Dr. Timothy Ferris

National Director of Transformation, NHS England

Kathy Hall

Director for Digital Transformation and Head of the Joint DHSC/NHSE Digital Policy Unit

Following the use of virtual wards for Covid in the first wave of the pandemic, which was supported by Covid emergency funding of £18m to assist, NHS providers rapidly put in remote monitoring services and tech platforms.

The NHS England planning guidance required all ICSs to establish virtual ward services for at least two conditions – acute respiratory infection (ARI) and Frailty. NHS England has asked systems to deliver virtual ward capacity equivalent to 40–50 virtual beds per 100,000 population by December 2023. This was accompanied by investment of £450m over two years to cover the costs of the workforce – around 90% - and the technology – the remaining 10%.

Every ICS now has a virtual ward and >80% of ICSs have at least one that is tech enabled open and supporting patients. The remaining 7 ICSs are planning, selecting and procuring their technology partner to enable their wards to benefit from tech enablement in the months ahead. There are over 200 virtual wards in total so many ICSs have more than one virtual ward in operation.

The models of care can vary. ARI services can be delivered remotely via telephone supported by remote monitoring technology supplied to the patient. Frailty services tend to involve in-person visits by a healthcare professional in the home, supported by remote monitoring. The service can be provided either out of an acute hospital, a community service team and the split is around 50:50. There are examples of other conditions which can be managed in a virtual ward including exacerbation of Heart Failure and chronic lung disease (e.g. chronic obstructive pulmonary disorders or COPD), early discharge post-surgery and support for children at home.

NHS England has run a programme to accelerate scale of digital home care more broadly – including for Long Term Condition management and vital sign monitoring in care homes. Called Supporting People at Home this has included some of the larger long term conditions (LTCs) such as Heart Failure and COPD and examples of impact follow, mapped against the Quintuple Aim of improving experience, health, reducing costs, clinician/care team wellbeing and health inequalities:

1.  Patient Experience

In Cheshire & Merseyside 80% of patients reported increased confidence in managing their long-term conditions following remote monitoring

2.  Population Health

In Airedale, technology enabled care for people with COPD has received more than 6,000 referrals and is supporting a caseload of 2,450 people.  Each month since Dec 21 the team monitors the new patients onboarded to see what the difference is in their rate of emergency admissions that month compared to the six months pre referral. This difference is around a 60% reduction on average, with range each month being between a 33%-83% reduction in the digitally supported cohort (compared to their rate in the six months pre referral).

In West London the team at Imperial has set up a similar model for people living with Heart Failure. Their study of the first 73 patients to use this tech enabled service was that after three months’ follow up A&E attendances were down from 46 visits in the three months prior to referral to 16 visits post referral, a 65% reduction and emergency admissions were down from 21 to 4, or 81%.

3.  Reducing Costs

The cost saving identified by the Imperial team was £398,000 over the three months of the study. This is a clinical time rather than cash releasing efficiency due to the reduction in admissions to hospital outlined in 2 above.

In Coventry & Warwickshire, over a 3-month period, there was a reduction of 15% in ambulance call outs that resulted in conveyances to hospital after remote monitoring.

4.  Care Team Well-being

People living with serious mental illness such as psychosis, need to have regular ECGs to check that their antipsychotic medication is not having cardiac side-effects. NICE guidance is that an ECG should be undertaken before first taking anti-psychotics and with any change in dose. ECGs are provided in a range of ways, commonly in hospital settings and sometimes in the GP practice or community though the kit is bulky for staff to transport and the procedure requires undressing as the electrodes are placed on the arms, legs and chest. There is then a wait for the ECG to be reported before medication can be changed. It involves considerable clinical time of the community nursing staff chasing for both appointments and results, travelling to transport kit back and forth and undertaking the testing itself.

The new pathway involves giving tiny handheld devices that are smaller than a credit card (called the Kardia Mobile by AliveCor) to community psychiatric nurses. These devices combined with a smartphone mean an ECG that measures the specific cardiac side-effect (QT prolongation) can be provided by putting the device to the knee of the patient in their own home as part of a routine visit. The test takes a couple of minutes. Readings are then undertaken by the supervising consultant with results back much more quickly than previously.

In North Cumbria, their assessment was that with 875 ECGs captured across two Trusts, this resulted in 766 hours of clinical time saved; which is 20.4 weeks of clinical time freed-up.

5.  Reducing Health Inequalities

It is known that people with serious mental illness (SMI) have a life expectancy of 20 years less than counterparts and that most of this is due to physical illness that is not picked up at all or early enough or is not treated adequately. Due to this there has been a focus on increasing uptake of an annual Health Check for this group, using simple point of care (POC) testing within GP practices. An example would be that the Greater Manchester one Primary Care Network (a group of GP practices working together) has established a One Stop Clinic for SMI Health Checks with POC testing increased the rate of people with serious mental illness having an annual physical health check from 19% in 20/21 to 60% in 21/22

Examples of benefit reported by projects include significant reductions in emergency admissions for COPD (Airedale) of 60% and Heart Failure (West London) of 80%, and a 33% reduction in ambulance conveyances from care homes (North London), more on these and other examples are below. There will of course be many more people benefiting from Digital Home Care through the establishment of services locally, but these are the numbers tracked centrally, that have been part of the Regional and National scale collaborative for Digital Home Care across the NHS in England.

