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Reports from the last few months have suggested that the centre of the NHS wants to move towards policies of levelling up and convergence.

Convergence has so far been framed as standardisation of electronic patient record systems, while levelling-up has been defined as directing national investment on those least digitally mature organisations.

However there has been relatively little debate or formal policy discussion as to whether EPR standardisation makes sense, and whether it offers the best dimension of digital maturity to focus on

The Digital Health Networks asked some of its members to take part in a debate on these new policies.

Good definition is key

First up, our panel explored the importance of having clear definitions for people to work with when it comes to convergence.

For Adrian Byrne, CIO at Southampton University Hospital NHS Foundation Trust, levelling up and convergence does make sense, but there are some details which need to be ironed out.

“I can’t argue the concept, but it is about how you get there, what are the priorities and what needs to be done first,” he said.

“There is convergence and then there is divergence and clearly, we don’t want to see divergence

“I think what we lack now is a good definition, it’s a principle at the moment, it doesn’t really have a solid definition.

“How do we know when we have achieved it? How do we know what good looks like in the context of convergence?”

He added that the sector needs to “find some direction and definition”.

This lack of definition was echoed by Debbie Loke, CIO and director of digital at University Hospitals of Derby and Burton NHS Foundation Trust, who said it was “one of the biggest problems”.

“Everyone seems to have a different view and then equally, each system is looking at their own areas and deciding whether convergence is more important than levelling up,” she said.

“In Derbyshire, we’re looking at convergence of an electronic patient record (EPR) across two acutes and we’re not focusing on any other area, which we know that will take us backwards in our HIMMS journey, but that’s the decision we’ve made to move forward with the convergence piece.

“I know others are doing different things so it will be good to get a policy view on whether what we are doing is right, or wrong.

“There’s a lack of direction I think from the national teams about how we should be managing that.”

Help from suppliers

Sticking with support from the centre, Loke highlighted the potential for national organisations to help with suppliers.

“There’s a real need for local systems to be able to make their own decisions about direction and use national policy and finding to support that,” she said.

“I think there is something the national teams can be doing is to help with the suppliers, I do think there is extra work they could do there with the monopolised areas like primary care.

“The national teams do allow suppliers on their frameworks and actually, if we’ve all got really bad reviews from certain suppliers and they’re not meeting our needs, there’s a question as should they even be on the framework?”

Market and competition

Byrne also addressed the issue of the market and competition.

“We talk endlessly about standards in digital and then we seem to be quite poor at implementing them and some of that is actually the market isn’t very rich and we could argue that we stifle that market in some ways,” he said.

“If we look at primary care, we have succeeded in creating a dominance for two vendors there by doing what we’ve done

“I don’t think we really want to be in that situation in the rest of the health service, but we are constrained by the market so you’ve got a tension there.

“I’d like to think that we could work a way though it and end up with a choice of systems, that will be based on some more modern architecture but more adaptable really

“I know we talk about standards on one side, and we talk about all the wonderful things like FHIR and openEHR and then we go and sign massive contracts with your favourites who are on 30/40-year-old technology. It doesn’t seem to compute to me.”

Working collectively

On the topic of differentiating between levelling up and convergence, Loke spoke about priorities.

“In my view, it [levelling up] is pretty much the same thing as convergence,” she said.

“I think it’s all about looking at the what the problems are across our system and then making sure we work collectively to review them and for some areas, it just means moving to different systems or processes or using the right levels of integration to help each other out.

“I think that they are kind of very much inter-linked but it’s all dependent on our own systems needs and populations and where the priorities are

“I do think some of the levelling up around transformation is a bit more difficult because, as I said, it’s not always about digital and data, some of it is about how we transform working practices and level that up and I am not sure always who leads on that at system level.”

BREAK

On a final note, chair, Paul Rice – who is chief digital information officer at Bradford Teaching Hospitals NHS Foundation Trust – spoke about the all important subject of finance.

“I’d underscore that for colleagues – that question of how do we get the numbers to align with the aspiration,” he said.

“I agree with the point that we need to make sure that finance function in particular is aligned or else we’re trying our best to present medium to long term plans, aligned plans, converge plans and then in practice, the money doesn’t chime with that approach and that’s why we’re in some real difficulties now.”

The new integrated care boards (ICBs) need to recognise that digital is at the heart of transformation and make the most of the opportunities that greater integration brings.

This includes growing the digital workforce and supporting the increasing role of shared care records – memorably described by one panellist at a recent Digital Health Networks debate as “fantastic integration engines”.

The latest in the Digital Health Networks Debate series took place at the end of October, just a short time after England’s 42 ICBs became legal entities.  It brought together leaders from across the country to discuss ICB digital priorities.

