Welcome, everybody to the second part of this morning's meeting.
We are moving on now to item nine on the agenda, Digital Health Services by 2020 and Tim, please,
we are very interested to hear from you on this.
Tim Kelsey: Well, actually, it is interesting.
So, following on from the conversation we just had, Caroline and I went to a meeting
with the [inaudible] and various others to talk about the importance of this.
Actually, I think one of the core roles, nationally, we have the opportunity of doing is setting
standards for, in a way, letting local autonomy be real.
So this paper is essentially proposing, as part of a very substantial piece of work that's
being overseen by the National Information Board that NHS England confirm its commitment
to the development of a core set of digital standards that need to become part of the
basic licence to operate, as it were, for people, or organisations, that wish to receive
and treat NHS patients.
The benefits case for interoperability or safe digital record keeping is now overwhelming,
I think, and as a result we, of course, have many places, many organisations in this country,
that are setting global standards in interoperability.
We have fantastic examples of that at University Hospitals Birmingham, in Oxford but also in
some of our District General Hospitals; Northampton, for example, has just developed and implemented
a real time record keeping system on its wards so that, in the middle of the night, doctors
are making safe decisions about prescribing and getting automated reports on nursing observations.
On its own, that report has reduced the error rate, in terms of misdiagnosis, by 300%.
I will not go into the details but, essentially, the evidence case is strong.
We also have some good emerging evidence of the productivity benefits and we have talked
a lot about the efficiencies opportunity.
One report, which we have commissioned and which has not yet been published, suggests
that just doing the basics, i.e. simply having what you could describe as supply side automation,
which is second nature in your warehouses if you are Tesco or Asda, could save as much
as £3 billion a year.
I think it not only makes common sense but I think it is almost self-evident that we
should be doing that.
Instead, the vast majority of our hospitals, in particular, are operating on fax machines
quite literally held together by bits of string, in terms of treasury tags and patient records.
However, this is set against the extraordinary achievement in primary care, where we now
have 100% digital record keeping and with that we are able to do some very unprecedented
things, like offer patients access to their own records, for example and start the revolution
that we have been discussing, the transformation that we have been talking about.
I would hope, therefore, that the board would recognise this as an important moment because
I think the history of technology and healthcare that it has operated in a kind of silo from
the mainstream operations of patient services.
What we are now saying is: by 2018, providers who do not meet these standards, having not
implemented them in primary, urgent and emergency care services will not be commissioned to
provide those service and the same will be true, by 2020, for all other services.
These are clearly very ambitious targets but they are not as ambitious as they might initially
appear.
Apart from the fact that, as I say, we have pockets of excellence already gripping the
digital opportunity, we have also been developing some programmes - the summary care record,
for example - where we are seeing very, very rapid rates of adoption as clinical staff
and management begin to realise the benefits that these kinds of data sharing arrangements
can bring.
So, just to give you an example, currently GP summary care records are being shared between
GPs and 111 and A&E in, now, nearly 50% of the NHS in England and that is a dramatic
increase on the situation last year.
To some extent, therefore, it is ambitious but we are building on a solid base of commitment,
I think, in the health service.
What we are saying, in terms of the timetable, is that we will hope to develop these standards
in collaboration, not just with provider colleagues with other organisations, such as the NHS
Confederation and the Foundation Trust Network and develop the kind of commissioning and
regulatory environment that will support their delivery.
However, we will also work with patients and community organisations just to start, in
a way, articulating better the benefits case for implementation of these kinds of standards.
By June, we hope to publish guidance to the health and care system on what the standards
should be and how to go about implementing them, that is the commitment the National
Information Board has made.
And we are proposing that, by April of 2016, both individual organisations, provider organisations
and local area commissioners will publish roadmaps for attaining those 2018/2020 objectives
and they will be supportively held to account for delivery of their own milestones through
those roadmaps through a process of, kind of, audits and we have called that the Digital
Maturity Index, described in the paper.
This will, therefore, be a transparent reporting and self-assessment of the degree to which
local health economies are achieving these objectives over the next few years.
So, in closing, I would just not underestimate the challenge of achieving these standards
and their implementation.
However, I would say that I think we - particularly given our history, over the last decade of
not getting this right - have adopted an approach which I hope will be embraced by local frontline
services because what we are basically proposing is a small but core set of standards, the
NHS number, which need to be implemented but leaving to them the decisions about how those
standards are implemented, with whom they work, which IT companies they might work with
and so on.
