For our most recent panel discussion, we were joined by Andy Carruthers, CIO at University Hospitals of Leicester NHS Trust, and Alistair Eaton, CEO at CCube Solutions, to discuss recommended strategies for an organisation in moving to the cloud, what good looks like in this space, challenges, solutions, and more.
Starting out with introductions, Andy discussed his role at University Hospitals of Leicester and the challenges the trust has faced in its digital programme, as well as how conversations about hosting and cloud are playing an increasing role in the trust’s strategy.
“Historically we’ve had a lot of different systems to do different tasks for different services, so when we talk about digital strategy in the acute sector we’re often talking really about the consolidation of systems and trying to reduce complexity,” he noted, “so I think for us, the role that the cloud can play in that is important.”
Alistair talked about his role with CCube Solutions, a supplier of electronic document management systems to the NHS, as well as his background working with healthcare software companies and using the cloud to deliver “a new generation of patient record systems”. He also highlighted his work overseeing the Docman 10 cloud service and the subsequent migration of 4,000 GP practices to the cloud.
Projects and experiences
Andy shared a bit about University Hospitals of Leicester’s journey to date, talking about the challenges of “the legacy of lots of systems”, and the trust’s strategy to “consolidate as much of our clinical frontline digital capability as possible into as few platforms as possible”. This includes work on a new EPR system, “which will allow us in the future to remove some of those old systems”.
He said: “We’re looking to exploit the right hosting arrangements for the systems we still have that are business-critical for us when we’re doing system upgrades, or when we’re looking at removing systems and implementing new platforms. We have a hybrid strategy for our hosting arrangements, so that allows us to leverage cloud capabilities and benefits where that’s the right thing for that particular application; but it also allows us some flexibility to ensure that, first of all, we’re getting the right value from that.”
On this point, Andy considered that what the trust currently has is “effectively some space in a co-located data centre… we’ve got connectivity to this out of the organisation, which allows us to reduce the risk that we’re carrying from running very old systems and services from rooms in the hospital. It helps us make sure we’re moving towards purpose-built facilities suitable for twenty-first century hosting.”
Acknowledging that the trust is largely hosting third party vendor-managed systems, Andy pointed out that this means that they are “dependent on our vendors to a significant extent, in terms of the scale and pace at which we would want to move some of those hosting arrangements around. Our risk mitigation at the moment is to get as much off premises as possible. If that’s a cloud native application we can do an upgrade, or we can move it straight to cloud hosting, as long as we’ve got an ability to fund it.”
Referring to what he called “significant technical debt”, Andy also highlighted the trust’s challenges with legacy systems, and “operating within a set of constraints, some of which are outside of our control” in terms of moving over to the cloud.
Alistair picked up on some of these points, highlighting the importance that vendors “rise up to the challenge” with trusts struggling with legacy systems, and “offer solutions which aren’t dependent on the trust hosting lots of infrastructure and the associated risks with that”.
At CCube, he said, there has been a lot of investment into the cloud platform CCube Cloud, which he described as a true cloud native solution. “Many of our customers are now either using it or planning to move from their on-premise solutions to that software as a service solution, one of the most recent ones being Royal Papworth. It’s important that vendors understand the power that is available within the cloud, and that they’re able to deliver that through true cloud solutions to the NHS, which is very much our focus at the moment.”
Benefits and motivations
We asked Alistair and Andy what benefits the cloud offers, and what motivations NHS organisations might have to make the switch.
Speaking from his experience, Alistair said, “It’s about removing the need to worry about things like buying and managing physical servers, expensive storage devices, Microsoft licences, security patching, hardware, and so on; moving away from all of that, and just simply consuming software as a service.
“Cloud is not about someone like me simply hosting your infrastructure; instead of you doing it yourself, most software vendors will host systems for you. They may even do that using public cloud, and Andy’s talked some of these hybrid strategies that he’s had to adopt; but it’s unlikely, unless it is native cloud applications, that you will get the cost benefits or the quality of service benefits that you’d get with a true cloud service.”
True cloud, Alistair continued, “is where a software vendor builds a solution which is both software and infrastructure; and where the software vendor is exploiting the power of the cloud to take care of all those things that I mentioned earlier.”
He continued: “The NHS trust can simply pay an annual monthly fee to cover all of that, leaving people like Andy to focus on transforming their services with digital rather than running lots of expensive and high risk IT infrastructure, which is why many will look to make the move to cloud.”
