Wade-Gery Review

Recommendation 1: commit to a patient and citizen centred organising principle for future service transformation The NHS must be bolder in stating that the health and care system should empower citizens to manage their health and well-being and give them the tools to take ownership. The citizen should expect services to be designed with them in mind. The best organisations, both public and private sector, have deliberately put citizen needs at the centre of their decision-making and service design. In healthcare, such an approach not only improves patient experience, but also results in earlier engagement from patient with their health and over the long-term improved health outcomes and associated economic and societal benefits. Whilst this recommendation may seem obvious, its importance cannot be overstated. There are significant implications for organisational design and technical or data architecture, standards, governance and policy. This approach will require the major axis for change to be care pathways centred around a patient or citizen view rather than settings of care or disease states and will require new capabilities (akin to commercial organisations’ customer insight functions) as well as data to flow across settings of care, with increased data interoperability and common technical standards facilitating a seamless experience for patients and staff alike. Effective implementation will require a significant cultural shift away from the current siloed approach in the centre with conscious management to ensure intentions translate to reality.

Recommendation 2: consider and mitigate digital inequality in all service transformation. Expand the role of the SRO for Health Inequalities to include digital inequality There are undoubtedly ways in which digital approaches improve access to health care services, for example, for individuals who are immobile, who cannot afford to travel, those experiencing anxiety in health care settings, or people who wish to remain anonymous and don’t want to be seen by other patients. However, digital approaches can have unintended consequences, such as excluding those who are less digitally literate or who do not have access to the most advanced telecommunication services. It will take focus to ensure the push for digital ways of working can help tackle these health inequalities rather than exacerbate them. NHSEI should develop national frameworks, guidance and best practice in designing and implementing digital solutions to reduce inequalities. When designing new models of care, these should include a choice for citizens between remote and face-to-face care. It is important this issue is managed actively. As such, the responsibility of the NHSEI Health Inequalities team should be expanded so that digital exclusion is seen as another lens within health inequalities.

Recommendation 3: commit to building patient and citizen trust and acceptance in the use of health data to improve outcomes. Provide more efficient access to data for analytics that ensures privacy and can be used to improve care delivery The NHS has a long and proud history in using data to improve individual and population health outcomes. Recent examples including machine driven diagnostics in eye care and the delivery of the vaccine programme demonstrate the power and potential of the use of advanced data analytics. The field of data science is undergoing a revolution as new tools such as machine learning transform our ability to gain insights and improve outcomes. These advances, combined with the explosion of new data driven commercial business models, have caused citizens to be concerned about the privacy of their individual health data and the controls in place over its dissemination and use. It is beyond the scope of this review to consider issues of the technical means by which we both improve the NHS’s ability to use data and respect data privacy; this is being considered separately by the Goldacre Review. However, it is critical for the effective delivery of digitally enabled healthcare transformation that citizen trust and acceptance in the use of data is built. Given its convening power and role in setting the national direction, the centre should work with other key national stakeholders to take active steps to both build awareness of the value of data to improve individual and population health outcomes, and to take action to improve the use and management of data within the healthcare system. Clinicians and management will need to further engage in the debate with the citizen in order to build understanding of the benefits of using data, both for individual patients and for local populations, and the safeguards in place to protect privacy and confidentiality. This review is being conducted in parallel with the Goldacre Review, the purpose of which is specifically to make recommendations on the more efficient and safe use of health data for research and analysis for the benefit of patients and the healthcare sector. Part of the way this can be achieved is through technology - specifically controlled data environments allowing permissioned access to data in a safe and privacy preserving way. These modern data platforms are key to how the NHS can achieve more efficient access to data to improve care delivery in a way that is privacy protecting and secure.

