241.The world is changing and the NHS must adapt if it is to continue to deliver the vital services millions of patients have come to rely on. This chapter highlights the NHS’s relative failure to secure the take-up of innovation and new technology at scale and make effective use of data. It also highlights the mixed picture on productivity and the persistent variation in the quality of care and outcomes. Ultimately, strong leadership and a radical culture shift are required.
242.The Five Year Forward View speaks of accelerating useful health innovation and exploiting the information revolution. Powerfully, it presents the information revolution alongside the agricultural revolution and the industrial revolution as one of the major economic shifts in human history; but it also acknowledges that the NHS has been slow to adopt information technology because of a tendency to either over-centralise on the one hand or let “a thousand flowers bloom” on the other.
243.New technologies are changing what type of care can be provided and how it is delivered. Andy Williams, Chief Executive of NHS Digital, outlined some of the ways in which new technologies would support NHS sustainability:
“In the future, as patients start to have access to their health records and so-called ‘artificial intelligence’ can be used to understand what is wrong with them and to compare their health record to the health records of the broader population, they can come up with smart diagnoses to help the patient understand what they should do next, and it could be to go to A&E or it might not be.
The second is that we can use technology better to create more efficiencies in the way the system works, through interchange and passing information around … Within hospitals, technology systems can not only improve quality but can increase efficiency and effectiveness.
The third area is a much better use of data generally … data can be used in all sorts of ways in the future: to understand how effective the system is; to develop new treatments and new drug treatments more effectively; and linking genomics data to phenomics data.”
244.Medical advances are constantly changing the way the NHS responds to patient need and the possibilities presented by digital innovations are enormous both for the workforce and patients. However, traditionally, the NHS has been slow to adopt and implement new technology. The evidence suggested that, worryingly, this is still the case. Some argued that this was because of inadequate levels of funding, others argued that this was because of persistent cultures of complacency. Alistair McLellan, Editor of the Health Service Journal, however, reminded us that this was not the case everywhere: “while the NHS faces many challenges, there is also an enormous amount of innovation, endeavour and improvement going on within the service.” Dr Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, also told us that there was a willingness to engage with new technology systems:
“We desperately need to embrace technology. Healthcare professionals love technology generally; it is just getting standardised, joined-up systems that we can use across the board. We want to be able to communicate with each other efficiently and effectively. It needs resource to do that, because IT will help us enormously with our jobs. When I hear that midwives are spending 50% of their time on admin tasks, we know that if we had better IT systems that could be reduced massively.”
245.There was disagreement on the possibility for cost savings which could be brought about by the use of new technologies; they might increase levels of productivity but cost more to procure. Some argued that new technologies, such as healthcare and assistive technologies, as well as the use of digital health, tele-health and wearable technologies, had the potential to transform care and could reduce costs and demand on NHS services. Professor Keith McNeil, Chief Clinical Information Officer for Health and Social Care and Head of IT for the NHS, provided an illustration:
“… give you a practical example of innovation and costs, when coronary angioplasty came in, which is putting a balloon in a coronary artery to treat a heart attack or a blockage, the previous treatment would be to open someone’s sternum and do an operation. The cost of doing an angiogram is much less than doing an operation, but the angiogram enables that technology to be available to a much wider population, so you get the balance between an individual procedure which is less costly and innovative but is available across a wider population and, in fact, the aggregate cost is greater.”
246.Andy Williams, Chief Executive of NHS Digital, argued that there were difficulties in encouraging the uptake of new technology at scale. He pointed to both a silo mentality and a “technology inhibitor”:
“… new technologies quite often get plugged into the existing technology of one of those organisations and it is unique to that, and trying to replicate it somewhere else requires an awful lot of planning, so it is hard and difficult; it is not simple just to take something from here and put it over there. From a technology point of view, over the next few years we have to make that much simpler.”
247.Professor Sir John Bell, Regius Professor of Medicine at the University of Oxford, explained that the incentive to innovate was often unclear. He argued that if innovation were to be seen in the context of saving costs, the uptake would be greater:
“I think the fundamental problem with innovation in healthcare is that we do not systematically look for the ways that innovation can extract cost from healthcare systems. In fact, the definition of ‘innovation’ should be to improve outcomes and to save costs, and it saves costs by changing pathways, allowing you to re-profile the workforce, which is essentially where healthcare systems spend all their money, and you should be able to extract very large amounts of money out of the system using those tools.”
He also explained the importance of applying this across the system:
“it is about being really rigorous about taking innovations and trying to evaluate how you can extract the costs of innovations in a closed system, measuring and evaluating everything and then recommending that across the system. That will make a huge difference.”
