Water, soap, IT…

Philip Scott has an excellent vantage point to look at the large-scale changes in healthcare technology, having worked in the NHS from 1994 to 2009 and subsequently returning during the pandemic.

‘I worked in all sorts of IT roles starting off as a data analyst then a programmer,’ he says, ‘then a project manager, then a head of department, ending up as part of a shared service providing IT support and development across acute services, community care, primary care, and mental health. I did an MSc and a PhD in health informatics and moved into an academic role at the University of Portsmouth in 2009 and last year moved to University of Wales Trinity Saint David where I'm running a Masters programme funded by the Welsh Government, specifically for health and care professionals working in digital.’

Large-scale change is never easy, so what did Philip find when he returned to the NHS during the pandemic? ‘I saw a huge step forward from when I'd left ten years earlier,’ he says, ‘with much greater recognition at the top of how important IT is. For example, we had a brilliant chief exec in Portsmouth Hospitals who went on to a national role. Having somebody at the top of the organisation who would come and chat to the IT department the same as he would come and chat to the doctors and nurses was excellent. Someone who knows that a business case for extended Wi-Fi could be as important as a new imaging device of some kind.’

In BCS, the role of the Health and Care Executive is to coordinate across all of the health specialist groups - mental health, primary care, nursing, and social care. Their focus at the moment is setting up a group for social care, where, Philip says, ‘we have a lead for technical standards that covers things like interoperability, clinical record keeping, as well as more technical kind of infrastructure standards. And we've also recently appointed an equality and diversity lead because we recognize that we want to try and broaden the scope and mix within the group rather than have just old white men like me.’

The group has also been working on assessing digital maturity, where there are some specific considerations for health. ‘Obviously,’ says Philip, ‘when you apply technology to health, it's got to be done right, otherwise you end up making things worse and possibly even harming people, as has sadly sometimes happened. So we're formulating a pilot project with one of the health boards in Wales to try out an approach to measuring nursing satisfaction with information systems.’

The Executive has also done a joint project with the Faculty of Clinical Informatics on computable knowledge, recently publishing a whitepaper on moving decision support from a sort of cottage industry into something much more scalable, robust, and open. 

‘What's been really positive about that,’ says Philip, ‘is we've had great reception from some of the national bodies. NHS Scotland, NHS England and NICE, the body that produces clinical guidelines, have all been actively involved with us in moving that agenda forward. So that's been a a catalyst for changing the way these organisations look at computable knowledge, that's been very satisfying.’

Getting the word out

One of the Executive’s key activities is publishing and co-publishing. For example, the BMJ Health and Care Informatics journal started life as an in-house BCS magazine. In 2019 it became co-owned with BMJ, which vastly increased the prestige and the profile of the journal.

‘What we're trying to do,’ says Philip, ‘is use that journal to get people involved in sharing knowledge in an academic journal, which probably they would never have done otherwise. We have created a specific category of publication, called an implementation report, where we're trying to get people to report their own local experience of implementing some kind of digital technology. Because otherwise so many of the lessons that are learned from these projects tend to get lost in history and you just move on to the next project and forget about the one you've just delivered.

‘It's the old saying, if you don't write it down, it didn't happen. So we're trying to kind of get a bit of a public record of successes and failures. We learn a lot from failure. So we’re hoping to see a bit more of that well… not more failure, but more willingness to admit lessons learned from failure.’

Current issues... water and soap?

In response to a question on current issues, Philip draws attention to the lack of investment in infrastructure across the NHS. ‘It's very variable,’ he says. ‘If you look at primary care GP services, they've had significant investment in it over decades and you know GPs are largely paperless and have been for years. But even GPs will tell you their infrastructure is not good enough. It's not fast enough. It's not reliable enough.

‘The austerity that the NHS has had over the last 10 years or so means there just isn't the money to go around. But IT is absolutely critical - it's like having water and soap. People expect digital to produce transformations, but it can't if you haven't done the fundamental things like have enough network capacity, enough Wi-Fi, enough storage, fast enough response times, and enough disaster recovery.

‘It's improved, but there's a long way to go. Social care, for example, is nowhere to be seen, really. And, of course, there's the workforce crisis generally. There's not enough nurses and doctors, let alone enough IT people.‘

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Culture shift

Philip’s view is that things have got better from the culture perspective. It's a huge task because it requires adopting a different way of looking at how healthcare is delivered when you have access to so much digital information. As he says, there are generations of healthcare workers still out there who see having a computer as nothing to do with being a nurse.

‘There is still more to be done to address the skills gap,’ he says, ‘but as part of the overall workforce challenge that is partly about retaining the clinical staff we do have and getting new ones and bringing them up to speed with digital and helping them to see it's not just how to log on and how to put in a request for a blood test.

‘COVID moved things on because things had to be done remotely. A classic example is multidisciplinary team meetings where, let's say, if cancer care is shared across two or three hospitals. In the old days, all the members of that team would drive to one of the hospitals to get in the room together and look at the slides and look at the reports and discuss the cases. Now that can be done virtually, which saves a lot of time and reduces environmental impact. But it has the infrastructure dependency and it has the digital literacy dependency.’

