Digital transformation in the NHS Contents

1Plans for digitally transforming the NHS

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care, NHS Digital and NHSX on digital transformation in the NHS.1

2.The Department of Health and Social Care (the Department) has a longstanding ambition to digitally transform the NHS and enable seamless data sharing (interoperability) between the many organisations that make up the health and social care system. The Department published its digital strategy in 2014 and in 2016 it set up the Digital Transformation Portfolio to deliver the strategy. The Department set out its priorities for improving the use of data, digital services and technology in its 2018 Vision for digital, data and technology, which included interoperability between data and systems as one of the first steps to allow the sector to benefit from cutting-edge technologies.2

3.Since 2016, management of the portfolio of national programmes to digitally transform the NHS has been overseen by a combination of the Department, NHSE&I and NHS Digital. NHS Digital has been the primary delivery organisation for national programmes. The Department set up NHSX in July 2019 to lead digital transformation across the NHS. NHSX reports to both the Department and NHSE&I. According to NHSE&I, the NHS will need around £8.1 billion to deliver its digital transformation ambitions, including £5.1 billion from national bodies and £3 billion from trusts.3

The scale of the challenge

4.NHSX, NHS Digital and other organisations highlighted how digital transformation of the NHS will be a huge challenge. As NHSX explained, the NHS’s digital estate comprises an enormous number of out-of-date ‘legacy’ systems that cannot easily interact with each other and some trusts are using up to 400 different IT systems. NHS Digital echoed this, telling us that there were lots of legacy technologies and different IT systems in use across the NHS. We received written evidence from the NHS Confederation, which told us that there were also systemic issues within the NHS with broadband connectivity and outdated hardware, and a lack of funding and resources to train staff to use the technology available to them. The Royal College of Midwives also wrote to us that there needed to be a cultural shift amongst healthcare workers so that they are engaged with new digital technologies.4

5.The Department’s previous attempt at digital transformation in health was both expensive and largely unsuccessful.5 In our 2013 report, The dismantled National Programme for IT in the NHS, we examined the Department’s attempt between 2002 and 2011 to introduce modern integrated IT systems and make patient records available electronically throughout England. We found that the benefits from the National Programme by that time were extremely disappointing and while the full costs of the Programme was still not certain, the public purse was continuing to pay the price for failures by the Department and its contractors. We were sceptical that the Departmental could deliver its vision for a paperless NHS by 2018 and recommended that the Department needed to draw on the lessons from the Programme and develop and clear plan for how it would deliver its ambitions.6

6.In late 2015, the National Advisory Group on Health Information Technology in England was formed to advise the Department and NHS England on its efforts to digitise the secondary care system, with findings published in the 2016 Wachter Review.7 The National Audit Office reported that while some high-level lessons were identified in the Wachter Review, it had not seen evidence that the lessons from the National Programme and other programmes had been captured systematically.8 In response to our questions about the lessons it had learnt, the Department told us that it had moved away from a centralised national programme which determined which technologies should be used and that it had made improvements in procurement and contracting arrangements. The Department also said it was balancing its ambitions with realism about the challenges of implementation.9

7.The NHS has not made the expected progress since its 2014 strategy and missed its main target to achieve a ‘paperless’ NHS by 2018.10 The 2018 target has since been redefined in a new target to reach a ‘core level’ of digitisation by 2024. We asked why a watered-down target had been put in place rather than the previous commitment to ‘paperless’. The Department told us that its ambitions for digital transformation within the NHS were no less ambitious, but that this target was “more realistic”. NHSX told us that it has made “considerable progress” against the new target, but admitted that there was still “a very long way to go”.11

8.NHS England & NHS Improvement (NHSE&I) increasingly seek to plan and coordinate patient care through partnerships of local health and care organisations, known as sustainability and transformation partnerships (STPs) and integrated care systems (ICSs). This makes sharing data between organisations essential to enable electronic patient records to be seen and updated by clinicians in different organisations such as GP practices and hospitals. A key part of the Department’s plan is the interoperability of IT systems within the health and social care service, which involves the seamless sharing of data so that electronic patient records can be shared between different organisations. NHSE&I expects that interoperability will release staff time and provide a better patient experience. For example, it is hoped that interoperability will reduce duplication of care, since clinicians will see information (such as test results) recorded by others. To enable interoperability, organisations need to upgrade their legacy systems to meet modern standards. However, in 2017 only 15% of trusts reported being mostly compliant with the standard for clinical terminology (SNOMED CT). NHS Digital asserted that the level of compliance was now much higher: it estimated that over 80% of trusts were now using SNOMED CT in one or more healthcare settings for information recording or reporting.12 Nonetheless, by May 2020 only three of the 10 sets of standards identified by NHS Digital for achieving operability were ready. We asked NHSX when the remaining seven sets of standards would be ready. NHSX told us that it was “making progress” but could not answer the question with a number. It told us that its digital medicines programme and its events management services was now live, and others, such as transfers of care for patients and pathology standards, were in progress. It asserted, however, that progress “was not binary” and we asked it to write to us with a note detailing progress against each of the standards.13

