What's the vision?
This may sound obvious, but it is worth restating: the board must start by asking what the trust is looking to achieve before considering any technology solutions.
Ideally this vision should flow from your strategy. For example, Portsmouth Hospitals' design principles, as set out in their digital strategy, inform all decisions on technology: any solution has to make things simpler, better connected, faster and more secure to enable the transformation of care pathways. Northampton General Hospital has an ambition to be ranked the most digitally mature trust in the country by July 2023, with clear and straightforward success criteria.
All too often leaders get hooked on a specific solution or tool and then spend time trying to justify their decision. Beware any technology enthusiasts showing shiny new tools before the board has an agreed vision. And board leaders shouldn't wait to receive full business cases before asking questions: start the conversation early so you understand how it supports your vision. This may take time, but this approach is fundamental to making the right technology decisions.
As a CIO I need support from my chief executive to hold the line on technology investments and ensure any decisions are aligned with our strategy. The board must not falter on this, even if it means making the hard decisions to turn down bid opportunities that are not in line with the trust’s priorities and do not solve a genuine business problem.Director of Digital Transformation University Hospitals of North Midlands NHS Trust
Trust, ICS or place level?
With Integrated Care Systems (ICSs) due to be placed on a statutory footing, trust boards must consider the decisions they are making within their emerging system context. Indeed, NHS England and NHS Improvement has placed digital and data at the heart of system working, with the ICS design framework calling for system leaders to "identify ICS-wide digital and data solutions for improving health and care outcomes by engaging with partners, citizens and front line groups".
NHSX's What good looks like framework takes this a step further, with seven success measures for ICSs, which include among other things having "an ICS-wide approach to the use of data and digital solutions to redesign care pathways across organisational boundaries to give patients the right care in the most appropriate setting". The framework calls for ICSs to have a clear digital and data strategy, which will guide trusts’ decision making on their technology decisions. Like other significant investments, ICSs will also be empowered with certain digital funding decisions. The principles for system-working on digital are really no different to ICS collaboration more generally:
- design for real patients and service users and involve them early in the process
- raise the profile of system level priorities within the trust boardroom
- when decisions are needed, get the right people in the room from across the system
- share resources where you can.
This is of course easier said than done. System maturity varies across and within ICSs. In some systems, such as Hampshire and the Isle of Wight ICS, trusts are already submitting joint bids for funding on things like enterprise-wide schedulers. The East Midlands Imaging Network (EMRAD) is jointly supported by eleven acute trusts, and its cloud based service has already saved around £130,000 in twelve months in postage costs, with turnaround times for medical imaging slashed from seven days to just one.
And of course, it is shared care records where much progress has been made in recent years. It is thought that 37 of the 42 ICSs now have some form of shared care record in place. Amongst other things this record includes connectivity between primary and secondary care and utilises the Health Systems Support Framework to ensure future interoperability. Shared care records enable trusts to access health and care records safely and securely. This is particularly helpful for mental health, community and ambulance trusts who are more likely to span multiple ICSs. Shared care records, such as Connecting Care, are also helping reduce unplanned admissions and improving discharge times. The foundations are now in place for most to explore more data driven and digitally integrated working.
Collaboration across providers within a smaller footprint presents further opportunities for digital. Some trusts are beginning to explore the possibility of jointly procuring technology solutions, including EPRs. The Surrey Safe Care programme is a single instance EPR programme shared between two trusts, Ashford and St Peter’s Hospitals NHS Foundation Trust and Royal Surrey NHS Foundation Trust. The potential benefits of collaboration include interoperability, economies of scale and pooling risk. Other trusts share certain IT support services, such as the Health Informatics Service, hosted by Calderdale and Huddersfield NHS Foundation Trust, while others have appointed joint digital leadership to align digital priorities.
Admittedly not every trust can pursue collaboration in these ways. Legacy systems, constrained funding and different priorities may make it difficult. But when trusts have successfully collaborated, it is because board leadership is fully driving the opportunities.
Choosing a joint EPR for the Bath, Swindon and Wiltshire Acute Hospital Alliance
“You need to put a lot of energy into collaboration if you’re making a decision across multiple trusts. Recognise the biases of your organisation but ultimately keep patients and clinicians at the centre of everything you do.”Chief Information Officer, Royal United Hospitals Bath NHS Foundation Trust
The three acute trusts have been working together in an alliance for some time and are now producing a strategic outline case for a single electronic patient record. Historically, each organisation has taken a different approach to EPRs which has resulted in different digital cultures.
The alliance's memorandum of understanding has defined the clinical model for the joint EPR. Each trust wants to ensure that digital services operate smoothly and seamlessly across the three trusts, which in turn will build resilience within services. Previously patients were moving between trusts but this was unmanaged with unclear processes.
The joint EPR is led by each of the trusts' medical directors. The journey hasn't been easy: each trust had different strategies, priorities, timelines and biases. But a deadline for one of the trusts has now focused minds. And there have been strong signals from each of the boards about the desire to make it work.
Executives have set clear direction, and the boards have been honest about pain points (such as timelines). Board leaders themselves have made the case to staff why the joint approach is better for the organisations than a single EPR, explained within the ICS context. That said, when there are difficult conversations to be had between the parties, a neutral party coordinates and facilitates these discussions.
Key considerations for boards
- Learn about your partners' technology plans: It’s likely that your organisations are facing similar challenges. How can you start to align on priorities?
- Avoid one-way door decisions: Think about the long term consequences of technology decisions you’re making today. If possible, start with decisions that have a lower impact or can be easily changed. For those that can’t, consider whether you should consult with your ICS, provider collaborative or place partners before committing.
- Level up: Are there any quick wins to help level up organisations across your system? Everyone has a vested interest in working together and exploiting opportunities, but the system is only as strong as your weakest link.
- Start small: Trying to implement new technologies across a single trust is difficult enough, doing this across multiple organisations in an ICS is even harder. It's best to start with a small test project in part of the ICS, then grow from there. Don't try to solve every case straight away but do consider what the ICS is aiming for, and what you'll need to do to scale up.