Can a digital revolution save the NHS?

As the NHS sinks ever deeper into financial crisis, and the search for efficiencies intensifies, it is unsurprising that the idea of harnessing the digital revolution to the way healthcare is delivered is gathering policy steam. Notwithstanding the spectacular top-down failure of the NHS National Programme for IT and the disappointing results of the national Whole System Demonstrator programme, it is entirely reasonable to revisit the ways in which advances in technology might offer smart solutions.

Currently the policy landscape is littered with strategies, reports and evolving structures. The health secretary, Jeremy Hunt, says the NHS must “go paperless” – by 2020 according to the Five Year Forward View; a national information board has been set up to deliver on this commitment; the air is thick with centrally-driven frameworks like the digital maturity index and local digital roadmaps; and a new digital delivery board has been set up by NHS England. Meanwhile, the influential Wachter Review along with weighty reports from the Nuffield Trust and the King’s Fund are all ratcheting up the pressure for change.

Research suggests that technology can indeed improve the quality of life of older people and their carers as well as support improvements in the safety and quality of care. Products are being developed at an astonishing rate, from low-level gadgets through to traditional telecare/telehealth and on to emerging digital technology including mobile phones, apps and televideo consultations. The key debate now is not so much about what can be done, but about how to put it into practice.

Four key issues need to be addressed.

Funding

There is thought to be about £1.3bn earmarked for the “paperless NHS” but little clarity over when it will be made available and whether it will be ringfenced. The size of the pot is also small for the shift from analogue to digital – Bob Wachter estimated a cost of £4.2bn for the secondary care sector alone. There is also the issue of allocation, with funding priority to be given to advanced organisations whose successes will, it is hoped, trickle down to the less advanced. Arguably the jam needs to be spread more thinly.

Stakeholder engagement

There are two main groups whose engagement needs to be secured – frontline staff and end users. Frontline staff are too often seen as passive recipients of new technology and are not involved in the development of a system’s architecture or user interfaces. Failure to convince them of the virtue of change can lead to all manner of resistance strategies arising from inadequate understanding, lack of time, challenges to established routines and fears around job security.

Users also have to be convinced of the value of using new devices. Technology varies in the ways in which it requires engagement and action on the part of users. At one end of the spectrum, a telecare system based upon monitoring and surveillance may require little more than consent to installation of the equipment; at the other it needs active self-monitoring, self-management and engagement with the technology and with professionals. Where an active role for users is envisaged, issues of digital literacy and resistance come to the fore, and localities will need robust strategies to maximise technological familiarity.

Systems not silos

Even now the focus of technological development tends to be silo-based – GPs have long since invested in their own systems; Wachter only looked at the acute sector; non-acute trusts and social care are still out on a limb. Any solution for the incompatibility between IT systems used by all the different parts of the NHS is generally only focused on communication between hospitals or, at best, between hospitals and GPs. The reality for growing numbers of patients is that their “journey” traverses all of these sectors and more. Currently, wherever patients present there is little or no information on where they have been before or about where they might end up subsequently. A more ambitious, system-wide approach is needed.

Patience

The danger with all this digital razzmatazz is that too much is expected too quickly. Politicians and managers may expect a quick and unrealistic return on investment, along with unattainable demands for hard evidence of impact. If no such requirements can be met, then hard-pressed decision makers may well be reluctant to take a short-term risk for a potential longer-term gain. It is up to NHS England to construct a more realistic timeline for investment and change.

Wachter’s main conclusion is that using technology entails both technical and adaptive change – while the technology is knowable, what is less well understood is the requirement for people themselves to change. It is, in short, about culture and whole system change. The potential role for technology is not one of serving as an optional extra to normal business but rather a new paradigm to structure the way healthcare is conceived. This will require much more investment and support than is currently on offer.

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Can a digital revolution save the NHS?