Speaking at the HETT 2019 conference on technology in healthcare, Matthew Gould, CEO of NHSX, explained the need to integrate and scale technological innovation across NHS systems
In early 2019 the UK’s Department of Health and Social Care launched NHSX, a new joint unit aimed at equipping the NHS with modern technological healthcare solutions. Speaking at the HETT 2019 conference on technology in healthcare, Matthew Gould, CEO of NHSX, explained the need to integrate and scale technological innovation across NHS systems to better support patients and healthcare providers.
Reconciling healthcare and technology
The health tech world is right at the intersection of two really interesting but quite different cultures: on the one hand, you’ve got the culture of the NHS and the medical profession, which is – for completely sensible and correct reasons – risk-averse. Lives are at stake when patient safety is at stake; [so] the idea of failing fast, the idea of moving quickly and breaking things isn’t really relevant. It’s not OK with patients, and rightly so. That has led to a way of doing things where innovation takes time. And this can be incredibly frustrating to innovators.
There was an NHS improvement statistic that said the time lag between clinical trials and a full rollout across the NHS of the technology was between 16 and 17 years on average. When you compare that time lag with the speed of the cycle of technological innovation, particularly digital innovation, you start to see the strong difference between the cultures and some of the reasons for the frustration. The health world values stability and predictability; and isn’t terribly big on surprises.
On the other hand, you’ve got the tech world, where it is all about moving fast; doing stuff and apologising later; failing fast; pivoting if your product isn’t right. It’s geared towards constant disruption, incessant change – and disruption is a good thing. It seems something to aim for; and in the digital world, this is clearly a brilliant approach.
When the tech world and the health world come together, you start to see some of the reasons why our work is cut out as people who care about innovation in the health tech sector: to make sure that join works, to make sure the processes are in place; the permissions are in place; the incentives in place, so that innovation can be done and can be scaled.
It’s important not to exaggerate the differences [when] there are obvious similarities. Both tech people and clinicians share a sense of impatience, they both want to make progress; and there is a potential overlap there. Crucially, the tech world and the health world are [both] deeply evidence- and data-led.
One of the most important things we can do is make sure that the data and the evidence is marshalled because if you want to shift medical opinion and get practice to change, the best way to do it is [through] data and the best argument is patient safety or patient outcomes. [Healthcare and tech] are both intrinsically problem solving cultures, where getting stuff done on behalf of your patients is prized above everything else.
That is why we set NHSX up – it was to be at this intersection between the health tech world and the NHS in social care, to make sure that innovation was encouraged; to [determine] ways to get it to scale; and making sure the staff and the citizens have the technology they need.
Identifying and meeting needs
In all this, need is the keyword: technology that meets the user need within the NHS and the care system isn’t necessarily always the technology that innovators want to sell us. We haven’t always been great, as the NHS or as social care, at identifying what we need and what our patients need and articulating that in a way that’s helpful. We haven’t necessarily made it easy to innovate within the system, to sell to the system; and, crucially, to scale innovation across the system.
[NHSX was] set up because as [UK Secretary of State for Health and Social Care] Matt Hancock looked across the system he saw the powers in technology split up in different places. You have the Department of Health and Social Care doing policy, holding the budgets, setting some of the standards and providing some of a political message. You have NHS England doing a lot of implementation work and running big projects. You have NHS Improvement doing some of the regulatory [process]; NHS Digital doing the heavy lifting, being the statutory safe haven for data, running the live services. That split of responsibility had the effect in practice of taking a difficult task and making it pretty much impossible.
My predecessors, who were trying to get technology right for the NHS, were having to spend a huge amount of their time managing this institutional complexity and [therefore] not actually trying to make progress on tasks where, in substance, there’s a huge amount of agreement. The [purpose of] NHSX was to try and bring together those levers in a single place; so we are at the same time both a part of NHS England and Improvement and part of [the Department for Health and Social Care], and we hold the mandate for NHS Digital who are really close partners in pretty much everything we do. Our hope is that by bringing those levers together, we can try to make progress in getting the technology right.
Issues on the frontline
It’s not just about institutional reorganisation – the NHS has seen a lot of those – it’s about what we are trying to achieve. I made it my business when I started [working here] to spend a month out in the system to see the NHS and social care in practice, trying to get a sense of the problems that people at the frontline are actually facing.
I visited hospitals, GP surgeries, mental health trusts, community teams, care homes [and] dental surgeries. I spent time in the back of ambulances, I visited hospices; and several things stuck with me.
I saw clinicians and staff really determined to help the patients they were looking after; I saw some brilliant examples of technology – but I also saw people struggling with technology, people feeling frustrated, people having slices of their time taken away from them by waiting for systems to log in or boot up. I saw slices of patient safety taken away from the process by information not being shared about patients in a way that would make their treatment safer and more effective. It struck me very hard that if we could add all those slices together of time and patient safety and outcomes and efficiency, and give them back to the system, it could be profoundly helpful to the people on the frontline.
I was in sitting in [an Accident and Emergency department] with the junior doctor who was on duty that night; and she showed me her system logging on, how long it was taking her and the frustration she had. There was a nurse on a community care team in the Midlands who wanted to show me her system: she logged on and we waited, and we waited, and we waited; and by the time it actually sparked into life I had to run for a train.
