At HTN Now: Digital ICS, we hosted a panel discussion featuring Dr Tamara Everington (chief clinical information officer and haematology consultant at Hampshire Hospitals NHS), Dr Dan Alton (chief clinical information officer at Buckinghamshire, Oxfordshire and Berkshire West ICS); and Paula Ridd (strategy director, health and care at Civica).
Tamara, Dan and Paula shared their views on a variety of topics, including the role and opportunity of digital in integrated care systems, projects to date, learnings and approaches, technical considerations and hopes for the future.
Introductions
Tamara: As well as being CCIO and haematology consultant, I’m the associate medical director for change at HHFT, which means that I run the integrated improvement team. That involves transformation, project management, quality improvement and more. I’m also the Caldicott guardian; I steered the trust on a digital care journey as part of the national GDE programme to where we are now.
My role evolved because although we’d done a lot of digital change, we also had to focus on the work around change management. We now have a portfolio of over 150 change projects within the organisation and an even larger number of QI projects. The three biggest domains for us at present include getting real-time data from the frontline, from our EPR and the linked e-whiteboards, to inform our operational dashboards; focusing on elective improvement and recovery through outpatient transformation and surgical pathway transformation; and work in the virtual sphere, supporting people to avoid admissions.
Dan: I’m a GP by background alongside my role as CIO for BOB ICB. It’s an interesting role; as we know, ICBs are relatively embryonic, and alongside direct responsibilities we also have a role to support our constituent trusts, our partners in social care, the voluntary sector and wider communities to think about their digital journey, literacy and inclusion.
My particular interest is population health management – I’m also a national clinical advisor in population health management for NHS England, so I can bring the national perspective as well. For me, that’s all about data being an enabler for transformational change, to bring to life the whole concept of an integrated care system.
Paula: I’m lead strategy director for health and care at Civica. We’re a global govtech leader and we cover a wide range of software within the public sector across local and central government, education, health and housing.
Health and social care is a major focus for us, with approx. 20 capabilities spanning strategic themes, such as clinical care, financial management systems, people and workforce management, and optimisation. One example is our digital specialist pathway solution to compliment the large EPRs, working to support the convergence agenda for specialist systems such as cancer and endoscopy. We’re launching our next-generation rostering as a service in residential care homes, and we also have community scheduling. We’ve got multiple AI projects running and some carbon footprint calculations to tie in with the sustainability agenda.
On a personal level, I’ve worked within healthcare for 20 years, in an acute EPR and clinical setting.
The role of digital for an ICS, and where the priorities should lie
Tamara: Every ICS is in a different place, some are very mature and others – like ours – are really quite recently formed. I think there’s a struggle between the ICS balancing what it needs to do, with what provider organisations need to contribute. Sometimes, we fall into the trap of thinking that the ICS needs to do everything, and in my mind, the ICS should take the role of a coordinator to make sure that we are all working to the same objectives and outcomes. They are the things we really need to be focusing on: elective recovery, flow through our hospitals, and the system pressures. They are huge problems, and digital is potentially an enabler in this space.
I think it’s fair to say that it hasn’t always been an enabler, sometimes it gets in the way of us doing the right thing. We go out and buy shiny new digital toys but we don’t work out what we need or implement it in the right way. I think that’s another way in which the ICS can help, by linking regional and national teams and highlighting what we want to achieve, the frameworks that can help us achieve it, and the best way to coordinate so that we can move things forwards step-by-step.
Some of the things we will do will be all the same, everywhere; we’ve got pathology and maternity systems across the board, for example. But other things will be different and choice-dependent, such as patient engagement platforms. We might choose to go down a different way, but ultimately, we’ll harmonise around the NHS App.
Dan: In BOB ICS we have varying levels of maturity in terms of our providers; they’re at different stages in their digital journeys. One of the key priorities is going to have to be ensuring that we level up. I think the economies of scale offered by ICBs and ICSs forming can help with that. What we often find in meetings between our CIOs and CCIOs is that we have a particular organisation that is embarking on a journey that has already been completed by another. We can have mutual aid. That doesn’t necessarily mean transplanting a project team to another trust; sometimes it’s just having the contacts so you can pick up the phone or send an email to someone else in another organisation. By creating that wider community, we’ve taken isolated teams and made them part of a bigger team, and we can reap the benefits of that.
