Laurence Eastham interviewed Rachel Dunscombe, asking about the role of the Academy, John Yates’ contribution and the future of digitisation in a 21st century NHS.
Everyone should get an hour with Rachel Dunscombe as an antidote to negativity about the NHS and its capacity to adopt IT solutions and meet its upcoming challenges.
If, like me, you have taken NHS incompetence in a digital context as a given, then an hour with Rachel will shake that assumption until it crumbles and you will come away praying that all Rachel’s positivity and expertise will flow through the veins of the NHS like a carefully targeted chemotherapeutic. Given Rachel’s pivotal role at the Digital Academy, that might be exactly what happens.
For those not already aware, the NHS Digital Academy is ‘a virtual organisation set up to develop a new generation of excellent digital leaders who can drive the information and technology transformation of the NHS’.
It works as a partnership with Imperial College London, the University of Edinburgh and Harvard Medical School. It provides a year-long, world class Post Graduate Diploma in Digital Health Leadership for digital change leaders. After a very successful first year, ‘Cohort 2’ have recently started their journey through the Academy’s programme.
Rachel made it clear that the Academy is designed to make sure that digital expertise is available within the NHS at board level. Participants in the programme are typically Chief Information Officers (CIOs), Chief Clinical Information Officers (CCIOs) or aspirant CIOs or CCIOs. But, Rachel tells me, it is a ‘wonderful mix of people – some with a digital background and some with all manner of clinical backgrounds, doctors, nurses, pharmacists and social workers’. I was taken aback by the age range too – from 27 to doctors in their sixties. That diversity of backgrounds required a diverse programme that will create a common frame of reference for this disparate group who will all end up leading digital in their sphere and location; Rachel mentioned that one of the criteria for selection for the programme, a highly competitive process, is that the candidate has ‘an appetite to lead’.
The Academy is part of a re-imagining of the work in which the NHS is involved, at all levels. Digital creates opportunities to veer away from unhelpful historic approaches. Delivering the right information at the right time and in the right place helps reduce hospitalisation – and that saves lives as well as resources. One (to me) surprising focus is using digital opportunities to deliver care in the home or near to home.
Rachel was at pains to point out that the NHS Digital Academy is not her creation but that the glory should go to a whole range of others; Bob Wachter’s vision and continued commitment and Ari Darzi insights getting special mentions (‘amazing men’). I was amazed by how quickly the initial programme had been put together – just five months. That would be impressive in any organisation of substantial size but in an organisation such as the NHS, which has a reputation for changing at a glacial speed, it is truly amazing.
Rachel acknowledged that participants had very different starting points and that might have created problems. But, by embracing a peer-to-peer learning strategy – ‘moving from the sage on the stage to the guide on the side’ that potential problem has been transformed into a strength. Rachel gave the example of a group that had included both a doctor with specialist insights on public health and a digital health expert with a background in cybersecurity, where the exchange of knowledge enriched the entire group.
But some areas do require outside expertise. The Academy has brought in experts to share knowledge and provide narrative and provides an international perspective with people from the USA, Russia, Estonia and Slovenia (to name but a few). It has heard from those with long-term experience in the field like Ali Parsa from Babylon Health, from the Lean Startup movement, and from patients as well as from experts from close to home.
John Yates is one of those experts from what Rachel described as the core faculty and has been associated with the Academy for some time. He provides ‘a crucial backdrop to the system’. Rachel described him as ‘second to none’ in terms of contracting and commercial in the NHS; ‘he has more experience [of NHS deals] than anyone else I have ever met’. Rachel thought it was important that participants in the Academy’s training knew something of ‘why we are where we are in terms of the commercial landscape for digital health’. She feels that ‘we are now in a world with very little guidance and very little expertise within the NHS’ because contracting was previously dealt with at a national level – and the standardised contracts are very old.
John Yates has provided ‘really fantastic thought leadership’ to the Academy’s participants, looking back on developments and, more importantly, on how we need to deal with contracting going forward.
One common hole in the knowledge of Academy participants relates to contracts: ‘clinicians have had zero exposure to contracting’.
John Yates is ‘fast-tracking their knowledge’. The training in Module 2 to which John Yates contributes aims to enable participants to ask intelligent questions about contracts and highlights useful resources. His input helps participants feel more confident in the commercial sphere.
John’s presentations include an examination of a 26-page ‘strawman’ contract that might be used where a contract is envisaged for a small app. Trying to adapt a 400-page standard contract for such a situation, when the spend might be as low as £20,000, is totally disproportionate. John talks about the different levels of transactions and how to approach them. He has also contributed ‘incredibly valuable’ White Papers.
