Making choices

Technology decisions can have long term consequences. The board is there to ask the right questions to make sure the trust is making high quality decisions with the information available today. This means going beyond anecdotes, and asking what is reasonable to conclude from what you've read, what you've seen and what you've heard?

Constructive challenge is critically important – board members shouldn’t shy away from asking tough questions, even if they are less experienced in technology. There is nothing in a boards' business that is not capable of explanation to a director whose professional expertise lies elsewhere.

There are some common, long running challenges to investing in technology within the NHS. NHSX has recognised many of these and is seeking to address them within the Who pays for what proposals. These include:

• Complex funding arrangements: general uncertainty within the sector about what money is available, a lack of transparency, misalignment of priorities, timeliness of money being released, the wrong mix of revenue and capital made available, single-year budgets and burdensome bidding processes.
• National policies that impede innovative technology investment: such as organisational financial targets focused on non-recurrent savings, activity-based payments and limited incentives for trusts to invest in digital transformations.
• Lack of innovation and measurements for optimising technology investment: a lack of oversight over how much organisations are spending on technology, lack of understanding of measurable benefits and an inability to measure financial payback on certain investments.

In addition to this, over the last few years there has simply been insufficient funding available for the NHS to invest. Given these constrained budgets, trusts have faced tough decisions on technology funding.

The board should also have a shared understanding of digital inclusion and clarity on priorities for action. This doesn't mean avoiding decisions on technology, instead it'll mean offering digital technology solutions to those that can, so you can spend more time with those who can't. Good patient and citizen engagement is important in bringing people along with you. For example, the Yorkshire and Humber Care Record team has produced explainers on data and population health management for its patients and service users.

Where should we invest our limited technology budget?

Board leaders should aim for a balanced portfolio of technology investments. The composition of this portfolio will depend on your organisation's circumstances, but it is useful to think about these dimensions:

Keeping the lights on vs. making improvements

A significant proportion of technology budgets are spent on running costs: support, maintenance, critical upgrades and infrastructure. Too little spent on running costs makes outages or unreliable systems more likely, diverting attention from other priorities. Equally, focusing exclusively on running today's systems will store up trouble as those technologies become obsolete.

Boldness vs. safety

Some cutting edge technology initiatives are high risk, high reward. Early stage Venture Capital firms specialise in taking calculated bets, hoping that one in ten of the start ups they invest in will become hugely successful (although most may fail). Trusts are generally not well suited to invest and incubate in this kind of innovation, but some – especially those with strong academic ties – have been successful. For example, Medway NHS Foundation Trust's innovation institute allows teams and services to bid for innovation seed funding.

While it may make sense to place a couple of technology 'bets', the vast majority of a trust's technology portfolio should be invested in initiatives that have a high chance of success – solid business cases, tried-and-tested technologies with clear demand from users. Beware of these 'bets' consuming management time and distracting from the real priorities.

Short term returns vs. long term returns

Large-scale, organisation-wide technology changes can take months or years to implement, and even longer for the full benefits to be realised:

"The history of the productivity paradox points to a lag of 10 years or more before the full benefits of health IT are realised." Making IT work, Wachter Review 2016

These benefits are not always financial, technology can make a major contribution to the quality and safety of care. While these big transformations are important, there will be lots of ways to make tangible improvements in the near term without a huge investment. Boards might want to ask:

• How can you design a portfolio that makes space for these kinds of small, no regrets investments alongside major projects?
• Do your funding, approvals and governance processes provide a fast track for low cost, low risk improvements?

Andy Kinnear, a former NHS CIO and now CHIME International faculty member characterises NHS IT spending as falling into four distinct categories:

• running the operation: e.g. support desks, breaking and fixing things, standard service delivery
• essential investment and renewals: Windows upgrades, pressuring to reduce running costs, server colocation, new desktops
• digital development: digitising paper based processes, EPR implementation
• transformation enhancement: population health management tools, artificial intelligence.

