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Written evidence submitted by NHS Providers

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. NHS Providers has all trusts in voluntary membership, collectively accounting for £92bn of annual expenditure and employing more than one million staff.

NHS Providers’ Digital Boards programme is designed to support NHS leaders implement digital change. The programme focuses on building understanding of the potential and implications of the digital agenda and aims to increase the digital confidence and capability of NHS trust boards.

The Digital Boards programme positions NHS Providers well to understand and reflect the challenges faced by trust leadership in delivering the digital agenda.

Key messages

• The digital transformation of health and care services is a significant undertaking and in recent years there have been a number of strategic asks placed on the sector: to reduce waiting lists, improve standards and increase productivity. To meet these demands, the NHS must embrace new digital ways of working. But previous attempts to digitise services have faced challenges in terms of clinical engagement, accessing sufficient and sustained funding and managing tensions between local autonomy and central directives.
• Since March 2020, progress on the NHS digital agenda has rapidly accelerated as the sector responded to the COVID-19 pandemic. Trust leaders are now tasked with building on this momentum in order to manage care backlogs, address the long-term impact of the virus and improve the delivery of high-quality patient care.
• This will require the transformation of services using digital ways of working, rather than simply applying digital technologies to existing processes. Success in the NHS will mean reimagining culture, processes and operating models, as well as the use of technology to better meet the needs of patients, service users, system partners and staff.
• Strong leadership that is aligned with this ambitious digital agenda is a prerequisite for driving change. Trusts leaders are well placed to deliver effective digital strategies and build and enable digital teams.
• There are further opportunities to progress digital through national prioritisation of the digital agenda, addressing funding barriers and by giving local NHS organisations the freedom and flexibility to deliver on digital.

The NHS digital agenda

1. The digital transformation of health and care services is a significant undertaking and in recent years there have been a number of strategic asks placed on the sector: to reduce waiting lists, improve standards and increase productivity. To meet these demands, the NHS must embrace new digital ways of working. This requires that trusts are supported by technology that is scalable, interoperable, flexible, fixable, resilient and fit-for-purpose. But previous attempts to digitise services have faced challenges in terms of clinical engagement, accessing sufficient and sustained funding and managing tensions between local autonomy and central directives.

2. Digital technologies were rapidly implemented to support patients, service users and staff during COVID-19. Large strides made by trust leadership include:
1. Driving digital innovation: a culture of digital innovation was fostered across many NHS organisations, with trust leaders empowering teams to get on and deliver change. For example, one trust encouraged clinician-championed digital solutions by establishing a small staff innovation fund to resource projects.
2. Increased internal communications: with a proportion of the NHS workforce shifting to remote working, often a large uptick in organisation-wide communication followed, including at board level. Staff were also equipped with technologies to keep them safe and connected. For example, one trust supported staff wellbeing by introducing an app to better enable staff to book leave – key at a time when they were facing severe stresses and needed to be able to best manage their rest and recuperation time – as well as providing them with tips and support during a time of unprecedented need.
3. Increased capability for remote working and remote patient care: there was accelerated adoption of digital tools that allowed clinicians to conduct remote patient consultations such as the large-scale deployment of Attend Anywhere. Among many trusts, the ability of staff to work remotely was also increased, which aided service delivery during the pandemic – given that the alternative would have been cancelling or postponing appointments, this was a critical development.
4. Improved use of data: newly developed business intelligence tools allowed trusts to better monitor activity and enable data-driven decision making. New workforce management tools were also employed by trusts to manage rota schedules and staff shortages across local systems.

3. In August 2021, NHSX published its ‘What good looks like[1]’ framework for digital transformation. The NHSX guidance sets out a national standard for digital transformation across the NHS and guides NHS leaders to digitise, connect and transform services. Within this framework, success will be evaluated across seven measures and will provide trusts with a “north star” to aim for in terms of digital maturity.
4. Trusts are at different stages in their digital journey. There is a wide range of trust digital maturity levels, with a variety of needs. The constituent organisations within a single integrated care system (ICS) are often at very different stages of their digital journey. This poses a logistical challenge for ICS leadership looking to ensure the ‘levelling up’ of less digitally mature trusts while at the same time not stifling innovation of the more digitally advanced trusts.

