Building a strong data foundation to power tomorrow’s public healthcare services

Podcast Transcript

Sam Massey:

As the COVID-19 pandemic rages on, our global healthcare systems have been forced to rethink how they operate to respond to the changing needs of both patients and staff. The UK's NHS is no exception. This episode of Pragmatism In Practice features Martin Warden, Program Director for Digital Transformation in General Practice at NHS Digital, interviewed by Stephen Foreshew-Cain, Chief Operating Officer at Thoughtworks.

We've partnered with Martin since 2018, working towards helping the GP IT Future's Program to address the challenge of interoperability and flow of data between healthcare systems to ultimately provide a better, clinically safe patient experience. In this podcast, Martin will share how the NHS is harnessing data to pivot and innovate in order to deliver better patient outcomes.

Stephen Foreshew-Cain:

Welcome, Martin. Thanks for joining us on Pragmatism In Practice. I'm very happy to have you with us. Perhaps before we get into things in too much detail, perhaps it's worth just you telling us a little bit about your role, and I guess we're all living in a very different reality, eight, nine months into 2020, than we thought we were going to be. Perhaps you could talk a little bit about how your role has evolved in light of COVID-19.

Martin Warden:

Yeah, hi. Nice to meet you, Stephen. My role in NHSD is Program Director. I work primarily in the GP space. I've been in that role for probably about six or seven years as a director, but before that assorted program delivery roles. But broadly working within general practice and the needs and ambitions that we are keen to continue to push in primary care. We've been on a big, long transformation journey. One of my biggest responsibilities is the marketplace, the national marketplace for IT solutions to primary care, but specifically general practice users.

Martin:

We are coming out of, I guess, the first step of that long journey in terms of re engineering the way the commercial arrangement's work and that might take place. A lot of our focus up to the end of 2019 have been in creating those new commercial arrangements. There's many challenges that we've had to face in getting there.

We were then really getting excited about using those as a springboard to move on and actually work in a completely different way with all suppliers in this marketplace. We had a great reaction to, essentially, the tender that went out, so lots and lots of suppliers with lots and lots of different excellent solutions showed interest in coming into this marketplace, which was a good sign that maybe we got it right. People walk with their feet and if we've got suppliers wanting to come and sell, we could argue we've done a reasonable job in terms of creating an exciting marketplace.

We then came to March time and we've had to really pivot and change in terms of focus and energy. It's been a huge learning curve but really, really interesting times for all of us to actually react to COVID and what was needed. And, that being a very almost daily a different consideration, a different need, a different focus. 

But we've really pivoted completely to say, "What does the NHS need, given primary care's central part in provision care to UNI's patients?" It's been critical that primary care has reacted in the way that it did. And we've really seen the benefits and some of the early strengths of the new arrangements that we've put in place at the end of the calendar year, that have allowed us to really react in a strong way to help general practice and patients deal with COVID.

Stephen:

Thanks for that. That's super helpful. I'm not sure that there's an industry on the planet, let along in the UK, that hasn't been affected by the global pandemic. Obviously the primary care data strategy, I think it was written back in 2019, has set NHS Digital on a certain path, but can I ask you, just given that you've just referenced the fact that you did have to pivot, what are the main challenges that the NHS has had to face specifically during this difficult time?

Martin:

The interesting thing around the challenges, we could almost, if we look at the strategic work that we did in 2017, '18 and '19, we had a lot of help from Thoughtworks and some other consultancies, as well. We've tested widely and the things that we thought were important, one would argue, when we looked at COVID and its demands on us, it's, at a minimum, given us confidence that the things that we think are important to see the NHS and certainly general practice, primary care, work in a way that we envisaged, our strategic intent, especially around data, is definitely the right one.

But what, I'd argue, we've found is it would have been great if it would have been a year earlier in progress in what we wanted to do. So something like analytics. We have a great ambition to make analytics a much easier service, certainly at a national level, than we've got at the moment through services such as the GP Extraction Service. Having that landed a year earlier would have been superbly useful for COVID.

What we have done, though, is absolutely make use of the existing services that we have around data and created and supported things like the shielded patient list that allows us to identify people who would need to work in that way in the COVID period. But it really has strengthened our resolve, desire and understanding of how a more up-to-date analytics service on a national level would really, really help.