People of all ages are benefiting, and particularly older people. For example, the rapid evaluation of the Croydon virtual ward model, which mainly cared for people with Covid, found that 25% participants were over 80 and their rating of the service was excellent with 89% agreeing that the tech, in this case a wearable, was simple and easy to understand.

The full evaluation of the Croydon Virtual Ward model was conducted by the Health Innovation Network[1] and focussed on seven key questions:

1. Who were the patients being admitted to the virtual ward?
2. What factors were essential to make the model effective?
3. Did patients find using the technology acceptable?
4. What was the patient experience of the service?
5. How did the service impact on healthcare utilisation?
6. Did the service deliver any cost savings?
7. What were the patient outcomes?

The full findings of the Croydon model are available in the Health Innovation Network report, however key findings include:

• Virtual ward patients tended to be older, with 60% aged 60 or over and 25% over the age of 80. The most common reason for admission was COVID-19, as opposed to long term conditions (LTC) or emergency episodes.
• On average, virtual ward patients had 4 comorbidities and were on 6 medications.

• Patients spent an average of 9 days on the virtual ward.
• Staff raised the following as key factors for success:
• The ward being run by community (not acute) services, pathways in place to ensure emergency treatment is accessed when needed,
• upskilling staff on continuous monitoring and knowing when to use continuous versus spot monitoring, and
• having a cross-system multi-disciplinary team, among others. Did patients find using the technology acceptable?
• Patient experience scores were very high with a net promoter score of 55, which is classed as ‘excellent’, this means that most patients that completed the questionnaire would recommend the Current Health devices to family and friends.
• Patients felt they were being kept out of hospital whilst receiving the same standard of care as they would in a hospital environment.
• Patients reported having their needs met above and beyond what they had anticipated, which in some instances exceeded their experience of being treated in hospital in terms of feeling safe.
• Mean number of telephone contacts per virtual ward patient per day was 1.27, which was much higher than the control group, while home visits were lower in the virtual ward patients.
• A&E attendances and admissions were similar across virtual ward and control patient groups.
• The estimated cost saving per patient in terms of the shift to telephone contacts instead of home visits was £522.12, and bed days was £220.32, leading to a total estimated cost saving per virtual ward patient of £742.44 compared to the rapid responses control group.
• Readmissions and hospital admissions post-discharge from the virtual ward were relatively low, at 12% and 9% respectively.
• Telehealth monitoring found significant pathology that was detected earlier or would otherwise not have been detected with possible fatal outcomes if not treated.
• Patient interviews indicated that there had been a significant improvement to patients’ quality of life since being cared for under the virtual ward team.

The NHS England Supporting People at Home team has supported digital vital sign monitoring or Remote Monitoring (RM) projects in care homes across all seven NHS regions. The benefits we are seeing include reduction in -

• 999 calls
• Ambulance conveyances
• A&E attendances
• Emergency (non-elective) admissions

A range of local evaluations have taken place or are underway at sites and summaries follow. Several of the studies (including Mid Essex and London) were undertaken when there were large waves of Covid locally and hospitals were a serious infection risk, so all steps were taken to keep people away from hospital where possible, which is why we see a level of reduction in ambulance conveyances from the non RM Care Homes, though this is much more significant in the cohort with RM in place. 

Benefit 1 - Reduced non-elective admissions (Population Health)

Mid and South Essex ICS A study from Mid and South Essex ICS on the impact of technology-enabled remote monitoring implemented in 232 care homes during the COVID pandemic, collected data during a 13-month period, and compared homes that had the technology with those that did not. A 24% reduction in non-elective hospital admissions was found (compared to 13% reduction in homes not using technology-enabled remote monitoring) equating to approximately 307 admissions avoided, or 24 fewer admissions per month.

Coventry and Warwickshire ICS The remote-monitoring project implemented by Coventry and Warwickshire ICS across care homes looked at the impact of ambulance conveyances after remote-monitoring technology had been implemented within those homes across the Coventry and Warwickshire footprint. Over a three-month period, there was a reduction of 15% in ambulance call outs that resulted in conveyances to hospital after remote-monitoring technology was implemented, compared to the baseline period where no remote-monitoring technology was in pace.

Cambridge and Peterborough ICS This project shows a 20% reduction in emergency admissions from remote monitoring enabled care homes. This is based on Baseline vs Actual Admission from Care homes. The baseline period was from Q1 & Q2 20/21 (265 admissions) and the actuals from Q1 & Q2 21/22 was 211. 

North Central London ICS has seen a 33% reduction in ambulance callouts and an 8% reduction in A&E attendances. The baseline is 6 months data from the ten care homes first participating in the scheme comparing the period Jan-Jun 2019 vs Jan-Jun 2021. They also measured whether impact was yet showing across all the Care homes in the sector of North Central London (this is 227 Care Homes) over 8 months (Apr-Nov 2019 vs Apr-Nov 2021). This demonstrated that Care Homes without RM had a 14% reduction in LAS call outs and those with RM had a much greater 28% reduction.

Hampshire and the Isle of Wight project has undertaken a total of 1,969 consultations from 04/20 to 10/21, preventing 335 (17%) A&E attendances; avoiding 256 (13%) hospital admissions and avoiding 453 (23%) ambulance conveyances. 