Funding modern technology

In addition to deciding where to invest in technology, trusts also need to determine how to invest. There are some practical considerations when trying to deliver modern technology using traditional public sector funding models:

• In-house technology teams
  It’s now more common to build technology expertise in-house, rather than rely on an entirely outsourced model. Even if you rely on vendors, you’ll still need to invest in some in-house skills to get the most out of them.
• Technology as a contributor to outcomes, not a distinct cost centre
  If your view of technology is primarily as a cost centre, it’s unlikely you’ll get the most out of it. Instead, it’s likely you’ll focus on reducing the cost and variance of technology. If you can shift to funding outcomes you can then have more informed conversations about whether your priority is improving your outcome, or in reducing costs.
• Technology as a revenue cost
  Software and infrastructure are now more commonly purchased as services (ongoing revenue expense) rather than physical goods (one-off capital expense). This can sometimes create perverse incentives for technology teams to adopt legacy technologies or contracting approaches based on the type of budget available, rather than choosing the most appropriate available technologies.
• Technology as a service
  The traditional model of public sector technology investments is to fund projects, rather than services. This can lead to a cycle of ‘feast or famine’, where systems are starved of investment once an implementation project has been completed, until a new project is started years later to replace that system. Internet-era organisations think about technology as a service, with a need for ongoing investment to make incremental improvements rather than big-bang projects.

Leaders need to set realistic expectations for the return on investment – boards must understand that in the case of EPR and digital transformation, return on investment is measured in years and not months.

Dr Ayesha Rahim    Deputy Chief Medical Officer and Chief Clinical Information Officer, Lancashire and South Cumbria NHS Foundation Trust

Should we invest in a new system, or try to improve or scale what we have?

Many trusts are struggling with legacy technology that is:

• unsupported by the vendor
• impossible to update
• no longer cost effective
• clunky or inefficient to use
• difficult to integrate with other systems.

Sometimes these technologies can be so old and unwieldy it is easier to move to something new. However, trusts should think carefully before deciding to invest in a new system. You may end up spending a lot of time and money to move to something new that doesn't provide any greater benefit than your existing system. Beware of:

• The attraction of the 'new': New technologies can be exciting for technology specialists and leaders alike. However, trusts should be wary of being led by the latest fashions. Improving an existing system may not be as eye-catching or announceable, but it may be the right choice.
• 'Not invented here' syndrome: This is the belief – common in some technology teams – that systems built in-house are inherently better than those built by others. Although it may be initially harder for teams to support systems they are unfamiliar with, this is likely to be an easier problem to overcome than replacing a system.
• Artificial commercial imperatives: Understand your vendor’s incentives – sometimes they may push you to upgrade for its benefit rather than yours.

Board members should ask: have we really explored the option to improve existing technologies? What benefits will we get from this new system?

The board observed that saying no to things that were contradictory to the trust’s strategic intent is a consistent theme from the leading global digital exemplars. Therefore our regular communication about a consistent vision is important in carrying forward due diligence and delivering an information system that meets the needs of our patients and clinicians.

Noel Scanlon    Executive Director of Nursing and Patient Experience, County Durham and Darlington NHS Foundation Trust

Should we buy or build?

A common technology question is often framed as ‘should we buy or build?’ However, the answer is rarely a binary 'buy' or 'build'. Trusts will often end up doing a blend of both.

Buying technology is the main pattern in the NHS. There are many common needs that trusts have, and software markets have developed to serve these. In an environment where technical skills are in short supply, not having to build and maintain your own software is an attractive proposition.

The downside of buying technology is a loss of control and flexibility, you may have some ability to configure commercial software but there will be limits to what you can do with it. Any feature requests you make to the vendor may take time, contract changes and additional money to realise – it is likely they already have a lengthy backlog of requests from its other customers. Your leverage over the vendor will be weaker if you’re a small customer, and will weaken as the more embedded its system becomes in your organisation and the threat of your trust switching to another system becomes less credible.

