We thought it would be interesting to explore the TRUST issues met by a CIO (or equivalent) in the NHS, where TRUST is at a premium, at the same time as the digital transformation of the NHS is a priority. I chose to speak with Adam Carson, from the Birmingham Woman's and Children's NHS Foundation Trust (BWC).
Bloor: First, could you describe the organisation you work for and your role in it?
Carson: We are an NHS Trust running services in two hospitals and the wider community in Birmingham. We cover local paediatric and women's services, as well as a number of highly specialist regional and national services. We have around 6,000 staff and an annual turnover of over £408m.
In BWC I am responsible for the development and delivery of our digital strategy - supporting the implementation of NHS England's vision for a paperless NHS by 2020.
Bloor: What are the particular issues you face when managing IT for your TRUST?
Carson: The NHS is a complex beast and highly politicised. While we deal with many of the same challenges that other organisations will have to we also have to contend with the fact we are often not masters of our own destiny. National policy shifts frequently - sometimes in subtle ways and sometimes much more dramatically. External and political factors play a huge role in how we define our strategy and it can sometimes feel like we're being reactive in our use and development of technology, rather than being able to set a long term vision. Of course the challenging financial outlook also hinders the innovative ideas that some of us would like to implement! While all of this is difficult to manage, I think the result is the little recognised fact that the NHS has some of the best change leaders in the world. We are used to shifting priorities, delivering efficiencies in times of huge financial constraint and balancing a complex picture of national and local priorities while still delivering care for our patients. The NHS is regularly rated as one of the best health care systems in the world - given the pressures, this is quite an achievement!
Bloor: So, in that case, why does the digital transformation of the NHS often seem, from the outside, to be proceeding slowly; and why does it always seem to be chronically short of money? Are there special challenges for the NHS, or are they what everyone faces?
Carson: By any measure, the NHS as a whole is one of the largest employers in the world, with around 2 million employees and a 'customer' base of about 60 million. Implementing IT systems at that scale is never going to be straightforward!
Pressure on the NHS has grown intensely over the last decade. People are living longer, which means there is a greater demand on the health service for the complex conditions people develop as they get older. This has been exacerbated with cuts elsewhere - like social care - it's well understood that if social issues aren't addressed demand on healthcare increases. While the NHS has fared better than some public bodies in terms of funding, the massive increase in demand means that funding for IT is not always a priority - even recognising the contribution technology can make to increasing efficiency. How would you justify having less clinical staff now to make a larger investment in technology when the A&E queue is out the door?
We also can't escape the highly political nature of the NHS - how often do we see press headlines about NHS spending on a building or an IT system? While we understand that for any business large capital investments are necessary, they don't always sit well in the media. Mistakes don't go unnoticed either!
Overall of course the NHS faces similar challenges to other organisations- the need for security and confidentiality, the pace of change and the need for culture change to go hand in hand with technological change.
Bloor: And does this impact your ability to provide IT systems and technology that your stakeholders TRUST? And who do you see as your stakeholders?
Carson: I always tend to consider our primary stakeholders as being our staff and patients, but of course the picture is much more complex than that. With a focus on targets, management reporting is critical. Increasingly the NHS is also moving towards regional models of accountability - sustainability and transformation partnerships (STPs). In this model, key stakeholders are also our local partners, and we've done a lot of work to share expertise, systems and practise with other NHS organisations locally.
I think the complex model of delivery in the NHS often makes it difficult for stakeholders to TRUST our systems and technology. We constantly hear patients say they've shared information with one healthcare provider, so why is it not available to us? That's a good question. We spend a lot of time ensuring stakeholder engagement is at the centre of transformation work we do - for example by having clinical leads for our major projects and establishing partnerships with other organisations locally to share technology and, increasingly, staff.
Bloor: Since the NHS obviously is delivering a service, and a much-loved one, how do you measure Success in digital transformation? Could this actually impact current service levels adversely?
Carson: As with any project, it's really important to work through the benefits before you begin. With digital transformation we'll often see a drop in productivity while staff get used to a new system. That can have a huge effect on a busy A&E or an already over-stretched outpatient clinic, so it's really important it's built into the plan up front.