Benefit 4 - Reduction in hospital length of stay (reducing costs)

Cambridge and Peterborough ICS Q4 data from Cambridge and Peterborough project shows an 11% (baseline of 256 admissions to 229) reduction in emergency admissions from Whzan enabled care homes across the ICS. This equated a NCRB savings of £82,674k i.e. 27 admissions @£3,062. 

Bedfordshire, Luton and Milton Keynes ICS Q4 data from BLMK Doccla project shows 11.5% reduction in non-elective hospital admissions from a baseline of 87 to 77. 5% reduction (baseline of 311 to 295) in GP contacts seen by the end of Q4. 279 (44%) bed days saved in 21/22 FY, from a baseline of 630 days to 351 days, equating to a NCRB of £111,000 (i.e. 279 @£400). 

Bedfordshire, Luton and Milton Keynes ICS Q4 data from BLMK Acoustic Monitoring project has seen a 20% reduction in Ambulance conveyance from a baseline of 251 conveyances to 201 conveyances from 09/21 to 12/21.

Humber and North Yorkshire ICS In North East Lincolnshire Place, a remote monitoring care homes project (Docobo) reported that since three care homes going live in November 2021, a total of 521 question sets have been carried out, and 73 alerts raised. Each alert avoided community nurse visit at an approximate cost of £134 each visit. The clinical time saving non-cash releasing benefit for care homes therefore in this period is around £9,782. Based on the usual costs issued by Docobo, the return on investment if the CCG had invested would be £4k. Estimated Cost (3 care homes x 8 months) £5,760, value of clinical time saving illustrated in the project (nurse visits alone) £9,782, return net of costs, £4,022.

Virtual Wards roll out across England

By the end of March 2023 there will be virtual wards in all integrated care systems in England and this is expected to continue to grow in 2023/24 in line with national policy and supported by the national virtual wards programme. By the end of December 2022 there will be over 7,000 virtual ward ‘beds’ in place (run by over 200 services) – an almost 50% growth since May. Each part of England has a plan in place to support rollout onwards growth. The policy and supporting guidance is publicly available.[2]

The Supporting People at Home programme reached 437,115 people with digital home care between Nov 2020 and Oct 2022, this includes 136,000 people for whom home is a care home and over 300,000 people living with a long-term condition where the digital support is provided within the home.

As noted above, every ICS now has a virtual ward and >80% of ICSs have at least one that is tech enabled open and supporting patients.

The remaining 7 ICSs are planning, selecting and procuring their technology partner to enable their wards to benefit from tech enablement in the months ahead.

There are over 200 virtual wards in total so many ICSs have more than one virtual ward in operation.

We collect data on the following metrics. Note that not all ICBs report regularly on every metric so this data should be interpreted as illustrating trends rather than absolute figures.

1. Growth in Minimal Viable Solution (MVS) 1.0 partner connections – the %age of NHS Trusts and primary care networks connected to their local Shared Care Record. This indicates the breadth of connectivity across that group. Where a Trust is not connected, it is usually as a consequence of a low level of digital maturity in that Trust. See Figure 1 in Annex B.

2. In October 2022 6 ‘collaboratives’ (regions) had 100% of their MVS 1.0 partners (Trusts and primary care networks) connected. See Figure 2 in Annex B.

3. In October 2022 the vast majority of ICB’s had all their MVS 1.0 partners connected but there are outliers in Cambridge & Peterborough, Norfolk and Waveney and the Black Country. All three ICBs have been funded for a ShCR – they have either not reported (Black Country) or are yet to implement (Cambridge & Peterborough and Norfolk & Waveney). See Figure 3 in Annex B.

4. For every 1000 people in a population the average number of views of a ShCR is around the high 70-low 80 mark. See Figure 4 in Annex B.

5. Weighted views by ICB, which shows the variability in the intensity of use – Lancashire & South Cumbria are very high users but there are a cluster of other significant users. These are generally the more mature, longest running, ShCRs localities. See Figure 5 in Annex B.

6. Number of views per user – this is a measure of how much it is used by individual clinicians (intensity of use) - so here we see in Lancashire & South Cumbria there were an average of 70 views per unique user in July 22 up from an average of 14 in February 2021. See Figure 6 in Annex B.

Digitising social care records

We are accelerating the adoption of digital social care records by CQC-registered providers. Our objective is to ensure that 80% of CQC registered care providers have a digital social care record in place by March 2024. Our baselined position in December 2021 was 40%.  CQC data (October 2022) suggests that more than 50% of care providers now have a digital social care record. This is a significant acceleration compared to a 3% per annum rise prior to central investment.

We have committed £25m to support with the scaling of digital social care records. This has enabled us to stand-up local implementation support teams and locally facilitated grant funds in 41 Integrated Care Systems. We have also brought forward a further £15m of funding in areas where we know we can go further faster. To date this funding has been made available to care providers to buy and implement care technologies including digital social care records, sensor-based falls prevention technologies, vital signs monitoring and technology to support people to live independently for longer within their own homes.

We are working closely with Integrated Care Systems and the care providers within their local footprints to provide targeted support around implementation. This includes raising awareness of our assured suppliers list and sharing best practice across ICS boundaries. We have also set clear expectations around how the funding should be spent and are monitoring benefits realised through an established assurance process.