[I] was in a [resuscitation] unit in London as a lady was brought in; [she was] in a terrible state but had the presence of mind and the capability to bring in her discharge notes from the previous visit. She had provided her own interoperability; and as a result of that, the treatment she was given was completely different from the treatment she would have been given had she not been conscious and able to do that. Thank heavens that she had the ability and presence of mind to do that, but that shouldn’t be the system.
Almost exactly a year ago my wife started chemotherapy for breast cancer. She’s treated in four separate places; and none of those places’ systems speak to each other, so she carries around a folder wherever she goes, with all the scans, all the letters and all the information she needs – so she’s providing her own interoperability. And that’s a crazy way of doing it.
How can NHSX help?
I’m really keen that NHSX should be focused on [the questions of] what are the real world outcomes that we’re trying to achieve? What’s the difference we’re trying to make? I’ve set five missions [which] I hope will drive everything that we do:
• Reduce the burden on commissioners and staff across the system;
• Make sure that we put tools and services directly in the hands of patients so they can
help drive their own healthcare, so they can be real partners in this;
• Make sure that patient data can be safely accessed by clinicians where they need it across the system;
• Help improve patient safety and
• Help improve productivity.
We can’t deliver those missions on our own. This emphatically has to be a joint effort. First of all with the frontline – we don’t deliver care to patients: it’s the doctors and nurses and carers and dentists and [physiotherapists] right across the system. Our job is to help them; and all the brilliant stuff that we talk about isn’t going to happen if they don’t have the basic tools, the faith in those tools, or the level of digitalisation needed to do all these brilliant things. So, a large part of my job is going to be to make sure that we get resources to the frontline: not to grow an enormous empire at the centre, but to keep ourselves rigorously focused on the needs of the frontline. [That] needs to be a joint effort with the health tech sector.
Our issue is not an innovation problem. It’s an adoption and scaling problem; and we need to work with you to help that. I don’t want any sort of misapprehension that the innovation is going to come from the centre, that we are going to sit in the middle and decree all sorts of brilliant innovations and build them ourselves. What I want is for the centre to set the standards and create the platforms so that innovation can safely flourish, to create an ecosystem in which the best, most useful ideas can be more rapidly adopted across the NHS and social care.
There are three aspects to this point. First of all, is standards: for innovation to flourish most easily, for systems to be able to speak to each other without everyone being on a single system, it needs standards. It needs technical standards and it needs semantic standards so that everyone is talking the same language and innovation can slot in in easy and predictable ways. I’ve seen any number of examples where this isn’t happening – I was at a hospital last week which had 288 separate systems – and you see this replicated across the NHS and social care.
Solving this is not as easy as my standing up and saying ‘here are our standards, everyone follow them, we will all be fine’. This is not going to be an easy task. It’s not going to be a quick task; and it will need all those levers that I talked about in one place to be able to enforce standards.
There will be an irreducible minimum of stuff that it makes sense for us to do [at the centre], but we can do that in a way which helps innovation, not hurts it. Take the NHS app: I think it’s very sensible that we have a sovereign app that does certain things that it’s right for the NHS itself to do; but I don’t want to pile so much functionality into the app that we start to suffocate innovation and crowd out people wanting to do their own innovation.
We’re going to impose a self-denying ordinance: we’re not going to put in more functionality than is appropriate for the NHS’s own app; and then we’ll expose the APIs, the data feeds that power the app, so that– as long as they’re compliant with the rules that make sure that patients’ data and privacy are properly protected – other people can use those APIs and innovate on top of them. That way, I think we have a chance to create a real ecosystem: whether you’re coming at it from a particular geography or a particular condition, you can use the framework, there is a structure and there is space for you to innovate.
We need to work out what the barriers are to scaling innovation in the NHS and what we are going to do about them. We’re working closely with the Accelerated Access Collaborative [an initiative within the NHS aimed at ‘fast-tracking’ emerging technologies and breakthrough ideas into the system], who are very focused on the rapid uptake of new technology, new treatments, new drugs.
We’re looking at accreditation: do you really need every new bit of the system to run exactly the same tests for safety and efficacy on every new bit of technology? Or can we rationalise that, can we make sure that new technology is tested once and that accreditation carries [over]?
We’re looking at how you might have a sandbox approach to regulation, where we get the regulators in the room with innovators and decide together how the rules should evolve to make sure that they’re fit for the future, not just for the past.
We need to look at how we manage access to data so we keep patient trust and the trust of citizens, but we also make sure that the value of that data for people who want to develop new therapies or new approaches that will help the NHS is available.
Together with Accelerated Access Collaborative we’re setting up an AI map: it will be focused on how we scale some of the more mature technologies so that they don’t just have to be in a single place – they can get to more places, be used in more locations, so we can start to develop the evidential base that those technologies need for full scaling. We’re going to be focused on making sure that the regulation of AI is fit for purpose as well.
A long way to go
I’m under no illusion about the scale of this challenge. We have bits of the system using old technology, networks aren’t sufficient; staff have become frustrated. There is a long way to go; we have a lot of work to do together – but if we can get it right, the rewards for staff at the frontline, for patients and for innovators will be huge.
The impact that this can have on patient safety and outcomes, on quality of care and the ability of our staff to do their job in a fulfilling way rather than spend their days fighting with their technology, [instead of] are being helped by it to do their job – those rewards are enormous, and I and my team are looking forward to working with you to try and make a reality.
Please note, this article will appear in issue 12 of Health Europa Quarterly, which will be available to read in February 2020.