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The NHS’s technology partner, NHS Digital, has been very busy since the start of the Covid-19 coronavirus outbreak, dealing with huge demand for its technology products, rapid scale-ups, data sharing and infrastructure to ensure the health service can operate smoothly during this challenging time.
Computer Weekly spoke to NHS Digital’s CEO, Sarah Wilkinson, about the work the organisation is doing, the challenges it’s facing and how technology has the potential to relieve some of the pressures faced by services.
One of NHS Digital’s best-known services, the NHS 111 non-emergency medical helpline, is one product that has seen a huge increase in use. Before the coronavirus outbreak, the popular service was used by around 10,000 people a day, but the organisation soon realised that the load on the service would rise dramatically during the Covid-19 pandemic.
Wilkinson says the team carried out a huge amount of testing to ensure the system could handle 12 times the normal load without any problems. However, demand for the service turned out to be far higher – on its busiest day so far (17 March) the service had nearly one million users, and for the whole month of March more than 16 million people used 111 online.
“111 online just blows my mind,” says Wilkinson. “In its peak day, it was taking 95 times the load. We have to constantly scale up in the background to accommodate that. The infrastructure that we did have has had to be boosted, probably about 10 times now, but you could never have predicted that you will have 95 times the volume on one of your major systems.”
It’s not just the increased usage of 111 online the NHS Digital team has had to deal with. The triage service has also had to rapidly change every few days as the pandemic has progressed.
The NHS App, which serves as a digital front door to health services, allowing patients to make GP appointments, order repeat prescriptions, help manage long-term conditions and access the 111 service online, in addition to features related to organ donation and end-of-life care, has also seen a huge increase in users.
In March 2020, there was a 111% increase in uptake, compared with the previous month, according to NHS Digital figures.
“We’ve had an extraordinary number of downloads of the app,” says Wilkinson, adding that this has naturally led to an increase in requests for NHS Login, the secure way for patients to access several NHS services, including the app.
It’s a heavy authentication process, which means a lot of extra work for staff at NHS Digital.
Shielded patients list
One of the biggest pieces of work NHS Digital has been involved with is the creation of the shielded patients list (SPL), which identifies patients who are extra vulnerable and will need specific guidance on isolation during the coronavirus outbreak. Those on the list have been advised to stay at home for at least 12 weeks.
“When this crisis started, it was very clear was that there were going to be a number of people who were more vulnerable and needed to be protected in various ways. And in particular, they just need to be more isolated, and more socially distanced,” says Wilkinson. “But in imposing that on them, it was absolutely critical that we make sure they are safe and that they are looked after.”
NHS Digital worked closely with chief medical officer Chris Whitty and his team, who defined the list of conditions they felt should be the basis of the original SPL. It may seem like a straightforward list, but it’s been a complicated process, which Wilkinson says took around 10 days of discussion.
NHS Digital’s work in compiling the list is where things got a bit more complicated. The organisation had to develop a clinical algorithm to identify those patients who were classed as high risk. The team had to pick out the right code sets to find patients with the conditions included on the list, then search through various datasets and pull all that data together.
“We had to take what looks like deceptively simplistic clinical descriptions and turn those into really clear codes that we could search the data for. Then we could look at the hospital datasets, maternity datasets, the GP datasets and other particular data sources,” says Wilkinson.
The list has been controversial, with some believing they have been left out of the original algorithm, but it is a work in progress. The first list covered 900,000 people, but this has now increased to nearly 1.3 million people.
“The original list is a baseline, because obviously there are people whose conditions are more complex than the list can allow for, and they will been to be considered as being vulnerable and needing shielding too,” she says.
“So the provision has been made for GPs to additionally flag patients who might not have been detected through the original algorithm, but who they know are also very vulnerable. There are also provisions made for acute trusts to do that, particularly for cancer patients, as well as for the specialist colleges to add conditions they think should be covered.”
Wilkinson says the list is not just to ensure those patients’ clinical needs are met, but that there is a real cross-government effort to ensure they are protected in every way, including coordinating food drops or financial help.
It has been tricky work, according to Wilkinson.
“You are never going to satisfy everybody when you put a list like that together, because you have a lobby of people who think the original algorithm has missed certain clinical categories. You have a lobby of individuals who think they have much more complex conditions than the algorithm allows for, and therefore they need to be added and included but haven’t been,” she says.
“You have data errors, because there will be issues with the quality of data in the primary and secondary care systems. So even when we run these reports, it’s inevitable that some people will be incorrectly included and incorrectly excluded.
“You have people who are unhappy that they have been incorrectly excluded, you have people who feel they are incorrectly included and don’t like that because they worry about the longer-term implications of having been classed as vulnerable, and people are very anxious about the privacy impact on that in various ways. So it’s a challenging process to put together and manage the list, but the basic intent is absolutely right.”
Data and privacy during Covid-19
Data and privacy is at the forefront of Wilkinson’s mind during the crisis. It’s a huge challenge balancing the benefits and risks of data sharing, especially when decisions have to be made very quickly.
“We’re being extraordinarily careful and rigorous about data dissemination around the system because this is this is a tricky time,” she says.