Recommendation 4: reorientate the focus of the centre to make digital integral to transforming care, with NHSEI overall accountable for executing digitally enabled service transformation. Provide clarity around the role of the centre, underpinned by a clear enterprise architecture and align with the ICS operating model The pandemic has shown the potential of digitally enabled transformation as a transformative lever. Service recovery following the impact of coronavirus (COVID-19) and the next phase of the Long Term Plan delivery must integrate digital, data and technology. This encompasses the shift from basic digitisation to service transformation. Over the past 18 months, NHSEI has been developing a new operating model that describes how different parts of the NHS work together to deliver nationally agreed and locally owned priorities to improve health and patient care. The NHSEI operating model now needs underpinning with a clear enterprise architecture – in simple language, what are the business capabilities needed to deliver care and what is the broad technology map and principles that deliver these. The NHS today is comprised of thousands of different IT systems, many of which do not easily talk to each other in the way that joined up integrated care requires. Interoperability is a key priority – but is not sufficient to address this fragmentation. This enterprise architecture will need to build on the excellent work done by NHSX and NHSD in this space and determine more clearly the respective roles of the centre and local systems in digitally enabled care pathway transformation. It should develop a national framework articulating the conditions under which certain tech-enabled transformation should be done once, the benefits of this, and how this aligns with the prioritisation powers of ICSs.

Recommendation 5: implement a new operating model across NHSEI, X and D to drive digital and data transformation This new operating model pivots the NHS to a more ‘modern’ operating model, more closely linking digital and data delivery to the business while clarifying accountabilities for supporting technical delivery. Leaders from across NHSEI, X and D have been engaged in discussions to review alternatives, share perspectives and identify the optimal operating model for the NHS. This new operating model has 4 layers, as follows: ‘System’ leadership for transformation The centre of the NHS has a critical role in providing leadership for transformation. This encompasses all the levers of value owned by NHSEI – from setting strategy, to building capability, to creating financial incentives, and supporting implementation. This builds on the work that has been undertaken by NHSX with a digital and tech focus, and places it firmly into holistic transformation, based predominantly around citizens and care pathways. The NHSX approach – of looking at all the available levers and using them to drive change – should drive the new approach to transformation more widely. This system leadership should be responsible, in a partnership model between the centre and ICSs, for setting out the business and technology capability requirements of ICSs and the centre with the roadmaps to realise these, and for determining the appropriate high level technical standards, and blueprints for transformed care pathways. It should provide professional leadership to Chief Clinical Information Officers in the wider system, ensuring alignment to a shared vision of clinical change and encouraging shared learning in individual systems’ transformation journeys. Transformation Factory To achieve the Long Term Plan aim, and respond to the rapid acceleration in digital adoption, NHSEI needs to ‘transform the way it transforms’ and improve how it supports innovation in the delivery of care. At the core, this involves the creation of a scalable capability that integrates clinical, operational and technological resources to transform patient pathways and service delivery. This capability builds real expertise in the art and science of transformation, learning continuously from experience. It needs to embed modern digital and transformation tools and techniques, and adopt a user, patient and citizen centred approach. It will use ‘agile’ change methodologies and operate through small, focused multi-disciplinary ‘service’ teams whose missions have longevity to build the right experience and continuity and technical solutions. Individuals will be part of service teams with day to day oversight from the Transformation Factory leadership but will be drawn from other functions (for example technology, operations, clinical) who will be responsible for their professional development and competence. The focus is relentless on delivering improvements in outcomes based on rapid deployment and continuous improvement rather than large scale traditional system programmes, although supported by underlying data and technology infrastructure. Examples of core initiatives could include the likes of digital triage for the elective backlog, or transformation of a clinical pathway such as at-home remote monitoring for the frail elderly. Creation of this capability, which mirrors the practice across leading public and private organisations, is challenging as it requires significant changes to ways of working, culture and behaviour, resource allocation, and funding. Building a Transformation Factory will require investment in skills and capabilities. These resources are in high demand, so to be successful in attracting and retaining key individuals, NHSEI will need to create a rewarding environment where individuals can make real and lasting contribution to health improvement and grow professionally. Focused leadership and alignment of intent across all functions within NHSEI will be critical. Technology strategy, infrastructure and operations Core technology, similar to transformation, is undergoing a revolution as cloud technology, ‘devops’ methodologies and software as a service and security-by-design standards change fundamentally target architectures and system design and management practice. The boundaries between traditional technology organisations and the wider ‘business’ are being increasingly blurred as more services are delivered through data and digital tools, and traditional programmatic software development is replaced by agile methodologies and rapid, continuous improvement. System resilience and system security and privacy expectations are rising and increasing focus is required on end-to-end risk management and control, including down the supply chain. It is therefore critical the NHS has a core capability, operating close to the service, that can lead the system wide technology capability and ensure adherence to common architectural principles and minimum standards, as well respond to evolving security and privacy needs. Therefore, the Technology Strategy, Infrastructure and Operations layer of the Operating Model should have overall responsibility for the technology architecture, standards and policies adopted by the central and wider NHS system. Working in tandem with the Systems Leadership capability, it would influence (and where necessary enforce) the adoption of common architectural principles, minimum standards in areas such as cyber security and privacy and promote interoperability and reuse. It would also have responsibility for the professional leadership of digital and technology resources operating within the NHS. And all this will need to align closely with the wider transformation strategy, to avoid recreating a digital silo separate from the needs and focus of the wider organisation. Key priorities for this central capability include efficient operations and delivery of core infrastructure, the enablement of the Transformation Factory through use of common componentry and tools, the creation of a coherent data architecture and infrastructure to meet the needs of different user groups, and the design of core infrastructure and standards that make it easier to scale solutions across different parts of the NHS. Data To power this operating model, data and analytics must become a core capability for NHSEI and the wider healthcare system going forward. This will be essential if the vision outlined in the NHSX Data Strategy published in June this year is to be achieved. Currently, this capability is split across NHSEI, NHSX and NHSD and, as a result, is being underutilised with duplicated activities, investments and capabilities. This crucially also includes developing necessary cloud-based data infrastructure to enable leading-edge digital and analytic solution development, foster data interoperability, and enable an easier scaling of solutions once developed. The current set-up is not as effective as it could be and bringing it together will improve decision making and better enable digital transformation. While the pandemic has significantly accelerated the use of data within the centre of the NHS, there has been no clear single plan and potentially duplicative investment. The centre of the NHS must bring together its data efforts, pool and strengthen its expertise and talent, and create a coherent data architecture and infrastructure that operates at the centre to meet the needs of different user groups. There must be a single agreed investment and implementation plan.

