The digital health and care plan: what must it address?

Introduction

Over the next three years, the health and social care system is set to take a big step forward in its digital ambitions, transforming the way care is delivered by organisations and experienced by patients and populations. At the same time as integrated care systems (ICS) become statutory entities, both NHSX and NHS Digital will merge to sit within the newly formed NHS Transformation directorate. These conditions provide the NHS with a pragmatic opportunity to meet the required digital maturity objectives, while taking opportunities to work with the centre to improve joined-up care and capabilities beyond 2025.

The drive to digitise, connect and transform technology is a core priority for the NHS and will bolster the health service’s long-term sustainability. But taking forward these digital ambitions comes at a time of considerable challenge for the NHS, with rising waiting lists, workforce capacity issues, stretching elective recovery targets, constrained funding and the continued focus on COVID-19 have led to significant operational pressures across the NHS. And with changes underway as a result of the Health and Care Act 2022, the service is once again at a critical juncture.

Digital transformation will be a core pillar of the post-pandemic recovery and reform. But to realise the potential, several elements of health policy need to align.

The digital health and care plan, soon to be published by the Secretary of State, will be crucial to delivering and enabling proposed reforms, including: accelerating the rollout of electronic patient records; expanding use of the NHS App; embedding virtual care and addressing challenges of interoperability; and supporting choice in elective care. The plan will for the first time propose a whole health and social care system approach to putting digital services first – mirroring the new system architecture from summer 2022.

We have worked with members across England to understand what they need to enable a digital step change. We have also engaged with NHS England and NHS Improvement (NHSEI) to influence its vision for digital and the delivery plan that will support the digital health and care plan. Our ambition has been to secure clarity on what is expected from NHS leaders, and at what pace.

This paper sets out the key messages from our engagement with members on the barriers and enablers of digital transformation. It details what leaders need the digital health and care plan to address to leave them best placed to digitise services, connect systems and transform health and care.

The view from healthcare leaders

Digitising services

Over the next three years, ICSs are expected to ensure:

• a core level of digitisation across all NHS secondary care providers
• 90 per cent of NHS trusts to have an electronic patient record (EPR) system by December 2023, 100 per cent by March 2025
• 80 per cent of adult social care services to have electronic records by March 2024
• ability to deliver uninterrupted provision of patient care even in the face of a cyber incident
• every patient to have the right to be offered digital-first primary care by 2023/24. [ ¹ ]

Where we are now

Leaders agree with the need to adopt new models of care that harness the potential of digital technologies, and that this transformation will be a core pillar of the NHS’s recovery and reform. They recognise the importance of achieving a core level of digitisation by March 2025, as per NHS England and NHS Improvement’s planning guidance. However, NHS leaders are facing a twin task: driving forward these innovative changes for the future, at the same time as managing the realities of considerable and sustained operational pressures.

“It is a very challenging time when we are being asked to balance the need to accelerate focus on recovery of services, still living with COVID-19, and the ask of frontline staff to be involved in progressing digital implementation and change.” NHS ICS Digital Leader.

They also report a further barrier to achieving the 2025 target is that different parts of the systems are at different starting points. Differing levels of maturity in terms of their data and digital capability have meant that some are further ahead than other parts of ICSs in procuring, using and embedding digital services.

Regarding EPRs, where they work well, benefits are being seen for caregivers getting real-time access to health-related information and patients themselves getting a simplified view of their own data. However, the expectation for each trust to have an EPR by end of 2023 is challenging in the climate of inadequate resource investment and rising costs. In a recent survey of our members, two-thirds said they do not have enough money to meet digital ambitions, including rolling out EPRs. 

The impact of continued underinvestment can also be seen in the NHS’s outdated legacy IT infrastructure. Over the ten years to 2020, capital spending in the NHS has been around half that of other OECD countries. [ ² ]

The plethora of legacy IT systems used by health and care staff, many of which do not work with other digital systems across the NHS, is hampering successful digital integration and potentially better patient outcomes. Almost a quarter (22 per cent) of doctors who responded to a British Medical Association survey [ ³ ] said that IT systems at their place of work are not fit for purpose – specifically the electronic medical record (57 per cent) and current operating systems (55 per cent).

