The NHS is heading for a significant financial squeeze, with its already tight 2021 Budget settlement eroded by inflation and the bill for a year of strikes - which has come in at around £1 billion.
With an appeal for help falling on deaf ears at the Treasury, the Department of Health and Social Care and NHS England diverted around £800 million to the frontline ahead of the Autumn Statement, including £350 million that had been earmarked for digital initiatives.
Old and inefficientThis kind of intervention is not unusual. Over the past decade, the NHS has been asked to manage with below-trend growth in its revenue budgets, on the assumption that it will be able to deliver significant efficiency savings. There has been little or no capital funding, and frequent raids on 'ringfenced' funds for headline-grabbing programmes.
The result is a £10.2 billion bill for backlog building maintenance: and what the National Audit Office described as “outdated and inefficient” IT infrastructure and "legacy" software. Which, the British Medical Association, think-tanks, and MPs have pointed out, is wildly inefficient.
"We have never invested enough in physical capital," The Institute for Government argued recently, so "we are employing more and more doctors and nurses and then wasting their time while they try to free up a bed... or spend hours trying to book a diagnostic test… or wait for an agonisingly slow computer to wake up."
Needed: a target operating modelThese issues must be contributing to the NHS' apparent lack of productivity, which is suddenly a hot topic for politicians and system leaders. "We have got 20% more people in the NHS than pre-COVID, but we haven't got 20% more productivity," industry expert David Hancock told a recent Highland Marketing advisory board discussion, "and the reason is a lack of capital funding.
“We have just had £350,000 taken out of IT. [Allowing for earlier raids, the cost of the frontline digitisation programme, and the cost of the federated data platform] that leaves us with about £200,000 [of the £2.6 billion earmarked for “innovative digital technology” in the 2021 Budget]: and that won't buy much.”
Neil Perry, a consultant who until recently was CIO at an NHS trust, argued that the digital arm of NHS England should go back to basics and draw up a target operating model for infrastructure. “At the moment, there is money for electronic patient records, but every clinician wants to know how they are going to be deployed,” he said.
“Is it going to be on iPads, or computers on wheels, or PCs at the ward station? That's because they're worried there won't be enough devices to go around. We should also have a basic limit on how old a piece of kit can get.
“We should have a stipulation that there is single sign-on where it's needed, because nobody has an EPR that does everything. We need some leadership to say what good looks like on infrastructure, and a target operating model, so everybody can work towards it.”
And clarity on 'who pays for what'Andy Kinnear, another former NHS CIO, said there should also be clarity on who should fund it. “There was a piece of work started by NHSX called who pays for what,” he said.
“It tried to unpick the Treasury rules, the DHSC rules, the role of the integrated care systems, trust level spending and the role of auditors - all the things that make this such a difficult environment in which to deliver a significant level of infrastructure investment. We need something like that again, so we can move forward.”
NHS England’s recently appointed chief information officer, John Quinn, told this year's Healthcare Efficiency through Technology conference that infrastructure is one of his priorities, not least because legacy systems are “expensive” and a “security risk.”
However, he didn’t sound like there's a big plan in the offing. Instead, he urged trusts to increase their spending on IT to the level seen in other service industries; and to adopt new delivery models, such as cloud computing or software as a service.
Shifting trust perceptionsAndy Kinnear felt the first point needs to be addressed. "Trusts tend to think of technology as optional, or linked to innovation, rather than essential,” he said. “They would not see electricity as a nice thing to have, and they need to start thinking about technology in the same way.
“You can't run a big, modern hospital without e-prescribing, or imaging. They're infrastructure, like bricks and mortar, and they need to be kept up the same way.”
James Norman, a former NHS CIO who now works for Pure Storage, backed the second point, arguing that when trusts do invest in their infrastructure, they can default to replicating what they have, instead of replacing it with more sustainable computing.
However, he argued trusts will need guidance on how to make the shift - and to navigate complex spending rules. At the moment, he said some trusts “find themselves at odds” with their auditors if they try and capitalise cloud computing and SaaS, while “others capitalise loads of stuff and don't get any push-back.”
At the same time, he added, all trusts suffer from the “digital hokey-cokey” in which the centre announces and re-announces funds, only to issue them so late that they have to scramble to spend the cash in a few weeks at the end of the financial year.
Rolling out legacy systemsIt's not just a lack of consistent policy, strategy or money that has left the NHS facing legacy challenges. NHS England is running a significant IT programme at the moment: frontline digitisation, which is spending £900 million to get some level of EPR into every trust in the country.
Yet, David Hancock pointed out, most EPRs being deployed now “are legacy systems”. More than one of the most popular EPR choices were first developed in the 1990s and are neither mobile-first nor cloud-native.
The big EPRs have persisted for reasons ranging from the need for their suppliers to get a return on the very significant cost of their development, to national maturity models that favour them, to “low risk” decision making by trusts, and a lack of clinical awareness of alternatives.
But they pose practical problems, of which the most discussed is their lack of interoperability, which impedes the drive for integrated, data driven care, and drives extra spending on workarounds like shared care records or the federated data platform.
Modern, UK-based alternatives are being developed, but for the moment they don’t offer all the functionality of a big EPR, and only a handful of trusts are willing to back them. So, while there are cloud-based, modular, and pay-as-you-go systems in the NHS, they tend to be found in well-defined and relatively small areas: running the back office; handling patient communications; rolling-out virtual care.
The big ask: a long-term, stable environment in which to planThe UK must have a general election by the end of January 2025, and could have one as early as next spring. The Labour Party has started to use the state of NHS IT as a polling issue.
Responding to the Autumn Statement, shadow chancellor Rachel Reeves said: “It says a lot that after thirteen years of Tory government, there are still nearly 12,000 NHS computers running on outdated software that is vulnerable to cyber-attacks” and that ten-years after now-chancellor Jeremy Hunt “promised a paperless NHS by 2018” there are still “26 NHS trusts using 600 fax machines.”
Despite this, advisory board chair Jeremy Nettle summed up by saying the NHS doesn’t want more headline grabbing fixes - like shadow health secretary Wes Streeting’s Fit for the Future fund to “double” the number of diagnostic imaging devices in use.
“There's a saying in business that IT infrastructure is like an iceberg,” he said. “You see the software you are deploying, but it's going to account for only a third of the total cost of a project.
“Two-thirds of the total funding will need to go on managing the infrastructure that supports these digital interfaces. And to make that level of investment, you need predictability.
“Predictable strategy, predictable capital spending, because without that, nobody can plan, including the suppliers that we want to develop these systems, and bring innovation to the table.”
About the Highland Marketing advisory boardThe Highland Marketing advisory board includes: Jeremy Nettle (chair), formerly of Oracle and techUK; Cindy Fedell, regional chief information officer at North western Ontario Hospitals, Canada; Nicola Haywood-Alexander, CDIO for Lincolnshire Police; Andy Kinnear, former director of digital transformation at NHS South, Central and West Commissioning Support Unit and now consultant at Ethical Healthcare; Ravi Kumar, health tech entrepreneur and chair of ZANEC; Dr Rizwan Malik, consultant NHS radiologist & director of SMR Health Tech Consultancy; James Norman, EMEA health and life science director, Pure Storage; Ian Hogan CIO at the Northern Care Alliance NHS Foundation Trust and Neil Perry, former director of digital transformation at Dartford and Gravesham NHS Trust and now director at Synergy Digital Health Innovation; David Hancock, digital health strategist specialising in interoperability.