Enabling service transformation in practice: reflections on the Wade-Gery review

The innovations we’ve seen in NHS services in response to the COVID-19 pandemic – such as more digital consultations, remote monitoring, and using data to prioritise vaccine rollout – have given us a glimpse of the potential of technology and data to revolutionise health care delivery.

As the relentless pressures on the health service continue to bite, it is therefore no surprise that people are increasingly pinning their hopes on digital tech to support NHS recovery and enable a shift to more sustainable and effective service models. This is the backdrop to the independent Wade-Gery review, commissioned by the Department of Health and Social Care (DHSC) and published at the end of November 2021, which aims to embed tech and data more centrally into wider service transformation.

Wade-Gery review pushes to integrate thinking on tech and service transformation

The review includes the recommendation, now accepted by Sajid Javid, that NHSX and NHS Digital be scrapped, and their teams merged into a new transformation directorate in NHS England (NHSEI), in order to integrate responsibility for the digital agenda. Although the review proposes to retain the joint NHS-DHSC nature of key policy teams that was established by NHSX, it calls time on Matt Hancock’s decision in 2019 to create a separate organisation to lead on tech. Surveying the current arrangements, Wade-Gery argues they have resulted in split responsibilities and funding for service transformation, duplicated activities, and many senior leaders ‘seeing digital as a separate, not embedded, enabler’. 

Few would disagree with the logic of integrating thinking on health tech, data and service transformation as closely as possible – while also being mindful that merging organisations does not automatically mean an end to siloed working. (Many will also be cautious about occupying lots of senior NHS leaders with reorganisation just as we head into a very challenging winter.) Bringing the chief executive of NHS Digital onto NHSEI’s executive recognises the importance of data issues in high-level policy, which is welcome, as is the review’s acknowledgement of the importance of building data analytical capability. And the review’s argument about tech being a means to an end – the benefits of which only derive from being successfully fitted into care pathways – is one we have been keen to emphasise at the Health Foundation (and, indeed, is a philosophy that NHSX espoused in all its work).

However, the Wade-Gery review provides less clarity on what the resulting approach to service transformation will actually look like, and leaves several questions hanging about the relative roles of the ‘centre’ versus the wider NHS.

A ‘transformation factory’

In merging NHSX and NHS Digital into NHSEI’s transformation directorate, the review envisages an operating model with several different layers. These include a transformation leadership function (setting out strategy and blueprints for change) and underneath this, core tech and data capabilities to develop the infrastructure and standards needed to make it easier to scale solutions across the NHS.

More controversially, the review also proposes the creation of a ‘transformation factory’. This is described as ‘a scalable capability that integrates clinical, operational and technological resources to transform patient pathways’ which will operate through multi-disciplinary service teams within NHSEI.

The notion of a factory conjures up the idea of transformation being made and delivered at the centre. And there will be occasions where that does happen; for example, simply putting in place infrastructure and standards to enable image sharing between high street opticians and hospitals can fundamentally reshape eye care pathways. But in the vast majority of cases, most of the transformation work will happen further down the system: at the level of pathways and providers themselves, where roles and processes need to be changed and new ways of working put in place. In these cases, the centre will need to be a transformation HQ, bank, procurer, adviser and evaluator, but not a factory.

Enabling transformation in practice

Achieving the right balance between top-down and bottom-up in service transformation is delicate. Integrated care systems don’t need to each invent their own app to allow patients to view their health records or create their own models for rare condition pathways. In some cases, design work might require niche expertise only available at national level. And where competing service models exist, evidence might show some to be more effective than others. So the centre has a crucial role to play in designing solutions, gathering evidence and sharing good practice (the kind of thing NHSX has been doing with its popular digital playbooks).

On the other hand, the complexity of service transformation suggests many aspects of it will be shaped by local context and circumstances – including the need to fit with other services – requiring further design work at pathway or service level, not to mention the hard work of implementing changes on the ground. For an interesting model of how to bridge local and national perspectives to co-create service solutions with those who will need to implement and use them, take a look at the latest Q Lab project (a partnership between the Q Community and NHSX).

