eHealth Strategy 2011-2017
The eHealth Strategy 2011-2017 provides NHS Boards with the opportunity to drive eHealth enabled improvements closer to the front line of service delivery and to align eHealth more closely with the NHSScotland Quality Strategy. Five new strategic eHealth aims have been developed and these will be the focus of activity over the next six years. They are: supporting people to communicate with NHSScotland; contributing to care integration; improving medicines safety; enhancing the availability of information for staff; and maximising efficient working practices. The eHealth Strategy aims to leverage the IM&T assets to support the quality improvements that NHSScotland has committed itself to through the Quality Strategy.
The potential of information technology to support and transform healthcare services is universally recognised. In Scotland, eHealth has a pivotal role in enabling a radical e-transformation in the way in which high quality integrated healthcare services are delivered efficiently and effectively to people of all ages across the country.
The focus on five strategic eHealth aims as an enabler of quality improvements in healthcare services across Scotland will have considerable implications for the way in which asset will be used to support service delivery in the future. Increasingly, patients and staff will focus on the use of IM&T assets rather than property assets to receive and delivery care. It also changes the way in which performance is measured. Boards' eHealth Plans will be aligned to LDPs and will include:
- benefits being maximised from IM&T assets that have been acquired during the previous strategy (2008-11);
- information and evidence on eHealth's contribution towards achieving the five strategic eHealth aims;
- promotion and implementation of good practice and successful local initiatives more widely;
- convergence of approaches to delivery in order to reduce duplication of effort and reduce cost;
- collaborative working between Boards and cross-border eHealth developments
Society is increasingly comfortable with self-service models of interaction and although face-to-face services have not disappeared, their dominance has been replaced by a much more diverse mix. Although NHS24 delivers telephone based and online services, NHSScotland relies heavily on face-to-face consultations and the way people receive healthcare remains largely unchanged despite the radical transformation in the way in which other public services are delivered. eHealth can enable NHSScotland to take advantage of the everyday technologies already used by most people in their daily lives. eHealth could contribute to a radical transformation in the delivery of health and social care services in Scotland over the next decade through enabling people to access and interact with their health records electronically, and through a greater emphasis on the delivery of services through different communication channels, e.g. online by patient portals or electronic windows to information, via email, websites, digital channels and social media.
Analysis of the IM&T Gartner Survey 2011/12 (used to identify the costs in this SAFR Section 3.4) shows that:
- over half of the benchmarked spend (c£74.9M) is classified as Applications Support or Development, and over half the 1,082 IM&T staff dedicated to these areas
- whilst Data centre costs are c£19.3M, over a quarter of this cost is attributable to the 138 staff
- the Data centre and 'Client and Peripherals' areas could be considered the most commodity like services, yet account for nearly 37% of FTEs (401) and c£42.8M of benchmarked spend.
Whilst NHSScotland compared well against its peer group, Gartner were able to indicate areas for improvement such as considering data centre consolidation, or shifting to cloud based services. The implications of this on staff and resources would need to be considered.
The priorities for work within the Applications and Infrastructure funds can be categorised into the following:
- 'Must Do' projects. These are systems at end of life, or existing contracts for services and licenses that are due for renewal.
- 'Invest to Save' projects. The sole basis for undertaking these projects is to release savings in the future.
- 'Potential Development' projects. These are projects designed to move the national infrastructure (including application architecture) in a strategic direction, or to absorb costs for new national systems.
Of the categories listed above, the last two are optional. The eHealth Leads could take no action in these areas. Ongoing costs for national solutions developed within the Strategic fund continue to be considered for accommodation within the existing Application and Infrastructure funds.
'Must Do' Projects:
Within the Applications and Infrastructure funds there are a number of systems and services that are due for replacement. During FY13 the Leads progressed all of the priority areas. During FY14 the focus will be on progressing the business cases for the 'Must Do' projects defined below:
- N3 Replacement (SWAN)- current contract ends FY14
- NHS Mail replacement - current contract ends FY14
- Support Needs System (SNS) - currently out of support
- Scottish Breast Screening (SBS) - due in FY2013
- CHI Modernisation - includes GPRS
- Child Health systems - dependent on the CHI modernisation
To date, NHSScotland has been able to fund the NHS contribution to the SWAN business case development from within the Infrastructure investment fund, and additional savings made by the NISG team managing N3. A significant cost pressure in FY15 will be associated with funding the repayment of financing for SWAN. To meet the proposed finance model in the SWAN business case, financing was required from the SG Health Department and NHS NSS. This financing has been provided to NHSScotland on the basis that it would be repaid in the subsequent 2 years. The overall amount to be repaid will not be confirmed until after the SWAN Business Case is completed. Provision in the Infrastructure investment fund will be made to absorb this cost, once the contract has been finalised.
