1948 was an eventful year.
Tanks rolled into Czechoslovakia. Mahatma Gandhi was assassinated. The state of Israel was created. The UN founded the WHO. And the LP (yes, Long-Playing record!) was invented.
1948 was also the birth year of the NHS. It was a historic moment when access to free healthcare became a basic human right in the UK.
Any attempts at NHS improvement today are largely informed by the mindset of that time: it is, essentially, a ‘sickcare’ system. While some aspects of healthcare have been transformed – medical diagnosis and treatment, for example – at a structural level, the system is antiquated.
Think about it. If someone feels unwell, they book an appointment with their GP. This may get escalated to a hospital appointment, with tests, scans, and diagnostics and, eventually, the necessary treatment. The gaps in between these appointments can be huge, with long waiting lists and administrative procedures to overcome.
These days, patient care has become increasingly distributed between different medical domains and organisations. But we still recognise the original mindset, including disconnects between different parts of the system.
(Dis)connected healthcare: NHS structure, then vs. now
In 1948, and throughout the rest of the last century, these disconnects were inevitable. The system relied on letters-in-the-post and filing cabinets.
But in 2021 and beyond, technology that connects people and places (GPs, nurses, consultants and medical centres) exists. And it could be seamless and secure – at least in principle.
In practice, not so. Take medical records. The Electronic Health Record (EHR) has replaced original handwritten formats. An EHR is like a digital version of a medical chart.
It contains information on things like someone’s medical history, treatment, diagnoses and test results. Oh, and home address and credit card details. A lot of information, some of it sensitive stuff. Having all this in one place makes sense.
Unfortunately, EHRs are often fragmented and poorly managed. They contain medical data in different formats across different systems. Time-pressurised medical staff struggle to manually log in every bit of information. This can lead to serious errors: duplicate medical records, misdiagnoses, delayed treatments, and even deaths.
Given the amount of personal information they contain, EHRs are valuable. They must be secure. I’m sure you wouldn’t want anyone to sell yours on the black market. But that kind of thing does actually happen. The digital format makes EHRs a target for hackers, who sell them for hundreds of pounds.
So connecting the NHS structure of medical staff, GPs, health centres, hospitals and care homes sounds great in principle. Achieving it would ease many pain points in healthcare.
What’s holding NHS improvement back?
The NHS is a giant. A massive people-scape of staff (medical, managerial, administrative and maintenance) and patients. It is also a massive techno-scape, because all its people rely not just on each other but also, and crucially, on technology. And that’s where it gets really complicated.
To offer the best possible care to patients, the NHS needs cutting-edge technology. It also needs technology that is safe when it comes to data and privacy.
That’s a tightrope because innovation poses risks to security, but too much focus on security will stifle innovation.
So the NHS is torn between security and innovation, or stability and dynamic change, on a scale that is mind-blowing. How do you wrap your mind around that?
There is no easy answer. But it helps to think of the NHS as a digital healthcare ecosystem.
The NHS structure: a digital healthcare ecosystem?
An ecosystem is an environment that contains different species and ecological niches. It’s like a community of interacting creatures and entities. These depend on each other for their survival and effectiveness: they need to communicate, collaborate and sometimes compete.
An ecosystem has to sustain itself but it also, crucially, has to keep evolving. It thrives on dynamic stability.
The NHS is very much like that. It contains people and ‘niches’ (GP practices, hospitals, management hubs…) that work together in interdependent, interactive clusters. All these different parts need to connect and communicate for the NHS to thrive.
Where does technology come in?
Technology plays an important role in this – that’s why we call it a ‘digital ecosystem. That technology will be part of a larger regulatory framework with shared organisational structures and principles.
Given the scale and complexity of the NHS, a (stable) regulatory framework is necessary. But that’s not the same as ‘regulate and forget’, because the ecosystem needs to be able to respond and adapt to change. The rapid rate of technological innovation is a key driver of change. The current pandemic is another one at the moment.
The NHS ecosystem has different layers: national, regional and local. Depending on the governing ideology, it may be more centralized or decentralized, more closed or more open.
Arguably, some of the failings in communication we’ve seen in the context of COVID-19 stem from the strongly centralized approach adopted by the UK government and Public Health England. The many problems thrown up by Test and Trace are one example of this; the current tensions between national and regional leaders.
The main reason is that this kind of ‘interconnectivity’ has to rely on a robust and secure ‘digital architecture’ that is adopted across the entire NHS structure. But the NHS is so huge and complex that building such a digital architecture is a Challenge (with a Capital).
There has been real progress towards this in recent years, with some exciting new developments. A particularly promising development uses the concept of APIs. API stands for Application Programming Interface. (That’s not exactly enlightening, we know!)
One way of thinking about APIs is that they are a bit like Lego bricks. Every brick uses the same standard for connecting to other bricks. But there are lots of ways of combining the bricks to make something new. Same but different.
That makes APIs both stable and flexible: similar components can be put together differently (spending on local needs). This opens up lots of possibilities, which is why we talk about open APIs.
There are other projects to develop the large-scale digital architecture the NHS needs, including a move towards cloud-based infrastructure. A lot of those are works in progress, with mixed results. But those mixed results have generated a lot of learning, sometimes on the basis of getting it wrong.
Here are some of the key things that have emerged from trying to connect the UK health system and improve the NHS.
- Different NHS stakeholders must be involved from day 1, all the way through design and into implementation. A big-boom top-down approach has to be complemented by small-steps bottom-up development, or the whole thing will fail.
- The design of healthtech architecture (and associated health and services) has to be fully inclusive. That’s because the NHS is a varied landscape, just like the people who support it.
- Physical and mental health exist in a larger socio-cultural context. Low digital literacy should not be a barrier to access. Those with the greatest health needs (including learning needs) are often those who get left behind.
- Even when people don’t use digital services themselves, they may still benefit. For example, other people (like nurses) may be able to give them more of the time saved by digital efficiency.
- Digital architecture in itself is not enough. It needs to go hand-in-hand with developing skills and capabilities that support NHS staff, like leadership and change management.
- Finally, ethical concerns need to be addressed every step of the way. An interconnected digital architecture has to prioritise patient privacy. That requires stringent regulations, and testing of proposed solutions.
Historically, the NHS has been accused of being both too monolithic (like one enormous block) and too fragmented. That’s probably not surprising: its organisational and bureaucratic structures are not just huge but also weighed down by legacy technology and commercial arrangements.
True NHS improvement means investing in efforts to thrive as an ecosystem. One recent example is the National Programme for IT (NPfIT), an attempt to develop an integrated digital infrastructure. But the NPfIT has been accused of not being cost-effective, and some people have called it a disaster.
That may be discouraging, but the NHS is looking towards the future and in for the long haul. A digital healthcare system that is both dynamic and secure would have huge benefits. There is a lot at stake.
The Covid crisis has made abundantly clear why the NHS must be able to respond rapidly; why data must be available and secure; why different parts of the health system must talk to each other, without disconnects; and why transparent, up-to-date information must reach the right people at the right time.
In the time of Covid-19, the interconnected NHS structure is more relevant than ever. The technology to achieve this exists, but it needs to be integrated securely on a large scale.