‘There’s no way back after this’: Inside the unexpected tech revolution at the NHS

Digital solutions have proven invaluable in helping the NHS cope with the demands of COVID-19. But will support for new ways of working survive beyond the pandemic?

Telemedicine is changing the way we see doctors

Technology has been absolutely vital in helping the NHS manage the overwhelming pressure placed on its services since the start of the COVID-19 pandemic. Everything from video conferencing and remote appointments with GPs through to artificial intelligence systems designed to understand the demand for hospital beds, has been used to help keep healthcare services operating throughout the pandemic.

In the early days of the coronavirus crisis, NHS Digital, which is responsible for a number of key digital services for health and social care in the UK, quickly found itself under strain as people began searching for information on COVID-19. In the first week of March alone, the organisation fielded an additional 120,000 calls to its NHS 111 hotline, forcing it to quickly increase capacity and set up an online system where people could check COVID-19 symptoms and get advice.

Within a week, more than one million people had used the service; at its peak, NHS 111 online experienced 95 times its highest ever use, with over 818,000 accessing the service in a single day.

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"No CIO prepares for that," says Sarah Wilkinson, CEO of NHS Digital. 

The experience was testing for NHS Digital, which had to rapidly scale up services at a pace that, while necessary, Wilkinson admits felt "too fast for comfort" at times. "We've really lived by the seat of our pants on some of the things we've done in the last few months," she says.

But Wilkinson says that how NHS Digital has responded to COVID-19 has shown that agility, even from one of the largest organisations on the planet, is still possible. "The interesting thing for me has been two big things: one, we've been able to show both the power of digital and data in serving the health and care system, and what we can do with the stuff we have at our fingertips," she says. 

Wilkinson believes the crisis has also shown just what NHS Digital is capable of as an organisation: its ability to deliver secure products and services at great speed. "That, I think, has been really confidence-building for us," she adds.

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Sarah Wilkinson, CEO at NHS Digital.

Image: NHS Digital

Deploying new tools so quickly has come with its challenges, including having to very quickly fix up the NHS's technical plumbing. This includes introducing massively improved connectivity to different parts of the healthcare system, creating tens of thousands of new NHSmail users in social care, bandwidth upgrades and new virtual smartcard authentication systems. 

"The infrastructure demand has been incredibly high, in ways that I really don't think we could have predicted at the outset of this," says Wilkinson.

The call for data has also been "extraordinary", she adds. NHS Digital and NHSX have been working on a number of data initiatives throughout the pandemic aimed at capturing and making sense of COVID-19 data from across the health system, striking up partnerships with industry partners including AWS, Google and Microsoft in the process.

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NHS Digital is now seeing an unprecedented demand from NHS organisations that want to access and connect this data, Wilkinson says: "We throw up a dashboard, and by the end of the day we have hundreds of people wanting access to it. We're trying to make as much of that as open as we can."

Perhaps unexpectedly, one of the most significant technology deployments of the pandemic has been Microsoft Teams, which was rolled out to every NHS organisation across England and Scotland in the days following bans on businesses and non-essential travel in the UK. The software proved instrumental in allowing NHS teams to coordinate their responses to the crisis and continue their all-important work in the face of a global health crisis.

"The Teams deployment had a huge impact on the productivity of the service," says Wilkinson. "That scale of deployment in that time with that resilience was phenomenal."

Embracing digital health

There's no contesting the argument that technology has the potential to transform healthcare. According to a recent study by the Institute for Public Policy Research (IPPR), greater use of digital tools within the NHS could save up to 20,000 additional lives each year, at an estimated £10bn saving to the health service.

Several attempts have been made to overhaul the NHS's IT infrastructure over the years, with limited success. Perhaps the most infamous example is the National Programme for IT (NPfIT), which ran from 2002 to 2011 and set out to create a single, integrated health record across the whole of secondary care that would allow patient data to be shared across regional boundaries.

While it was credited for establishing a few key pieces of national infrastructure, it ultimately failed to achieve its goals after being hobbled by top-down decision-making that ignored local needs, and was eventually scrapped. Renewed attempts to join-up the UK's health and care system are underway as part of the Local Health and Care Record Exemplar (LHCRE) programme, which aims to join-up care records across primary, secondary and social care settings across regional geographies.

