Innovation challenges in the NHS
Placing patients and clinicians at the heart of digital health services design.
With the benefit of several decades experience in digital project and programme delivery, most recently as a Transformation Director for an international digital service practice, I have witnessed first-hand how advances in service design and digital technology and are helping organisations deliver ever better services to their stakeholders.
Across a range of examples including mutual aid requests for police forces, improving fire and rescue services, delivering city clean air zones, sustainably managing our land assets and learning from patient safety incidents, common themes emerge. Increasingly sophisticated user centred design approaches are being combined with increases in computational power provided by cloud computing and a new emphasis on data science, AI, and machine learning to deliver a new breed of digital services, far better tailored to each organisation’s needs.
In health, people are increasingly embracing the opportunity to take control of their own healthcare pathways. No longer will the majority be passive recipients of care, with the recent rapid growth in use of the NHS App testament to a public appetite to gain more direct access to healthcare services and their individual healthcare records.
As we move beyond the current crisis into recovery, Integrated Care Systems (ICSs) will also become a reality as an essential ingredient of the NHS Long Term Plan, with all parts of England served by an ICS from April 2021. The need to ensure that data flows readily and securely between centralised and regionalised care centres is vital.
Greater effort is now being put into designing the services that empower citizens to fully participate in their health and social care by ensuring the availability of digital tools and services that allow direct access to information and healthcare services. Additionally, personalising patient experiences to meet individual needs and improve healthcare outcomes through timely, effective interventions, and enabling more effective interventions across UK integrated care settings continues to be a driver for digital transformation throughout the NHS.
The evidence we have gathered through consistent and successful delivery of nationally significant digital services points to the needs of the service user at the centre of digital service design. In February this year, we were named a strategic digital partner to the NHS through the Digital Capability for Health Framework. We understand that for our own national health service, world class digital services must first and foremost meet the needs of patients. They must also deliver the insight and capability that empowers clinicians and care providers to treat patients and keep them safe through their treatment pathways.
We have all at some point been a patient, or a carer for someone that needs treatment or care. Our need as a patient or carer is a simple one to articulate: we want access to care, regardless of our setting (at home, primary or secondary care); we want the health service to have accurate information about us, but we also want control of how that information is managed, secured, and shared. Our clinicians also want access to patient information and treatment pathway services through effective, efficient, and interoperable platforms that deliver connected digital services, allowing them to provide the best possible treatment in integrated care settings.
With this patient and clinician centric view, the NHS IT Strategy Vision, followed by the NHSX Tech Plan Vision were created to help empower patients (and where appropriate their carers) to maintain their own health, manage their illness or recovery, and interact with the NHS in a way that improves convenience and effectiveness for the patient and NHS clinical teams distributed across national, interconnected care systems.
To achieve this aim, digital service designers must first consider and then intimately understand a patient’s practical needs. For example: How are they using health services? What devices and applications do they have access to? What physical care settings are most appropriate?
To develop the infrastructure that clinicians need and patients demand, digital service design must be executed by highly skilled, multidisciplinary teams that create and shape services based on an explicit understanding of users, goals, and environments. Users (patients, clinicians, and care administrators) must be involved through the design and development of a service, which is driven and refined from whole-of-experience user evaluation
In understanding and positioning user centred design as a critical platform for successful digital health service delivery, we should perhaps look at the technology and system reality we are currently faced with. Through the work and insight from NHS Digital, NHS England and NHS Improvement, and NHSX, we have a growing appreciation of the scale and complexity of the challenge that is required to meet ‘simple to articulate’ patient and clinician needs.
techUK’s seminal Ten Point Plan for Healthtech, which was released in February this year, revealed that as of February 2020 (just over a year ago), a quarter of healthcare providers in the UK had no Electronic Patient records, while a third of social care organisations still ran on paper-based systems. In some settings, it was claimed that care providers had to log on to as many as 15 different computer systems to care for just one patient. A significant proportion of UK health services do not have access to the data needed to manage patient treatment pathways, with literally hundreds of systems unable to connect or share information effectively.
This varying landscape has formed over decades as the NHS estate has developed into a complex, multi-tiered, primary, and secondary care environment, which is served by an increasingly complex and diverse technology landscape. Added to this set of circumstances, significant volumes of patient data, locked in legacy silos (or paper-based records) is very hard and incredibly expensive and time consuming to capture, record, store, share, and access. This is reinforced by low levels of (and in many cases absent) data and system interoperability standards, as a further challenge for effective integrated care.
Lastly, this divergence of environment and technology has been exacerbated by significant digital skills variance across national, regional, and local care centres.
This systematic fragmentation continues to increase the cost of care provision (or alternatively, our continued, forced investment in technical, data and skills debt). We cannot yet take advantage of an economy of scale, whilst increasing errors and the continuing delays in data sharing between systems adds risk to patient treatment (and safety), and delays undermines integrated care providers in their quest to better treat and care for patients.
With existing levels of fragmentation and divergence across the NHS, interoperability remains a fundamental building block for the development of a new digitally enabled integrated care service for all. The definition of Interoperability is the ability of computer systems or software developed by different ‘manufacturers’ to exchange and make use of information. Our view is that data sharing platforms should not merely be defined by the available technology, but by the needs of platform users (patients, clinicians, and relevant health care supply chain operators).
A truly effective interoperability ecosystem should provide an information infrastructure that uses technical standards, policies and protocols to enable seamless and secure capture, discovery, exchange and utilization of health information, as defined by Healthcare Information and Management Systems Society (HIMSS).
We can see through our work with NHS England and NHS Improvement on a major national Patient Safety Incident Management System (PSIMS), that industry sign up to and membership of technical standards including DICOM, IHE ,and HL7 is having a significant and positive impact on data sharing and insight that will help consistently and constantly improve patient safety in care settings. It has also been encouraging to see NHSX taking the lead on standards and interoperability, most recently with publication of five key priorities in September 2021.
Creating a better and empowered digital health service depends on aligning technology, interoperability and standards, which will go a long way to assuring digital transformation success for the whole of the healthcare system and enable successful integration of ICS services across England.
Whilst most of industry works towards complete interoperability (all digital information available everywhere), significant progress can be made through the user centred design of digital experience services that take advantage of real-world patient and clinician requirements. In doing so, we can deliver single, integrated digital patient and clinician experience workflows that improve health provision efficiency, whilst enabling real change in the pace and effectiveness of health stakeholder engagement.
This can be achieved as part of a move to value-based care, which revolves around achieving the best outcomes at reasonable cost and moving away from purely health supply-designed services towards authentic patient and clinician centred systems that improve health service experiences and enhance the efficiency of treatment pathways for patients and clinicians alike.
The NHSX Tech Plan – Vision states: “We will know when we have succeeded when citizens have the digital tools they need to drive their own care. They can easily access advice, book appointments, communicate with a healthcare professional, receive a referral, order a prescription, access, and contribute to their record and choose who they share it with. They understand how their information is used, are confident in its uses and understand how to exercise their information rights”.
The combination of user centred design and interoperability are essential keystones towards realising this vision. With digital experience, data analytics and unification, and smart and ethical use of artificial intelligence and machine learning being central ingredients that help shape a modern, empowered digital health service that places both patients and clinicians at the heart of digital service design.