the COVID-19 open research dataset (CORD-19) hosted on Google’s Kaggle platform have further enabled data scientists, clinical informaticians and data enthusiasts to predict and detect the progression and risk factors for the disease through modelling and newer technologies such as artificial intelligence. Much focus has been placed on forecasting critical care requirements and examples of this include those developed by teams from the University of Cambridge and the London School of Hygiene and Tropical Medicine’s CMMID nCov working group.
By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest — Confucius
Lessons from the past
The COVID-19 crisis has certainly fueled the NHS digital revolution by increasing the appetite for innovation and technology by patients, clinicians and providers alike.
The are many who call for the pace and drive for innovation to continue and insist that there is “no going back” to the ways of the past.
While there is a willingness and funding of more than £14bn available to vital public services; the explosion of technological solutions and innovations have also blurred the digital landscape making it more challenging to appreciate the benefits, risks and ensure there has been due diligence.
A reminder of the learning from the findings and principles of the Wachter report from the past remain pertinent today.
Eventually, a post-COVID-19 era will arise and organisations and clinicians will need to ensure that they digitise for the correct reasons for better health, healthcare and lower cost. The delivery of healthcare is complex and it is important to recognise that digital may serve to increase or decrease this complexity.
Within the current climate, there is a desire and pressure to implement one of the numerous solutions available. Video consultations are on such example, but it is better to get digitisation right than to do it quickly. There are likely to be many reasons why there are different similar solutions available and it remains important that proper processes are followed to avoid getting it wrong. This includes ensuring interoperability built in from the start and that the health IT systems embrace user-centered design so that they are usable.
Organisations must also remember that the “return on investment” from digitalisation is not just financial but can include increased clinical engagement, productivity and user experience that can all lead to improved patient care and outcomes. With the emergency coronavirus response fund there have been significant changes in organisational finances but this needs to continue once this source has dried up.
When it comes to centralisation, the NHS should learn, but not over-learn, the lessons of NPfIT. NHSX has expressed this learning by reforming procurement by providing new frameworks for technologies and that they support NHS standards. While not centralising to the same extent, sustainability and transformational partnerships (STPs) and integrated care systems (ICSs) should be looking at these procurement frameworks for collaborative digital transformation.
While privacy is very important, so too is data sharing. This has been particularly evident for the strategy against COVID-19 with temporary changes in information governance to enable data sharing. Whether patients and clinicians will continue to value the importance of data sharing in the future remains uncertain but there is hope that concerns have been allayed and the benefits appreciated in current times.
Going live with a health IT system is the beginning and not the end; and requires both technical and adaptive change. To get things right requires the correct infrastructure, governance, workforce and leadership to ensure there is a successful and sustained implementation. Part of this requires the workforce to be developed so that they have the necessary digital literacy skills as described by Health Education England (HEE) so that they will be digital ready. The current crisis will have sped up the evolution of a proportion of the workforce but this work must not be forgotten and will need to continue to be supported.
The will to win, the desire to succeed, the urge to reach your full potential.. these are the keys that will unlock the door to personal excellence — Confucius
The changes in the NHS over the past few months has been unprecedented and the digital health revolution has made significant progress. Lessons from the past must be learnt to avoid repeating those mistakes in the future.