The NHS mail replacement business case has been underway throughout the year. Different models and funding scenarios have been explored at a high level and business case development will progress during FY14. The proposed solution will require migration from the existing NHS Mail system, and if agreed, from non-NHS Mail systems to the new service. Work will be required to define and agree what the new service will provide, and the migration plans of each Board into the national service. If the replacement service incorporates existing non-NHS Mail Boards there is likely to be a net increase in the annual cost of NHS Mail. A provision of £500K p.a. has been included in the financial plan to cater for the increase. A provision of £1.7M has been made to cater for migration costs to the replacement service.
The Scottish Breast Screening Programme (SBSP) IT replacement project has been delayed. As agreed with the Scottish Government, the eHealth Leads would not contribute to the development of the replacement system. eHealth Leads will continue to have a presence on the project board for the IT system replacement, monitoring progress and raising concerns with the project chair on potential impacts on the Boards.
The VME modernisation programme was progressed throughout FY13, with an Outline Business Case developed for CHI Modernisation, and an Output Based Specification for the Child Health Systems. If the OBC is agreed then a competitive dialogue procurement will be commenced throughout FY14. There is some latitude on when the business case is approved and the implementation begins, however it is recognised that this may result in additional costs on SCI Store (demographics services) and local Board systems. The Child Health systems replacement for School, Pre-School, support Needs System and SIRS will progress throughout FY14 with work commenced on the OBC for these systems. Extensive stakeholder engagement will be required on the development of these documents.
Emerging Trends in the Supplier market
Over the past five years NHSScotland has made significant investment in both the GP and PMS markets. When considered against the 'locked out' market created by Connecting for Health in England, this has been an attractive market place for eHealth suppliers to come to. NHSScotland has made its investment decisions, and a number of key suppliers have now been selected for the future of eHealth in Scotland.
In the past 2 years there has been a significant shift in the eHealth market across the UK. With the dismantling of Connecting for Health, and the scaling back of NPfIT, the eHealth market in NHS England has now become open to many of the vendors that had previously been 'locked out' of that market. In addition to these changes, the Department of Health has made significant sums of money available to support eHealth initiatives in NHS England. With the shift in direction from the NHS in England a number of our key suppliers are focusing time and effort on this market. This is likely to continue for the next 2-3 years and could result in a lack of access to the best resources from our suppliers, and a shift in strategic development focus towards the demands of the English market, ahead of those for NHSScotland. This is likely to be most noticeable in our GP suppliers, PMS supplier and PACS supplier, but may also become evident in some of our more niche suppliers such as Carestream.
Large scale investment in new eHealth systems in NHSScotland is unlikely over the coming 5 years. Following the successful implementation of new PMS solutions across the majority of NHSScotland hospitals, and the GP systems deal with EMIS and Vision, there remains small scale investment in key pieces of the eHealth architecture. Contrast this with the emergence of tenders in NHS England, and the scale of investment announced there, keeping suppliers focused on Scotland will be difficult.
The current Atos contract ends on 31st March 2018. This represents a significant opportunity to transform this relationship and the core pieces of the eHealth architecture. For a number of key systems (CHI, ECS, SCI Store) this provides a clear break point where changes can be introduced with limited financial impact. At worst it allows eHealth to reset key elements of the contract to fit with future delivery, and a mechanism to encourage other suppliers into NHSScotland.
Horizon Scanning 2016 onwards
To ensure ongoing affordability of the Infrastructure and Applications systems and services, monitoring of the agreed cost reduction work from previous years will need to be maintained. Given the criticality of the funding gap in FY16, slippage on these projects will add pressure to an already tough fiscal position.
As outlined in the previous sections, there are a number of inbuilt cost pressures within existing contracts and agreements for the Infrastructure and Application funds. The overriding priority for the eHealth Leads is to ensure that these cost pressures are met from within the existing allocation from the eHealth Programme Board. Activity to identify and implement cost reductions will continue to be a priority.
FY16 represents a year of significant financial pressure on the Applications and Infrastructure funds. On present projections there will be a deficit of c£3.3M that will need to be addressed. Significant work will be required during FY14 and FY15 to close this gap, and to develop a contingency plan for dealing with any residual deficit.