Funding / governance

The Digitising Social Care Programme is made up of both policy and programme delivery colleagues. It sits operationally within the NHS Transformation Directorate but is wholly funded by DHSC Social Care Group through the system reform funding allocation as part of the 2021 Spending Review. Digitising Social Care is accountable to the DHSC Social Care Group for the delivery of its objectives but maintains alignment with the NHS Transformation Directorate from a wider digital strategy perspective.

Benefits

The Digitising Social Care Programme business case identified benefits to the people working in care, people receiving care and the wider health and care systems. We will be measuring the following benefits for digital social care records:

• reduction in medication errors,
• reduction in length of stay in hospital,
• reduction in readmission into hospital,
• cost avoidance for reduction in paper,
• printing and postage costs and time saving for care homes that can then be reinvested in the delivery of care.

We will be measuring the following benefits for sensor-based falls prevention technologies:

• reduction in the number of falls,
• time savings for care workers to reinvest in delivery of care and improved quality of life due the avoidance of falls.

These benefits have been baselined in our programme business case, alongside a framework setting out how we measure benefits realised through the programme, which includes a combination of active and passive measures, leveraging national data sets and local ICS reporting (described elsewhere in our return).

Dependencies

The Digitising Social Care Programme is dependent on care providers achieving an adequate level of digital readiness. This includes appropriate connectivity (delivered in part through connectivity improvements delivered by the DCMS BDUK Programme), cyber resilience (delivered through the Cyber3 Programme) and digital skills (delivered through the NHS Transformation Directorate’s adult social care team in partnership with the workforce team in Social Care Group, DHSC). The success of the Digitising Social Care Programme is a dependency for the government’s wider objectives for the integration of health and care data.

There are 6,486 GP practices in England employing 142,800 staff. All GP practices are fully digitised using clinical and business systems made available to them through the GPIT Operating Model commissioning framework arrangements which includes the Digital Care Services (DCS) Catalogue[3] of Frameworks to support GP practices.

Currently there are three main suppliers: EMIS, Cegedim and TPP. Work is underway to expand the choice of systems for GP practices and encourage richer digital innovation.

The framework describes core clinical system functionalities such as:

         Appointment management

         Recording consultations

         Prescribing

         GP Referral management

         Patient information maintenance

         GP practice resources management

         Electronic requesting of tests (from other organisations)

         Document management and scanning

         Communication management between patients and GP practice

         Online and video consultations

61.8m people are registered with GP practices.

GP system transactions amount to 3.7bn per annum, which equals to 103k per second.

There were 325.5m appointments and 1.14bn prescriptions were issued per annum (2021/22).

The systems also provide patient facing capabilities:

         Appointment management

         Prescription ordering

         View record

         Update details

         Share record

29.8m patients are enabled for online services

A more detailed description can be found in the GP IT Operating Model,[4] which governs the provision, use and development of digital systems and services available to GP practices. 

GP systems integrate and exchange information with other relevant accredited NHS systems and applications. These include:

         Summary Care Record – a core patient data set available to view to users across NHS organisations (please see section above for statistics)

         GP2GP – electronic transfer of records between GP practices when patients move (approx. 3m records transferred annually)

         Electronic prescribing (EPS) – an electronic transmission of prescriptions to community pharmacies (utilisation in Aug 2022 was over 91%)

         NHS e-referral service – offers a choice of providers to referred patients

         Integration and data exchange are supported by:

o        Message Exchange for Social and Health Care (MESH) via a centrally located server

o        GP Connect products through a series of Application Programming Interfaces (API), which enable authorised staff access to patient information held in GP records

Where implemented locally, GP practices have access to Shared Care Records (please refer to the section above and previously submitted evidence for further details).

The NHS App was originally designed to be ‘data light’ meaning data was disconnected at an individual user level limiting our ability to understand the demographic profile of users.  This approach has since been challenged and we have responded to calls to link data to understand our users better, support uptake and adoption, and to understand the risks of digital exclusion and health inequalities in relation to the NHS App.

There is work ongoing to better understand and segment users according to demographic parameters through a data linkage and warehousing workstream in the NHS Transformation Directorate. The data used in the Beta version of the data warehouse is for a limited period and is therefore not representative of the NHS App userbase. We are therefore not currently able to share the data, however we would be happy to provide an update at a later stage once the data has been expanded to cover a more considerable period.

To give an indication of the geographical location of NHS App users we have provided a breakdown of NHS App registrations at CCG level (data as of 23/11/22) below.

All adults in England registered with a GP practice can download and use the NHS App. GPs and hospitals then enable patient/user access to different transactions which results in local variations in App functionality. We do not currently hold data on which services/transactions within the NHS App have been enabled/disabled at GP and Trust level, nor the alternative digital platforms/providers that are being used to offer comparable service/transactions (e.g. GP appointment booking).