Andy talked about his own experience in Leicester, saying that, “once you start looking at the value of hosting in the cloud, it almost becomes a no-brainer. You want to get the full capability of whatever application or system it is that you’re looking to buy – if the system is designed for the cloud and you don’t get the functionality of the system without it, it’s a very different proposition.”
Andy also discussed his trust’s new data platform, which has historically been managed in house, but which his team is looking at “leveraging some of the capabilities from cloud vendors” for.
“To leverage that cutting-edge capability you’ve got to make the leap. We’ve seen the benefit of being able to better manage that capability as we start to move some of our test and development environments across.”
Key considerations
Andy outlined some key learnings from his team’s journey, including the need to make sure that the mindset shift happens alongside the switch; that “staff don’t leave everything switched on as every minute it’s running it costs you money”; that everything is migrated across safely; and that you ensure that poor performance doesn’t have a detrimental impact for the end user.
“Ultimately, our colleagues across our hospitals shouldn’t know, or care, where their service is being hosted from, as long as it performs,” he stated. “One of the other projects that we ran very early was with some imaging software. We saw that posting some of that away from the hospital made perfect sense from a risk perspective, not having to have all this high-powered computer and storage capacity on our sites; but your prerequisites have got to be there, your connectivity has got to be up to scratch.”
Getting “the technology foundations right”, Andy continued, is a key factor in the process, since in Leicester attempts to move some services “haven’t necessarily gone as well as we would have liked from a performance and end user perspective”.
He explained: “You can’t just rely on one single connection; you’ve got to make sure they’re up to speed and up to scratch in terms of bandwidth. So it does take time to get there, because that’s additional investment over and above the investment in the new installation. We’re starting to realise some of the benefits from it, but it’s certainly not been a straightforward set of steps, and it’s been a much more incremental experience for us.”
From a vendor perspective, Alistair offered some insight. “In an ideal world,” he said, “software vendors would offer a simple software as a service-based solution, and Andy wouldn’t have to worry about all of those things he just mentioned.
“As these applications become more available to the NHS and more people start to look at adopting them, it’s important that they understand the total cost of ownership of their existing infrastructure. Often I speak to people who think that hosting software themselves is cheaper than cloud. That’s often because perhaps the infrastructure comes from a different budget, or there’s already been quite a significant capital investment in servers and licences. But all of those things need to be refreshed over time, so the long-term costs of maintaining that infrastructure, or even using cloud to solve problems like Andy’s having to do, soon mount up.”
A vendor should be “building an application once and then selling it many times,” Alistair said. “It should be a lot cheaper overall for the NHS to adopt cloud based solutions, rather than building their own infrastructures for each of their individual applications.”
Overcoming challenges
The conversation moved on to consider some of the challenges with making the switch, and how these could be overcome.
One of the challenges that Alistair mentioned was the “relatively short list of suppliers who can offer a true software as a service, native cloud solution at this point in time”.
He said: “There comes a point where, if vendors are going to be innovative in the future, it’s important that they adopt cloud. That means they may well have to rewrite their applications, or certainly make significant updates, which could be expensive. From a vendor perspective, that is one of the things that all vendors will have to overcome in order to adopt the native cloud technology, get the benefits, and be able to deliver that to their customers.”
Andy agreed with Alistair’s points on being “constrained to some extent by the capability offered by vendors”, adding: “It’s great if vendors bring us new cloud-based solutions, but it’s absolutely still the case that provisioning infrastructure as a service from the cloud is not a cost-effective way of moving forward. As I said earlier, for us it has to be value-led, so we’re getting the right hosting for the right price. There are some very obvious financial implications of reducing the stuff that we host in our rooms on site, because we’re not paying the electricity anymore, and in some cases you can make a case for moving stuff out based on some of those savings and reinvesting them. You need to look at the whole cost, don’t just look at the monthly fee. You’ve got things like not having to replace some of your infrastructure from your own capital investment, not having to pay for some of the power, and so on.”
Andy also talked about the different skillset required to cope with cloud-based services, and the challenges that can come from needing to take some “local responsibility” for running services, as “if your broader team don’t understand it, you’ll still be designing stuff in the old way”.
There is a need to look at skills across the whole team, he noted, including your architecture function, your finance team and some of your technology specialists. “That can be a real challenge, and if you’re going to take a multi-cloud approach then you’ve got multiple versions of that challenge to manage.”
