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Paperless 2020 “likely to fail”, says Wachter review of NHS IT

NHS England’s target of having a paperless NHS at the point of care by 2020 is unrealistic and there is risk in digitising too quickly, says Robert Wachter’s review

Robert Wachter’s review of NHS technology has recommended pushing NHS England's paperless NHS target back three years to 2023, saying the current goal is “likely to fail”. 

Wachter’s review, which was commissioned by health secretary Jeremy Hunt in October last year,  looked at the experiences of clinicians and senior leaders of health trusts, “as well as the current capacity and capability of trusts’ IT systems”.

The review said the mandate by NHS England that all NHS organisations must be paperless at the point of care, with integrated electronic patient records in place by 2020, is unrealistic and should be put back to 2023, ensuring all trusts are in a position to go digital.

“Our Advisory Group was very concerned that an aggressive push to digitise the entire secondary care sector by 2020 was more likely to fail than succeed,” the review said.

“We believe that the target of ‘paperless by 2020’ should be discarded as unrealistic. The goal is not paperless – it is improvement, facilitated by having information where it’s needed, when it’s needed.”

The 2023 target is a long way from the original “paperless by 2018” aim, which was later revised to 2020.  However, this echoes the views of NHS CIOs who, according to a recent survey, are concerned they won’t be able to meet the 2020 target. The survey, which asked 115 NHS trusts about their readiness for a paperless NHS, found that 39% said they had yet to digitise patient records. 

They cited lack of suitable technology and in-house skills as barriers to going paperless, with 75% saying that budget restrictions were also a problem

Two-phased approach

The review sets 2023 as a “reasonable goal to have robust clinical information systems implemented in all NHS trusts, along with a high degree of interoperability” and recommends a phased funding approach to achieve the goal.

“National subsidies should be offered in two phases, giving trusts that are already digitally advanced the chance to become even better, trusts that are ready to digitise the chance to do so, and trusts that need time to prepare for their digital journey the opportunity to do so before starting,” it said.

The first phase, lasting from 2016 to 2019, should use the £4.2bn announced by Hunt in February this year to “promote digitisation”. 

Wachter recommended funding should be split into four groups: one for trusts that are already relatively digitally mature; the second for trusts ready to begin implementing digital systems;  the third for trusts “who are not yet prepared to digitise”; and the fourth for trusts that are “reasonably far along” but not ready to advance. The latter should receive minimal or no funding, Wachter’s review said.

The third group should get a smaller amount of funding, and should not be used for implementing clinical information systems, but rather help trusts build capacity so they are ready to implement in the second phase, with smaller amounts of funding to trusts that are not yet prepared to digitise. This funding should not be for the implementation of robust clinical information systems in 2016 to 2019.

Read more about NHS paperless 2020

Twelve trusts will receive up to £10m each to become “global exemplars” and pioneer new approaches to digital services in the NHS.

The government announces a £4.2bn investment in a ‘paperless NHS’, with money to be spent on electronic patient records, cyber security, apps and Wi-Fi.

NHS England commits to patient-facing digital services by 2020 in its Personalised Health and Care framework paper.

The current funding ends in 2020, when Wachter suggests a second tranche of funding should be made available.

“It would be reasonable to expect all trusts to have achieved a high degree of digital maturity by 2023,” the review said.

“We favour 2023 as the year after which no more government subsidies will be available, and after which regulators will begin to deem trusts that have not reached a high level of digital maturity to be out of compliance on quality and safety grounds, or simply unable to meet heightened clinical performance standards linked to payments.”

ROI measured on clinical benefits

The review, which sets out 10 recommendations, also said that investments should not just be based on the return on investment (ROI), but on the other benefits coming from digital.

“Measuring digitisation in pure ‘return on investment’ terms is a mistake – both because the ROI is unlikely to be immediate, and because the ‘returns’ should be framed in overall benefit, not simply financial benefit,” the report said.

The review team was concerned that many national IT and health policy leaders referenced financial returns as an end goal, and said it’s important to “appreciate that the returns on investment are more likely to be clinical rather than financial in the short term”.

Wachter is also concerned at the lack of clinicians with informatics training.

“We visited several NHS trusts that had one or, at most, two individuals with such backgrounds – and their aggregate time allocated was less than one whole-time equivalent. That is not nearly enough to get this difficult job done well,” the review said.

The report recommended that a chief clinical information officer (CCIO) should be appointed at every trust, with “appropriate organisational and budgetary authority”. It added that at an average size NHS trust, should have at least five “well-qualified clinicians with advanced informatics training”.

Other recommendations include ensuring interoperability as a core characteristic of the NHS digital ecosystem, organising local and regional learning networks, and for the NHS to set out a “thoughtful long-term national engagement strategy”.

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