Availability of all GP online services (including but not limited to NHS App)

Patient Online is an NHS England programme designed to support GP Practices to offer and promote online services to patients, including access to coded information in records, appointment booking and ordering of repeat prescriptions. Data is provided by GP system suppliers to NHS Digital on a monthly basis and published on the 15th working day each month pending no issues, otherwise as soon as possible thereafter. POMI data is publicly available.[5]

Of all Practices in England:

• 92% offer patients the ability to book/cancel appointments online
• 99% offer patients the ability to order repeat prescriptions online
• 99% offer patients the ability view detailed coded records online

However, Practices then enable/disable online transactions at a patient-level:

• 42% of patients are enabled to book/cancel appointments online
• 48% of patients are enabled to order repeat prescriptions online
• 14% are enabled to view their detailed GP record online

Wayfinder – secondary care appointment management integration within NHS App

Wayfinder launched in September and is in the initial stages of being rolled out nationally. 13 trusts are currently live with Wayfinder and one is set to launch with an agreed date in December (Milton Keynes). In total there have been c.281K visits to the Wayfinder portal from users.

Trusts live with Wayfinder are as follows: University Hospitals Birmingham, Royal Berkshire NHSFT, West Suffolk Hospitals, Nottingham University Hospitals NHS Trust, Chesterfield Royal Hospitals, Leeds Teaching Hospital NHS Trust, Royal Cornwall Hospital NHS Trust, Sherwood Forest NHS Foundation Trust, St George’s University Hospitals NHS Foundation Trust, South Warwickshire NHS Foundation Trust, Mid Yorkshire Hospitals NHS Trust, York and Scarborough Teaching Hospitals NHS Foundation Trust, East Cheshire NHS Trust.

Emerging findings from quantitative analysis conducted by Imperial College London as part of the NIHR funded evaluation of the NHS App

Differences in the NHS App registration rate (using App data up to February 2021) at GP practice level split by IMD, ethnicity, gender, healthcare needs, age-group and practice size.

• Deprivation: Practices in the most deprived areas (IMD quintile 5) had a 25% lower registration rate (p<0.001) compared to the practices in the least deprived areas (IMD quintile 1).
• Ethnicity: Practices with the highest percentage white patients had a 36% higher App registration rate compared to practices with the lowest percentage of white patients (p<0.001).
• Gender: Practices with the highest percentage of males (registered as patients) had a 13% lower App registration rate (p<0.001) compared to the practices with the lowest percent males.
• Long term health condition: Practices that had more patients with long term chronic illnesses or disability had lower App registration overall (p<0.001), with a difference of 2% between the practices with the highest percentage of people with greater heath care needs compared to those with the fewest percentage of people with chronic health illness or disability.
• Age: Practices with the highest percentage of the youngest age group (i.e., 15-34 year olds) had a 23% higher registration rate compared to the practices with the lowest percentage of 15-34 year olds.
• Practice size: Practices with the largest practice size (i.e. more GP registered patients) had a 44% higher App registration rate compared to practices with the smallest practice size.

A note on the method: Negative Binomial regression showing unit change in the NHS App registration rate per 1000 GP registered population at February, 2021, with other variables held constant. Please note all findings and figures are subject to peer review.

An initial paper detailing the first wave of quantitative analysis conducted as part of this work was published as a pre-print paper in May 2022. The paper is entitled ‘An observational study of uptake and adoption of the NHS App’ in England.[6]

Digital health should be seen as part of a multi-channel offering that meets the needs and preferences of users and includes non-digital options to ensure equitable access.

Alternative access routes (e.g. face-to-face, telephone) must remain as part of the offer - as they currently are - for those who are unable or unwilling to access digital services.

Examples of workstreams and programmes to support digital inclusion and enable more people to engage with and benefit from digital health services:

• Digital Health Champions programme was a proof of concept to support citizens who have no or low digital skills with understanding how to access health services online. It comprised an online learning and support platform to train people to become ‘digital health champions’ to then “train” or familiarise local communities about NHS health resources and how to access NHS Services, particularly in Primary Care.
• The Widening Digital Participation (WDP) programme ran from 2013 to 2020, originally managed by NHS England and then by NHS Digital. This programme aimed to ensure more people have the digital skills, motivation and means to access health information and services online. The results from phase programme with 220,000 participants in phase 1 (2013-16) and a further 166,162 in phase 2 (2017-20).
• NHS App ‘Spoken Word’ Pilot project was designed to test the efficacy of promoting NHS digital health products and services in languages other than English, to underrepresented, ethnically diverse communities (notwithstanding that the products or services themselves are in English). The level of engagement suggests an encouraging degree of receptivity in relation to ‘spoken word’ communications, even if the digital products are only available in English.   
• We commission and conduct ongoing research with citizens and the workforce to better understand the issue of digital inclusion. For example, NHS England commissioned Basis Social and the Good Things Foundation to conduct research to understand how to motivate the use of digital channels among people that have the capability and opportunity to do so. The full findings were published on 11 October 2022.[7]
• In A Plan for Digital Health and Social Care, NHS England committed that By May 2023 they will produce a framework for NHS action on digital inclusion with our future plans and will develop further resources to support systems in practical action.
• The NHS Covid Pass is available through the NHS App, nhs.uk and by calling 119. Our inclusive letter service is designed to assist individuals where they
• need information in other formats, for example Braille, audio and big print
• need NHS COVID Pass information in another language – information about the NHS COVID Pass in other languages is available on gov.uk.
• have no digital access, for example no access to a computer or smartphone, or are requesting on behalf of someone who has no digital access
• are a parent or legal guardian of a child aged 5 to 11 living in Wales

The Digitising Social Care programme is working with the sector, local authorities, suppliers and ICS teams to ensure that 80% of CQC registered care providers have implemented a digital social care record and 20% of care home residents who are identified as at high risk of falls are protected by sensor-based falls prevention and detection technologies by March 2024.