And we're not out of COVID yet. Clearly we've got a lot of work ahead of us for the winter with flu, with maybe a spike in COVID, so our desire to push on and create those types of services absolutely front and center of what we've got in our heads right now. The analytics side is really, really interesting because I think people can probably look the that and really understand how, having the data available, being able to analyze it, being able to support the operational needs of the NHS on a national level, for national policy, makes so much sense.

So a more efficient way of doing that, which is what our strategy's all about, would be easy for people to pick up and understand why it would be beneficial. When it comes to something like data sharing between care settings, you look at something like 111 where, before COVID, we were working through a piece of work to establish access to the patient record for those operators on the 111 line who can actually then look at the record and make a better judgment about the next stage in the pathway for that patient on the call.

COVID has allowed us to really, really accelerate. People can see that benefit, but then recognizing that we want to get that out on a national scale is exactly what we've done. So that's really been a great, I would argue, reflection of the right strategy, not yet out there fully national but then people seeing it for what it can do in support of COVID and that really accelerating out to the English estate and that now being part of the fabric of how we do business. Which is brilliant because we've always been about getting the patient record, the GP patient record in the right place for the right clinician with the right governance. That means UNI's patients are going to have a far more effective experience when we're being treated across the NHS.

So I think we've got a real opportunity, again, to build on what we've seen work and the benefits that people can clearly look at and touch, to ensure that we continue with that agenda. What we do have to be aware of, as part of COVID, the national data sharing that we've put in place, we really need to demonstrate the benefits of that as a concept.

Before COVID it was very much about local data sharing agreements between different clinicians and care settings, organizations. We've now moved to, in the COVID, we've allowed essentially a national data sharing to cover off those arrangements. If we want to keep that type of effective way to share data, we're going to need to really demonstrate why that's been a really good thing for us, which we would like to do.

So data sharing that allows the patient record and clinical care to be much more effective has been critical. Analytics, again, critical. And think the other point is some of the solutions that have come to market to support the new ways of working. So, if you think about general practice, it's had to adapt. We can't have everybody turning up at general practice to find treatment.

And the way that we've moved to a total triage type solution that allows patients to actually act digitally in terms of the way that they interact with general practice, and having good solutions that support that e-consultation type environment, or video consultation type environment, we would have found that really difficult to really establish the ones, the solutions we already have in the marketplace, and bring new ones in, unless we'd have had the more flexible commercial arrangements that we brought in at the end of the calendar year.

That's really allowed us to look at standards, look at solutions and how they fit and quite quickly get them to market and get them out into general practice and be used by clinicians. So I think the ability to accelerate those solutions into the marketplace to support the changing operational needs of general practice have been critical. We've had some great successes. Video consultation solution is out there now. There's definitely interest now in working in a very different way and I think we've got good commercial arrangement that would allow us to continue with that way of working.

Stephen:

I think you've explained quite clearly there why it is so critical in the work that NHS Digital does to improve clinical care through better data sharing. Are you able to give us just an example to flesh out for people, I guess, how better data sharing has really helped GPs on the front line deliver better care during the current crisis that we're facing?

Martin:

How have with managed to do that? How have we managed to create an environment where people feel secure? Certainly data control, as GPs, to share that patient record with 111 and actually see that as a way to allow the controller to give much more effective care when deciding how to deal with the patient.

In addition to that, things like booking directly into the GP appointment book have been really, really useful, as well, so it's not just the patient record view. It's things like transactional stuff like booking appointments has been really, really important. I definitely pick on the 111 example. It's out, it's got a clear example of how we've actually seen the patient record shared in different care settings and that being hugely beneficial for the care of patients, given that the information's available to the clinician.

Stephen:

Yeah, brilliant. I guess one area that I'm particularly interested in, I'm a technology consultant myself back in the day and I have consulted to organizations who talk very much, when they start to think about their data strategy, about interoperability, about the many ways technology is the engine that can drive change in organizations, but data is the fuel. And where you are fueling your different bits in different ways and not being able to talk consistently across very broad and complex businesses or, indeed, something that I think is even more complex, the health sector, how do you think the NHS can obtain more value from the data and what are the sorts of improvement you're looking for to bring that about?