9.We were particularly interested in one aspect of interoperability, namely the opportunities afforded by the cloud and cloud computing. For example, vendor-neutral digital image sharing through the cloud can benefit patients, radiologists and consultants. But suppliers might experience difficulties in providing these services to the NHS. NHSX told us that, to facilitate the use of cloud (for image sharing, and more widely), there were a number of actions that could be, or had been, taken. First, it could ensure that the policy and standards facilitate the use of cloud and image sharing. Second, that NHS Digital had already undertaken work to ensure the connectivity and bandwidth were in place to allow these types images to be shared. Third, care pathways could be designed to make use of digital image sharing to deliver a more efficient service and better outcomes.14

10.The Department, NHSX and NHS Digital told us that the COVID-19 outbreak had shown how quickly and efficiently the NHS can introduce new IT services and adapt to new technologies.15 This view was echoed by NHS Providers, which told us in its written evidence that the pandemic had resulted in many trusts accelerating their digital plans, including by increasing remote consultations and improving the way data is captured and used. The Nuffield Trust also told us that there had been a surge in patients’ uptake of remote health services, including using the NHS app, NHS login and e-prescription services.16 NHS Digital told us that the pandemic was showing that the NHS could be more ambitious than it had been in the NHS Long-Term Plan and get more effective at sharing data across the system. It explained that, as a result, it was more confident in the potential for the digitisation of the system than it had ever been previously.17

Governance and accountability arrangements

11.Since 2016, management of the portfolio of national programmes to digitally transform the NHS has been overseen by the Department, NHSE&I and NHS Digital. The National Audit Office reported that these governance arrangements were complex. It found that problems included confusion caused by there being multiple stakeholders, funding held in multiple budgets across organisations, and unclear lines of commissioning, funding, delivery and accountability. The NAO concluded that these issues contributed to slow delivery and transformation within the NHS. It found that previous attempts to improve these arrangements had been unsuccessful for a variety of reasons, for example, because accountability for managing development costs and for achieving programme benefits were shared across different organisations. The Department set up NHSX in July 2019 to lead digital transformation across the NHS to resolve conflicting priorities and confusions and take overall responsibility for digital transformation.18

12.In May 2020, the new governance arrangements for NHSX had not been finalised.19 We received written evidence from NHS Providers, which told us that national governance and oversight arrangements remained fragmented and ambiguous, with many trust leaders still unsure where responsibilities sat between NHSX, NHS Digital and NHSE&I.20 The Department, NHSX and NHS Digital admitted that there were still tensions in the governance model, a lack of clarity over the roles of NHSX and NHS Digital, and overlaps in work. NHS Digital told us that it had started working with NHSX to clarify where the boundary between the two organisations should sit, although it said the work has become less of a priority while it dealt with the COVID-19 outbreak. It told us that the new Chair of NHS Digital was due to take their post within the next few months and would review the approach that had been taken to digital transformation, including the operating models being used across NHS Digital, NHSX and NHSE&I.21

13.NHSX is not a statutory body and does not prepare financial statements for audit. We asked how the Department was tracking the performance of NHSX and ensuring that money was being well used given that NHSX was not audited. The Department explained that NHSX’s funding came from the budgets of the Department and NHSE&I, and would therefore follow the normal funding allocations processes within each of these organisations. The Department accepted that the budgetary arrangements for digital transformation were not straightforward and this was an area it should keep under review. It said that it would be worthwhile to get “the money tidied up” so that there was greater accountability over how NHSX prioritised its spending.22

14.NHSX was responsible for the initial development of a new NHS COVID-19 app, before this responsibility transferred to the newly-established NHS Test and Trace. The app, which was initially due to be launched in May 2020, alerts people who have had close contact with someone who has tested positive for COVID-19. It was launched on 25 September, after our evidence session and some four months after it was due. We asked NHSX why it had taken so long to launch the app. It told us that while some areas of the project had worked “extremely well”, other parts of the technology had not worked in the way it anticipated. It explained that it started the project before the Google and Apple framework had been announced or developed, and it had changed direction to using this framework very soon after it was announced. It asserted that it had tested “very extensively” to make sure it understood the effects of the app, how it worked and how people would interact with it, and had changed its approach as a result. NHSX estimated that the cost of developing the app and supporting it will be £36 million. It estimated that the cost of the first stage of developing the app was some £10.8 million. Of that, some £4 million was spent on developing the version of the app that it moved away from, £6 million was on development that was necessary for both versions and £0.8 million was on Google and Apple technology that is now being used. It estimated that a further £25 million would be needed for the second app in 2020–21.23 NHSX was not able to tell us what impact it would have on the successful tracing of people, because that would depend on many variables, but said it would give useful information to people.24