What about the creeping privatisation of different health services the UK has seen in recent years? Philip comments: ‘My experience has generally been that when private sector are brought in for outsourcing, it can make things worse because you're introducing even more gaps. So for example, when I was in the NHS, we had an independent sector treatment centre built in the hospital car park with a minor injuries unit and they did various radiology things and it just created another silo of information, another place where you had to be able to get the data. We managed to find a way around it to get the images they took transferred into the hospital, but it was another gap rather than introducing more continuity.

‘I understand operationally why there is an argument for having certain things outsourced, but the problem is when the outsourcing is planned, they only think about it as a commercial exercise. They don't think about it as a continuity of care exercise, and they certainly don't think about transmission of patient information. So that's a challenge - the people that make the decisions about outsourcing are people with commercial heads on. They're not people with patient care heads on and they're not people with digital health heads on. Without being too political, outsourcing is supposedly about making things more efficient, but in reality what happens is these private sector providers are completely underwritten, so they have no financial risk at all and typically get paid more unit costs than the NHS gets paid. So the cheap, profitable stuff gets outsourced and the difficult, expensive stuff stays with the NHS, who have to pick up the pieces.’

Getting the patient as focus

Philip has three main concerns to keep the patient at the centre of the conversation. ‘Number one,’ he says, ‘is infrastructure spend. There needs to be a minimum percentage spent on IT infrastructure on an annual basis so that maybe some of that can move away from purchasing to a lease or managed service scheme, but they do need to see it as important as water and soap and oxygen. You know you can't run a hospital without those things. You can't run a hospital or any health service without IT - you have to be able to move the information around seamlessly.’

Secondly he mentions interoperability standards. ‘There has been progress on interoperability standards, but it's been painfully slow. So we do need to see an accelerated progress on interoperability standards and the international standards are fairly mature now. They need a little bit of tailoring for UK usage and that has been in progress in fairness, but very slowly. And interoperability needs to be about knowledge, like NICE guidelines, not just data.’

Finally, in digital literacy, there needs to be a recognition of the gap that exists for the current and future workforce and the funding issues around it.

Distribution of services

The NHS is geographically split, and there is an attendant uneven distribution of services and digital maturity. ‘That was actually specifically encouraged by previous government policy,’ says Philip. ‘They set up these things called global digital exemplars, gave them loads of money. And the idea is that they were supposed to be kind of the best of the best to show everybody else the way. I'm not convinced that actually happened. Some of them have produced some very good things, but I wouldn’t honestly say any of them are globally exemplary.

‘It is patchy and it depends on the people you know. Some organisations see the importance of digital and they've seen successes, they've seen transformation – they have put their money where their mouth is. Other places are a bit more old fashioned and think, “oh no, we need to spend money on patient care, not on computers,” missing the point completely that we're doing it for the sake of the patients to make their care better.

‘Health is a devolved policy, so we have different approaches across England, Wales and Northern Ireland and Scotland. There is a measure of collaboration, but the structural and political differences of how the health service works in the four nations limits that inevitably.’

Good practice

In keeping with his optimistic mindset, Philip draws attention to some of the practical benefits he has observed.

‘A good example,’ he says, ‘was a hospital sending an electronic pre-discharge process where they ask for a care package for a person who they're planning to discharge – which has to be in place before they can discharge them. One of the big problems with hospitals at the moment is they can't get people out because they can't organise social care packages. But years ago it was shown it can be done as an electronic communication between the hospital system and the social care system. When a patient is discharged, that record comes through to the local authority for the social care assessment.

‘There are also virtual wards, virtual outpatients, virtual GPs – these are things that have really moved on in the pandemic. A lot of this is via telephone. You avoid the transport issues, patient inconvenience, infection risks and so on. Primary care has moved very much more to a triage model where things go through call handlers. Very often the patient doesn't need to see a GP - they might need to talk to a nurse or a pharmacist, or a mental health advisor. That makes the whole thing better for everybody. So I think that is a very positive step forward.

‘It’s the same with outpatients, although it's slightly more complicated there because more often there's need for some sort of physical examination. But with things like dermatology, for example, patients can take a photograph and send that in to the consultant. It may not be a perfect image, but it might be good enough for a first cut opinion about how serious the case is.’

Philip is a particular champion, from the patient perspective, of the NHS app. ‘It's a bit limited at the moment, but it's a good platform to build on,’ he says. ‘So in the same way as the COVID app in the end turned out to be quite good, although it took an awful lot of time and money to get there, I think the NHS app offers a great opportunity for patients to get access to their own records and make that the cultural norm.

‘Unfortunately, that is still highly variable between GP practices because it's up to the GP practice what they're willing to release, which does seem rather perverse to me. You would think it would be up to the person to decide what they wanted to see, but of course I know there are problems with how things were recorded historically. Things were not written in such a way that they are necessarily patient-friendly. For example, maybe you don't want patients to see every single “query cancer” note in the record.

‘Some sort of curation is necessary, but as a path going forward, I think the NHS app - as a means to request repeat prescriptions to book appointments, to look ahead at a schedule of appointments, to look at test results - is a great step forward. It just needs to have more content and more functionality. But as a platform, it's great.’

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