The importance of context means that central blueprints need flexibility. It also has important implications for capability building. The review is ambitious about boosting NHSEI’s tech and data capabilities, which will no doubt improve its capacity to formulate digital service models and support digital change. But critical for effective transformation is building capability where the service change actually takes place: at the point of local adaptation and embedding.

For example, the review suggests the transformation factory might undertake initiatives like ‘the transformation of a clinical pathway such as at-home remote monitoring for the frail elderly’. But that’s exactly the kind of service change where we would expect most of the work (and corresponding capability needs) to be at the level of individual systems and services, and where we would expect significant contextual variation.

Capability building will have to go beyond tech and data too. Successful service change also requires skills in quality improvement, change management and project management. And this logic applies at the centre as well as throughout the system: the new operating model proposed by the review will need to be joined up with important improvement work going on within NHSEI.

Delivering on the review’s wider ambitions

Getting the transformation model right will be particularly important for delivering on the review’s recommendations to ensure service change is patient-centred and reduces inequalities. While technology plays a critical role in these two agendas – by enabling greater personalisation, shaping how patients can access services, helping to overcome communications barriers, and so on – it is not just about technology. Values, behaviours and the relationship between a person and their web of local services also play a role. As ambitions, they will be hard to achieve unless digital capability is joined up with improvement capability and support for locally driven change is more clearly defined.

Building public confidence

The review also leaves a range of other issues to be worked through. Little is proposed on how to move forward with developing public trust, yet progress on this will be essential if transformation efforts are to be successful. Recent Health Foundation polling shows the NHS has not yet ‘sealed the deal’ with the public on tech-enabled care, with around one in three people unconvinced about the long-term use of digital approaches beyond the pandemic. So there needs to be meaningful public engagement to understand and address concerns, and build confidence, including around data.

Funding the change

Buried in the small print of the review are proposals around financial management which could be very important: a more agile approach to business cases to enable multi-year funding requests; more sophisticated assessment of the benefits of digital transformation (which are often downstream and organisationally dispersed); and a review of how commissioning and payment frameworks can better support digital transformation. It’s vital these proposals are followed through.

The integrity and coherence of health and care statistics

There are also questions to ask about bringing the statistics function of NHS Digital into NHSEI. The official statistics that NHS Digital produce are governed by the law and the Code of Practice on statistics, which is fundamental to their quality and integrity. NHSEI will need to be in a position to deliver against these standards, including oversight from an experienced and senior chief analyst.

Furthermore, while NHSEI represents the NHS, these statistics extend to the wider health and care system. Governance arrangements will have to take the needs of the whole sector into account, which may require representation from other organisations. This also highlights the need for a more coherent statistics strategy across health and care as a whole, considering the role of the Office for National Statistics as well as that of NHSEI and DHSC.

What’s missing?

Beyond the transformation model itself, the review is quieter on several other important aspects of service transformation.

The first is the workforce. Workforce planning and development will be essential for delivering the new service models and ways of working envisaged by the review, but beyond the odd reference to training, there is not much discussion of how the recommendations will connect to the broader workforce agenda.

The second is research. Moving forward at pace with digital transformation is going to require faster ways of building evidence on what works and what doesn’t, to support the testing, iteration, adaptation and course-correction that are an inevitable part of complex service change. So the NHS’s research infrastructure needs to adapt to help.

The third is measurement. What is service transformation trying to achieve? And how will we know we are making progress? Only by measuring the right things will we be able to determine if things are moving in the right direction. Conversely, getting the metrics wrong could distort priorities and create perverse incentives.

These issues may not have been within the scope of the review. But they will nevertheless be critical if the new arrangements set out by Wade-Gery are to drive forward digital transformation successfully.

A leap forwards?

In summary, much remains to be clarified and worked through to deliver on the logic of the review’s recommendations. But it’s worth taking the time to get it right. Ensuring the new transformation model reflects the reality of delivering service change on the ground will ultimately determine whether the review can enable the leap forwards on data and tech that the NHS so badly needs.

Tim Horton (@timjhorton) is Assistant Director (Insight and Analysis) in the Improvement team at the Health Foundation.