Another major priority is linked data. It is hugely advantageous for so many reasons. At the top of the list: tackling healthcare inequalities. We know that there are healthcare inequalities in this country and in some cases they are significantly embedded. In order to do something about that, we need to identify where they are and put in place interventions to turn the tide. Linking data across health and social care can give us a powerful tool to shine a light on this area, and there’s also all the other advantages of a population health management approach in terms of creating change through a very data-driven methodology. It helps us ensure that we are concentrating our transformation efforts in the right places for the right cohort, and of course, we should also be making sure that we involve patients and communities in that process of co-design and co-production.
The third priority that I’d point out would be the creation of a culture of innovation. Sometimes, historically, we have been almost reticent to try something because it might not work. The temptation is to carry on what you are doing, and just push harder. What ICSs need to do is instil a culture where we can try something innovative – often you’ll find that it’s already been done in some capacity elsewhere in the system. We need a culture where it’s okay not to get it 100 percent right at the first turn of the wheel. On this note, we have an innovation programme in place which is designed to help lots of innovative usages of digital and data to get started.
Challenges facing the ICS
Dan: As a clinician, often the biggest challenge to overcome is simply having the headspace for change. Often people agree to new ideas, but daily pressures get in the way. It’s worth trying to spend the time to create that headspace in order to allow clinicians to stop and take stock of where we are going in the longer term. That involves carving out time to bring together clinicians, clinical leaders, patients and community leaders, analysts, and finance leaders. When you get them in a room together, virtual or otherwise, and encourage them to think about where we are, what our problems are and what we are going to do about them, you begin to build that culture of innovation and you get past the initial resistance. It’s about creating a shared vision and winning trust, particularly of the wider clinical community. It should be irrespective of whether we are introducing a new solution or methodology.
Tamara: I think we forgot a lot of what we learned in COVID very quickly. In the pandemic, the first thing we had to do was stop. Stopping was necessary in order to start the joined-up, system-wide thinking that allowed us to do things differently. When we perceived that we were ‘moving on’ from the pandemic and closing those ways of working, all of those past issues came back, and virtual work actually exacerbated some of it and added pressure. Being able to connect virtually with colleagues on Teams, for example, can lead to people stuffing last-minute meetings in your calendar and just assuming that you can come. We’ve re-cluttered our world, which is taking away brain space for thinking about how to do things differently. So I’d say the first thing we need to do is actually stop doing things, because there’s way too much noise in the system.
Another key priority is to get the resourcing model for IT right. We’re still relying on cash drops from the centre, which often happens at the last minute and doesn’t always deliver what we want to deliver. There’s also a tendency to think about digital as a side project, rather than a key enabler.
The third priority is around supporting our IT team. They’re really struggling. What the NHS is prepared to pay for their expertise is very different to what these people can get paid in a private market. Recruiting and holding onto people in that space is therefore a major challenge.
Paula: As a supplier, we’re going through a similar transition. Dan mentioned the importance of taking time out and thinking about the art of the possible. We’re thinking like an ICS too – – how can we continue to join up our solutions and the data between our products, to help trusts solve more problems? As the ICSs are maturing and balancing different perspectives, suppliers have a call to arms to support with this agenda. We need to take the time to consider how best to do that.
The point has been raised about leveraging experience that has gone before – I think that’s partly our job as a supplier, to help broker some of that. We will be learning as we implement projects across the ICSs. We need to harness the insights that we can provide so that they become actionable, and we need to be at the table with the ICSs to help work through these challenges.
Culture change
Tamara: The principle of ‘everyone is an improver’ is core to what we do at Hampshire. That doesn’t mean that everyone needs to be hugely creative in their own space – it’s about all of us having an understanding of what we need to be achieving and how we can coordinate efforts to get the best possible results.
Creating the ‘everyone is an improver’ model really is about including everyone. At a conference last week, we heard about a whole range of projects and programme – we had a porter talking about the change he has initiated in terms of making sure that oxygen cylinders are full enough during transfer of patients, we had the stroke team discussing their iterative improvement programme to help them gain an ‘outstanding’ rating, we also had the chief executive talking about how she worked on recovering the complaints process. We try to mesh digital in with everything else, so that when you bring in a digital change, you’re bringing it in the context of a whole system transformational change.
Dan: I think it’s interesting to point out that we’re half an hour into a discussion on digital health, and we haven’t actually spoken about tech much. I think that’s quite important and quite correct. It lets us place the emphasis on that culture change instead.
The work we are doing at BOB ICS broadly falls into three categories, in terms of creating a culture of innovation. It’s about trying to embed knowledge, skills and attitude. The knowledge requires an element of professional development, an offer to upskill.