Martin:

It's probably worth me talking about what we're doing now and what we've been consistently trying to do for the last couple of years. I'll just give you the pointed history. If you think about, what have we got, something like 60, 70 million patient records sat within a few clinical systems, certainly the GP record, we've been on a journey for probably four or five years to open that access up for those records, to essentially provide better care UNI's patients. The work that we've done has been, to some degree, a challenge, as we brought everybody along on that journey.

But we're getting to a point now where we can see the fully structured record FHIR standard in terms of its transport mechanism, becoming the benchmark, the baseline, for how data will be available, not just within general practice and not just between solutions in general practice, because we're trying to create a marketplace that's got many, many different solutions in it. All of them will need data to work and be able to provide the type of service that we would want to see.

So that standard, I'd almost call it at maturity-level one where we can actually see and share the structured record between care setting and, within general practice, feels like the first major milestone that we will get to in terms of general interoperability. If we can then add to that, which is our current workload, the update of the record, so essentially you have read-and-write into the GP record. Once we've established that, that will allow a really flourishing market around the electronic health record for different systems that want to have access to it.

And the key to all of that is that we do it in a standard way. We have a hoop model in terms of the way that we're allowing data to be shared, so effectively consumers don't need to connect with every single supplier. You can do that through a hoop model. And I think if we can establish that as the mature way in which the record is managed, accessed from other care settings, and the ability to read and write, feels like a major step forward.

I think in 2021 we should see that really start to establish itself as the norm. We would look operationally today, as well, though, where the priorities are. So things like total triage, which is the digital way in which we can actually interact with the general practice service. The information flow out of the systems that deal with that e-consultation, we need to think hard about how do we actually get that information written directly back into the record and avoid some of the manual workarounds that need to go around that.

So we're very keen to understand operation. Where are the quick wins, the benefits now? As well as look strategically at establishing a read-and-write maturity level for the record. Beyond that read-and-write, I think we are really into how do we really want to mange data going forward. Part of our data strategy was to think hard about that. I think we really need to establish with our suppliers and with our colleagues in the NHSX and elsewhere, what we think the right push going forward would be. We have a view and we do think in the end we would ideally not have data flowing around the system. We would look to cloud-based technologies to be how data is managed going forward.

If we can align on that, I think that'll be the hard transformation work we'd want to do in the next two or three years would be to start to enact and see development around how we actually move all our data to a cloud-based technology standard and actually stop the movement of data around the system. The other part I would throw into this debate is around what we've called that GP information standard. What we really would look to do is look to start to standardize how data is captured in the first place and have a semantic level around that data so we can actually have an agreed definition of what that data means from a business perspective. So that feels a really, really important part of what we do is actually establish what we mean by the information standard for GP. We've got some of that work done but, again, more work to do.

Stephen:

Thanks for that. I just want to go back. You made a comment at the start that one of the early signs of success for the work that you've been doing was really about how the marketplace started to flourish, that you had a lot of people wanting to make their services or their capabilities available to the health sector. Can you talk to me a little bit about the digital care services marketplace? I'm thinking about how it both is obviously attracting a rich and vibrant supplier pool, but it is also the context in which you are making standards core and applicable to the products that they're bringing to market.

Martin:

If you think about the marketplace before GP IT Futures or the Digital Care Services framework, it was very much a "We'll open the doors, we'll create a framework. Suppliers will bid and the door will be essential shut for four or five or six years and those suppliers that are on the framework are the ones that can do business in primary care." So the world we've created now is very different from that in that we essentially have a regular rhythm of access for new solutions from different suppliers. So the ability to join in this marketplace at regular intervals is now something that suppliers can do.

That gives them some flexibility, dependent on their business plans and their needs and where they think they're going, to make some choices about "Well, we'll wait a year or we won't. We'll join now. We think it's a worthwhile investment for us." So that feels really important that that marketplace and that barrier to entry we've removed. In terms of creating what we've called a buying catalog and associating all our standards in that space away from the more technical procurement work, is really, really helpful in focusing solutions on the compliance against those standards.

So it's a really simple model of here we have a set of business features that you would want to associate with a particular function within primary care, and we have a set of related standards that might well be about data. It could be about IG. It could be about infrastructure. But ultimately a very transparent sense of what does my solution need to comply with before I can sell it in the market.