248.The benefits of using new technology are well known but we were told that encouraging uptake was difficult. One possible solution might be a system which would appraise new technologies, come to a decision on cost-effectiveness and need, and then make it clear to providers that implementation should follow. Lord Willetts suggested that providers should be told what was expected of them more broadly:
“… with social care, I look at some of the extraordinary advances in technology, where they can literally track your pattern of electrical use. They can work out when you are turning on a particular device, and register that this person is turning on a kettle between 9.30am and 10am and she has not turned it on and it is 11am, just by monitoring the electricity supply. We need to use technology and embrace the capacity of innovation. We experimented, and one way of making it happen is a list of required innovations that healthcare providers are expected to introduce.”
It was unclear, however, who should be charged with undertaking such a detailed technical appraisal and imposing the resulting requirements on providers, or whether there were currently any penalties for failing to do so.
249.The PHG Foundation argued for financial incentives to encourage innovation and Professor Sir John Bell suggested that the penalty for failing to make progress could be financial:
“It is worth remembering that the Americans did this in a really short timeframe. They, essentially, digitised their entire healthcare system, which, as you know, is chaotic at best, and they did it by incentivising the hospitals and making sure that reimbursement was directly related to the ability to digitise. If the NHS tomorrow said, ‘Do it at whatever pace you like, but you will not get paid if it is not digital data’, I can tell you that, by Christmas, you would find a lot of stuff had happened. Hospital trusts have a lot of stuff on their plate, so why would they do it when they are doing everything else? There is a bit of a problem in incentivising these places in the way we need to. The American example shows that it can happen really fast.”
250.There is a worrying absence of a credible strategy to encourage the uptake of innovation and technology at scale across the NHS. It is not clear who is ultimately responsible for driving innovation and ensuring consistency in the assessment and the adoption of new technological approaches. The provision of appropriate training and development of strong leaders to support this agenda within the NHS will be critical to its success.
251.The Government should make it clear that the adoption of innovation and technology, after appropriate appraisal, across the NHS is a priority and it should decide who is ultimately responsible for driving this overall agenda It should also identify the bodies and areas within the NHS which are falling behind in the innovation and technology agenda and make it clear that there will be funding and service delivery consequences for those who repeatedly fail to engage. This could involve relocating services to places that prove to be more technologically innovative.
252.The effective use of data is of critical importance for the long-term sustainability of the NHS. We now know more than ever about the health of patients, but the continued failure to use this data effectively is costing too much money and resulting in unacceptable levels of variations in patient outcomes.
253.The use of Big Data was raised a number of times. Big Data is a term that describes the large volume of data—both structured and unstructured—that flows into an organisation on a day-to-day basis. This may be how many people have booked appointments in certain areas of the country, cancer diagnosis rates or average prescription costs for a specific drug. However, the PHG Foundation pointed out that the existence of Big Data is not enough: “The health service is already awash with ‘big data’, but its inability to standardise it, aggregate it, share it, analyse it and then use it intelligently to drive changes in practice means that its impact on reducing cost and managing demand are limited.”
254.We were told that data sharing and access was also important for continued medical research. The Association of Medical Research Charities explained that “researchers use health information to develop understanding of disease and ill-health, discover new cures and treatments for patients; and improve the care provided by the NHS and provide efficiency and cost savings.” They continued to say that: “without access to health information, the advancement of medical research will be hampered and with it the benefits to the NHS’s future sustainability.”
255.The Secretary of State for Health acknowledged that there was still more work to be done in the patient sphere:
“What we do not do at the moment, but it is starting to happen, is allow those records to flow around the NHS, but we have complete histories of people, which is a fantastic asset … Now we have around two-thirds of A&E departments able to access people’s GP medical records, and next year we will go a step further and introduce what we are calling the Blue Button scheme. At the moment you can access your own record if you go to your GP surgery and get a code, so you can go online and access your record, but from next year we will have a system where you can go online and identify yourself online without having to go to your GP surgery. That will be very significant, because people will be able to download their record on their phone. People with long-term conditions will be able to get engaged in their own treatment … It will save a lot of time. In short, I think there are some very exciting things happening.”
256.Dr Ron Zimmern, Chair of the PHG Foundation, argued that data sharing went to the heart of the effective use of new technologies:
“No matter what technology you look at—epigenetics, microbio, liquid biopsy—in the end it is about data and data sharing. To do that properly, you have to engage the citizen, you have to break down silos and you have to actively develop leaders. Without that, you will not get the data sharing which is absolutely at the heart of everything that we want to do.”