Recommendation 6: re-align organisational responsibilities to ensure delivery of the new operating model Create a new Transformation Directorate at the heart of the NHS to drive transformation, including the establishment of a ‘Transformation Factory’. Evolve NHSX into the strategy function of the new Transformation Directorate, with NHSX’s delivery teams integrating into the wider technology and transformation teams. Having successfully advocated for the integration of digital into the whole, NHSX no longer needs a separate identity, and can become a key, integrated driver of the new approach to transformation. Embed NHSD into NHSEI as its tech function and as the NHS centre of excellence for technology, with an intent to merge legally once legislation enables this. The CEO of NHSD should therefore now also be appointed as Chief Information Officer (CIO) for NHSEI, and be a member of the NHSEI Executive Committee. Clarify detailed responsibilities and eliminate current duplication between the new Transformation Directorate and NHSD. ‘Join up’ Board governance between NHSEI and NHSD in the interim, for example through Committees in Common, to align priorities and resource allocation whilst maintaining and respecting current statutory accountabilities. Move sponsorship for NHSD away from the digital transformation and tech policy directorate of DHSC to be aligned with other arm’s length bodies. Replace formal ‘internal commissioning’ between NHSEI and X and NHSD with joined-up business planning and a more iterative dialogue that navigates between business needs, technology considerations, and budgetary constraints. NHSD’s separate technology and data services provision to other organisations (such as NHS Test and Trace and Public Health England, now both the UK Health Security Agency), should continue to be served by NHSD (and later the combined entity), with separate funding, appropriate service level agreements and management information. Empower the Transformation Directorate, drawing on the expertise of the embedded CIO Directorate, to provide digitally enabled transformation leadership to trusts and healthcare delivery organisations within the scope of NHSEI. Use all NHSEI and DHSC ‘levers of value’ to work with trusts and the wider system to define the business and technology capability requirements, clarify the role and responsibility of the centre, ICSs, trusts and other NHS delivery organisations, and promote innovation, reuse, and the adoption of best practice. Retain the dual mandate that has been held by X in the Strategy and Policy function of the Transformation Directorate, so that the Strategy and Policy function is also the digital transformation directorate of the DHSC. This will allow it to use all of the levers required of system leadership including supporting ministers to set direction, policy, legislation, regulation and a voice in cross-government policy and decision-making, while at the same time being an integral part of the centre of the NHS. Consolidate data analytics capability. Create a Chief Data and Analytics Officer for the NHS to provide professional leadership to the data community but nest activity as close to the end user as practicable. Create a data plan that recognises the heterogeneity in its source, type and user (for example, individual patient care data for clinical decision making; operational and system performance data for planning; financial performance data; population health management data; data for research) and design a suitable data strategy, architecture, data models, tooling and permission rights to support effective data driven insight and decision making Ensure the data privacy, information governance and official statistics publication arrangements in the combined NHSD and NHSEI entity are appropriately robust, and in the interim maintain the independent responsibility and accountability of the NHSD CEO and Board for its statutory functions on data. Continue the use of expert advisory and professional groups as part of the sign off processes for data access, as well as the continued publication of details of what has been approved. Ensure that the research and life sciences communities continue to receive priority attention in accessing NHSD collected data to serve their needs. This includes the need to understand the extent to which the underpinning data architecture is shared between NHS data users and those from the research community, and the extent of efficiencies in data collection and curation. Implementing the organisational re-alignment, consistent with the Operating Model will require significant changes to the ‘engineering’ of how NHSEI (including NHSX) and NHSD operate.