We've got more work to do, again, in terms of simplifying that model. But ultimately, you, as a supplier, our ambition is that you come to this marketplace, the barriers to entry are reduced, you have an easy and understandable way to actually get through to a point where you are a compliant provider, and that compliance badge, I think is hugely important for GPs. They look to the old world of GP SOC, or GP Systems of Choice, and took a lot of confidence in the fact that a solution was compliant under that framework.

Equally, the same with Digital Care Services. I think the sense of confidence that the system has in seeing solutions that have gone through that national compliance under our governance, feels really, really important. So combine easy access or easier access certainly, and more to do with the confidence that comes with the compliance badge. Suppliers have found that an attractive proposition and we've, I think it's something like, over 70 suppliers, over 150 solutions that we now have interested in providing services and solutions into primary care.

And you compare that on the GP SOC, which was less than 20, that's a significant change in attitude from the supplier base into this market. The trick will be, as we're still in the foundation stage, in my mind, in terms of establishing that market. We've got the interruption of COVID. It will be about how do we actually get into, I guess the word would be taking advantage of that changing supply base and actually see those solutions start to flourish in the marketplace. 

Stephen:

But one thing that I pick up in that is usually when you see a market that has a lower or has easier access to enter it, and then you see a simpler route for certification or accreditation to give the right to compete in that market, it tends to also have the impact that you see innovation. Is that also one of the intent and hopes for the sort of changes you're introducing?

Martin:

The way we position our world is we've put a lot of thinking capacity and capability into what I call developing the market.

So keeping this marketplace relevant is critical, and part of that comes through stimulating innovation and that stimulation of innovation means that we need to put time, effort and energy into bringing in new supply, people who want to innovate, not just with the main system that's competing, that we want to see competed in general practice, but other solutions that would sit around that main system, as well, so accuRx has been a great example for us in that they have established themselves from virtually zero as a market share to now something over 90% for video consultations.

We've only been able to help those guys come to market, and others, as well, there's quite a few in this space, by actually having the right attitude to innovation. You could argue that the commercial arrangements are all about trying to stimulate and bring in interested supply by reducing those barriers to entry. We would argue that the work around our new market entrance for the Foundation's solution. We've got three really interested organizations that have been with us for about two years now, looking to actually compete with EMIS and TPP, Vision and Microtest, with a genuine alternative to those suppliers.

Having curated their interest, they've put their investment into this marketplace and we would hope to see, in '21 financial year, the fruition of those suppliers coming to a point where they have compliance, they are able to sell and compete in that way. Some of the technologies that they are coming with are superb. They're cloud-based, the ability to work out of the office, comes out of the box. These types of modern technologies that we at times during COVID we've struggled to accommodate. We've had to work to understand what alternative ways could we ensure a GP could work remotely. It's not been an easy answer for us and it should be.

These guys are creating solutions that would facilitate those, what we'd expect is normal business practices, through the solutions that they would offer. I think we'd argue with, if you look at EMIS, they're doing a lot of work to re-platform, Vision, as well. Microtest have been bought by Public. There's some really exciting developments within our incumbent supply and we are absolutely keen to see those suppliers flourish just in the same way as we would any new entrant coming in.

Our goal is to see general practice have the best technology, the best solutions available to it. The marketplace is focused purely on creating that type of environment. What we're looking to do is focus our energies on a vibrant market, and if it includes all today's players, even better. So that's kind of a reflection on innovation but we're desperately keen to foster as much of that as we can do.

Stephen:

Stepping back for a second, because, once again, just listening to some of the things that you're talking about, when I speak to business leaders, a common refrain that I hear is "I just need better information and I need better insight around that information." And they're talking about data. They're talking about the data that their systems, their businesses, their processes are producing. On the other hand, the health sector is possibly, if not the most, complicated. Certainly one of the most complex, broad and deep domains that I've ever had the privilege to work with. What would you recommend as the first steps to any leader who is looking to harness their data insights or to improve the quality of information and insight that they're able to derive?