We want there to be a range and a diversity of different approaches; we think that's what
people are asking us to give them.
Malcolm Grant: Thank you very much, Tim.
Let me invite comments.
Noel.
Noel Gordon: Briefly, Tim, we heard earlier from Ian on the new models of care, of which
PACS, in particular, require interoperability as a critical enabler to make them work.
Are we aligned sufficiently on the timeline between your NIB universal initiative in introducing
interoperability and what our new models of care will need?
And if there is misalignment, in any sense, for good reason, how can we help the vanguard
sites in particular, in an accelerated way?
Tim Kelsey: Ian and I have been talking and I have been talking to Sam and various other
colleagues about this very, very intensely over the last few weeks because it is very
clear to all of us.
Indeed, the vanguards are asking for support to make real not just these kinds of interoperability
objectives but also other aspects of the digital opportunity, the data opportunity, that they
want to embed in their approach to new models of care.
We will therefore need to provide a sort of package of support, which we have not yet,
of course, decided with them, to secure exactly that objective.
And for that reason, Simon has also asked if we can embed in all the kinds of initiatives
that we are incentivising over the next period of time, a set of core, basic requirements
around adoption of digital standards.
So, for example, we would expect any local health economy or provider that is receiving
funds from us for transformation to use the NHS number 100% of the time; you know, basic
stuff.
We are just discussing at the moment what those five, high impact, digital requirements
should be; almost preconditions for being in the family of transformation that we are
working with.
So that is something that we are discussing at the moment but your point is extremely
well taken and certainly we will need to support the vanguards and other innovators to get
to the point of interoperability faster than we would expect, necessarily, everyone else
to do it.
Malcolm Grant: Margaret?
Margaret Casely Hayford: In a way this goes back to the question that I asked you and
Karen earlier on but it is sort of building on that.
It is about the other standards, if I can call them that, the standards for meeting
our obligations with regard to ensuring patient security, patient privacy and also system
security and so on.
With regard to that, I think what I can see is, if I was in charge of a CCG, for example,
or if I was a GP, I would want to own all of the data and keep everything because it
makes one have greater control over output and the way in which you are interacting with
patients.
However, it strikes me that the metadata and the ability to respond to requests that might
come from patients would be assisted if the CSUs were able to support, in the way that
would mean that they had a greater control over systems and formats and so on.
I am wondering whether there is anything that we should do to encourage that cooperation,
or reliance on CSUs.
Tim Kelsey: So I think there is one really important principle which we just need to
kind of get around, which is that what the National Information Board, NHS England and
Five Year Forward View has said, implicitly, is that, from now on, any confusion about
whose data this is, is resolved: this is the patient's data, the GP, the doctor or the
nurse has the privilege of, in some cases, acting as a custodian for that data but it
is the patient's data.
And what we have said, in the National Information Board's framework is that, by 2020, we want
people to have the complete control over who it is that accesses their data, so we want
to move to a consent based system.
In the meantime, we have to work out how we maximise the advantage to patients and citizens
of that data being used to the maximum beneficial clinical effect.
I think there are lots of ways in which we can support local health economies, particularly
in the vanguards, to start deriving real value at the bedside, in terms of greater interoperability,
which is what I have just said, but also, if I am getting your meaning right, to start
looking at this data much more effectively as a source of insight into a real time and
rapid improvement in the quality of services provided, assessing outcomes and so on.
And I think CSUs absolutely have a role to play in that, in helping to bring analytic
and other capabilities to bear.
On the security issue, which we discussed just briefly before, it is obviously core
that we cannot trade privacy, in any sense, for the clinical benefits that we derive from
interoperability.
However, we recognise we live in a digital world, where security cannot be guaranteed
all the time but obviously we need to meet the highest standards.
So the development of that new rubric around what a safe health system looks like in a
digital age is one of the core priorities for the National Information Board, as a collective,
to solve and Dame Fiona Caldicott and others are deeply engaged in working through what
the principles of that kind of commitment, that new contract, if I can put it like that,
should be.
Malcolm Grant: Thanks.
Victor and then David?
Victor Adebowale: I think we have to get on with it, have we not, really?
It is overdue; we need to get on with it.
However, some time ago I was curious about patient citizen data and the possibility that
individuals might receive some kind of report on how their data is being used and you were
quite keen on the idea, as I recall.
I just wondered what progress had been made?
I mean we just need to do this but I just wondered about that particular bit.
Tim Kelsey: We are committed to three bits there.