Recommendation 7: undertake a fundamental organisational capability intervention across NHSEI and D to build and nurture the skill base to support data and digitally enabled transformation and adapt ways of working to support the new operating model Build basic data and digital literacy and capability at all levels Understanding the importance of data and digital and being able to use them effectively must become a requirement for staff at all levels in NHSEI and in the wider NHS, increasing alongside their seniority. This expectation of broad digital and data literacy needs to be set in all aspects of career development and should be achieved through a combination of on-the-job training, peer support and mentoring, and formal training. NHSEI should be responsible for developing the right curriculum and that competency frameworks be updated to include levels of data and digital literacy. Develop and where appropriate recruit into NHSEI leaders who can lead integrated teams that combine managerial, clinical, operational, and digital and data experience. The NHS has many years of creating leaders who combine managerial and clinical perspectives; it also has some strong technology and digital leaders. However, there are too few leaders and a limited pipeline of future talent who combine both. This should be done through a mix of recruitment, training and secondments – both within the wider NHS, across government and with the private sector. One model, piloted during the review, has brought an NHS trust CEO into the centre at an early stage in their career to lead a discrete transformation project for a defined period. This should be expanded into a programme. Expand and strengthen technical capability in data, digital and technology, starting with a zero-based skills audit and capability mapping of existing teams, to create the right environment and remuneration to attract the most able. Brilliant technologists, software engineers and data scientists are essential, and in high demand in the wider economy. As the technology centre of excellence for the NHS, the new CIO function will need more of this talent to drive up its overall capability. The ability to do work at scale that saves lives is a significant attraction for recruitment but must be complemented by creating an empowered working environment and suitable remuneration. Working closely with the new Chief Digital and Data Office in the Cabinet Office, NHSEI and D must make the case for appropriate career structures and pay arrangements, particularly for exceptional talent. This should include specific work to ensure clear digital career paths and roles are incorporated within NHS Agenda for Change frameworks.