257.The benefits of data sharing are obvious; it can lead to improved patient engagement and ultimately better overall outcomes. Andy Williams, Chief Executive of NHS Digital, told us: “I think we can do much more, as far as the patient is concerned, by better use of digital technologies to allow patients to understand more, to access their health records and increasingly to use intelligent systems to allow them to look at self-diagnosis.” The Royal Pharmaceutical Society echoed this point and said that “there should be a shared patient record that all relevant healthcare professionals can read and write to. There needs to be systems and processes in place that enable the electronic referral of patients, and information, between one care setting and another.”
258.Professor Sir John Bell argued that an additional benefit was the ability to track the costs associated with a patient’s treatment pathway:
“The advantage of the digital agenda is that you will be able to capture data on the same patient in primary, secondary and social care, and you will be able to know the captured cost of that whole pathway and then manage that to try to get yourself in a better position in terms of cost reduction.”
259.The Government’s flagship £7.5m care.data project aspired to create a giant database of medical records showing how individuals had been cared for across the GP and hospital sectors, and was intended to help them develop new treatments and assess the performance of NHS services. The records would have been anonymised, removing identifiable data, and would only have revealed the patient’s age range, gender and area they lived in. The project was abandoned in the summer of 2016 because of data protection concerns and accusations that the Government had mismanaged the process of public consultation. The failure to successfully implement care.data was cited as a missed opportunity and, although instances of good practice were highlighted, there is clearly still more to be done.
260.Andy Williams, Chief Executive of NHS Digital, agreed that public consultation was key:
“… care.data, in part, failed through a lack of public trust in the use of the data that was going to be generated. When we are thinking about the benefits of data in the future, which are enormous, we have to bring the public with us and this comes down to the public having to trust that we are handling their data with care and respecting whether they agree with the use of their data. We have to convince the public that we are doing the right thing and involving them and asking them.”
261.Professor Sir John Bell said that the key was public consultation at a local level where trust already existed:
“There is an important point here, which is that engagement is unlikely to be done by Government Ministers. It is very likely to be done at a local, not a national level. If you get a letter from these guys—who are terrific, I have to say; NHS Digital are terrific—saying how they are going to use your data for X, Y and Z, you will flip. If somebody in the local GP surgery or the local hospital says, ‘We are going to try to get a system where you can look at your records. Will that be okay with you?’ you are likely to say, ‘Yes that is kind of interesting’. If they say, ‘We would also like a system whereby the hospital consultant can see the GP records and the GP can see the hospital records’, if the patient knows the GP and they know the hospital, they will say, ‘Well, I thought you did that already’, which we do not, and then they will say, ‘Well, of course you can do that because then, when I go to see the consultant, he will know what the GP said and vice versa’. If you can build their confidence at a local level, it becomes much easier to make those things associate with each other and you then end up with very powerful master databases, but it is all done with consent on things that will benefit the patient. If this does not benefit patients, it is going nowhere.”
262.The failure of the care.data project illustrates the inevitable consequences of failing to grapple with important issues relating to personal privacy. NHS Digital and all those responsible for data sharing in the NHS should seek to engage the public effectively in advance of any future large-scale sharing of personal data. Public engagement on data sharing needs to become a priority at a local level for staff in hospitals and the community, and not be left to remote national bodies.
263.Many witnesses also referenced the Carter Review which set out how non-specialist acute trusts could reduce unwarranted variation in productivity and efficiency across every area in hospitals to save the NHS £5 billion each year by 2020/21. It was clear that, as NHS Improvement emphasised, operational productivity and efficiency were “key components to the sustainability of NHS services”. This view was echoed by the Health Foundation who argued that narrowing the gap between efficiency of the best and the average would make “a substantial contribution to the efficiency challenge in the Forward view”.
264.Variable levels of productivity in the health and care systems remain an endemic problem with wide differences in levels of provider performance. Although productivity and efficiency in the NHS has improved over time and although the health system is a national service, there is an unacceptable level of unwarranted variation in what is provided and the costs of providing the same care. This presents a picture of an ineffective and inefficient NHS which is failing patients.
265.There is the potential to do much better in this area. The Office for Budget Responsibility (OBR) projections show that improving the productivity and efficiency of the health system is not simply a requirement of the current period of austerity but a fundamental, long-term imperative for a sustainable NHS. The Carter Review and RightCare programme on NHS efficiency and value reveal how much better the NHS could do. The significant underuse of technology, data and digitalisation is having a direct impact on levels of productivity. According to Dell EMC, better use of data and technology “would improve efficiency in the healthcare sector by between 15% and 60%, resulting in savings to the NHS of between £16.5 billion and £66 billion per year”.