The panellists, all of whom are closely involved in development of ICBs, were able to share experiences from their own patch, and shine some light on emerging priorities and direction.

Care around the patient

According to Dermot Ryan, director of frontline digitisation, NHS England and NHS Improvement, the creation of ICBs has meant a paradigm shift. “It’s transitioning away from care being provided by organisations and people fitting in with that, to care being defined around the patient. In the context of that shift, digital strategies have to be focused on how digital supports integrated care.”

Ryan warned ICBs against “walking before they could run”. “There’s loads of great advances in what can be done in healthcare, with artificial intelligence and automation,” he said. “But I think you need to focus on the foundations first, before going after these things in earnest.”

Linda Vernon, acting digital culture and transformation clinical lead, Lancashire & South Cumbria Integrated Care Board, said that digital should be an integral part of ICBs’ strategies. “We all know that digital transformation is just a part of transformation – so I think the fact that we’re doing separate digital plans probably isn’t the right approach,” she said.

“I agree to an extent that we have to walk before we can run, but there’s something around us not getting so bogged down in the basics and fundamentals that we stifle innovation.”

A chance to be proactive

There’s an opportunity with the ICBs to think strategically and to be proactive rather than reactive, she added. “This has given us a chance to really think about where are we going to invest our time and energy, and have we got the capacity to deliver across the wider system.”

ICBs have lead responsibility for joining up digital strategies across integrated care systems, and obviously they have many and competing priorities. But the panel debated to what extent their role was mainly in co-ordinating what was going on locally, or actually setting digital strategy in a more directive way.

According to Andy Williams, interim chief digital and information officer, Humber & North Yorkshire Health & Care Partnership, the focus should be on how different organisations within the ICB area work together with more shared resource over time. How this will happen will become more obvious as financial systems begin to align – and if there is a period of political stability, he added.

“I’ve had the pleasure of sitting on the IC board meetings and it’s a wide, diverse group of organisations that are represented there,” he said. “Yet they’ve all got the system and the patient at heart, and they’re all trying to figure out what is it as individual organisations to benefit the greater good, the greater whole.”

Place-based approach

Balancing organisational priorities with ICB priorities means looking at joint priorities – and taking a place-based approach, Williams added. “It’s a really good start in terms of the different organisations in a place coming together and talking as partners about what could we do that makes a difference to solve some of these really difficult problems – around waiting lists, ambulance queues, elective recovery, that everyone is really struggling with.”

Vernon gave the example of her area which has had experience of working across boundaries as an STP then ICS. “There’s already been a lot of joint working at place,” she explained. “We had five places within our geography with four acute trusts and councils already working really closely together at place.”

This helps with optimising and sharing workforce, as well as working together at scale on big issues such as cybersecurity, she added.

ICB structures shape digital plan

Her area had a well-established digital strategy for the original ICS, she said, which was reviewed last year to ensure it was fit for purpose. “Increasingly there are structures within the ICB that are going to help shape the plan as it unfolds.”

In the chair Lisa Emery, chief transformation, innovation and digital officer, Sussex Health & Care, and NHS Sussex, raised the issue of legislation and the role of mandation in the system.  Ryan said it was a “mixed bag”. “We definitely need mandation and legislation in the tool box… and sometimes you have to use them as an option of last resort, but it’s certainly not an option of first resort.”

Williams said that he was in favour of light touch legislation but emphasised that having the right culture in an organisation was key to making positive change. That includes having proper inclusive conversations and coming to agreement about the best way forward.

Vernon agreed that co-design was crucial. “I’m always in favour of the carrot rather than the stick,” she said. “If we design services with the people who are going to deliver them and use them, whether that’s digital or not digital, we have a much better chance of adoption, of people feeling part of that bigger community doing something together.”

Investing in the digital workforce is also key, the panel agreed. Ryan said it was important to have a talent pipeline. As well as growing the digital workforce, improving digital skills in the wider workforce is crucial. “There’s no doubt that as digital becomes more interwoven into the delivery of healthcare to patients that we need to consider digital as a kind of core skill set alongside the other skill sets that make up the NHS,” he added.

New era shared care records

Shared care records will only become more important in the future, the panel agreed. Vernon suggested they have a key role to play in ICBs’ assessment of their digital maturity. “We have an established shared care record… we’ve done a brilliant job of setting that foundation,” she said. “But we’re now starting to think of next stages, which is around the structure of data sharing so that we can facilitate real-time views of patient data – that I can see as a patient, perhaps, as well as being shared across different sectors and different clinicians and boundaries, such as care homes.”

Williams emphasised that shared care records should be a priority for ICBs as they can “stick” different sectors and domains together, and drive integration. “For me, things like shared care records can be used as fantastic integration engines, as information sharing records and as data platforms as well.”