Alongside the funding we are defining a set of priorities for standards in social care to support the adoption of digital social care technology via a Dynamic Purchasing System (DPS); currently we have 9 assured suppliers on the DPS. This DPS will help adult social care providers to purchase fit-for-purpose, standards-compliant digital social care record solutions with confidence.

We are also creating and publishing a digital social care record roadmap for standards adoption and capabilities compliance, working with CQC, DHSC and other partners to ensure data and data standards reduce the reporting burden on social care providers. 

During the peak of the pandemic, we also distributed 11,000 data-enabled iPads to care homes most in need of support, so that residents could access remote care and stay connected to loved ones virtually, along with a package of support to embed usage.

The dependencies map is a work in progress and still requires some validation and is subject to the approval of business cases by HM Treasury for the major programmes. Once these approvals have been secured, we can provide this information (expected date February 2023). The map will help us to understand the extent of the impacts of reprioritisation, following funding reductions. Once programme plans have been developed this mapping will be refined to milestone level within our Aspyre PPM tool which will give transparency between programmes.

A ‘Benefits Map’ is included at Annex C which shows the portfolio of programmes within the wider Transformation Directorate, with their main benefits mapped to the health triple aim (efficiency, safety, outcomes). Whilst the map includes activity beyond the tech portfolio, it does not cover programmes which are out of, or in the process of transitioning out of, the Transformation Directorate. For example, the Digital Social Care programme reports to the DHSC's Adult Social Care portfolio, though we continue to support dependencies and benefits for social care technologies (see Area 1 above). 

The proposed transfer of NHS Digital’s functions into NHS England (NHSE) will now happen in January 2023. Accelerating the transfer will lead to faster improvements in cooperation between the key digital bodies of the NHS by bringing them under one roof for the first time. This should support improved management at a strategic level of complex technical projects. For example, the alignment of separate teams from X, D & E on the NHS App and Screening has considerably improved working relationships and ensured better alignment on objectives and priorities.

The previous delivery of technology programmes had multiple layers of control to assure each legal entity. This led to delays while governance was undertaken in NHSE England and DHSC to ensure the commission was appropriate and the right mode of delivery. There was then parallel approvals to accept the commission and test deliverability. There was friction caused by this process with delays and reviews at multiple stages. The new approach brings together delivery and the understanding of the requirements of the NHS into single leadership. It deduplicates the governance and allows teams to by dynamically reprioritised. It removes the artificial distinctions between funding transformation and running and maintaining services. Moving to a product led model creates significant opportunities to deliver faster incremental improvements.

All the expertise and activity in relation to data and digital services will be together in a single organisation as intended by Laura Wade-Gery's review, as staff and assets are transferring; this will help maintain continuity, and ensuring any upheaval is minimised is a priority of work to ensure Day One readiness.  

The transfer of the functions of NHS Digital to NHS England is not intended to weaken the safeguards we have in place for the safe, and appropriate use of patient data. The transfer regulations – and accompanying statutory guidance – are intended to ensure the same robust and proportionate governance in relation to data access, a characterised NHS Digital. Equally, there is no intent to impede the appropriate access of researchers or service planners to the data they need to help improve outcomes; existing directions and requests to NHS Digital will be legally transferred to NHS England.

The governance arrangements which NHS England will have in place, will include appropriate scrutiny of data access requests, covering both internal and external uses of data.   

NHSE is considering the Data for Research & Development (R&D) Programme ifor assignment to the Cabinet Office Government Major Projects Portfolio (GMPP) and as such it would be subject to GMPP governance. Given its scale (over £50M) it’s Programme Business Case is approved by HM Treasury. It is listed on the DHSC Major Projects Portfolio. 

The Programme Senior Responsible Officer (SRO) is Dr Claire Bloomfield who oversees the Programme and is accountable for the benefits. Dr Bloomfield represents the Programme, and NHS data for research more broadly, as a member of the Life Sciences Vision Data subgroup; the Research, Resilience and Growth (RRG) Board; co-Chair of the RRG Data and Digital Subgroup; and a member of the National Genome Board and co-Chair of the Data and Research Subgroup.

Within NHS England, the programme reports into the Executive Transformation Group (ETG, formerly Delivery Oversight and Approvals Board of NHSX) supported by the Transformation Portfolio Office (TPO).

The Programme has a senior level Programme Board, including stakeholders from all of its funding bodies (BEIS, DHSC SRE, and NHS England). Membership also includes the NHS England Director of Transformation and the Chief Data and Analytics Officer. See Figure 7 in Annex B for further details.

At the July 2022 NHS England (NHSE) Board a new commercial strategy for NHSE was approved. This laid out plans to support the NHS commercial community, drive collaboration across commercial teams, leverage NHS collective buying power and provide clear, consistent guidelines on how to contract with the NHS. One element of this strategy was to review how NHS procurement and commercial teams could be supported to drive the uptake of innovation.

Approximately £35bn of the NHSE budget flows through commercial and procurement processes. There is an opportunity to utilise this spending power to deliver the best health innovations to patients faster than ever. We are committed working with key organisations and partners, such as the Accelerated Access Collaborative (which has a remit to support the adoption and spread of the most promising innovations), to achieve the greatest value through a systems approach.