Innovation in the public health system has occurred in small pockets, though it has typically been GPs and doctors at the forefront, with hospitals and social care lagging behind. For instance, nearly all GPs now use electronic health records and computers in their day-to-day interactions with patients, while many hospitals still rely heavily on paper-based processes and other outdated formats.

The expansion of appointment booking and remote consultation apps has also created disruption in this space, giving patients more freedom over how to interact with their doctors and their data, while at the same time offering GP practices a means of reducing in-person visits and prioritising only the most important cases.

Progress towards "digital-first" primary care has skyrocketed during the COVID-19 pandemic. A national rollout of the eConsult platform, for example – which planned to target around 1,200 GP practices by the end of June – had already been deployed to more than 2,200 GP surgeries by April. According to data from NHS England, 99% of GP practices are now actively using remote-consultation platforms as a safer way to talk to patients, with NHS bosses now assessing how progress in this space can be "locked in".

It isn't just GPs benefitting from the telehealth boom: on the Isle of Wight, Lighthouse Medical has been running a teledermatology clinic for the past year that allows patients with suspected skin cancer to be diagnosed more quickly.

Using a platform called Dermicus by Swedish company Gnosco, staff can capture high-quality images of patients' skin abnormality and send them to a specialist dermatology team for review. Based on the images, doctors can determine if any further action, such as a biopsy, is needed.

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Amy Poyner, GP and former clinical director at Lighthouse Medical, tells ZDNet the technology has been "completely essential" in allowing the clinic to continue running cancer services that might otherwise have been paused – as they have elsewhere in the country – as COVID-19 spread.

"The support that it's provided means that we are still completely within all of our targets for the cancer wait times," Poyner says.

"We haven't fallen behind at all during COVID-19, because the teledermatology service has enabled us to continue while reducing unnecessary patient contact."

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The Dermicus Teledermatology Assessment Service has reduced the number of patients needing in-person appointments on the Isle of Wight.

Image: Lighthouse Medical

The Dermicus Teledermatology Service had already reduced the number of patients needing in-person appointments prior to the COVID-19 outbreak. In a sense, then, nothing has changed, though Poyner says the appetite for using digital services in this time has grown noticeably. 

"The main thing that has changed is that patients have been using eConsult with their GP surgeries and sending in images themselves, which in itself is a version of teledermatology," she adds.

In some ways, the coronavirus pandemic has improved access to GP services on the island: with doctors directing patients away from their surgeries and to virtual services instead, routine waiting times have nosedived. Where patients might have had to wait up to three weeks for a physical appointment, those using eConsult are generally able to speak to a healthcare professional within 48 hours: "a game-changer", according to Poyner.

"There has been a sea change in the patients themselves, because a lot of them don't want to physically see us or go to a GP, because of COVID-19 shielding. They are going out of their way to work out how they can get a photo to us," she adds.

"I think it has completely revolutionised how we've been able to deal with COVID, and reducing face-to-face contact to anyone that is absolutely clinically necessary."

Maintaining the human touch

COVID-19 has also accelerated the introduction of virtual consultations at Royal Surrey NHS Foundation Trust, where nurses and ICU staff have been using specially designed smartphones coupled with telehealth software to safeguard patients and staff, as well as conserve precious personal protective equipment (PPE).

More than 40 intensive care staff at the hospital have been using smartphones designed by Swiss company Ascom to conduct remote ward rounds. The handsets, which are designed specifically for healthcare environments and can be easily sanitised, feature Attend Anywhere's video-consultation platform and a single sign-on system from Imprivata. 

Where four doctors clad in PPE might have attended each ward round before, a single doctor will now enter the quarantine sector of the ICU and coordinate the round with other doctors watching from a meeting room, where the video is projected onto a screen. Following the success of this initiative, it's now being used across all 14 of Royal Surrey's adult in-patient wards, in its community hospitals and in other departments.