Martin:

We've worked on the basis of user need, so we've looked, and we need to do more of this, as well, we've looked hard at what we think clinicians and patients need as the NHS, certainly primary care, general practice, develops, and try to respond to those needs. But then we've also factored in what I would argue strategically what makes sense, so this becomes whatever we do and whatever we've done to establish those data services, we've looked to ensure that they have a degree of longevity, that they support more than maybe just what we're doing for that particular use case or instance. But we've genuinely tried to establish an understanding of what does the NHS need when it comes to information, and try to demonstrate, therefore, the value in strategic intent.

We talked earlier about the analytics world. We have a way of actually provision of information now on a national scale. That's probably been a unique feature of what NHS Digital has been able to provide over the last four or five years through the GP Extraction service. But that is, if you reflect on the unmet demand, and if you reflect on the new and increasing demand on data, it's simply something that's not sustainable as a longterm service. We've done a lot of work to establish a different way of creating a more robust way to actually provide users with what they need. We're not there yet but we will get there.

What we've also done, we've given the uniqueness of patient information and the sensitivities around patient information and the IG environment that goes with it, we've really focused hard on stakeholder engagement, working with our colleagues in general practice, working with patient groups, working with other parts of the NHS that are dealing with the data agenda. Because it is unique to understand exactly what we need to do and what we implicitly want to do to create a trusted environment. Because without trust in this environment, we will really struggle to make progress.

I think one of the great achievements of the last two or three years is establishing a level of trust with all our stakeholders and what we're trying to do and not moving at a pace that feels like we are rushing or are moving to an end state where we've not really fully tested through user research, through proving benefits that these things are actually sustainable and hold true in terms of IG, in terms of transparency. We're very, very keen to ensure time to time whatever we do when it comes to data, we do that in a collaborative way.

I think the use of standards and adopting FHIR has been really, really helpful and we had some real challenges through our supply base as to what should we be using, what works. But establishing that as the standard I think has helped us quite a lot in terms of giving us a solid foundation for building the technology.

I think probably the other one is we do want to work in partnership and we do work in partnership with our supply base. We have put a lot of effort into not working in a contractual way with our suppliers, actually working in a collaborative way, recognizing we should consider ourselves in partnership with our colleagues at TPP and EMIS and Vision and Microtest, and we're doing the same with the new entrants that are coming onboard.

We're very, very keen to be seen as a group of people that are delivering really, really important change into the NHS and if we treat that relationship in that way, I think that's been hugely beneficial to allow us to progress built on trust rather than working through contractual-type mechanisms.

Stephen:

Cool. You mentioned FHIR there and I'm just conscious that perhaps not everybody who's listening to this podcast will be familiar with what FHIR is. Would you be able to give us just a quick, short explanation of what that is?

Martin:

I'll tell you what it means to me, it means that we have a standard way of actually ensuring that the way we define the record is recognized outside of just primary care. It's one of those international standards that people will look at and go, "Actually, yes, we can use that information flow into our system somewhere else in the NHS." It's based on a standard that's understand and is becoming more widely accepted. So any kind of decisions that we make that allow us to ensure we are all working to a very similar standard. SNOMED is another great example. It's one of the big changes that we put in a couple of years ago. Those more universally accepted ways of actually looking after data, data management, feel really, really important in terms of getting the structural environment right.

Stephen:

Yeah, you do. I think the important thing about FHIR, which is not spelled the way it sounds, for those who are listening. It stands for the Fast Healthcare Interoperability Resources. It's a global standard, right? So, by adopting things that are already available and accessible, in this case it's free and it's open and it's designed to be quick to learn and implement, that can once again foster that solution market that is core.

Martin:

I'm hoping that in adopting these standards that they stick and that they iterate. It's almost as important in that it gives us that common universal global standard for data, but equally there is a lot we can do with SNOMED that we don't do today. I'd be really interested to see, now that we have it more established within primary care and elsewhere, how that develops as a standard and we may take the benefits that we don't maybe do today from it.

Stephen:

You referenced just a little bit earlier that collaboration and the pace of introducing change is equally a concern, to make sure that the sorts of changes that you're implementing actually stick. I guess I'd be interested to know what you think the biggest barriers are to digital innovation in public healthcare. I'm thinking beyond the tech. I'm thinking as much about the tech as I am about people, processes, and potentially even organizational culture, that people need to be mindful of, that could actually be a barrier to innovation rather than an enabler.

