For HTN Now we recently hosted a panel discussion on digital across integrated care systems, including how ICSs can tackle challenges such as cyber security, digital in managing demand and flow, the primary-secondary interface, and data sharing. We were joined by John Kosobucki, founder of OX.DH; Dan Bunstone, clinical director at Warrington Innovation Network and Warrington ICB; and Kate Dawes, programme director for digital diagnostics for North Central London ICB.
We started off with some introductions, with Kate sharing her experience of working in the NHS for over 25 years and her work as programme director for digital diagnostics in North Central London, which she described as “a busy ICS with lots of different levels of maturity and different requirements for digital”.
Dan, a GP by trade, shared some insights into his current role as clinical director in Warrington, within a “pretty large ICS with around two-and-a-half million patients”, where a focus has been on developing a digital front door and on “prevention, proactive care, and helping to protect the lives of tomorrow by treating better today”.
Bringing a supplier perspective, John spoke of working in the financial industry around data integration before launching OX.DH to focus on digital healthcare, “to take some of the experiences from other industries and technology that’s been used there and apply it in healthcare”, adding that “there’s a significant technology debt that exists in healthcare, and incrementally making changes and introducing reusable components that can scale across an entire ICS is a great way to move forward”.
Tackling challenges from an ICS perspective
On what types of challenges can be tackled from an ICS perspective, Dan highlighted the potential around proactive care, using the example of hypertension as “a relatively low-cost and easy disease process to manage, but something which can quickly translate into things like heart attack and stroke, with untold human cost and substantial ongoing costs to the system.”
He continued: “Big opportunities like that exist at system level which are probably better managed there than in the smaller units, due to the need for a wraparound approach.”
Kate considered that “the greatest value an ICB can bring is that role of collaboration and brokerage; acting as that independent broker across all of the different providers, including our voluntary and care organisations.”
She shared that one of the projects she has been involved in with North Central London is “an operating model to facilitate that collaborative working, and to support a workforce that isn’t necessarily digitally literate; so having a standardised approach to digital literacy and digital inclusion to ensure that we don’t minimise access for those that aren’t necessarily digitally literate. The weakest link within our system is actually the weakest link in our interoperability and our broader digital maturity; that’s where the investment needs to be made, and I think that can only be done by an independent partner.”
John talked about some of the challenges at ICS level that the supplier community might be well placed to tackle, agreeing with Dan’s point on the need to focus on proactive care, and the possibility of bringing in automation to “remove friction” in managing things like hypertension, as well as in promoting standardisation of processes across the system.
He added that “one good thing that did come out of COVID was the adoption of Microsoft and Teams across the NHS, which quickly became a central platform for sharing information and communicating; from our perspective, we follow that same model of building integrated cloud native solutions that are actually plugins to the Microsoft environment.”
Selecting suitable solutions for ICSs
The panel moved on to discuss how digital and data solutions can be identified, and how to find out what solutions would be suitable for use at ICS level.
Kate highlighted that the current approach in North Central London is “very formulaic”, adding: “We’re developing a strategic investment framework for digital, looking at our critical success factors, outcomes, and issues across the system.” Whilst it is great to have “those shiny new investments”, she went on, “having the foundational infrastructure and accurate data is a core part of that.”
Dan noted the number of available solutions out there, likening the selection process to “almost going around with a hammer, looking for a nail”. He encouraged people to “look at the broader strategy, strategically plan what you want to achieve, and then make sure it’s all wrapped in together in terms of interoperability.”
In the NHS, Dan commented that “we spend a lot of time trying to create ‘perfect’, when ‘excellent’ or ‘good’ is often good enough. What we need to move away from, he added, is the “paranoia potential around spending taxpayers’ money and having to get it right first time. Instead, we need to get more comfortable iterating and creating a strategy – and perhaps failing, but failing fast, and then moving on to the next thing.”
John agreed with previous comments on a fear of failure preventing innovation and people coming forward with ideas, commenting that engagement is a key priority in turning people into “champions and ambassadors of change”. It is also important, he added, to “plan for issues to arise, and incorporate that into everything we do.”
The finer points of ICS collaboration
Taking a closer look at how ICSs can collaborate, and what this might look like in terms of things like governance, Dan said that one of the benefits of this type of system working is that there is often already “overlap across lots of areas, so the governance is probably already there.”
Using his perspective as an example, he acknowledged that there will be parts of Cheshire facing different challenges to Liverpool or Warrington. “It’s about creating general architecture and an arena where innovation can flourish, letting ICBs work within those guide rails to achieve that common goal.”
Kate considered that since the move from CCGs to ICSs, “the approach now is very different than it was before; less about pure assurance and performance management, and more around that collaboration, partnership and brokerage. I think it’s really important that the governance reflects that.”
On what that should look like, Kate said: “It should be function-led and based on three functions: assurance, delivery and then strategy, cooperation, and developing that culture. From a delivery perspective, it’s important that we have that reflection of across the system, and patients do not see the organisational boundaries, they just see NHS. Having the right people at the table helps ensure that we can get the job done.”