Don't knit your own underpants

Most trusts have at least some software that has been built – even if it was built for them, rather than by an in-house team. This could be a website, or a data service, or an integration between systems. There are some things, however, that trusts should avoid building. There’s usually no point in building technologies that are readily available as a commodity, especially where the needs of your trust are not unique or special. Productivity and communication tools like email and building blocks like databases and storage are all now available as cloud services or open source software.

If you are going to ‘build’, build things that will fundamentally change healthcare and deliver real innovation. It is a waste of valuable NHS resource to build digital solutions that will just maintain parity with the external market.

Gary McAllister    Chief Technology Officer, OneLondon

Beware of 'fake' off-the-shelf systems

Commercial off-the-shelf systems of the type used in trusts are rarely as straightforward as the name implies. Large off-the-shelf systems can take months and armies of consultants to implement. This can often come as a surprise to organisations who have been promised a simple, 'turn-key' solution by vendors, but find that the reality requires a significant amount of customisation to make it work for its needs. Some have compared this to "ordering a new car and instead getting a large box of car parts".

This kind of 'fake' off-the-shelf system can be the worst of both worlds, the amount of customisation required can negate many of the benefits of adopting an off-the-shelf system in the first place. Heavily customised systems often can’t receive the regular updates from vendors and lock your organisation into a long term relationship with the vendor. These systems end up looking like 'built' systems, except they are more expensive and less flexible.

Technology options are always changing

There are lots of things that are now commoditised that weren't a decade ago. Building your own on-premise data centre is a lot harder to justify now than it was in the 2000s. But there are also things that are making building technology easier. Cloud services that can be assembled so easily that it's better to have the flexibility that comes with gluing them together yourself rather than paying for a packaged solution.

The right answer to build or buy is not static: it changes over time as technology evolves.

Case Study

Adapting to changing needs at York and Scarborough Teaching Hospitals NHS Foundation Trust

“The board need to remain open-minded to fresh thinking. Horizon-scanning is ever more important. Everything in the digital world is moving so fast so you can’t get wedded to one solution.”

Lynne Mellor    Non-executive director, York and Scarborough Teaching Hospitals NHS Foundation Trust

Context

York and Scarborough Teaching Hospitals NHS Foundation Trust had built its own Core Patient Database (CPD) EPR system. CPD had evolved over the last 30 years and was developed in-house by clinicians and IT. It was seen as leading edge for many years and popular with staff. However, maintaining the current system began to prove costly as patient and staff needs changed, technology shifted and the need to integrate with the wider care system became increasingly important.

Approach

The trust, in collaboration with the ICS has now decided to develop an 'open platform' integrated care record solution with a preference to develop/procure a cloud based solution. The benefits of this approach include:

• opportunities for better health and care outcomes for patients as clinicians have a more easily-accessible holistic view of the patient's health and care record
• reduction in costs with the development and deployment of one integrated care record across the system
• faster future technical agility as the digital and supplier landscapes continue to change.

This decision was not taken lightly: the board has accepted this is a large undertaking which must be done carefully and securely in alignment with patient, staff and partner needs and is likely take 5-10 years for completion from inception, to delivery, to embedding the change.

But the trust's leaders will continue to be open-minded and flexible in their thinking. The board accept it needs to have the wherewithal to pivot when the time comes to change again.

Key considerations for boards

• There's no one-size-fits-all: Whether the decision is to 'buy' or 'build', implement a new system or invest in an existing one, there is no 'right' answer. You need to make these decisions based on your trust’s context and constraints.
• Balanced portfolios: Don't put all your eggs in one basket. A mature approach to technology is one that balances between old and new, short and long term, basics and transformation.
• Changing the way digital is funded: Making the most of modern technology requires a different approach to funding. Boards can explore creative ways to invest – within existing rules – that enables teams to deliver and decisions to be made at the right level.