The Download: Can NHSX unpick the digital quango tangle?

When HSJ asked around about plans for a central tech unit now officially known as NHSX, it was greeted with scepticism.

One senior NHS official said it probably wouldn’t happen and another replied, “Is that even a thing yet?”. After the story was published, one source said they’d heard rumours of an “NHSX” but had dismissed them as a “bit barmy”. It didn’t sound like a real thing.

But NHSX is now officially a thing. Health secretary Matt Hancock announced on Tuesday that NHSX would drive the national digital strategy in the NHS and assume much of the digital powers and responsibility that currently sit across NHS England and the Department of Health and Social Care. It even has a Twitter account.

But what problem is NHSX trying to fix and is a joint-venture between a government department (DHSC) and two NHS quangos trying to be one quango (NHSE/I) the solution to the NHS’ digital malaise?

All the quangos at the digital table

The problem that NHSX is trying to fix, according to Mr Hancock, is too many digital voices saying different things.

The health secretary told HSJ on Monday that to get anything done on NHS IT – which is the thing he wants to get done – involves pulling a lot of arms-length bodies and stakeholders into his office and corralling them into a consistent policy position on even the most mundane aspects of NHS IT. In Mr Hancock’s world, waiting seven months for everyone to agree that email is usually more sensible than a letter for communicating with patients is a real drag on exciting digital transformation.

NHS England has, pre-NHSX, led the IT strategy, national operational decisions, decided who gets money and what it should be spent on. DHSC has had oversight of higher-level digital policy and often does the actual doling out of money. NHS Digital builds and provides some central IT systems, collects NHS data, and provides digital support services for providers.

But it doesn’t collect all the data or provide all the central IT – Public Health England does some of that too. The Care Quality Commission regulates some aspects of digital technology (how it is used), but so does NHS Digital (sort of), and the National Institute for Health and Care Excellence, and the Medicines & Healthcare products Regulatory Agency.

Then there is the national information board that wrote an NHS IT strategy in 2014 that we are still nominally following. They still meet occasionally but haven’t announced anything since November 2017. The digital delivery board, set-up in 2016, is meant to oversee the NHS digital strategy. NHS Digital is accountable to DHSC and Parliament, but mostly takes orders from NHS England. Both these boards are chaired by the NHS chief clinical information officer Simon Eccles, who is employed by NHS England but is also DHSC’s senior representative overseeing NHS Digital.

I could go on about the Office of Life Sciences, Health Data Research UK and Health Education England, but, suffice to say, Mr Hancock has a point.

The question then is not whether NHS digital leadership is fragmented and messy (it is) but whether NHSX is the tool to unpick it.

A quango by any other name

First off, while NHSX is now officially a thing it is also, in another sense, not a thing.

NHSX is not a new arms-length body even though it will probably act like one. It’s not a legal entity and won’t become one. NHSX is an agreement between two (or three if you count NHSI) organisations to pool their digital responsibilities, with the terms not yet fully articulated.

It will have a chief executive (probably employed by DHSC) but it will not employ any staff. Instead, NHS England, NHS Improvement and DHSC staff will continue to be employed by their respective organisations while working together as NHSX. NHS Digital will now report to NHSX, but legally it will still be accountable to DHSC and Parliament.

Mr Hancock has said NHSX will have all the operational, financial and policy powers of NHSE and DHSC combined when it comes to digital. Taken together, the mandate for oversight of central tech funding, policy, IT standards, cyber standards, industry collaboration, contract reform, and embedding digital skills should give NHSX substantial power to accelerate digital transformation.

But it is likely to be a derived power, dependent on continuing agreement between the organisations that support it. Throwing these senior digital folks together might be valuable, in the way the best sustainability and transformation partnerships may claim to have better relationships and more coordination. But it might go the other way, with competing interests defending their own patches.

And because NHSX is not replacing any existing organisations, it may also become just another voice in the digital cacophony. DHSC hasn’t even decided whether to disband the digital delivery and national information boards, both established, like NHSX, to improve the coordination of NHS digital policy.

An NHS Digital staff memo that went out on Monday, obtained by HSJ, described NHSX’s remit as “evolving”. But its first task would be “defining a strategy and roadmap for digital transformation” and helping “the NHS to look outwards to the health tech market”. The NHS already has more than one digital strategy/roadmap/vision and many organisations interfacing with the tech industry. It is not clear it needs another.

Whose quango is this quango?

NHSX is very much Matt Hancock’s project and one of the initial aims was to give him more power, and conversely, NHS England less, to direct digital policy. But it is not clear that this is what will occur.

An early proposed version of NHSX would have placed it firmly within DHSC with its own director general reporting to Mr Hancock. This model, HSJ was told, was not popular within NHS England and what was announced on Tuesday is far looser. NHSX will float somewhere between NHSE/I and DHSC with the chief executive accountable to both organisations.

NHS England remains responsible for delivering the long-term plan, much of which relies on new tech. Many of the top digital brass at NHSX (NHS chief information officer, chief clinical information officer, and chief digital officer) will still receive their pay cheques from NHSE.

In his statement in support of NHSX, NHS England deputy chief executive Matthew Swindells emphasised its roles to “help us” deliver the long-term plan (NHS England’s plan). It is hard to imagine Mr Swindells completely surrendering his current responsibility for setting NHS IT policy, given its fundamental importance to the plan.

Much may rely on the personal ability of whoever becomes NHSX’s new chief executive to bring disparate voices together. NHSX success or otherwise could rely more on that person’s personal power to persuade than the power to direct.