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A picture of the National Audit Office logo Report by the Comptroller and Auditor General Department of Health & Social Care, NHS England & NHS Improvement, NHS Digital Digital transformation in the NHS HC 317 SESSION 2019–2021 15 MAY 2020 Our vision is to help the nation spend wisely. Our public audit perspective helps Parliament hold government to account and improve public services. The National Audit Office (NAO) helps Parliament hold government to account for the way it spends public money. It is independent of government and the civil service. The Comptroller and Auditor General (C&AG), Gareth Davies, is an Officer of the House of Commons and leads the NAO. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether government is delivering value for money on behalf of the public, concluding on whether resources have been used efficiently, effectively and with economy. The NAO identifies ways that government can make better use of public money to improve people’s lives. It measures this impact annually. In 2018 the NAO’s work led to a positive financial impact through reduced costs, improved service delivery, or other benefits to citizens, of £539 million. Department of Health & Social Care, NHS England & NHS Improvement, NHS Digital Digital transformation in the NHS Report by the Comptroller and Auditor General Ordered by the House of Commons to be printed on 13 May 2020 This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act Gareth Davies Comptroller and Auditor General National Audit Office 12 May 2020 HC 317 | £10.00 This report considers the readiness of the government to deliver its ambitions for digital transformation in the NHS in England. © National Audit Office 2020 The material featured in this document is subject to National Audit Office (NAO) copyright. The material may be copied or reproduced for non-commercial purposes only, namely reproduction for research, private study or for limited internal circulation within an organisation for the purpose of review. Copying for non-commercial purposes is subject to the material being accompanied by a sufficient acknowledgement, reproduced accurately, and not being used in a misleading context. To reproduce NAO copyright material for any other use, you must contact [email protected]. Please tell us who you are, the organisation you represent (if any) and how and why you wish to use our material. Please include your full contact details: name, address, telephone number and email. Please note that the material featured in this document may not be reproduced for commercial gain without the NAO’s express and direct permission and that the NAO reserves its right to pursue copyright infringement proceedings against individuals or companies who reproduce material for commercial gain without our permission. Links to external websites were valid at the time of publication of this report. The National Audit Office is not responsible for the future validity of the links. 006583 05/20 NAO Contents Preface 4 Key facts 5 Summary 6 Part One Digital transformation in the NHS 15 Part Two The governance of digital transformation in the NHS 26 Part Three Financial and human resources 32 Part Four Technical challenges in realising the NHS’s ambitions 40 Appendix One Our audit approach 50 The National Audit Office study team consisted of: Appendix Two Javed Ahmed, Yvonne Gallagher, Our evidence base 52 Ernest Obumselu, Jonathan Pownall, Tunmise Usikalu, David Williams and Paul Wright-Anderson, under the direction of Robert White. This report can be found on the National Audit Office website at www.nao.org.uk For further information about the National Audit Office please contact: National Audit Office Press Office 157–197 Buckingham Palace Road Victoria London SW1W 9SP Tel: 020 7798 7400 Enquiries: www.nao.org.uk/contact-us Website: www.nao.org.uk If you are reading this document with a screen reader you may wish to use the bookmarks option to navigate through the parts. If you require any of the graphics in another format, we can provide this on request. Please email us at www.nao.org.uk/contact-us Twitter: @NAOorguk 4 Preface Digital transformation in the NHS Preface These are unprecedented times for the United Kingdom. The coronavirus pandemic is having an extraordinary impact on the National Health Service and its staff as well as on all parts of government, society and the economy. The effects will last long after the pandemic has subsided. This report describes the state of digital services in the English NHS and examines its readiness to deliver digital transformation. It focuses on the plans, governance arrangements, resources and technical challenges. We carried out the fieldwork and prepared the report before the pandemic hit the UK. I have decided to publish the report at this time because digital transformation in the NHS will increase in importance as a result of the crisis. Digital services can enable health and care services to be delivered flexibly and remotely where necessary and provide better information. Over time, more patients should be able to access medical information and advice without face-to-face contact with clinicians, and risks to everyone can be managed more effectively. Better data will underpin clinical decision making, vital research and government planning to help the NHS manage anticipated demand as well as threats like those we are experiencing now. I am grateful to the Department of Health & Social Care and the NHS for their help in confirming the factual accuracy of the report and hope that its findings are of assistance as they take forward the digital transformation of the NHS when the current emergency allows. Gareth Davies Comptroller and Auditor General Digital transformation in the NHS Key facts 5 Key facts £8.1bn July 2019 2024 estimated cost of the updated NHSX unit launched to lead target date for NHS trusts and digital transformation strategy digital transformation in the NHS NHS foundation trusts (trusts) to (excluding £1.6 billion for live reach a “core level of digitisation” services), the great majority to be spent between 2019-20 and 2023-24 £4.7 billion budget for the digital transformation strategy between 2016-17 and 2020-21, including live services £3 billion amount trusts are expected to contribute to the £8.1 billion digital transformation cost, between 2019-20 and 2028-29 (the majority being expected to be invested in the fi rst fi ve years) 16% proportion of trusts that self-assessed their digital capability as low (in 2017) 1998 the year the NHS identifi ed the importance of seamless sharing of data between IT systems and the use of national standards to achieve this 15% proportion of trusts reporting that their information technology (IT) systems were mostly compliant with the SNOMED CT standard of clinical terminology (in 2017) 54% proportion of trusts reporting that their staff could rely on their digital records for the information they needed, when they needed it (in 2017) 6 Summary Digital transformation in the NHS Summary 1 The NHS’s health and care services are dependent on people, processes and information technology (IT) systems, and some of these IT systems are outdated and inefficient. The Department of Health & Social Care (the Department) and NHS England & NHS Improvement (NHSE&I) believe that it is essential to implement new ways of working and that improved digital services are central to this. In other words, the NHS will need to undergo a digital transformation. However, the previous attempt to achieve this, between 2002 and 2011, was both expensive and largely unsuccessful. Since then the Department, NHSE&I and NHS Digital (the arm’s-length body that seeks to use information and technology to improve health and care) initiated the Digital Transformation Portfolio (the Portfolio) to deliver their 2014 digital strategy. The Department and NHSE&I are now updating their strategy and the Portfolio, and in July 2019, they set up a new unit, NHSX, to lead digital transformation in the NHS. NHSX intends to use a different approach to digital transformation to that attempted in 2002, though the objectives are similar. In particular it will allow over 220 NHS trusts and foundation trusts (trusts) more autonomy to develop their overall approach to digital transformation and the IT systems they implement so long as they comply with national standards which are currently being specified. 2 This report describes the current state of digital services in the NHS and examines the readiness of the NHS to deliver digital transformation, focusing on: • strategy and implementation plans, including lessons from past strategies and progress made to date (Part One); • the governance of digital transformation (Part Two); • financial and human resources (Part Three); and • technical challenges (Part Four). Key findings Digital services in the NHS 3 Digital transformation of the NHS is a huge challenge. The need for large-scale process and behavioural change and for substantial financial investment in IT systems mean that digital transformation is inherently difficult. In the NHS, transformation is further complicated by major challenges including aged (‘legacy’) IT systems, the nature of healthcare information, the large number of organisations and stakeholders, complex governance arrangements, and existing commercial arrangements with technology suppliers (paragraphs 1.2 to 1.4, 1.23, 2.2 to 2.5, 2.16, 4.2 and 4.3, and Figure 2). Digital transformation in the NHS Summary 7 4 The NHS has not made the expected progress since 2014, including against a headline target to achieve a ‘paperless’ NHS.
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