Kate also talked about the formal and informal sides to strategy development, noting how she has worked to establish a safe space within her ICS to develop an ICS level culture, to have a subject matter expert advisory group to avoid purchasing products that have been designed without the user or clinician in mind”, and to enable the consideration of “some of the flows and the clinical processes involved”.
Best practice for taking an ICS wide digital approach
On best practice around ICS wide collaboration on digital, John discussed the importance of looking at “reusable components that can be applied consistently in key areas such as patient engagement, managing appointments, and for virtual consultations”. This type of approach can help deal with things like the audit trail for consent, he continued, whilst being open to the potential to be “adapted and configured for different use cases in the future”.
Dan mentioned what he views as a “fixation” on creating a digital front door. “There’s a reason we don’t have a banking app that opens all of your banks at the same time, or that opens all of your app games at the same time; I think we spend too long fixating on trying to create a digital front door when most patient’s phones are probably already loaded with a whole variety of different apps that they use,” he stated.
He added that, “it is also worth bearing in mind that in many cases the populations targeted with digital tools are “already underserved by the traditional system – I think there’s a tendency to hamper digital with having to solve all problems, for all people, all of the time. By trying to get that Holy Grail of a single point of access for all apps, we probably slow things down in the process.”
John mentioned the “great progress” made on the NHS App and the emergence of new patient-facing services that are being published for vendors to interact with. He added: “I definitely agree with what Dan was saying on feeling that we need to be ‘excellent’ all of the time; that shouldn’t be an obstacle waiting for that to be available, and shouldn’t inhibit what we’re doing today.”
The real value of ICS working, Kate said, is “around developing economies of scale; identifying good practice and blueprints, and harnessing that to develop broader economies of scale”. She noted that it’s important to consider that often multiple organisations are not necessarily at the same level of appetite in terms of digital transformation, and that whilst the NHS is “fundamentally in the business of caring for people, we should be fundamentally a digital organisation. It’s not just about putting tech in, it’s about addressing issues that we have within the system, and we are doing it for this very reason.”
Sustainability
We asked our panellists how they thought ICSs could bests work toward net zero targets, with Dan talking about ongoing work in Warrington around remote care which allows patient journeys to be saved on things like blood pressure checks and reporting changes. He considered that there are probably “a whole host of things you can apply this logic to, including outpatient clinics and pre-op clinics, where there are things you can do to minimise the need for patients to have to come in to hospital.”
Kate pointed out that whilst there are lots of activities that ICSs undertake in support of net zero, there is a risk that “it is almost seen as a tick-box exercise, in that we’ve achieved net zero contributions because we happen to have done other things. For me, I think the role of the ICS is about prioritising the net zero agenda and sustainability.” The emergence of things like remote care, virtual wards and the move to cloud are examples of “moving in the right direction”, she continued, “but having that support on the ground is that constant reinforcement from the top to remind people of the importance.”
Supporting organisations with a move to the cloud has been one of the focuses for OX.DH, John told us, since “you just can’t achieve the same level of environmental savings on premise. During COVID there was a spike in phone and video consultations – that now dropped off a little bit, but it’s about making it as easy as possible and encouraging people to do those type of consultations remotely.”
Looking to ICS working in the future
Looking to the future of ICS working, our panellists discussed what “good” might look like, and their ambitions for the next few years.
Kate raised support for the What Good Looks Like framework, praising the “nice balance of technical functionality and those softer things that support digital transformation.” She would like to see a framework that supports that integration in the future, she said. “I think we’re achieving collaboration and partnership in spite of the existing framework at the moment, and I would like to see that changing”. Having funding earlier and having multi-year funding available, she went on, would help with “getting into the swing of planning, as at the moment we’re very reactive rather than proactive; and that doesn’t allow ICSs to do their appropriate due diligence.”
Kate also mentioned workforce challenges in digital and her desire to do more design thinking with clinicians and users in mind, referring to digital maturity assessments and “big things that come out of those on patient empowerment and patients owning their own records”. She continued: “We need to build this as a core component into the workforce of the future, making digital a fundamental part of the job description and the way that performance is managed.”
Dan talked about needs for digital ICSs in the future, including funding, since “from a provider perspective these things take years to develop, and there will be costs associated with deploying them.” He also noted the need to create “an environment where innovation can flourish, taking the word ‘failure’ out of the equation, and creating that North Star vision – create that full bag of sweets for people to choose from, rather than just certain parts of the pick and mix.”
Finally, John pointed to the NHS’s commitment and ongoing partnership with Microsoft as “a huge asset that can be leveraged for a lot more than it is today”, and the emergence of subscription services that “can be turned on and off if you don’t like the vendor any more or if they’re not providing a good service; with new interoperability standards it will be much easier to make the switch.”
We’d like to thank our panellists for their time, and for sharing their insights with us on this topic.
Want to learn more about HTN’s upcoming panel discussions? You can find our upcoming event schedule here.