Martin:

It's complicated. We've had people come in to help us with our thinking and they all, as you've already referenced, Stephen, they go away thinking this is a really, really complicated environment to do change in. I've worked in the private sector most of my life and coming into the NHS is a very, very different and a very much more complicated way to do business. It's just how it is.

So there's something about, in terms of pace of change, how do we actually create an environment where change can happen much more quickly than it does? The interesting thing about COVID is when we're all focused on the same mission, the ability to actually get change progress at pace, is surprisingly more straightforward. One of the problems with a complicated environment is that we have competing objectives. We have a natural need to create an environment where we focus on our priorities as a shared group. That's not always easy given we've got three or four organizations that are all working together on slightly different agendas at times.

I'll give you an example of what we're trying to do. We did a lot of work last year with how do we actually accelerate change, technical change, to support business needs in general practice, and we did a lot of user research with what were the real problems operationally in general practice and, out of that work, we came out with a playbook about what we would do to push change through much more quickly than we do today.

Part of that was around a product mindset in terms of how do we actually organize ourselves in terms of getting change done. Something around the user and user need and users being fully centered in the work that we do to actually establish what the change would be. So I'd argue as an organization we tended in the past not to necessarily put users absolutely front and center in terms of change work that we've done.

There's something also about if we really want to get to grips with working at pace, we need to probably look at how we fund our organizations because there's something around working year to year and funding challenges that come in on an annual basis. The desire would be to look at a product in terms of its lifetime and look to fund it on that basis. I think that switch in the funding model at some point would be a really, really beneficial thing for us, rather than an annual almost bid for money.

Stephen:

Thank you for that. I'm interested in what excites you about the future of digital innovation in public healthcare. And, I guess, most importantly about how that will, in turn, improve the quality of patient care overall.

Martin:

So, what excites me. I think seeing some of these new technology solutions. If I look at what we experienced in our home lives and the brilliant technology that we use, I would love to be in a position when it comes to general practice, primary care, that becomes the norm for our clinicians, of the patients that are using the healthcare apps that are connected in some way to the patient record, that we actually have really brilliant user experience when they're dealing with technology. If I look at Starling Bank as an example and how that has really revolutionized the ease in which we do banking, the simplicity in which we interact with a bank, which is, in my mind, revolutionized the way we do business.

I'd love to be in a position where we've created an environment where that type of innovation is just a natural part of the general practice, primary care marketplace and we see such brilliant solutions arrive and they... Plug and play is probably a bit of a lazy sentence but the ability for if solutions to work together seamlessly feels critical. Dependence on one supplier to do more enterprise-wise stuff, I would argue, has its place but the ecosystem that sits around that with different solutions that can just work in a seamless way, data flows as needed, feels hugely exciting to imagine that type of workplace.

I think the other one is, and COVID's been interesting for this, you and I, as office workers, are used to having laptops and working anywhere, we've all learnt hugely, I think, from that experience. I'd like to think that the future general practice clinician, as the norm, has that type of technology that kind of works anywhere, so the ability to actually do your normal day job wherever you choose to do it, it's a long overdue standard, if you like, within solutions that exist in primary care. And we're absolutely seeing that through some of the new suppliers and some of the incumbent suppliers are absolutely moving towards that type of model. But that feels really exciting to be in a place where the technology just enables that way of working.

Stephen:

That sounds very exciting, very exciting, indeed. Just before we wrap up, I was wondering is there anything else that you wanted to talk about in the work that we haven't covered?

Martin:

The world that we work in, it does take time. We're doing some really structural change here when it comes to how the marketplace works in general practice. It will take a number of years for these ambitions that we've talked about to really start to materialize, so the need to recognize this world in that context, I think, is really, really important. I think the other thing that we're really, really keen to see is value added early. We're not focusing on just long term transformational need, I'm actually, as we develop a sea change, how do we take advantage of it and really start to demonstrate why what we're doing is already making an impact on general practice.

We probably don't do that well enough but we've already done some great things in support of COVID and we should and will continue to maybe think about how do we, as we go through this longer transformational phase, ensure that the benefits of what we are creating are more widely shared.

Stephen:

Brilliant. Well, thank you so much, Martin, for joining us. It's been a pleasure, a genuine pleasure having you on the podcast and talk about the work that you're doing in NHS Digital so thank you very much for joining us.

Martin:

Thanks, Stephen.