The AAC and the NHSE Commercial Directorate conducted a rapid piece of work with local commercial and procurement directors to understand the challenges and set out a collective approach to addressing them (this work has involved over 50 one-to-one interviews with commercial and procurement directors to understand problems, and a series of group workshops to navigate the proposed solution).

The NHSE Commercial Directorate is also working to develop the ‘Commercial Innovation Pathway’ to test, trial, adopt, and scale innovation. We continue to work with the AAC, and other partners, to continue to sponsor and look to expand this work before an evaluation is conducted.

This was presented to the AAC Board on 23rd November.

NHS Digital Health Technology Standards Audit, assessing Digital Technology Assessment Criteria (DTAC) compliance

Currently, although there are many solutions being deployed, there is limited centralised data held at a national, regional or ICS level, on digital solutions and digital health technologies used across the NHS, outside of Electronic Patient Records (EPRs) and core Primary Care systems and those products that have received national funding or via an Award.

The NHS Digital Health Technology Standards Audit, focusing on DTAC compliance of technologies, will provide the first national list of digital solutions deployed across the NHS.  The first Audit, a mandatory data collection, closes on 15 December and will set the baseline for this work. The initial focus is on secondary care and this will expand further in future iterations (we are considering a planned approach to social care now that ICBs are becoming established). 

Audits will take place at least every six months as we move to a dynamic system of reporting so that other NHS organisations have better access to evidence based, DTAC compliant technologies. Actions plans will be put in place where NHS organisations and technologies are not complaint.

The Audit will enable the NHS to understand what technologies are deployed where and their scale across the NHS. This will enable a data driven approach to quantifying scalability and whether this is increasing over time.

DTAC has set consistent entry criteria for products being used and adopted in the NHS and all products should be assessed against this.  There is currently no single linear pathway for adoption and scale within the NHS.  There are however a number of funds, awards and programmes that are supporting and enabling products to be used or scaled.  These schemes however only reach a relatively small number of technologies compared to the thousands that are deployed within the NHS and include the Digital Health Partnership Award, Small Business Research Initiative for Healthcare and MedTech funding mandate.

During 2022, NHS England’s Policy team have been working with NICE to develop a pathway using the Early Value Assessment (EVA) for technologies which offers a rapid assessment based on clinical effectiveness and value for money, services and patients will be able to benefit sooner. This is currently in pilot phase, as are the NHS England post-guidance interventions including adoption support for evidence generation. There is however a significant challenge with the capacity for this type of assessment and it remains unclear whether NHS organisations will take any actions based on this guidance, including replacing products with those that may signal better value or increased efficacy.

NHS England’s DTAC Programme has developed a product akin to DTAC to support organisations in evaluating the clinical efficacy and value proposition of products that have not been subject to NICE’s independent assessment.  This will support the NHS in making better buying decisions, and innovators to surface their evidence in a consistent and recognised way. 

It also continues to work with NICE and the MHRA on IDAP, the Innovative Devices Access Pathway for selected medical and digital health technologies that are new and innovative and meet critical unmet need in the system which aims to get these technologies to patients quicker.

Examples of scaling innovative solutions

A programme that focuses specifically on external partners is the Digital Health Partnership Award which was launched in 2021 focusing on how strategic partnerships can accelerate and sustain the delivery and impact of digital health technologies across local systems.

• Three rounds of funding to date have scaled 46 projects to support over 100,000 patients manage their health at home or closer to home, in the local community. Each project must demonstrate how they build strategic alliances with NHS organisations, technology; patient activation and benefit partners who agree roles and participation in advance of any funding decisions.
• It is forecast that these will reach up to 500,000 patients through the £9.6 million funding, delivering in excess of £20m of financial benefit to the NHS. The programme is currently identifying which projects look to deliver systematic and patient impact and how we share knowledge and build wider capability to deliver further reach and scale. The programme involves 150 unique partners who are outside the NHS and play a role in achieving scale; they include digital health innovators, industry partners, charities and larger tech companies.

• The “Little Hearts at Home” project at Alder Hey NHS Trust was one of the first Partnership Awards supported. It aims to enable babies and infants with congenital heart disease to be discharged from hospital sooner with home monitoring equipment and promote recovery in their homes. The technology ensures that their vital signs are captured and shared with clinical support teams, ensuring that clinicians and parents or care givers are confident with their progress and actions taken based on live data. The anticipated scale of a successfully project will be working across the Children’s Hospital Alliance, focusing on the largest paediatric hospitals in the UK.
• Health Beacon's smart digital sharps box for managing injectable medications supports medicines adherence - Used in the US and other health economies, the Award has deployed the first NHS pilot focused on patients with IBD, a model which can be applied to other conditions that require injectables including diabetes and chronic asthma. Early evidence has demonstrated higher than average adherence to medication, and supported carers of CYP managing their conditions know when medication is being taken correctly.
• Virtual wards and long-term condition management technologies continue to be scaled across the NHS. In North West London, the Award brought together three organisations to deploy the Luscii remote monitoring platform simultaneously for the first time. This model has saved cost, supported the technology convergence agenda and delivered a platform that is supporting patients with multiple co-morbidities be discharged sooner, manage their long-term conditions more effectively and ensures that the technology is the same across multiple condition areas

We don’t currently have direct visibility of these call-offs across the system, though in some cases they will be tracked manually at the project level via engagement with the issuing framework providers. NHS England is deploying the Atamis procurement and contract management across the secondary care system which should lead to better visibility by 23/24, although the use of the system is recommended not mandated.