Generally success is easy to see. In most areas the NHS is still heavily paper-based, so the efficiencies from digital transformation are quick to see and measure. Recently technology has allowed greater sharing of information and information on the move for clinicians. Certainly in my Trust the clinical staff can see and feel how that improves caring for patients.
Managing tangible benefits is of course important, but I also like to say to our clinical teams, 6 months after a change "If we turn off the system and give you back a pen and paper, what would you think?" If the answer isn't 'don't you dare' then we haven't managed the culture change well enough!
Bloor: Now, let us turn to Security, as this has been a recent NHS issue. Have incidents such as the recent Ransomware incident affected the TRUST people put into NHS technology? Is this a CIO issue and, if so, what are you doing to address this area?
Carson: Incidents such as the recent Ransomware attacks certainly have affected TRUST, both in the NHS and wider technology sectors. While the WannaCry attack was a terrible headache for many IT professionals - we need to think about what we can learn from it. TRUST is important, but that mustn't be mistaken for complacency - which all too often exists with new technology. Issues like the WannaCry attack really help to bring risks into focus, and of course with that follows funding.
In the NHS we focus a lot on mutual TRUST. While our staff and patients need to be confident in the systems and services we provide, it's also important that we're able to TRUST our staff who access and manage potentially sensitive data every day. We train and retrain our staff on the appropriate ways to manage information systems and we openly communicate about security and risk. The latest attacks show us that an infallible system is difficult (and expensive) to achieve - but we must be ready for the larger and more sophisticated attacks that are bound to come.
Bloor: It seems to me that the NHS has a tension between handling very private data, that patients are very protective of; and the patients very reasonable expectation that, if they fall ill on holiday, their nearest A&E has complete and immediate access to all of their medical data. How does this affect your role as CIO?
Carson: Confidentiality and data protection are always at the heart of how we use information. The NHS has specific principles - the Caldicott principles - for how we should handle and manage data. They're a really useful guide.
Increasingly though, there is an increased focus on safely and appropriately sharing data. The clinical benefits of an A&E in another part of the country having access to relevant data are clear, but then it's also fair to assume that details of a private conversation I have with my GP about a mental health or sexual health condition, for example, are not widely shared. A lot of effort in my job and the wider NHS is going into defining the boundaries - what is right to share and what should be protected.
Another challenge we face is access to technology. Apps like Whatsapp are so ubiquitous and accessible that clinicians may use them to share data with each other if we don't provide safe alternative to which we can maintain oversight. It's a difficult balance to be made.
Bloor: Now, as an NHS CIO, what other challenges are you facing (not necessarily to do with security)?
Carson: I think I've covered much of this! The difficulties are financial - having the money to fulfil the vision. Balancing political and local needs. The rapid pace of consumer technology means that people's expectations are higher than we have the capacity of means to deliver.
Bloor: And, to wrap up, can we distil some key points out of your experience. For the NHS CIO, what works?
Carson: I think that to lead digital transformation you need to not only understand technology but also have an understanding of social behaviour and culture change. In the past, I've been involved in projects that keep their focus far too much on whether the technology works, and far too little on how people will use it and how their practice will change as a result.
I think maintaining TRUST is incredibly important. In an environment like the NHS where we have our own digital priorities, the priorities of the organisation and regional STPs and the constantly shifting political landscape and targets, it's difficult to know which direction you're moving in, or what the priorities will be tomorrow. Maintaining a clear direction, being adaptable and maintaining strong partnerships with stakeholder both inside and outside the organisation are the keys.
Bloor: And, what doesn't?
Carson: ICT is no longer something that can sit in a silo separate to a business. Technology is weaved through the fabric of everything we do, and all people in all roles are increasingly reliant of digital systems to do their job. We can't just provide technology and hope for the best, CIOs need to be tuned into the needs of the business, its staff and its customers, in order to ensure that what we are doing is really adding value.
Bloor: Finally, what is the one vital thing other CIOs, either inside or outside the NHS can learn learn from your experiences?
Carson: Technology is a tool, people are the drivers of change.
Bloor: Well, thank you very much for all that. I think that the journey for the NHS CIO, over the next few years, is going to be a particularly interesting one.
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