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Claire Richardson, a nurse specialist who has been using the Ascom handsets, says the mobile technology has had a huge impact on patient wellbeing during the crisis – and given back precious time that had been lost to COVID-19.

"Human contact and family contact is huge to patients' recovery," she explains. "When they were isolated, it was so difficult for patients and for their loved ones, so we wanted to have some way of bridging that gap.

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Staff at Royal Surrey NHS Foundation Trust have been using Myco smartphones designed by Ascom to conduct virtual ward rounds and enable virtual visits between patients and relatives.

Image: Ascom

"I would be the first to say an actual visit is better than a virtual visit; but if an actual visit is not possible, a virtual visit is the second best thing."

Richardson points out that even beyond coronavirus, there will always be value in technology that removes geographic or physical barriers, particularly if it's designed in a way that puts its users – namely, clinicians – at the centre.

"Nurses are not always the first to embrace new technology – but I think when even a nurse can see that something is going to make a big difference to your patients, then that's your motivation to embrace it and take it on," she says.

"I don't see this stopping at the end of COVID-19, because there will always be people in hospital who can't have a visit from their loved one, for whatever reason. I suspect we will look at other ways that we can use the technology."

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Adoption by necessity

While large parts of the health system have embraced digital with open arms, a few pockets of resistance have made overall progress slow. COVID-19 has nudged the digital dial forward, simply because there hasn't been much of an option to do otherwise.

"What's happened is awful, but it's forced us to adopt it," says Mandy Griffin, CIO at Calderdale and Huddersfield NHS Foundation Trust.

"It's developed some confidence from people that maybe would have taken a bit longer, had they had a choice."

Griffin points out that much of the technology that's seen widespread adoption over the past few months has been out of the necessity of limiting person-to-person contact. At Calderdale and Huddersfield, this has ranged from restricting how patients move through the hospital, to the introduction of voice-recognition technology to limit how often clinical staff have to touch keyboards and physical devices.

Hospitals were not exempt from the rapid shift to remote working caused by COVID-19 either. Roughly a third of the staff at Calderdale and Huddersfield were forced to work from home due to the virus, Griffin explains: a situation which, like many organisations, it never envisioned.

Microsoft Teams has ensured staff remain connected during this time. Not only has it allowed the hospital to offer virtual visits and video consultations in some of its specialty clinics, but the software has also improved communication with Calderdale's care home workers. 

"We've been able to rapidly roll out Teams and gave them the hardware to do it to 38 care homes in Calderdale to make sure our community teams could work with the care home team – to make sure patients were OK, but also, to make sure they were OK," says Griffin.

The communication conundrum

While hospitals are increasingly adopting mobile working, digital communication remains a challenge for the NHS. Outdated and heavily-siloed communication has hampered the NHS for years, something not least demonstrated by the fact it still relies heavily on pagers and fax machines.

This issue received increased focus in the aftermath of 2016's WannaCry ransomware outbreak, with a report from the National Audit Office warning that poor communications early on left many organisations without a clear picture of how the event unfolded. The problem was compounded when staff were locked out of IT systems, leaving many to fall back on consumer services like WhatsApp to communicate.

In many ways, the COVID-19 crisis has opened the doors to a lot of digital tools that had been around for a while and simply waiting for their time to shine. Hospify, a clinical-messaging platform that became the first to be approved by the NHS App Library in March this year, has seen its user base quadruple as a result of being fast-tracked by NHS organisations looking to keep staff in communication with each other in difficult circumstances.

Cardiff and Vale University Local Health Board (UHB) approved Hospify in early March, just before the UK went into full lockdown. The health organisation is one of the largest in Europe, employing more than 14,500 staff and providing health and care services to a population totalling in the region of 475,000.

Rachel Goodwin is one of around 20 staff at Cardiff and Vale UHB's Artificial Limb & Appliance Service, which provides assistive technology and communication devices as part of a community rehabilitation service and for individuals with serious disabilities. Goodwin, a senior clinical engineer and pre-reg clinical scientist within the service, has been using Hospify as a means of speeding up admin work and transferring sensitive patient data while protecting more vulnerable colleagues.