Emerging trends in successful digital transformation

5. As the sector looks to build on the learning from COVID-10, trends are emerging that point to the common conditions for successful digital transformation:
1. Collective board ownership of the digital agenda. Responsibility for delivering digital is beginning to be shared across trust boards. With all board leaders engaged in transformative digital thinking, there are opportunities to align digital with other areas such as quality improvement. 
2. Ensuring technology and information teams are not siloed. This often sees building the appropriate level of digital expertise and representation into multidisciplinary teams across an organisation, as well as providing resources to level up digital skills across the trust enabling an empowered workforce, including at board level. Digital is no longer the preserve of the IT department in trusts that are delivering effective digital change.
3. Expanding focus from technology alone to transforming culture, operating models and processes. Transformation of service delivery and ways of working is as much about creating the cultural conditions for digital, including giving a clarity of purpose and freedom to act, as it is about the technology itself. Securing digital alignment with the operating models and processes within a trust is needed to ensure the efficacy and sustainability of digital initiatives.
4. System-wide collaboration and peer-learning. Collaborative working and peer learning are key tools that can help a trust capitalise on the resources and developments that are available to achieve digital transformation more efficiently. For those more advanced trusts, this involves grappling with difficult challenges around interoperability, supporting their system partners with divergent starting points and pooling capability across their ICS.
5. Board-level understanding of the user experience and the effective design of digital services. There are opportunities for board leaders to get closer to those using their services, whether they be patients or staff. For example, in one trust, the chief executive regularly spends time answering calls on the IT help desk to gain a better understanding of the digital needs and experiences of staff. In digitally mature trusts, leaders are therefore able to place user needs at the forefront of their minds when overseeing the redesign of services and ways of working.
6. Prioritisation of digital programmes. Digital delivery depends on trust leaders recognising that their strategic vision should translate into more specific and realistic priorities that can be communicated to the rest of the organisation, rather than a wish list of initiatives or series of deliverables.

Remaining challenges for the NHS digital agenda

6. Challenges remain that will make it difficult for some parts of the NHS to further progress digital. These include:

1. Managing legacy technology. Trust leaders recognise the risk of systems that are old and unsupported: they are burdensome both in the ongoing costs of maintenance and in their increased vulnerability to cyber attacks. However, overcoming the large-scale changes to processes and culture that are often needed to successfully modernise legacy systems pose a challenge for many trusts.
2. Recruiting and retaining staff roles with digital skills. Some trusts continue to struggle to recruit and retain staff roles with internet era skills that will enable them to delivery digital change, such as designers, product managers, and user experience researchers. Digital skills training within a trust and providing staff with fit-for-purpose digital tools and systems enable staff to do their jobs well and are needed to build and retain a digitally empowered workforce.
3. External funding pressures. Constraints on what money is available and the way in which that money can be spent often make it difficult for trust leaders to navigate digital funding. As the National Audit Office recently set out in their ‘Digital transformation in the NHS[2]’ report, NHS England & Improvement estimate that trusts spend less than 2% of their total expenditure on IT, which falls well below the 5% recommendation. A blended model of capital and revenue funding is needed for digital that accounts for both day-to-day expenses such as software licensing and one-time capital expenses. The government’s upcoming comprehensive spending review presents an opportunity to establish multi-year settlements that will allow trust leaders better opportunity to plan and execute their digital strategies.
4. Maintaining local autonomy amidst national directives. At a national level, there is an ongoing tension between centralised coordination of digital priorities and local autonomy and decision making. While the setting of a national standard for what good looks like in digital is welcomed as an aspirational goal for trust leaders, a balance must be struck that allows trusts to choose their own way forward while still meeting national expectations.

Conclusion

7. Digital is supporting the NHS to adapt to the needs of its patients, service users and staff. Trust leaders are sustaining the momentum built during the COVID-19 pandemic and delivering digital change across health and care services. However, they continue to face organisational, workforce, funding and strategic challenges to delivery. Sustained focus at a national level in this area combined with the freedom and flexibility to deliver on digital locally presents a great opportunity for advancement of the digital agenda. This will empower NHS leaders to build the conditions of success for digital change within their own organisations.

September 2021