Market Review Market Review Paper by Bloor Authors Paul Bevan, Simon Holloway, David Norfolk, Richard Rose Publish date May 2017 NHS Technologies Bloor’s Framework for NHS Technology Maturity Market Review NHS Technologies Bloor’s Framework for NHS Technology Maturity Introduction This review document is not a conventional Bloor Initial scope of the Bloor CCMI project Market Update. It is a survey of available NHS UK NHS healthcare. technologies relevant to Bloor’s study of NHS • Not US healthcare; US healthcare is different – Process Maturity in the context (initially) of Clinical • in the USA patient: doctor is 1: 1, whereas in the Correspondence and Bloor’s Enhanced Clinical UK patient:doctor is 1: many, as patient moves Correspondence Maturity Index (CCMI). Maturity between acute and community care, inpatients is a question of Process; the understanding of and outpatients – US systems are based on a what process you have; institutionalising process different data model. and sharing good practice across the organisation; process metrics; continual improvement of • Not Legal; many Health IT voice and electronic process based on key metrics; and, pro-actively document technologies used in Clinical managing process. However, process automation Correspondence can also be used in Legal is usually key to achieving maturity and keeping it business correspondence – making process maturity “sticky” – so the choice • Initially, just Outpatient Client Correspondence of technology can be an approximate indicator Systems; we can expand the scope later. of process maturity. Although, of course, just buying the right technology doesn’t guarantee maturity, it has to be used in a mature process, but it is unlikely that a high-maturity clinical correspondence process, for example, will use manual dictation and store correspondence in paper archives. This Report will be of interest to practitioners trying to improve maturity in the NHS and to their managers. This Market Review represents our best efforts at documenting a large and changing market as of March 2017; it will be reviewed at intervals as we get more information. © 2017 Bloor 2 Market Review Key market issues Two key market issues are the complexity of Ultimately, these outcomes, particularly including the NHS technology environment, strategy, and cost management, must be the focus of any high- its development; and what “maturity” means maturity “continual improvement” initiatives. in this context. There are many independent An overview of the strategy in detail and Health Trusts, using different technologies, and how it is changing is in a KingsFund report at standardisation is a long way off – although https://www.kingsfund.org.uk/sites/files/kf/field/ much of the technology implemented in different field_publication_file/A_digital_NHS_Kings_Fund_ individual areas may be quite advanced. Sep_2016.pdf. A further issue is that the NHS as a whole NHS strategy may be modified by the Wachter probably behaves as a dynamic feedback- review (see https://www.gov.uk/government/ controlled system, exhibiting desired behaviours, uploads/system/uploads/attachment_data/ associated with dynamic equilibria and changed file/550866/Wachter_Review_Accessible.pdf ). by transitions between system states. However, “It is not yet clear whether the government intends Bloor believes that parts of this whole, such to accept this; however, it looks likely to take account as clinical correspondence, can be adequately of Wachter’s recommendations to give most acute analysed in terms of process. For this reason, the hospitals more time to ready themselves for change” analysis of the NHS using systems thinking will – Chris Rodwell, of Winscribe. not be pursued further here – although readers should be aware of this possibility. Issue 1: the NHS Strategic Direction NHS imperatives today stress reducing total cost and moving patients from expensive hospital care to cheap community and home care. This translates into: • The NHS “Digital Transformation by 2020” (this used to be the “Paperless NHS by 2018”; but this has been pushed back and now includes cyber security as an objective – https://www.england.nhs.uk/digitaltechnology/ info-revolution/). • The use of secure sharing of medical information inside, outside and between organisations (this is predicated on the achievement of digital transformation). • Innovative initiatives exploiting advanced technology – examples include “virtual clinics” (visiting your doctor, or possibly even a medical “artificial intelligence” or AI) via in internet chat session or video conference), and integration with Uber transport (to address the issue of getting patients to clinics etc. where public transport isn’t available and the patient doesn’t have access to a car). © 