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NHS digital transformation ‘slower than expected’, says NAO

The digital transformation of the NHS has been plagued by insufficient funding, technical challenges and lack of clarity, according to the National Audit Office

Digital transformation across the NHS is progressing at a much slower pace than anticipated, and suffers from inadequate investment, the National Audit Office (NAO) has found.

A report published by the NAO, which was originally prepared before the Covid-19 coronavirus pandemic, said the transformation programme had struggled with changing strategies, lack of funding and confusion.

It said the government had very ambitious plans for the digital overhaul of the NHS, but progress had been “slower than expected” and the current level of funding might not be “sufficient to meet the government’s ambitions because plans are based on very limited cost data”.

The current estimated cost of the digital transformation is £8.1bn, which is to be spent between 2019-20 and 2023-24. Trusts are expected to contribute £3bn towards the cost, but “it is uncertain that planned funding will be sufficient, and there is a significant risk that trusts will be unwilling or unable to fund the £3bn”, the NAO report said.

It called on the government to collect more data to “enable a better understanding of the full cost of delivering digital transformation and prioritise the work programme” and said essential work to lay the foundation of interoperability and digitisation should be done before it began investing in newer technologies. 

Confusion and planning 

This is not the government’s first attempt to digitise the NHS. The first try, the National Programme for IT (NPfIT), ended up costing the government £7.3bn, before being scrapped in 2011 without having delivered much.

In 2013, the NHS published a new digital strategy, which aimed for a paperless NHS by 2018, later revised to 2020. In 2014, the government published its Personalised Health and Care framework, which set out how the NHS would become digital at the point of care by 2020. The 2020 target was seemingly scrapped following recommendations made in Robert Wachter’s review of NHS technology, in favour of the NHS Long-Term Plan, published in January 2019.  

In July 2019, health and social care secretary Matt Hancock launched NHSX, a central government unit that would lead on NHS digital strategy by bringing together responsibility for policy, implementation and change in digital, data and technology across the health service in England.

The government also introduced sustainability and transformation partnerships (STPs) and integrated care systems (ICSs), which have seen organisations across the NHS and social care, including acute trusts, clinical commissioning groups, GPs and community trusts, come together to form plans for their regions.

“NHS England & NHS Improvement (NHSE&I) increasingly seeks to plan and coordinate care through partnerships of local health and care organisations known as sustainability and transformation partnerships and integrated care systems,” the NAO report said.

“This makes sharing data between organisations essential and NHSE&I expects that by working in partnership, organisations’ data sharing will improve, although many of the existing IT systems within these organisations pre-date this approach to working.

“Seamless sharing of data (or interoperability) will allow electronic patient records to be seen and updated by clinicians in different organisations such as GP practices and hospitals.”

However, the current arrangements – and all the previous changes – have caused confusion for many.

“These changes, and the fact that national bodies were focused more on managing a delivery portfolio rather than a strategy, make it difficult to evaluate progress against the original proposals made in Personalised Health and Care 2020,” the NAO report said.

It added that the NHS was still struggling with legacy IT and fragmented systems.

“Changing national strategies have contributed to a fragmented environment, which makes achieving current ambitions more challenging. Digital services in the NHS rely on a vast array of IT systems critical for delivering services,” it said.

“National strategies have moved between centrally managed and ‘hands-off’ approaches to digital transformation, and this has contributed to the proliferation of legacy systems.”

“The delivery of healthcare will continue to change, and it needs to be supported by modern, integrated and up-to-date information systems”
Gareth Davies, National Audit Office

The current digital transformation portfolio is still monitored against a revised structure set in 2017, it said, although NHSX has recently “conducted a prioritisation exercise which further changed the portfolio with the intention of making it affordable and focused on delivery of the Long-Term Plan and the vision for digital, data and technology”.

However, the goals set in the Long-Term Plan are challenging, including one which calls for all providers to reach a “core level of digitisation” by 2024.

“Clearer objectives, set at the beginning of the portfolio, and consistent monitoring throughout its life would allow better oversight and earlier identification of problems, and reduce the risk of adding to the scope of the strategy without due consideration,” the NAO report stated.

Commenting on the report, NAO head Gareth Davies said the NHS had a poor track record for digital transformation, “with key targets such as a ‘paperless’ NHS by 2018 not being achieved”.

“Local NHS organisations in particular face significant challenges, including outdated IT systems and competing demands on their resources,” he said. 

“The delivery of healthcare will continue to change, and it needs to be supported by modern, integrated and up-to-date information systems. To meet this challenge, the [Department for Health and Social Care] and its arm’s-length bodies need to develop a better understanding of the investment required, set a clear direction for local organisations, and manage the risks ahead. 

“If they don’t, they are unlikely to meet their ambitions for digital transformation and achieve value for taxpayers.” 

Interoperability and sharing best practice

In 2016, the then health secretary Jeremy Hunt promised extra funding for trusts selected to become global digital exemplars (GDEs). The aim is for the GDEs to become centres of digital excellence and lead the way in digital transformation.

However, the NAO report said there was uncertainty over whether the GDE programme would deliver all of its intended benefits. It said that while trusts in the GDE programme were reporting improvements in digital maturity and had developed blueprints to help other trusts, this might not “be enough to spread good practice, including on how to manage adaptive change, to other trusts as intended”.

“National bodies have previously been unsuccessful in other (non-digital) programmes that sought to spread good practice across the NHS in this way,” it said.

Another issue is interoperability and plans to expand the supplier market. One of the key differences between this digital transformation programme and NPfIT is that the government is allowing trusts to make their own decision on which supplier and approach they use. Some are choosing to buy everything from one supplier, which will then overhaul the trust’s entire IT, while others are going for a best-of-breed approach.

The NAO said increasing the number of suppliers could make interoperability more difficult to achieve because more system-to-system integrations would be required, especially when NHS organisations all use different systems that need to communicate with each other.

It added that NHSX was planning on addressing this problem by asking local organisations to build a data layer, which supports data access and exchange.

“However, NHSX has not yet defined what work is needed to achieve this; our previous work shows that other parts of government found similar approaches to be expensive and problematic,” the NAO said.

“NHS systems were originally supposed to be sharing data seamlessly by 2005. Fifteen years later, the NHS hasn’t even established a complete set of standards for trusts and the IT industry to follow”
Meg Hillier, Public Accounts Committee

The report also found that trusts taking the best-of-breed approach to digital transformation would take longer to improve digital maturity.

“NHSX does not have data on the whole-life costs of the different approaches. However, it noted that while the upfront costs of the enterprise approach are higher, the running costs of a best-of-breed solution are likely to be higher and that the NHS cannot afford to implement an enterprise system in every trust,” the NAO said.

The report also noted that cyber security remains an area of concern for NHS organisations, despite progress having been made to address underlying issues.

Public Accounts Committee (PAC) chair Meg Hillier said the NHS’s digital transformation plans had taken too long.

“The DHSC knows what a digital revolution could mean for NHS patients. However, it hasn’t drawn up the detailed plans needed to make one happen,” she said.

“NHS systems were originally supposed to be sharing data seamlessly by 2005. Fifteen years later, the NHS hasn’t even established a complete set of standards for trusts and the IT industry to follow,” added Hillier.

“The NAO report shows that not enough has been learnt from previous failed IT strategies. Meanwhile, continuing dependence on obsolete systems leaves the NHS open to another WannaCry-style cyber attack.”

Read more about the NHS and digital transformation

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  • The Covid-19 outbreak has led to huge amounts of work for NHS Digital, shifting its priorities and creating unprecedented demand for products and data, but it has also had a positive impact, says CEO Sarah Wilkinson.

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