Primary care networks (PCNs) in particular identified the lack of consistently available IT infrastructure as a limiting factor in their development, hindering their progress. [ ⁴ ] These digital systems are often siloed in their ability to share information and data and can hold varying levels of clinical and non-clinical records. This means that not all staff can access the information, or if they do, it is not usable in their specific role. Members across primary care have voiced concerns that the sector lacks quality, usable IT, such as laptops for multidisciplinary teams.

Members have reported that this hampers not only the effective delivery of care, but means that opportunities are being missed to provide more efficient care in the future. For example, 64 per cent of clinical directors and PCN managers agree there are significant opportunities to expand the use of digital channels. [ ⁵ ].

“We are currently unable to properly build on our investment to date in EPR systems because we don't have enough capital to upgrade our network and wifi infrastructure. This will mean continuing frustration for colleagues and patients as our working practices remain in the last century.” ICS Leader.

In addition to the challenges described, digitisation of health records and services also represents a significant shift in the way the NHS works. The current divergence of environment and technology across different parts of the service has been exacerbated by significant variance in digital skills across national, regional and local care centres.

Our members say that it will take time to train staff in the required skillsets in digital and for these skills to become valued in the service. A significant barrier to digitisation will be the perception that changes in digital requirements represent an added task to an employee’s day-to-day work, rather than supporting better delivery of care. All of this will require additional capacity to happen.

At the same time, the NHS workforce is in crisis with 105,000 vacancies and widespread burnout. Even with the ideal digital system plans, there must be a shared understanding that the workforce is already running on empty. Digital systems have the power to transform working practices but not before time and capacity are first given to co-designing, training, embedding, learning and continuously re-visiting digital systems with staff and users.

One ICS leader told us:

“Finding workforce capacity to support transformation and digital change at a time when change capacity is required to address ongoing operational pressures, recovery and respond to system reforms, is creating tensions… recruiting for digital roles is competitive because we can’t compete with other sectors offering better packages and remuneration.”

What the digital health plan must address

The digital health and care plan should prioritise action to address the barriers to transformation and innovation posed by outdated or non-existent IT equipment, particularly for many primary care network roles. [ ⁶ ] Creating a more equal infrastructure baseline for services is likely to require further investment to update or replace legacy IT, which the plan should address.

In addition, there should be steps taken to remedy the problems stemming from the plethora of systems in use, such as issues with procurement and embedding new digital systems. The plan should also outline a sensible timeline for this. For instance, by rushing to meet the target for electronic health records for the few remaining trusts, we risk installing a poor-quality system that does not meet the needs of clinicians, administrative staff or patients.

NHS leaders expect the digital health and care plan to provide the necessary support to roll out effective digital solutions which promote quality data models that will improve accessibility. Digital solutions can be complex and need diverse platforms to function, but if these are to share information and deliver results across whole systems, they must be underpinned by considered and quality architecture. This requires adequate financial investment when replacing legacy IT systems.

Therefore, the upcoming plan should provide for a proper technology assessment to establish what each ICS needs in terms of investment and actions to provide high-quality standards of digital care. Investing smartly now will reduce the technology debt for the future, creating the foundation to build our way to digital transformation.

NHS leaders would like to see an ambitious plan and recognise that digital tools help providers to plan, design and deliver services in a more personalised way while saving time for staff. However, when looking at implementation, it must acknowledge and support local leaders to lead digitisation in a way that best suits the needs of their local populations and staff. The plan should include timeframes that allow time for staff to acquire new skill sets in digital and for cultural conditions to develop and encourage moves away from often entrenched ways of working.

Without investing in our present workforce and addressing future needs, even the best digital systems can only transform so much. However, having the right mix of leadership, knowledge of best practice, capital resource and digital solutions can go a long way to help alleviate pressures caused by staff shortages. A clear national framework which encourages this culture can lead to digital systems taking hold more quickly, with staff empowered to use a better functioning digital system that ultimately improves their working practices and can increase uptake.

The plan should also provide support for leaders navigating and creating the right conditions for these changes. For instance, we would welcome proposals for specific guidance and best practice sharing around pathway redesign or leadership support at ICS board level. Making a software change and investing in new digital services is only part of the solution. This will help embed changes in a sustainable way. It must be clear to staff that digital transformation and their own digital literacy improves how and what they can deliver for patients. Their ‘buy-in’ is crucial to successful implementation of new technologies at a time when the service is under high levels of pressure and will continue to be for the foreseeable future.