Creating plans and incentives for delivering on the ground

15.The NHS Long-Term Plan includes some challenging ambitions for digitising the NHS, including the target that all trusts reach a ’core level of digitisation’ by 2024. However, the NAO found that there was no digital implementation plan which set out how digitally enabled care will be rolled out across the NHS and its plans were underdeveloped. For example, there was no clear schedule for achieving interoperability, which risks making interoperability harder to achieve in the future.25 We asked NHSX how long it expected it to take to achieve interoperability between systems. NHSX was unable to provide a timeframe for achieving complete interoperability, stating that dealing with the enormous legacy of IT systems was an “extremely complex” process and could take “years”. NHS Digital similarly explained that there was no easy way to migrate legacy systems to modern standards, but acknowledged that there needed to be a clear plan for moving away from each legacy system.26

16.In response to our questions about when there would be an implementation plan, NHSX told us that it had intended to produce a digital strategy during the first eight months of this year. It put out for consultation the vision part of its digital strategy in February 2020, which was to be followed by six months of consultation and “co-creation” between the national bodies and frontline. The Department explained that the development of the strategy had been delayed as a result of the extra demands that had been placed on organisations as a result of COVID-19, but it was still its intention to undertake this consultation.27 The Department told us that it will take a “blended” approach to planning, which will take place nationally, as well as locally by NHS systems and individual organisations. NHSX added that its digital ambitions would primarily be delivered by the frontline, so their capability, decisions and progress were fundamental to overall success. As such, it considered that it was important that the national bodies helped local systems and organisations by giving them parameters, support and guidance.28

17.The National Audit Office found that arrangements for ensuring trusts’ technology spending was consistent with the national strategy were still being developed.29 We asked NHSX what levers it had to influence trusts’ digital investments, and whether there were any circumstances where it would intervene in local systems if they were out of step with national strategies. NHSX told us that it wanted to implement “more nimble” spending controls, covering much more of trusts’ technology spending than the current business case approvals process for large projects. It explained that these controls will be used to ensure that the systems purchased by trusts were consistent with its standards and can speak to each other.30 NHSX told us that it was using procurement frameworks to save money, as well as to ensure that organisations are purchasing from a set of products that it has vetted and which it knows are compliant with the standards. We asked NHS Digital how it would manage the tension between achieving interoperability and increasing the number of suppliers in the system via the procurement frameworks. NHS Digital responded that interoperability would be a foundation condition for a vibrant, competitive market for healthcare technology.31

1 C&AG’s report, Digital transformation in the NHS, HC 317, Session 2020–21, 15 May 2020

2 C&AG’s report, para 1,1.6,1.7 & Figure 2

3 C&AG’s report, para 1, Figure 2 & 3.4

4 Q32, 50; DGT0014 - The NHS Confederation, para 2; DGT0007 - Royal College of Midwives submission

5 C&AG’s report, paras 1,19

6 Committee of Public Accounts, The dismantled National Programme for IT in the NHS, HC 294, Session 2013–14, 15 July 2013. Available at:

7 National Advisory Group on Health Information Technology in England, Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England, 2016

8 C&AG’s report, para 19

9 Q36

10 C&AG’s report, para 4

11 Qq 41–42 & 44

12 C&AG’s report, para 14 & 1.7; Qq 44- 45; Correspondence from NHS Digital, dated 24 September 2020.

13 Q48; C&AG’s report para 14

14 Qq 52–53

15 Qq 74 & 78

16 DGT0011 - NHS Providers, para 3; DGT0021 - The Nuffield Trust submission, para 5,

17 Q 31; NHS Long-Term Plan, NHS England, January 2019

18 C&AG’s Report, para 11, 2.2–2.3

19 C&AG’s Report, para 11

20 DGT0011 - NHS Providers

21 Qq 56–59

22 C&AG’s Report, para 11; Qq 67 & 69

23 Qq 23, 25 & 29; Department of Health and Social Care announcement, 25 September. Available at:

24 Q24 & 29

25 C&AG’s Report, paras 10, 15 & 1.15,

26 Qq 50–51, 54

27 Q37

28 Q37

29 C&AG’s Report, para 12

30 Q 71

31 Qq 35, 54, 71

Published: 6 November 2020