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Hospify, an NHS-approved clinical-messaging app, has seen usage skyrocket during the coronavirus pandemic.

Image: Hospify

"During this crazy time, a lot of our team are obviously shielded and they can't come in, so we've been covering other peoples' roles," Goodwin tells ZDNet. "It's meant our teams have not had to come in, they've not had to collect patient files or anything like that."

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It has also been a boon for staff who have been forced to work from home, yet don't have the necessary set-ups to do so, Goodwin says. "Hospify has worked really well for us in that a lot of our admin staff didn't have home working, or any way of accessing their emails, so it was a really quick way of getting them to have a way that we could then transfer patient-sensitive data securely, and in a way that's approved by the trust – which is a major thing for us."

It's not just clinicians that have changed their attitude to digital health, says James Flint, CEO of Hospify – patients have, too. "There's been a huge rise in the proportion of people now happy to consult with their doctor using phone, messaging or video, when even as recently as last January it felt like a fairly risky and even slightly suspect thing to do," Flint tells ZDNet.

"Because the digital tools in question are now reasonably mature whole areas of the industry have been able to switch to new ways of working relatively seamlessly, and now that this is happening very few people seem to want to go back to the old ways of working, regardless of what happens with COVID."

Goodwin agrees. "I think this whole period, of the last few months, has really forced people to get used to using technology – people who would never have touched it before have had to do it," she says. 

"When you approach the idea with them of having to do a video call, you don't have that resistance that you had before and they're much more willing to do it.

"I know as a service we won't be going backwards with that, because we can use that time much more wisely." 

Hospify is by no means the only app to have seen its user base skyrocket since the beginning of March – other digital health services have seen a similar surge of interest. 

Joost Bruggeman, founder and CEO of clinical-messaging app Siilo, suggests COVID-19 has once again highlighted the need for modern messaging services that allow NHS teams to quickly and safely exchange information, using the devices they have in their pocket.

This has become especially important during a time in which doctors, nurses and other health and care staff need to be able to share information with colleagues as quickly as possible.

"Before the COVID crisis, we had to actually explain this to IT managers in hospital trusts," Bruggeman says. 

"In a normal situation, you have to arm twist or educate a little bit more to make sure everyone is on the same page – the classic enterprise sales motion you have to go through. All of a sudden, that is gone, because everybody is looking at the same [problem]".

For Bruggeman, COVID-19 has brought what he calls "the WhatsApp problem in healthcare" back to center-stage. Except this time, there is "a clear vision on how to move forward".

"The voice that became super-clear during the crisis is BYOD," he says. 

"Instant, asynchronous communications tools, such as a messenger application, suddenly makes clear sense to everybody. There's no way back after this, because everybody understands that that's the new normal."

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Speed and scale 

Digital innovation has never moved at great pace within the NHS – a problem faced by practically all public-sector organisations. Aside from the huge considerations for information governance and data privacy, the complexity of the UK health system, both technically and bureaucratically, makes rapid change difficult.

NHSX's troubled COVID-19 contact-tracing app is a perfect example of this. The delays that have plagued the app are well documented, ranging from vague notions of when it might be launched, to an array of privacy concerns and technical complications that eventually culminated in a complete U-turn by NHSX, when it announced that it would ditch the centralised approach it had staunchly defended for so long in favour of the model proposed by Apple and Google. At the time of writing, we still don't know when it's coming.

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NHS Digital's own app is designed to be a digital front door to primary care services in the UK - not to be confused with NHSX's contact-tracing app.

Image: NHS Digital

Even NHS Digital has felt knock-on effects from the confusion surrounding the app. Wilkinson tells ZDNet that users seeking out NHSX's contact-tracing app have mistakenly been downloading the NHS App instead – a service designed by NHS Digital that is completely separate from that developed by NHSX and allows patients to access primary care services though their smartphone.  "We had quite a lot of people being really confused by that," says Wilkinson.

"To some extent I think this is our fault because we gave our products really simple names – NHS.UK, the NHS App – it's been easy for those names to be used differently."