Connecting systems

Over the next three years, ICSs are expected to ensure:

• every ICS has a fully functional integrated health and social care record that can be used fully by all constituent parts of the ICS.

Where we are now

Interoperability remains one of the largest digital challenges highlighted by our members. It is imperative that the digital health and care plan recognises the scale of the challenge and further supports the move to ICSs from July this year, as well as the delivery of the more integrated data and digital landscapes.

“At best digital systems can connect providers within the same footprint, but ensuring the same tech works for all constituent organisations in an ICS, including sharing with local authorities, is going to be hard to implement.” ICS Chief Clinical Information Officer.

The interoperability challenge is one that has formed over decades as a complex, multi-tiered, primary and secondary care environment has developed, served by an increasingly complex and diverse technology landscape. This has been reinforced by low levels of (and in many cases absent) data and system interoperability standards, as a further challenge for effective integrated care.

At the beginning of the pandemic, a quarter of healthcare providers in the UK had no EPRs, a third of social care organisations still ran on paper-based systems and, in some settings, providers had to log on to multiple computer systems to care for a single patient ⁷ . There are still hundreds of systems unable to connect or share information effectively. In addition, some patient data remains in legacy silos or paper-based records. This is likely to be difficult, expensive and time-consuming to capture, record, store, share and access.  

Members report this often making it difficult to share data and information effectively with partners in their systems. It is particularly relevant for mental health services and in primary care, where often the voluntary and community sector is commissioned by the NHS or social care to deliver services and will hold pertinent data that must be shared seamlessly within a multidisciplinary team context and between health and care.

In addition to the interoperability challenge, for data to be shared between parts of the health and care system, patients and communities must agree to it. In the recently released Data Saves Lives: Reshaping Health and Social Care with Data, the government acknowledges that it must better listen to and engage with individuals to increase levels of opting of sharing personal health data. Both transparency and trust are key to people agreeing for their health data to be used beyond their individual care and enabling the scaling of digital healthcare. However, only 20 per cent of people feel sufficiently informed about how their data will be used, with more than half fearing that they might regret giving permission. [ ⁸ ]

What the digital health plan must address

For every ICS to have a fully functional health and social care record that can be used by all constituent parts of the ICS, it is imperative that data can be shared safely and effectively via interoperable systems. These must operate between trusts and connect to shared care record systems in ICSs, national digital systems and social care systems run by local authorities. Only with this in place can we avoid people having to repeat health information to multiple professionals; something that can be especially traumatising for patients in mental health care settings.

To avoid perpetuating the challenges of interoperability that members are facing, the digital health and care plan should propose that systems are supported to set and follow interoperability standards, including in commercial contracts. Additional guidance and technical support are required at an ICS and national level to support consistency in this space. This guidance should appreciate that to deliver high-quality care which reduces health disparities and improves population health, some systems and places may need to maintain some bespoke, local features. This juxtaposition in standardised systems with the ability to meet different needs must be respected.    

Although trusts and ICS systems may need to continue to adopt different digital technologies and solutions to suit their requirements, using these new standards, they will be able to articulate requirements that facilitate vital data sharing from the point of procurement. A truly effective interoperable ecosystem should provide an information infrastructure that uses technical standards, policies and protocols to enable seamless and secure capture, discovery, exchange and use of health information. [ ⁹ ]

Beyond interoperability of the technology, the digital health and care plan should consider the ultimate owners of health data and the importance of building and maintaining public trust in how it is used and shared. We welcome the commitment made in the recent Data Saves Lives strategy to keep data secure, transparency, build trust and give people a say in how their data is used. Citizens must fully understand and agree with how their data will be used and moved across health and social care, between partners and providers.

This is not a one-off requirement: government must continuously promote and encourage safe use of public health data so we can create, deliver and maintain quality healthcare based upon evidenced need. This must be delivered at a national level, with clear and consistent public messaging as new technology emerges. National reach is beyond the scope and ability of any NHS organisation or system.