Recommendation 8: revise financial management arrangements both within NHSEI and between NHSEI and DHSC
Simplify and align funding streams across NHSEI and DHSC. Ensure the right alignment of technology and other spend to support service transformation. Currently revenue funding for digital transformation and live services comes partly from DHSC and partly from NHSEI, with capital solely from DHSC. As part of NHSEI taking ownership of the digitally enabled transformation agenda, all revenue funding from DHSC for NHS digital activity should be routed from DHSC to NHSEI, via the NHSEI CFO, and remain ring-fenced to ensure no diversion for other activities. This will help ensure full alignment of digital spend to overall NHSEI transformation priorities. Furthermore, DHSC and NHSEI should consider whether capital for digital activity should also be managed via NHSEI given the industry trend towards greater shifts to more revenue-based models. Adopt a more flexible business case approach for digital transformation in line with processes adopted elsewhere in government. Digital transformation is a multi-year endeavour. Adopting the approach taken by the Government Digital Service and HM Treasury, the NHS should use a more agile approach to business case development and approval. The goal should be for this process to allow funding requests to be iterative, multi-year and aligned to both strategic and technical ambitions. Review the way benefits are measured and tracked for digital initiatives across the NHS, in particular looking at the way ‘downstream’ benefits of national digital investments are measured; the lines of accountability in instances where the spend is national but benefits local; and developing more robust ways to assess benefits in business cases. Align financial, payment and other mechanisms to incentivise digital transformation within the wider NHSEI system. NHSEI set the frameworks for commissioning and payment of services in the wider NHS. A systematic review of how these may act as barriers to digital transformation should be undertaken and establish how they should be adapted so they actively incentivise digital transformation. This work has begun in NHSX as part of its development of ‘Who Pays for What’ but needs to be expanded. Strengthen NHSEI’s commercial expertise and influence so that it can better support ICSs and develop a single, multi-year strategy for market development. Procuring technology solutions is often expensive and infrequent, meaning local teams do not always have the commercial expertise to provide adequate support. The centre should actively support local systems during this process as well as leveraging the purchasing power of the national team to support supplier management. In addition, there is a need for better management of the complex digital, technology and related provider market, to avoid over-reliance on a few key suppliers and provide more clarity to industry around the direction of travel and areas of investment.

Recommendation 9: re-prioritise NHSEI spend to lift the quantum devoted to digitally enabled system transformation. Assess the level of ‘technical debt’ across the wider NHSEI system and update estimates of technology spend required to enable the delivery of safe technology operations. In conjunction with DHSC, make the case for increased funding to deliver safe technology operations The requirement for digital transformation in other sectors has driven up the proportion of their spend on digital and technology. Benchmarking the overall spend against other industries is extremely challenging, not least because there is currently no solid data available on total technology spend across the NHS, since the vast majority is spent by local organisations. NHSEI estimate that trusts spend less than 2% of total expenditure on IT, while Lord Darzi and the Institute for Public Policy Research suggested this should be nearer 5% by 2022. Informed third parties have also queried whether the level of funding proposed is sufficient to enable secondary care to digitise. NHSEI should therefore as a matter of urgency determine the levels of spend on IT across the wider system and seek to re-prioritise spend from within the wider NHSE budget to support accelerated digital transformation. In addition, audits of the wider NHS indicate that there is a very large legacy ‘end of service’ technical debt, creating significant additional cyber and operational resilience risks to the NHS as a whole. NHSEI should update their estimate of the likely costs and work with DHSC to make the necessary case for additional funds to address this risk over time. Implementing the enablers for change, consistent with the Operating Model will require significant changes to the culture, skills, capabilities, people processes and financial process across NHSEI (including NHSX) and NHSD.