The skills part can be achieved by giving people the opportunity to try, which sometimes will mean trying to carve out funding to put behind new projects. As I mentioned earlier, things might not always be a success, but at least we’re trying something new. For example recently managed to identify some funding for robotic process automation (RPA), to attempt to help general practice in reducing administrative burden. Some of our trusts have experience in RPA, so we’re able to connect practice leaders to have those conversations. We couldn’t have done that before we formed these links.
Attitude is the most difficult element. That comes back to the headspace; ensuring that we are creating a unified vision of what we are trying to achieve, having the time and space back to explore that with individuals, and instilling an attitude of innovation. It’s a bit more difficult to describe than the other two, and it can feel a bit nebulous. But it is key.
Paula: We are certainly seeing that piloting some of that innovative, cultural change using technology is really helping due to the ability to share the adoption perspective and the lessons learned. We worked in one of the cancer pathways, looking at how we can implement one single queue across the region. By taking one service and demonstrating a 42% reduction in waiting times, we can look at the experience and what was learned and then re-roll it out. Taking that small-scale step and then driving adoption from there can be beneficial and a helpful way of thinking.
What does digital ICS success look like?
Paula: Data is king. I would like to see a much more ubiquitous joining of data across all care settings. It comes back to providing actionable insights that consider all of the data in the system. Take our Civica portfolio – it would be great to use data management tools to bring together data from across the ecosystem – things like educational data as well as health records. If we can start to drive that collaborative approach, better our understanding of insights and increase our knowledge of how to action them, it would be a superb place to be – as a citizen within the ecosystem, not just as a supplier.
Dan: I think the easiest way to consider success is to look at it from different perspectives. From a patient perspective, the best case scenario in three years’ time would see us having made real inroads into tackling inequalities in terms of digital exclusion. Access to services would feel seamless, and they would be given the information that they need to take control of their health as much as possible. It needs to be meaningful – for example, if a patient has high blood pressure, they should be able to access information on their blood pressure, how best to manage it and local services that are available.
Success from a clinician’s perspective would see digital helping them to do their job as best they can. That includes a cyber secure, intuitive systems being used in order to rapidly support them with data.
From a wider population perspective, success means making better use of data – using population health management methodology in order to shift from reactive to proactive care at every level of the system, by identifying cohorts and co-designing interventions with that community to tackle disparities. It also means using data to better plan services, both now and in the future, through modelling.
Engaging through data
Paula: A really good set of examples from our portfolio is our artificial intelligence solutions. We’ve been using our AI to provide data insights that frankly would have been like looking for a needle in a haystack if we had been doing it manually. By honing in on those insights, we can very rapidly identify areas for further attention and we can look at two million episodes in a matter of minutes. We’ve been working with a number of regions on how they can use that data to look at clinical variation – in cataracts, for example, identifying variations has yielded about £300,000 in savings just by changing some work patterns, shifts and looking at allocations. Looking at practices across the region and sharing experiences has also supported that.
It involves a lot of stakeholder engagement and it comes back to time – we’ve seen the best outcomes when we’ve had time carved out for clinicians to get involved in these insights. The difficulty is the pace; using a tool like AI means we can build up those insights incredibly quickly, but being able to get stakeholders in the room to share the learnings happens at a slower pace. I think using these opportunities to think and plan for the future is really important.
To support ICSs, as suppliers we need to keep having those conversations with stakeholders, so we welcome opportunities to talk and find out how we can support them to work in faster, smarter ways.
Data for positive change
Dan: There are a huge number of examples, but I’ll pick out two. Firstly, there’s data for proactive care. We are using data in order to identify cohorts of the population who could benefit from a slightly different approach. Often, those cohorts of patients are not necessarily experiencing poor health outcomes today, but are likely to experience them in the future; for example, if their diabetes control gets a little worse year by year. We use population health management methodology to design interventions for the specific needs of that population, which will differ depending upon the local geography. For example, in central Reading, we have a large number of people of Nepalese background who may experience poor health outcomes in terms of diabetes. We are working with that community in order to design a specific intervention, with group consultations run by a Nepalese-speaking GP, and we can use this to adapt our approach to their needs. We wouldn’t be able to do that if we didn’t have the data to identify this problem in the first place.
Another huge advantage of linked data, at a wider level, is how we can use it to plan services. Traditionally, we’ve looked at a number of factors to decide where an urgent care setting should be located, for example, but we haven’t had all the granular data to make that decision. We’ve tended to design services based on what suits us, rather than what suits population need. It’s complicated, from an ICB perspective – taking BOB ICS as an example, we are an amalgamation of three CCGs each with its own data architecture. Linking them together involves an element of compromise, but it’s important that we have one system with one linked data source, to give us the power to help your population locally and at a wider level.