The use of framework agreements for the compliant procurement of goods and services is a well-established practice. There are a range of procurement frameworks that cover clinical digital and IT solutions, which are widely used in the NHS.

Procurement of clinical digital and IT solutions (e.g. Clinical Software/SaaS/Apps and Services) is predominantly led and undertaken on a local organisational level and in certain cases spanning Integrated Care Systems or wider geographical areas. This procurement activity will generally be supported by the framework provider, but the service wrapper differs by framework provider and framework.

There currently is no central aggregated insight into the number of contract awards off these frameworks. The most reliable providers of such information would be the framework suppliers, which in certain cases may be willing to provide data, whilst in other cases may be hesitant to share this for commercial sensitivity. Even framework providers are reliant on the contracting authority to notify the framework provider that they will/ have used a specific framework agreement to assure accurate record-keeping. An overview of recommended routes to market can be found here, which lists the different relevant frameworks and framework providers.

The NHS is onboarding to Atamis, a single cloud-based procurement and contract management system, across secondary care NHS providers and NHS Integrated Care Boards. Adoption should lead to better visibility by 23/24, although the use of the system is recommended and not mandated. It is also reliant on procurement teams to accurately record the specific framework agreement from which the contract was called off.

NHS England is leading on the implementation of the Cabinet Office commercial assurance. This will include the approval of all frameworks by Cabinet Office. These controls will give visibility of pipeline on any contracts over £10m.

Cabinet Office acknowledges that greater visibility is required across the framework landscape and has published that they will develop a “register of commercial tools – allowing contracting authorities to view which frameworks and dynamic markets they can use to conduct their procurements, and seeing which contracts have been won through different commercial tools” as part of the transforming public procurement transparency ambition and the underpinning central digital platform.

With the abovementioned caveats and context, NHS England is one of the recommended Digital and IT framework providers through the Health Systems Support Framework. Over the past 12 months 6 known contract awards have been made through this framework with a total contract lifecycle value of £39m, which cover ‘digital and IT solutions’ (i.e. it excludes the contracts through lots that are not ‘digital and IT’ focussed).

NHS London Procurement Partnership is also one of the recommended Digital and IT framework providers. Over the past 12 months 31 known contract awards have been made through the Clinical Digital Solutions framework for a total contract lifecycle value of £63 and 7 known contract awards have been made through the Clinical Digital Professional Services framework for a total contract lifecycle value of £7m.

The Provider Selection Regime is a new set of bespoke rules which commissioners of healthcare services in the NHS and Local Government will follow when procuring or otherwise arranging healthcare services in their area.

The Provider Selection Regime will give commissioners of healthcare service more flexibility when selecting providers. This will empower decision-makers to design and deliver well-coordinated systems with more joined up care and unlock opportunities to innovate through increased collaboration and integration of services.

DHSC and NHS England are working to establish the Provider Selection Regime and will provide an update on a plan for delivery in due course. The rules which will set out the Provider Selection Regime will be subject to parliamentary scrutiny through the affirmative process before they can come into effect.

The baseline of 46,009 does not include social care – this figure is from the 2021 published HEE Report titled – Data Driven Healthcare in 2023: Transformation Requirements of the NHS Digital Technology and Health Informatics Workforce.[8] See table below.

The target figure of an additional 10,500 is a pro-rated number of WTEs from 2022 – 2025.

18 Trusts have signed SLAs to for 41 graduates during April 2022 to June 2022.

NHSE has commissioned a new graduate Digital Data and Technology (DDaT) Scheme in July 2022 to source Band 5 & 6 digital, data and technology graduates for the NHS Service Providers.  The existing number of graduates being supported is 126, with a further 135 in the pipeline. The target number of new talent recruits is 500 for FY22/23, which spans both graduates and apprentices.

Health Education England’s DDaT Apprenticeships Annual statistics also show:

• 36% year on year increase in DDaT apprenticeships
• Top 3 DDaT Apprenticeships
• Level 4 Data Analyst - 38%
• Level 3 Data Technician - 24%
• Level 3 Information Communications Technician - 9%
• Circa 19% of the DDaT apprenticeship annual starts in FY22 are for Level 6 (integrated degree) and 7 degree apprenticeships

Further data from 2017-2022 is outlined in Figures 8 and 9 in Annex B.

NHSE Digital Workforce team is also working with the Frontline Digitisation Programme to mobilise and deploy 200 digital graduates across priority group 0 and 1[9] and a few select high-risk Group 2[10] Trusts for 24 months. Graduates will work on EPR programmes and placements will be part-funded by the Frontline Digitisation programme. This covers roles within the Electronic Patient Records project team as well as backfilling BAU roles e.g. Configuration Analysts, Trainers, Project Management / Support, Cybersecurity, IG, Software Development, Data Analysts.

The 10,500 target is for healthcare only. We are currently undertaking workforce planning activity to develop a baseline and forecasts for social care.