Digital transformation in the NHS Contents

Conclusions and recommendations

1.The Department and National Health Service have a poor track record for transforming NHS IT and have made insufficient progress against national ambitions. Digital transformation of the NHS is a huge challenge due to the vast array of IT systems, many of which are out-of-date legacy systems that cannot easily interact with each other. The Department’s previous attempt to reform how the NHS uses IT, running between 2002 and 2011, was both expensive and largely unsuccessful. We are therefore alarmed at how little progress has been made against current ambitions. The NHS missed its main target for a ’paperless’ NHS by 2018, and this has now been watered down into a new target to reach a ’core level’ of digitisation by 2024. NHSX acknowledges that there is “a very long way to go” to achieve the new target. Despite being recognised as essential to managing patient care, there has also been a lack of progress on interoperability (seamless sharing of data). Only three out of the ten standards for interoperability so far identified by NHS Digital were ready by May 2020, and the national bodies are unable to tell us how many are now ready. The use of digital services within the health and social care system has increased during the COVID-19 pandemic—including providing more services remotely—showing the substantial potential for organisations to use digital services more and adapt quickly.

Recommendation: The Department should set realistic targets for transforming digital services and sustaining the gains made during the COVID-19 pandemic, and publish details of these by March 2021.

This should include a mix of longer-term and intermediate targets for tracking progress for both nationally-led programmes and those delivered at local health and care system level.

2.The Department’s failure to ensure clear and transparent governance arrangements for digital transformation is putting the successful delivery of the Vision for digital, data and technology at risk. There are many organisations working at both national and local levels to deliver the digital transformation of the NHS. Yet governance arrangements are complex and confused. The Department, NHSX, NHS Digital and other stakeholders recognise that there is a lack of clarity over the roles of NHSX and NHS Digital and the overlaps in their work. The new Chair of NHS Digital is due to review the approach that has been taken to digital transformation, including the operating models being used across NHS Digital, NHSX and NHSE&I. However, we are concerned that governance arrangements for NHSX have still not been finalised over a year after it was set up. NHSX is not a statutory body and does not prepare financial statements for audit, and so there is little transparency over its spending and activity. It has spent an estimated £11 million on the first phase of the delayed contact-tracing app, and expects to spend another £25 million on the second stage. Given the taxpayers’ money involved, transparency is important to allow Parliament and the public to hold it to account.

Recommendation: To improve clarity and transparency, the Department should:

3.Without a proper implementation plan, the Department and NHSX cannot be sure that the £8.1 billion of taxpayers’ money being invested in the digital transformation programme will deliver value for money. The Department’s 2018 Vision for digital, data and technology is not an implementation plan as it does not set out how the NHS will deliver its ambitions in practice. It does not include a timeframe or plan for achieving interoperability, which NHSX acknowledges is an “extremely complex” process and could take “years”. The Department asserts that it will take a “blended” approach to planning, which will take place both nationally and locally by NHS systems and individual organisations. However, the Department has not demonstrated that national and local initiatives will be sufficient to meet the overall ambition. Furthermore, the national organisations have not yet put in place the planned levers and incentives to encourage trusts and other parts of the NHS to take the appropriate action on the ground. This will make it harder to ensure that local organisations are carrying out transformation in a way that is consistent with the national strategy and will benefit patients and staff.

Recommendation: NHSX should, as a matter of urgency, publish an implementation plan for meeting its ambitions for transforming digital services. This should:

4.To deliver the digital Vision, NHS organisations’ IT systems must be interoperable. Many of the standards required to enable this are not yet in place, and much work is required before benefits, such as digital-image sharing, can be realised. NHSE&I increasingly seeks to plan and coordinate patient care through local partnerships of health and care organisations, making data sharing between organisations essential. Currently, many local organisations rely on legacy systems that are unable to do this, so these systems need to be upgraded. But at May 2020 only three of the 10 sets of standards for achieving interoperability, identified by NHS Digital, were ready and NHSX could not tell us when the others would be ready. Interoperability will also help the NHS to make good use of the cloud which could, for example, benefit patients, radiologists and consultants by facilitating the sharing of digital images.

Recommendation: NHSX should urgently bring forward the remaining standards in order to provide clarity for trusts and suppliers, including providing trusts with guidance on the potential use of the cloud to enable digital image sharing.

5.We are concerned that patients and local health and care systems could be left behind if some less digitally-advanced trusts are unable to invest in the technology and skills they need to catch-up. There is wide variation in the digital maturity of trusts, with 13% of trusts assessing their capability as ‘high’ and 16% of trusts assessing it as ‘low’ in 2017. It is essential that trusts have the necessary digital skills if they are to improve their digital maturity and make national ambitions a reality, but these skills are in short supply. We are particularly concerned about the lack of skills in cyber-security, as legacy IT systems are especially vulnerable to attack. But despite these shortcomings and the variation between trusts, the Global Digital Exemplar programme has focused on improving the digital maturity of a small number of higher-performing trusts. NHSX’s focus is now moving to helping the less-advanced trusts to catch up. However, we are concerned that trusts may be unable to invest the £3 billion expected of them by the Department under its matched-funding arrangements. Our reports have illustrated the long-standing financial challenges facing many trusts.

Recommendation: As part of the implementation plan, NHSX should work with NHS England & Improvement and NHS Digital to develop a more-focused package for those local health and care systems most in need of support for planning, funding and implementation, and with a clear basis for priority action.

6.The Department and NHSX lack the information they and local organisations need on which of the options for achieving digital transformation in local health and care systems achieves the best value for money. The Department considers that the £8.1 billion being invested in digital transformation will be sufficient to achieve its ambitions, but its costing estimates are based on very limited data. The capital element of this funding is subject to approval at the next spending review, due in autumn 2020, and there is likely to be financial pressures on the Department as a result of the COVID-19 response. NHSX plans to assess the cost and benefits of different approaches to electronic patient record systems within the next six months. Local organisations will need information on the whole-life cost and benefits, and the conditions on the ground needed for success, so that they can make the best choices about how to invest the limited funding available.

Recommendation: NHSX should develop and publish a cost-benefit analysis of the various approaches available to local organisations when implementing their system solutions. It should also use the information to assess the realism of the £3 billion contribution from the NHS trust sector toward the overall budget of £8.1 billion.

Published: 6 November 2020