Rachel recalled some feedback on John Yates’s material and the module to which he contributes: ‘people expected it to be dry but they fully engaged and one CCIO remarked that it had removed some unknown unknowns’. Participants felt more confident in having intelligent conversations in a hitherto alien sphere. The positive feedback has run well above any that normally runs with adult learning programmes at Imperial College. Indeed, the reaction to the various contributions in Module 2 has been so positive that the Academy has received requests for it to be opened up to the wider NHS.
Our conversation moved on to contract methodology. Rachel is an advocate of Agile but is very much aware of its limitations, as she says ‘it is all about adopt and adapt … all of these things require common sense and good leadership’. What the Academy has focused on is aligning Agile with IHI (Institute for Health Improvement) Quality Improvement Methodology. It requires monitoring to prove that there really is an improvement in what you do. Rachel is the driver behind an insistence that measurement and base-lining is done in a scientific fashion. That produces the crucial evidence that you are acting constructively and not ‘flying blind’. Agile needs to be allied to clinical rigour and clinical safety – ‘you can get to a Yes or a No or a change of direction quickly, it’s speed to value with safety’.
I was very struck by the scientific rigour that underpinned Rachel’s approach and suspected that her background studying biochemistry was a great influence – a suspicion confirmed by Rachel who feels that she may have made more use of some of the knowledge acquired at university in the last three years than ever before.
We then talked about data protection and privacy issues as ethical challenges in the NHS. Rachel sees a sea of misunderstandings and a failure to grasp both risks and opportunities. She outlined one particular example: where a data set is shared which could be attributed back to a patient and researchers ask some very specific questions with the aim of improving a service that may be valid – it is about justifying; it is not a black and white issue. While privacy must always be respected, there is good practice in relation to informing the citizen about the way in which their data is being used.
The Blood Transfusion Service will, for example, tell the donor where his or her blood has been used – echoing back information to the citizen – and this may be an exemplar. The NHS is under an obligation to monitor levels of success (Rachel cited hip operations as an example) and in such situations there is no way for the patient to opt out but Rachel would like to see greater transparency so that patients know how that data is used and this could help encourage greater citizen engagement.
The privacy and GDPR aspects are not the whole story – courtesy, engagement and ethics are important factors. She spoke about the ‘fantastically vibrant debate’ that focuses on these topics and weighs whether we can publish data back to the citizen to allow others to use it for their research. Rachel has more patience than I muster for what I (probably simplistically) described as data protection fundamentalists; she regards them as ‘bringing a healthy tension’ to debates on the topic.
The Academy has a useful role in encouraging discussion of these topics, where both sides can air their views. One example of bringing the citizen into these debates is that both a renal surgeon and a transplant patient were on the stage for an Academy presentation about data usage. Rachel suspects that the Finnish example, where citizens’ data is placed in a central repository over which the citizen has control and gets an account of how that data is monetised, may point a way forward: ‘those of us who are social beings would willingly give our data to put back into the NHS’.
We moved on to legacy systems and the problems that arise. Rachel highlighted the issues surrounding getting data from legacy systems: ‘the future is interoperability … aggregating data into an open format that can then be read into other modern clinical records … that will take a lot of contracting work and clinical enterprise architecture.
We are entering an era where we have to see the data as valuable but not necessarily those legacy systems’.
Change needs more than a change of mind-set, it needs funding. Rachel knows that: ‘if we are going to use digital as our main platform for transformation in the UK, we either need to find existing money in the system that can be pushed in or new money – we need to invest further in digital’. Properly applied, digital can replace buildings, bringing services closer to home, and substitute for the expert clinicians that the NHS is struggling to find but ‘money has to flow’ for that to work.
I asked Rachel if she felt that the NHS Digital Academy model could be applied elsewhere. She felt that the model could definitely be successfully transferred to other areas, citing the tech industry that sits around the NHS and social care and life sciences generally: ‘we all have to pivot together towards a new model for delivery’. Life sciences are moving into the digital space and also personalising drugs with greater precision; the tech industry that provides us with everything from wearables to robots needs to be able to keep really close so that it understands our needs. Rachel and the Academy are ‘very keen in the future to open up the curriculum – we are already in discussions with techUK and Rachel is working with a sister programme, HDR UK, to provide the data sciences programme for the life sciences industry in the NHS.
We closed our conversation with a look at the future for digitisation initiatives across the NHS. Rachel sees a vibrant future with continued and wider input into NHS England and NHSI (NHS Improvement) from Ari Darzi, whose Imperial College team lead the Academy, and new blood at senior levels, with the likes of Dido Harding joining the NHS Board. Rachel believes that the new leadership really understands the potential for digital. She sees a future of rapid and effective change. She convinced me.