In addition to the potential to improve patient care, the sharing of patient data safely and securely at a local, regional, national and international level can facilitate life-saving research. NHS leaders welcome the Data Saves Lives strategy, which aims to promote data models that improve accessibility while implementing the highest standards of information governance, transparency and security. 

Ongoing, straightforward access to relevant, high-quality data will be essential to measuring, evaluating and rolling out large scale digital services, procuring new digital tools and working with industry for future innovation relevant to the NHS. This, alongside support to build on existing partnerships between the NHS and innovative industry partners, will help to ensure that we are systematically evidencing the impact of new technologies, evaluating impact for patients and staff who implement them, and enable more rapid adoption.

Transformation

Over the next three years, ICSs are expected to ensure:

• 75 per cent of adults registered for the NHS App by March 2024
• services are transformed to provide access to digitalised care and promote digital inclusion
• the workforce is fully trained, confident and proficient in using digital technologies
• innovation is enabled and embedded into the NHS health and social care system.

Where we are now

The pandemic spurred the rapid adoption of established and newer technologies to reduce face-to-face contact and manage patient needs. Traditional models of care are not always accessible to patients or aligned to their needs, resulting in missed appointments, poor health outcomes and greater use of emergency care. Replacing face-to-face care with remote digital tools has offered increasing opportunities for a more flexible and responsive approach. For instance, via the NHS App and website, which are more and more becoming a front door to the service and the use of which has increased to significant parts of the national population.

The acceleration of virtual care and virtual wards has seen many benefits. Improved accessibility, flexibility of care and reducing costs have in turn improved efficiencies for many providers. The rapid shift to virtual care during the COVID-19 pandemic precipitated innovative ways of working and deepened integrated working within and between systems, teams and professions.

However, not all online and remotely delivered care is suitable for all patients. In pursuing a digital care agenda, NHS leaders feel strongly that we must not unintentionally create digital isolation or digital exclusion, thereby exacerbating poorer health outcomes. This is especially true in communities where existing health inequalities have led to poorer health outcomes. NHS leaders are reporting that moving to digital services have in some cases reduced the accessibility of services. For instance, for the around 1.7 million households in the UK which do not have internet access. [ ¹⁰ ]

Digital innovation is being used beyond offering remote appointments. ICSs are using digital tools to transform the delivery of high-volume, low-complexity tasks, providing support, information and care for patients while waiting for treatment, during treatment and post treatment. This is helping to streamline elective waiting lists and administrative process, enabling greater provision of virtual care in people’s homes, home rehabilitation and other innovative practices.

However, the opportunity to scale these advances is being missed. Our recent survey of NHS leaders showed that almost 90 per cent of respondents cannot transform their patient services to meet current Long Term Plan targets. And further, that provision of ‘21st century healthcare’ is being jeopardized by insufficient capital funding. [ ¹¹ ]

What the digital health plan must address

The digital health and care plan should reinforce the existing ambition to increase the use of digital channels, such as the NHS App and website, to help people stay well, get well and manage their health. However, to overcome issues associated with digital exclusion, our members would like to see the plan provide for the continuation of easily accessible, usable and consistently available choice of service provision. This means funding the provision of internet to those without access to ‘close the digital gap’ and maintaining the option for people to access services in person as well as remotely.

Leaders cite this as a vital component for successful implementation of long-term use of digital services within healthcare. They would like to see the Digital Health and Care Plan put choice at the forefront of its strategy, protecting these rights even in the face of stretching elective recovery and other activity and efficiency targets. The NHS is committed to actively mitigate against digital exclusion, so as not to inadvertently worsen health inequalities for groups of people who already experience poorer health outcomes.

The plan should endeavour to build on existing good practice in this space. NHS leaders are already working to address digital exclusion and the plan should refer to, for example, the recent digital inclusion guide from our Mental Health Network, co-designed with an independent advisory group of people with mental health problems. The piece sets out key principles for designing digitally inclusive services, that providers of healthcare should follow. More generally, the plan should allow for local system leadership to decide and act on what is best for their communities in terms of co-production of services, patient engagement, evaluation and monitoring.