NHS Digital wants "as many people as possible" to download the NHS App, which Wilkinson labelled a "critical entry point" to NHS primary care.

"One of the things we're trying to achieve in our big digitisation of the system agenda is that every citizen in the UK has an NHS login and they are able to use that for the app, and to access all the other services we want to put closer to the citizen," says Wilkinson.

"Now we're working with suppliers across the space to get them to use that as the standard authentication mechanism, so anybody going into any NHS services will be authenticated through that one login. It's also massively driven up our standardisation of an identity and authentication strategy."

Sustaining the momentum

As the UK slowly comes out the other side of lockdown, the momentum we've seen around digital adoption in recent months is likely to slow as service demand returns to normal. But the progress that's been made, and the lessons that have been learnt during this period, won't be forgotten. For many clinicians and NHS staff, digital health has won the all-important hearts and minds game.

Whether the funding will be there to support sustained transformation is, as always, far less certain, particularly as healthcare services face up to the mountain of unmet needs that have accumulated in recent months. A King's Fund report prepared ahead of the COVID-19 pandemic had already concluded that the planned £140.4bn spending by the Department of Health and Social Care in 2019/20 would not be enough to deliver the widespread changes needed to transform care in the NHS, or improve its performance against key waiting-time targets.

A report from the UK's National Audit Office in May also highlighted the struggle the NHS faces in its digital transformation ambitions, putting the estimated cost of doing so at £8.1bn and questioning whether hospitals could afford the £3.1bn they were expected to contribute themselves towards new technology.

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With this in mind, and despite more than £6bn in emergency response money from the UK government, funding for digital looks uncertain as we emerge from COVID-19. Andy Webster, chief clinical information officer (CCIO) of Leeds Teaching Hospitals NHS Foundation Trust, points out that while funding channels for projects aimed at mitigating COVID-19's impact have been opened in recent months, tech budgets will soon be competing against other demands, such as putting in extra capacity to deal with longer waiting lists.

"There are obviously going to be pressures throughout all sectors of health and social care," says Webster. 

Looking ahead, the Leeds CCIO says investment in tech should be prioritised for projects that enable a so-called "left shift" in the delivery of healthcare: namely, reducing the reliance of the traditional hospital model, enabling more care in the community and only sending patients to hospital when they absolutely need to.

Patient-facing digital health services are the key here, says Webster. "I think the message before COVID was that we need to use technology to help empower patients to improve their health... things like patient portals to provide the ability for them to be better informed and enable self-care, the wider use of data to pick up patients earlier in the course of their illness to provide proactive, not reactive, care," he says.

"This needs to continue... Hopefully, investments we make will be evidence-based and shown to be effective and be a part of a health and wellbeing strategy."

Certainly at Lighthouse Medical, where the benefits of teledermatology have been proven, moving backwards is not an option. "The one thing I would say is that primary care has transformed itself, literally, within eight weeks," says Poyner.

"Our telephone and video consulting has worked so well, and been so well received by patients, there is no way we're going back."  

This sentiment is echoed by NHS Digital's Wilkinson, who likens the recent uptake of digital health tools to "opening up the floodgates".

She adds: "What's really great is that we're seeing so many more people in the system who have a hunger for digital products and direct, hands-on access to data... I don't think that's going to go away, because I think it's a cultural revolution."

The role of innovation

Innovation will undoubtedly have a role in helping the NHS overcome the challenges that lie ahead, such as working through huge backlogs in patient appointments for critical services.

Machine-learning algorithms could be put to use here. Since April, NHS Digital has been experimenting with an AI platform designed to help hospitals anticipate demand for beds and other vital equipment by COVID-19 patients, which could in the future be developed into broader frameworks. 

Wilkinson suggests this is an area NHS Digital will continue to explore: "You do these things in a crisis because you have to, and one of the great things about it is it gives you real confidence in the power of them. And then you keep going with them," she says.

"We want people to focus on digital tools that make the lives of clinicians and patients much easier and systems that allow us to get value out of all the phenomenal data we have, and systems that allow us to support clinical research," says Wilkinson.

"That's where the energy should be, and that's where the focus of the system should be."

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