So the first thing is, very rapidly, certainly during this next calendar year, people who
access their own GP records, as they now can do, as of the end of this month, will also
be able to access a kind of an audit trail of who else has seen their records because
that is something that is already collected; I would say creating of visibility of that
to the patient is important and we can do it, so, as you say, we are going to do it.
More complex is the other commitment that the National Information Board has made, to
giving some insight into how their data is being used when it is being used for analytic
purposes: you know, a researcher over here or NHS England over there; who is using my
data to what benefit?
This would really just be to explain to people how their data is contributing, let us say,
to a better understanding of variation in outcomes in diabetes; people want to know
that.
That is a more complex technical issue but we are committed to resolving and to provide
people with, as far as we can, full transparency around the uses of their data for those purposes
as well.
The third thing is we want people to be able to actually write into their own records so
that there is a kind of parity between the clinical voice and the patient voice in determining
appropriate solutions for a person's health and care journey, kind of almost like a personalised
care plan for the 21st Century; we have committed to that taking place in 2018.
I therefore think there is a radical commitment to transparency of uses of data and of people
who are accessing your data, given it is your data and you should have the right to decide
who sees it.
David Roberts: Tim, clearly this is take all stakes for any form of modern health and care
system so, as Victor rightly said, we need to get on with it.
In terms of encouraging people to get on with, there is one way, which is sort of the club,
which I think you are deploying.
However, the other way is the motivational aspects and actually the best way to do that,
I think, is to get the patients themselves to demand it.
I guess, therefore, my question would be: are we doing enough, particularly in building
apps, or enabling a market to build apps that we are supportive of?
Are we being sufficiently aggressive in communicating the benefits and showing people the benefits
of owning and seeing their own data in a way that actually gives the providers who might
be reticent no alternative because people are just going to be unwilling to accept that
they cannot get hold of their data and use it?
Tim Kelsey: It is a really big question but the one amazing thing that has happened in
the last 12 months is that the community in general practice, which did have the technical
facility to do this, has decided to do it.
So, although it is contractually required, actually there has been an enormous recognition
of the potential benefits in general practice.
So when your hospital colleagues or colleagues in social care are looking, we have a very
large constituency that is already saying, 'Well, we have just done it,' and I think
that is a helpful narrative which we need to make the most of and have not yet started
to do.
However, I could not agree more on, in a way, activating the citizen to demand access to
these kinds of services, because they are going to, so to try and make sure the NHS
is ready for that demand as it comes is a very important objective.
Indeed, this week we launched the first mental health app store on NHS Choices, backed by
the NHS, because we know that digital tools work to drive up access to talking therapies
and people want it and the NHS just has not expressed an opinion on whether these things
work or not.
David Roberts: This seems to be a strategic theme for us because, again, in thinking about
how we can engage people in preventing illness and condition, as opposed to 'suffering it',
in inverted commas, I think is a very key part of our agenda going forward.
Tim Kelsey: Yes, I completely agree.
Malcolm Grant: Moira?
Moira Gibb: Where I come back on all of this is that I completely agree with the imperative
to just get on with it.
However, there is the back story which is still in my mind and I think that what I am
asking is this: as you build your very large and important, multi room building, every
time you want to extend it, that we as a board have an opportunity to look and see; check
that the building regulations requirements have been met, if I can put it that way?
We would need, therefore, periodic reports to give us comfort about the systemisation
and how it is working; that would make me feel comfortable and I will be quiet.
Tim Kelsey: No, I completely welcome that; I think we have to be transparent in every
direction.
Certainly transparency to the Board of the way in which this multi room - if that is
the right concept - this process is being developed so that it is safe, it is clinically
compliant, it is actually benefiting people in a really measurable way is really critical,
so I would certainly welcome that.
It almost goes back to your genomics point: why would we do this rather than physiotherapists?
Malcolm Grant: Okay, look, I think we are all clear: get on with it.
However, the issue is this is what Derek Wanless wrote about in 2002, for goodness sake; the
outcomes he held out for the NHS in 2002, we still have not got there.
I would now like to invite the board, on your behalf, to approve the current priority list
of digital standards for 2015/16 and to support the future priorities for 2016/18.
We are happy to do that and to confirm our intention to use all available commissioning
levers to get on with it.
Tim, thank you for this; I would not go so far as to say this was a high, historic moment
but I do think that it is something of a turning point and I hope that you feel you have the
full support of the board in taking it forward.