The digital health and care plan must not only include more ambitious plans to transform care pathways, technology and introduce new channels for access, but must back these up with corresponding commitments to invest and scale these advances. Providing choice means that we must back this up with the capacity to deliver what the person chooses. With the NHS under unprecedented operational pressures in urgent and emergency care, and with stretching elective care targets to deliver, this capacity is unlikely to continue to exist in the system and so will require new investment to be delivered.

The Secretary of State recently referenced that the NHS could achieve cost savings of £12.5 billion a year by fully automating routine and administrative tasks. [ ¹² ] The service is ready to modernise and with the right funding this can be a reality. By investing up front, we can kick start a virtuous cycle – improving day-to-day patient experience, freeing up more time for clinicians to focus on patient care, and reducing costs to be reinvested for a more sustainable future for the NHS.

Viewpoint

The views from NHS leaders are pointing towards an optimistic future for health and care delivery. They see opportunities to offer higher quality care, more choice and greater efficiency, without exacerbating inequalities. Crucially they are up for the challenge to transform how they work and see more potential than is currently being exploited. There are some things that are within their gift, which they are starting to do, but there are also other enablers of transformation that require support from the centre. This digital health and care plan is the opportunity to deliver this support. In our view, there are four areas that can provide a stimulus for change that reflect NHS leaders’ views:

1. The plan must first and foremost include how and when greater investment will be provided to match the level of ambition in this space. Investment will enable the service to take a critical first step, which is to create a more equal baseline of technology across all parts of ICSs by removing outdated IT. Proper funding will enable it to be delivered with due care, underpinned by the data architecture that will maximise interoperability and improve accessibility. We think that by using technology assessments to better understand local needs, investment can be targeted upfront and reduce the technology debt for the future. The NHS is starting this journey on the back foot, with the majority of our members reporting they do not have the capital funding to meet even Long Term Plan commitments, never mind deliver ‘21st century healthcare.’ Investment must be the first foundation block to building our way to digital transformation.
2. The plan must propose a realistic and considered timeline for change. If transformation is worth doing, it is worth doing right. This is particularly important when it comes to developing and nurturing the right skillsets and ensuring they are valued. Culture change takes time, and we risk imposing change that does not ‘stick,’ leading to investment and opportunities being wasted at a time where operational pressures mean we can ill afford to do so. Equally important is not rushing to meet targets around, for instance, EPR roll out if this does not deliver quality, interoperable solutions.
3. Although NHS leaders are best placed to make decisions for their local populations, there are areas where national support, specific guidance and best practice sharing at a national and regional level will be beneficial to support consistency and learning when they are making innovative change. Given the fast-paced nature of developments, there is a need for ongoing, structured support on, for instance, pathway redesign, digital skills and leadership, interoperability standards and smart procurement. This alongside support to build on existing partnerships innovative industry partners, will help to ensure that we are systematically evaluating impact for patients and staff who implement them, and enabling more rapid adoption.
4. The fourth area that national intervention in this agenda would add value is in ensuring that no one is ‘left behind’ as transformation happens. We have seen health inequalities exacerbated throughout the pandemic; a trend we must be focused on reversing. NHS leaders are clear that central to this is maintaining choice on how people access services. Protecting these rights in the face of stretching elective recovery and other activity and efficiency targets will be difficult, therefore we would like to see the digital health and care plan put choice at the forefront of its strategy.

To be truly transformative, we must also consider the digital agenda in a broader context. With the merger of NHSX and NHS Digital into NHS England’s newly formed Transformation Directorate, the NHS is presented with an ideal opportunity to approach digital care holistically. Digital frameworks and plans must integrate with the whole of the transformation and reform agenda: integrating ambitions to deliver the world’s first net-zero health system by 2040; using pioneering innovation and artificial intelligence solutions to partner with life sciences and industry; join up the three-pronged aims of the NHS, government and industry and deliver the vision of transformational care where we have a positive impact on the broader social and economic aspects of healthy society.  

Finally, we must acknowledge the most fundamental enabler of not only digital transformation, but of the future of the service: the NHS workforce. Ambitions to digitise, connect and transform our NHS cannot happen without human effort servicing the technology. This digital health and care plan must sit alongside a fully funded long-term workforce strategy for the NHS and social care. Without investing in our present workforce and addressing future needs, even the best digital systems can only transform so much.