“We must get data to where it’s needed to manage coronavirus, but we must also think beyond the coronavirus pandemic itself, about the implications of highly confidential and personal data being shared and how we will control that in the long term, and the extent to which we have confidence about the way it’s being managed and stored during Covid-19, as well as the extent to which we can make sure it is deleted, post-Covid, and the appropriateness of its use.”
“We’ve proven to ourselves that it is possible to be absolutely rigorous around privacy and confidentiality and to be fast in the way in which we process and disseminate data”
Sarah Wilkinson, NHS Digital
Wilkinson admits that the team has been “absolutely drowned” by such huge demands for data.
“We have people insisting they need the data tonight because they’re trying to run a service for the vulnerable, because they’re going to do some critical clinical research which is going to have a big impact on Covid treatment, or some other reasonably meaningful purpose. But we’ve had to, in every case, go through quite difficult conversations with people, because they want to move very fast – we have to be very, very rigorous about data privacy and confidentiality.”
Wilkinson says the NHS Digital team refuses to compromise around data security. “We’ve proven to ourselves that it is possible to be absolutely rigorous around privacy and confidentiality and to be fast in the way in which we process and disseminate data.”
It has also done a huge amount of work on how to better visualise data and how to get data out to people more easily, and better curated.
With former NHS staff returning to work, and staff moving around different hospitals, there has been huge pressure to quickly authenticate staff, and give them access to hospital systems and services.
NHS Digital has had to massively ramp up the old physical smartcard infrastructure, including staff taking smartcard printers home, printing out new smartcards in their kitchens and sending them by courier to the people who need them.
“We’ve done a massive amount of work to ramp up the physical capacity,” says Wilkinson.
NHS Digital has also been working on the delivery of NHS Identity, a new way for NHS staff to authenticate themselves and gain access to IT systems, eliminating the use of the physical smartcards. Wilkinson said NHS Digital had not yet approved virtual smartcard usage because it was “not fully content with all the security provisions of the products available”.
However, due to the coronavirus outbreak, the organisation has had to take a “different risk position” and has made a judgement that it’s acceptable to use a virtual smartcard solution from supplier Isosec, and has now procured that nationally.
The deal means NHS organisations will be able to obtain virtual smartcards directly from Isosec. NHS Digital is also working with the supplier to develop an enhanced electronic signature version.
“We’re working to make sure we get the security structures we think are critical for the long-term use of that product set up, and by doing so, deploying and making available a virtual smartcard solution, that is automatically accelerating the authentication process,” she says.
“We want to make absolutely sure verification is still robust. Access to patient records is still an enormously sensitive business, and the law requires us to be absolutely sure we know who has seen a patient record and who has changed it. So we must maintain and preserve the integrity around that, but what we sought to do is to introduce a sort of virtual solution that could play on top of the physical solution to accelerate capacity really quickly in the near term.”
The hard work of tackling the coronavirus pandemic has led to a change in priorities for NHS Digital. Some projects have been postponed or put on hold, as resources have had to be shifted.
“The big programmes that we thought we’d be really tucking into right now, such as digitising appointment booking, we haven’t made much progress on in terms of big national infrastructure. But what we have done is pilot the bejesus out of the possibility, so some of those programmes might have been officially put on hold in terms of large platform build, but when we go back to them, we know exactly what the art of the possible is and what’s going to work,” says Wilkinson. “I think the projects will end up taking vastly less time and delivering pretty quickly.”
NHS Digital has also had to take resources off the NHS App Library, which has caused “some frustration on social channels”.
“But, you know, that’s reality. We’ve had to take resources off areas that are not Covid-19 critical,” she says, adding that the real test will be to judge correctly when the resources can be put back, and not end up being overly cautious about spending resources on crisis tasks.
The increased workload, and the demand for getting things done very quickly, has also had a positive impact.
“We’re adding capacity into the infrastructure to cope with escalating demand in real time. That’s the joy of this thing. Suddenly, we just respond – we don’t go through extensive periods of contemplation, we just get on with it and deliver stuff,” says Wilkinson.
Sarah Wilkinson, NHS Digital
“Stuff that we would probably have prevaricated over for days, weeks or months, we have been forced to make a decision on pretty quickly, and that’s been really powerful and helpful.
“We’ve reached a new plateau. That’s the key thing for me. We’ve reached a new plateau where there’s a new level of understanding of the extent to which these tools can be used, and where they can be deployed.”
Both primary care and secondary care services are also increasingly utilising video technology, whether that’s through meetings using Microsoft Teams, which has now been made available to hospitals across the country, or through remote consultations with GPs or outpatient clinics.
“People try things that previously they would have worried about simply because they weren’t standard practice,” says Wilkinson.
“I think there has been a sort of sense in the system that somehow it wasn’t quite right not to be in the room with your patient, and that nobody wants to break ranks and create a new modus operandi for how that kind of interaction should work.
“And of course, suddenly, we’re testing these new ways of working and they work absolutely fine. So I think it’s going to be a really different NHS when we come out.”
Read more about the NHS and Covid-19
- With the risk of the Covid-19 virus spreading, NHS Digital has needed to make rapid changes to its 111 service.
- NHS Digital has been racing to ensure the systems and protocols are in place to prepare the health service for the coronavirus. We speak to its CEO about the preparations.
- As the pandemic grows and creates enormous pressure on the health service, NHS organisations across the country are using technology to help cope.