NHSE – Lessons to learn

Andy Kinnear, former NHS CIO and now Independent Consultant, reflects on what lessons can be learned from the forthcoming subsuming of NHS England functions into Department of Health and Social Care (DHSC).

It all started with the best intentions, as these things usually do. The digital wing of NHS England has had an interesting journey. I joined the NHS in 1991 so have had decades to watch this story unfold. The relatively successful but underpowered Information Centre (IC) from the 1990s was injected with steroids to create ’Connecting for Health’, (C4H) the agency charged with delivery of the National Programme for IT (NPfIT). While the NPfIT was successful in small pockets, ultimately it failed to deliver the vision of a national programme and C4H was transitioned into the Health & Social Care Information Centre. This later became NHS Digital and latterly combined into NHS England.

Sadly though, since the turn of the century the grand vision to deliver the digital transformation the NHS needs to modernise and meet patient demand, free of political interference, has not been achieved, at least not completely, quickly or with the oft-promised transformation of services. In my view there are three main factors that have contributed to this situation, that we must learn from.

1. Proximity to the frontline – The national agencies have too often lived up to their ‘arm’s length body’ status, sadly arms-length to the frontline NHS that it is. Not a conducive approach to transforming care where the service meets the patient.

A little anecdote - Around 2015 I was seconded into the Health and Social Care Information Centre (HSCIC) part-time as a Local Delivery Advisor – I was one of a few folks charged with trying to help them bridge this gap. Put simply, my role was to help the management to get closer to the frontline. One thing that struck me, as I had a string of meetings with various project managers and programme leads, was the lack of their ‘primary’ focus on patients and clinicians. Business drivers were nearly always financial targets, commercial and contract driven, eagerness to use new technology, and sometimes political drivers. Rarely did anyone think about the effect on doctors, nurses, care professionals or even patients without prompting. Evidence to me that the culture was somewhat offset from where it needed to be.

At the time, I wrote a paper recommending closer ties with the frontline of healthcare delivery by locating staff on hospital campus around the country – which was received politely before being quietly parked on a shelf. That said, we have some examples of successful digital transformation driven nationally but in these cases you can usually find an individual or small team at the ‘Centre’ who has taken the time to build a network of frontline contacts, engage directly on the problems and design programmes to address these needs. Sadly, these folks have not been the norm.

2. Leadership – When I joined the NHS in 1991 the folks leading the digital agenda were primarily at a regional level operating under a light-touch national framework from the IC. The leaders were grounded in frontline healthcare and the footprint they controlled was big enough to deliver at scale but small enough to allow them to stay close to the frontline.

In the South-West we had the same Patient Administration System (PAS) in every hospital, we had a single data clearing house for the region and we had a leadership that had struck the perfect balance between what was delivered inside the NHS and what came in from our commercial partners. It was working and I am 100% convinced that had this model simply been sufficiently funded and allowed to flourish our digital journey would have been much better.

In the push to deliver NPfIT many frontline NHS organisation executives no longer felt responsible for the technology agenda. This task was going to be done for them by C4H and its commercial partners. This lack of exposure to the technical agenda led to a leadership cohort lacking skills, and the understanding that we need to invest in technology, and then to continue to support it. Technology evolves, and to get the best return on investment it needs to be maintained, it’s not a one-time purchase.

There have been glimmers of hope - Around 2025/16 when Keith McNeil was appointed National CCIO and Will Smart National CIO. Here we had a doctor who was also a former Acute CEO in a leadership seat. Moreover, as CEO at Addenbrookes Keith had implemented the most advanced EPR in the country. He was a CEO who got digital. Will was a former frontline CIO who now sat in a national seat with an unrelenting focus on doing the best for the frontline. Together they created the Digital Exemplars programme to build towards an enterprise architecture from the ground up. Had that work continued then again, I am sure we would be in a better place.

3. Lack of Understanding – The overriding feeling that those in charge didn’t understand the unique challenges of healthcare delivery at the frontline.

Healthcare is the perfect example of a high reliability industry, with its hyper-complexity, tight interdependence between different departments for patient outcomes, multiple levels and hierarchies for decision making, and the requirement for fast, emergency action often in short timescales with critical outcomes.

It’s hard to understand this until you have been directly involved, and those that have not worked on the frontline personally need to take the time to be genuinely interested, active listeners engaged in understanding and supporting healthcare delivery.

NHS England’s abolition is an opportunity to create a new version of the ‘The Centre’ based on lessons learned from the past. Whatever organisation emerges from this maelstrom it must have a connection to the frontline, it must have a leadership that understands healthcare to their core and above all it must be willing to listen.

Our frontline clinicians are the kindest people in our society. They took a decision in their young lives to care for strangers at their time of need. Our national digital agency needs to recognise this incredible sacrifice and ensure everything it does works towards supporting them.