266.Sir Muir Gray, Honorary Professor at the Nuffield Department of Primary Care Health Sciences, explained how some of these variations could have a direct impact on patient outcomes:
“I have brought along one of our atlases of variation, which we publish to destabilise the professions, to show huge variation: a fourfold variation in amputation; a twofold variation in the percentage of people dying at home; a fiftyfold variation in knee ligament surgery; and a hundredfold variation in rheumatoid factor interventions—all by people who thought they were doing evidence-based medicine.”
267.He explained to us that the variation in outcomes was often accompanied by a lack of awareness of the true overall costs of treating certain conditions. He placed this in the context of the overall budget allocation:
“There is £115 billion on the table, there is a twofold variation in allocation of money and a tenfold, twentyfold, fiftyfold variation in activity, and we cannot see that explained by need or explicit choice. It is about thinking of programme budgeting and getting clinicians and patient groups together to think about whether we are making the best use of the resources we have for this population … There is a split between purchasers and providers, and game-playing goes on. We know to the nearest pound what we spend in every hospital. I can tell you what we spend on car parking in the Oxford University hospitals trust because it is in the annual report, but no one you meet in Oxfordshire could tell you how much we are spending on women’s health or on respiratory, because the GP prescribing is over there and the hospital over there.”
268.This disjointed approach to tracking costs inevitably leads to different levels of service being delivered in different parts of the country. Sir Muir explained some of the work that was taking place to help the sharing of best practice to reduce unwarranted variation. He spoke of the importance of benchmarking and learning from others working on the same problems in different areas:
“The proportion of people dying at home varies from 78% to 46%, so there is something going on at the local level that is very difficult to recognise. The question is getting people to start looking at where they stand in comparison to others. Both the 78% and the 46% of people will think that they are working their socks off. We have been trying to say to them, ‘Why don’t you go and see these other people and see how they’re doing it?’”
He went on:
“[The RightCare Team] are going to every CCG and showing them where they are … We are setting up a casebook, as you would in any well-run organisation, where people can say, ‘Okay, we have a problem with emergency calls in Scunthorpe, and this is what the Blackpool Ambulance Service did’. Learning from within the system needs to be accelerated greatly.”
We believe that such initiatives should become part of the normal way in which clinicians and managers carry out their duties. Those in a position to effect change should be unafraid of questioning local practice.
269.Unwarranted levels of variations in patient outcomes are unacceptably undermining the effectiveness and efficiency of the NHS and there is no plan to bring about a greater consistency in levels of performance. However, there is an immediate opportunity in the implementation of STPs to take this forward. Moreover the professional regulators and professional bodies should consider how they can assist in reducing variation in productivity and outcomes as part of their regular inspections and reporting.
270.The Government should require a newly unified NHS England and NHS Improvement to work with commissioners to achieve greater levels of consistency in NHS efficiency and performance. Greater levels of investment and service responsibility should be given to those who improve the most.
271.We received a large amount of evidence on the enormous potential for cost savings, improved efficiency and higher productivity where new technologies and the effective use of data are harnessed. The evidence was almost always accompanied, however, with a call for stronger leadership and more effective management. Technologies do not implement themselves and innovative ways of working will only be adopted where there is a culture which embraces change. Dr Ron Zimmern articulated this point and noted that individuals had to take a conscious decision to implement change:
“… although innovation is necessary, it is not sufficient. There are huge barriers at the moment to diffusion—although we should not use that word because it is passive and, if you allow it to be passive, it will not happen. Change management is the thing. If we are going to have disruptive change, we need to have change champions. There are issues about both having and developing clinical champions, clinical leadership, managerial champions and managerial leadership for change management. It will not happen by itself. It is an explicit activity.”
272.Andy Williams, Chief Executive of NHS Digital, also pointed to leadership as the answer:
“… this is not a technology challenge; the technology largely exists and will continue to exist. Like everything, it is a people challenge, so the one thing I would point to is to get the leadership at all levels across the system to understand the benefits generally and the benefits in particular to their organisation of these sorts of technologies.”
Lord Willetts said: “The NHS is a slow, late adopter of innovation. It seems to be a management challenge: shifting to a new way of doing things is hard to organise.”
273.Many witnesses questioned the quality of the current leadership and management in the NHS. Professor Alistair McGuire, Chair in Health Economics at the London School of Economics, argued that improved management was a priority. Dr Sarah Wollaston MP, Chair of the House of Commons Health Select Committee, also pointed to good quality leadership:
“The role of leadership is extraordinary. We have heard time and again that that is what is driving culture change, making things happen and dealing with variation and morale within the workforce. You can make differences and make efficiencies in the way health and care operate, but, without good leadership, that is much more challenging.”