In order to achieve the target date for VME Migration (31st March, 2018) focused effort will be required over the next 4 years. Whilst the current plan for the CHI/GPRS, Child Health systems and SIRS replacement would see the bulk of spending on a new system being incurred in FY16, there will need to be procurement activity undertaken in the preceding years, and preparation activity on the mainframe, as well as an active programme of engagement with the diverse stakeholder community
As the 'closing the loop' work continues, it becomes clear that a HEPMA business case may come forward in the next 3 years. Whether funded by the Boards, the eHealth Directorate or in a combined funding model, like PMS, this is likely to represent an investment in the tens of millions, over the lifetime of the project. Given the SWAN funding position, and the continued pressure on eHealth IM&T budgets, work will need to be done to identify savings that could be released to fund this programme of work.
Health and Social Care Integration will increasingly take focus across NHSScotland. With the creation of the Health and Social Care Partnerships (HSCPs) a new model of commissioning NHS services looks likely to arise. From this, complex and at present, difficult to determine IM&T requirements will come forward. This is particularly acute for Health Boards with more than one HSCP to support. Working towards open systems and open models of information sharing will be key to delivering the needs of these partnerships. For some Boards this may present a significant internal challenge, especially considering the current shape of the workforce. Whilst Health and Social Care Integration may not require significant investment in systems, it is likely to drive up the demand for mobile devices, and mobile access to data, which will have an impact on workloads for eHealth across NHSScotland.
With the rise of smart phones and tablet devices, there is an increasing demand for access to systems and data away from the traditional desktop environment. This represents a significant challenge to eHealth and suppliers, who have traditionally sourced systems fit for MS Windows based environments. unless there is significant demand from other clients, suppliers are likely to choose a preferred mobile/tablet provider and make their product fit for purpose. Others may not consider any investment in this space. NHSScotland Health Boards may choose different devices to provide services to their clinicians, potentially leaving suppliers in a position where they must support 3 different platforms for one system. All of this is likely to increase cost pressures on IM&T over the next 5 years. This is without considering the necessary support models and structures required for mobile working.
Patient centred care is an integral part of delivering healthcare. With the increasing penetration of smart phones, tablet devices and the internet usage, it should be expected that patients will demand more information about their care pathway, and to see more of their data on-line. Whilst this is currently a mostly passive relationship with the citizen, increasingly this will change, following the success of initiatives such as 'My Diabetes, My Way', and through telehealth and telemedicine initiatives. Boards will need to increasingly cater for this type of interaction. In-line with equity of access policies, and consistency of care across Scotland, this will require much greater standardisation across the NHS both in IM&T and in some instances care delivery. eHealth departments will increasingly find themselves in the middle of this, having to securely make data available, and harmonise systems across their portfolio.
With the procurement of TrakCare, and the deployment of Clinical Portal, there is an increasing reliance on IM&T to support NHSScotland activity. As Order Communications is deployed across health boards, it becomes increasingly necessary for IM&T departments to provide 24*7 support. In some cases this is at odds with existing terms and conditions for staff already employed in departments. Increasingly clinical directors will be looking for continuity of support, and the eHealth Leads will need to find a way of providing this. Given the current shape of the workforce, a regional support model, or shared service model may need to be considered, as not all Boards will be able to provide 24*7 support for all systems and services.
Significantly changing the contract with Atos in April 2018 has the potential to release streams of funding that can be used to encourage smaller and more nimble suppliers. Whilst this may introduce complexity into NHSScotland contract management, the potential benefit is to have a set of suppliers more aligned to eHealth strategy. In addition the changing of the contract will allow NHSScotland to significantly change key parts of the national IT infrastructure without affecting service delivery. Doing this would allow for re-investment to support some of the opportunities and issues highlighted above.
eHealth Finance Strategy 2011 - 2017
In March 2014 the eHealth Strategy Board agreed to the update of the eHealth Finance Strategy and development of an outline business plan that:
i) Aligns all eHealth funding streams with delivery of the updated eHealth strategy.
ii) Identifies the strategic priorities and budget required to maintain the existing level of service and support key Scottish government policy developments such as health and social care integration and 2020 vision.
iii) Identifies changes to current budgets and priorities that maybe required to achieve the updated strategic outcomes.
iv) Sets out the strategic role that some of the special Boards have in delivering and supporting national IM&T infrastructure, services and information management in support of the eHealth strategy delivery.
v) Considers whether strategic priorities are best delivered nationally/regionally/locally, and the right mix of workforce skills and sourcing strategy to deliver.
vi) Considers the supplier partnerships and funding mechanisms that will be required to achieve the outcomes and drive innovation.
Email: Gillian McCallum