Being clear on responsibilities when beginning work with a vendor is also important, Andy highlighted, since issues such as runaway costs need to be planned for ahead of time, to outline whether it’s the vendor’s responsibility to fit within a set budget, or whether there’s an expectation that “if your data consumption goes up, somehow the trust is going to start paying for it”.
Security
We asked Alistair what would happen if an NHS organisation was using CCube’s technology in the cloud and experienced a security issue; what a response would look like to that, and how long it would take for the service to go live again.
Alistair highlighted the importance of “really scrutinising” what happens when things go wrong when looking at working with a vendor, to ensure that an organisation is prepared for if “the very worst happens”.
A traditional problem, he continued, is that “once your environments are infected, and probably encrypted due to that cyber attack; that environment is rendered useless. One of the key advantages of the cloud is that there’s an almost infinite amount of infrastructure available to you. With a good true cloud service, under extreme circumstances like that, a software vendor should be able to rebuild that cloud environment in a totally segregated, totally clean, totally new environment, in probably about 20 minutes.”
Backup strategies also “become much simpler”, Alistair told us, since “the billions invested by companies like Amazon and Microsoft have solved those problems for you”.
As an example, he shared that CCube’s backups are stored in completely separate locations over 100 miles away. “The networks are totally segregated, so in the unlikely event that we were subject to a cyber attack on our production environments, the backups will be completely protected; because the cloud enables us to just create a new operational environment and restore those backups straight away. My advice would be that if you are adopting cloud services from software vendors such as us, then make sure you are scrutinising those services as well as you can.”
Andy talked about business continuity, and the fact that the trust has “a lot of systems that are really critical to the way we operate”, adding that those systems “are running in real-time supporting flow of patients through the hospital and managing the workload of lots of our staff”, making high availability a major priority.
“The other thing that cloud offers is mitigation in the event of a local outage, which is something we did experience a couple of years ago. Knowing that your data and your services are still running in the cloud offers you another set of benefits there, and you can potentially look for ways to access the cloud through other connectivity. The cyber attack point is also really important, and it’s about making sure that wherever you’re hosting any of your services, you’ve got a plan in place.”
In terms of value, Andy also highlighted the benefits in increased flexibility, speed, “ability to spin-up capacity on demand”, and mitigation in case of any disruption or disaster.
Future capabilities
The discussion moved on to consider the potential future capabilities of cloud services and how they could pave the way for further developments, new integrations and technologies such as AI.
“Increasingly in health and care,” Andy considered, “we’re looking to break out of our organisational silos and share in different ways. Whether that’s across ICSs or provider collaboratives, it’s about sharing and meeting patients needs and their expectations. So putting systems and platforms in place that span across organisations via cloud provisioning is just a logical step; because if we’re siloing off our own local data stores, it’s then quite difficult to bring all that together. As we start to move to cloud-enabled vendors and platforms, we should be removing some of those constraints on the ability of our staff to see records across different organisational boundaries; their ability to collaborate across organisational boundaries; it starts to unlock a lot more of that capability as well.”
Alistair noted the potential for “exploiting the power of AI”, and getting more out of data, with the cloud offering more opportunities for data sharing, research and collaboration.
“The reality is that suppliers to the NHS today are behind many other industries – but the industry will catch up, and it won’t be long before organisations are only selecting suppliers who offer true cloud services, because of all the operational benefits and the cost savings. Going back a few years, a team would have to go out and buy licences, buy servers to run it on, install it, configure it, and then worry about things like disaster recovery. In 10 years’ time, that will be a thing of the past, and people will be just simply paying a subscription.”
Andy said that in 10 years’ time “we shouldn’t be talking about IT infrastructure other than local connectivity, as cloud hosting will be the standard way of provisioning”.
He added: “The challenge we have in healthcare is the time it takes to get from the invention of a new capability to it being fully adopted by vendors and customers. The ability to leverage new technologies and capabilities in the cloud will probably accelerate that. With the new hospitals programme, those new buildings will be generating more data than we’ve ever seen before, and managing all of that in any way other than through the cloud is almost inconceivable.”
In 10 years, Andy continued, he would like to see “everything connected and data flowing in real-time, so we could be looking at the opportunities around things like generative AI.”
We’d like to thank Andy and Alistair for sharing their insights with us on this topic.