274.Sir Muir Gray highlighted a potential distortion in the way certain categories of leader viewed their primary role:
“Changing the culture is more important than changing the model. In Derbyshire, we asked how many people there were with type 2 diabetes, and no one could answer. We asked them what the deficit was and they said £16 million. These are clinicians. Changing the culture is the function of leadership; it is partly behaviour but it is also the language.”
275.Professor Sir Mike Richards, Chief Inspector of Hospitals at the CQC, called for leaders from different areas of expertise to come together: “We need to build the cadre of leaders, both clinical and non-clinical. Where we see good leadership and things are happening already, we need to put people working alongside those very good leaders so that they can learn from them.”
276.Professor Sir John Bell explained that, in some cases, the cost of maintaining a digital system could be the same as employing people to carry out the work manually and that in many cases the problem was one of the wider prevailing culture. He shared the following anecdote about the same digital system being introduced in different countries:
“… All the savings came from the efficiency of the radiologists who could flick through 10, 20 or 30 X-rays from individual patients or multiple patients much faster, so their efficiency hugely improved. In America, where they introduced the same system, they fired a lot of radiologists. In the UK, everybody just drank more tea and ate doughnuts. That is the problem and that is what you have to fix.”
279.NHS England should develop a system to identify and financially reward organisations and leaders who are instrumental in driving the much needed change in levels of productivity, the uptake of innovation, the effective use of data and the adoption of new technologies.
196 NHS England, Five Year Forward View (October 2014): [accessed 28 March 2017]
197 (Andy Williams)
198 (Alastair McLellan)
199 (Dr Helen Stokes-Lampard)
200 Healthcare and assistive technologies include any product or service designed to enable independence for disabled and older people, such as wheelchairs, stairlifts, aids for daily living and artificial limbs.
201 Tele-health is the provision of healthcare remotely by means of telecommunications technology.
202 Written evidence from British Healthcare Trades Association (), Association of Medical Research Charities (), Wellcome Trust (), Association for Clinical Biochemistry and Laboratory (), Doctors for the NHS (), Royal College of Emergency Medicine (), The ASHN Network (), The Royal College of Ophthalmologists (), Institute and Faculty of Actuaries (), The Royal College of Radiologists () and Mrs Susan Margaret Oliver ()
203 (Professor Keith McNeil)
204 (Andy Williams)
205 (Professor Sir John Bell)
206 (Professor Sir John Bell)
207 (Lord Willetts)
208 Written evidence from the PHG Foundation ()
209 (Professor Sir John Bell)
210 Written evidence from PHG Foundation ()
211 Written evidence from Association of Medical Research Charities (), The ASHN Network () and Sense ()
212 Written evidence from Association of Medical Research Charities ()
214 (Jeremy Hunt MP)
215 (Dr Ron Zimmern)
216 (Andy Williams)
217 Written evidence from the Royal Pharmaceutical Society ()
218 (Professor Sir John Bell)
219 Sarah Knapton, ‘Controversial £7.5 million NHS database scrapped quietly on same day as Chilcot Report’, The Telegraph (6 July 2016): [accessed 28 March 2017]
220 Written evidence from Association of Medical Research Charities () and The Royal College of Paediatrics and Child Health ()
221 (Andy Williams)
222 (Professor Sir John Bell)
223 Lord Carter of Coles, Operational productivity and performance in England NHS acute hospitals: Unwarranted variations, An independent report for the Department of Health by Lord Carter of Coles, (February 2018): [accessed 28 March 2017]
224 Written evidence from NHS Improvement ()
225 Written evidence from the Health Foundation ()
226 Lord Carter of Coles, Operational productivity and performance in England NHS acute hospitals: Unwarranted variations, An independent report for the Department of Health by Lord Carter of Coles, (February 2018): [accessed 28 March 2017]
227 The NHS RightCare programme was set up to assist local health economies to reduce unwarranted variation, using local data and evidence on outcomes, and working in partnership with local organisations. For more information see the NHS RightCare Programme: [accessed 28 March 2017]
228 Written evidence from Dell EMC ()
229 (Sir Muir Gray)
230 (Sir Muir Gray)
231 (Sir Muir Gray)
232 (Sir Muir Gray)
233 (Dr Ron Zimmern)
234 (Andy Williams)
235 (Lord Willetts)
236 (Professor Alistair McGuire)
237 (Dr Sarah Wollaston MP)
238 (Sir Muir Gray)
239 (Professor Sir Mike Richards)
240 (Professor Sir John Bell)