2017 Bloor 3 Market Review Issue 2: NHS Structure Only a simplified picture of the NHS structure is provided in this paper, there are charts showing the bigger picture, including hospital business systems, but at the level of this report, they are likely to add to the readers’ confusion. See, for example: Figure 1: NHS Information Management Systems. CLINICAL INFORMATION SYSTEMS PMI PAS A&E Maternity Pathology PACS RIS SPINE SERVICES DATA WAREHOUSE (PDS, PSIS, SUS, Theatre Pharmacy Oncology GE HANDLING SECURITY) Child Health Cardiology Others MIS APPS TION ORDER COMMUNICATIONS TA TION ENGINE / MESSA Ordering Results ORKS BUSINESS SYSTEMS A Finance HR Payroll AL/W Systems PRESCRIBING SYSTEMS RT INTEGR WEB SERVICES Business Document Procurement PO Support Management Chemo Full LOCAL INFRASTRUCTURE Data Storage LAN Wireless PCs / Workstations Portable Devices Access Controls N3 Link to a list of commonly used NHS acronyms here. A YouTube animation, “An alternative guide to NHS England is the commissioner for primary the new NHS in England” from the Kings Fund at care services such as GPs, pharmacists and https://www.youtube.com/watch?v=8CSp6HsQVtw dentists, including military health services and probably gives a more approachable idea of some specialised services. An example of this the full picture, and of the complexity problem is NHS England inviting clinical commissioning readers will face. groups (CCGs) to take on an increased role in the commissioning of GP services. You can read At “business function” level, we have a more about co-commissioning and its benefits hierarchical NHS structure, more or less: on NHS England’s website. NHS England The UK Government. The UK Government manages around £100 billion of the overall Secretary of State for Health has overall NHS budget and ensures that organisations are responsibility for the work of the Department of spending the allocated funds effectively. Health (DH). DH provides strategic leadership for Regional teams work closely with organisations public health, the NHS and social care in England. • such as CCGs, local authorities, health and well- It is responsible for the strategic leadership and being boards as well as GP practices. funding for both health and social care in England. For example, there is: The DH is a ministerial department, supported by 23 agencies and public bodies; see the DH website – a North of England regional team; at https://www.gov.uk/government/organisations/ – A Midlands and East of England department-of-health. regional team; – a London regional team; • NHS England is an independent body, at arm’s length to the government. Its main role is – a South of England regional team. to set the priorities and direction of the NHS • Clinical commissioning groups (CCGs) replaced and to improve health and care outcomes for primary care trusts (PCTs) on April 1 2013. They people in England. See NHS England’s Five are generally chaired by a GP (members include Year Forward View (https://www.england.nhs. GPs, nurses and consultants and others) and uk/wp-content/uploads/2014/10/5yfv-web.pdf), are statutory NHS bodies responsible for the which sets out the future vision for the NHS. planning and commissioning of healthcare © 2017 Bloor 4 Market Review services for their local area. A CCG has about • Acute (urgent and emergency) Health Services 60% of the NHS budget and must take into These are divided into major areas: account service quality, using both National – A&E Institute for Health and Care Excellence (NICE) – Inpatients guidelines and the Care Quality Commission’s (CQC) data about service providers. – Outpatients (this is where the CCMI is used today and where Winscribe mostly is). In addition to GP practices, NHS primary care services cover dental practices, community Acute Healthcare Services interact with A&E, pharmacies and high street optometrists. Inpatients and Outpatient systems: CCGs commission: – PAS (Patient Administration System) – most community health services; – Radiology – mental health services and learning disability – Pathology services; – Maternity – some GP services (this is supposed to increase). – Scheduling Commissioning services from GP Practices – etc. (about 80 overall). (which are private companies) is strategic but quite controversial, because GPs serve on CCGs • Acute health care is standardising around and there might be a conflict of interest. cross-hospital Electronic Patient Records (EPR) and typically uses Cerner (https://www.cerner. • NHS secondary care services are commissioned com/); Allscripts (http://uk.allscripts.com/); and from, for example, private suppliers (including Epic (www.epic.com/). charities) and local community hospitals (community healthcare trusts), to provide • Again, data is distributed