Our delivery directorates: 1. Product Development

Giving people greater control of their health and care is not only a good thing  in itself, it is critical to the sustainability of the NHS and our social care system.

Mobile computing and internet-facing services have transformed the way we work, shop, manage our finances and keep in touch with our friends. We demand more from the organisations that serve us. We expect them to be transparent, accessible and responsive – and we expect them to offer full digital control of our interactions. In healthcare, this revolution has been slower than in many other areas of our lives. The NHS Long Term Plan, the 10-year strategy for the health and care system published in January, acknowledged that in many areas we are still locked in a provider-centred service model created when the NHS was founded in 1948. 

However, this much is clear: if we are going to respond to the needs of a growing, ageing and more demanding population and make the most of the extraordinary potential  of modern medical and genomic science, we must make full use of the power of modern communications to put the individual in charge of their  own health and care.

Our teams in Citizen Health Technology are building the platforms and interfaces that allow individuals to play this central role. According to the NHS Long Term Plan, the NHS App will “create a standard online way for people to access the NHS.”

At launch, its most basic functions allowed people to check symptoms using a health A to Z and use the NHS 111 online service. Other functions are being activated on an area-by-area basis. As GP practices across  the country get connected, patients will see new services: the ability to book and manage GP appointments through the app, order repeat prescriptions, view their records, register as organ donors and change their data-sharing preferences. 

We will continue to develop the NHS App to create a  secure, easy and consistent  way for people to access the NHS digitally.

The NHS App was the first major platform to use the NHS login service, which provides a simple, unified method for individuals  to sign on and access multiple digital health and social care services. It removes burdens on people accessing online  tools and reduces the costs incurred by organisations in delivering identity verification and authentication.

We’ve engaged with more  than 100 health and social care organisations and published a self-service process to help partners who wish to integrate with the service. Five partner services were being piloted by the end of 2018-19,  including an online triage and consultation tool for NHS GPs and a project in Leeds to allow patients to update their own medical records.

In 2019-20, we will be developing automated identity verification checks to increase the capacity of the service, introducing proxy access to allow patients to nominate  their carers to manage their care online, and exploring new ways of verifying identity including fingerprint and face recognition.

In June 2018, we published a set of standards for identity verification and authentication across health and social care. These standards provide a consistent approach to identity and describe why and how a person should  prove their identity to access digital health and care services. They will support interoperability between services and ensure safety and reliability.

The NHS website (NHS.UK) exists to improve health outcomes, improve people’s health, care and well-being, reduce pressures on the frontline and make the system more efficient. It is the UK’s biggest health website, with an average of 46 million UK visits per month through 2018-19. It achieved a satisfaction rate of about 80% over the same period. 

We removed the ‘NHS Choices’ name and logo in 2018, so it’s now simply ‘the NHS website’. We created a refreshed mobile-first homepage design with much easier navigation, introduced a new content management system and published a digital service manual setting out user-centred standards for service and visual design. We now have a modern platform capable of reaching more people with better information, advice and tools  to help them manage their health and care. We have also lowered the reading age needed to understand our articles.

We have also improved the  ‘findability’ of NHS content and have connected to more young people through our social media campaigns. Our partnerships ensure that we reach more people. We have 1,300 partners signed up to our syndication offer, with audiences conservatively estimated at about five million a month.  

We will lead on more campaigns throughout 2019-20 and make it even easier for people to find the information they need to look after themselves and those they care for.

There are now more than 70 approved apps on the NHS Apps Library. We are working with more than 105 developers and have over 119 apps in review, providing information and support on topics from diabetes management to helping teenagers cope with mental health issues.

In June 2018, we published updated guidance to developers explaining their responsibilities under the General Data Protection Regulation (GDPR). All apps on the NHS Apps Library were assessed for compliance with the new regulations and 56 of the 70 were approved.  

Fourteen apps have been required to take immediate action to address GDPR issues. Ten apps have been removed because they were unable to satisfy the assessors.

To increase the number of trusted apps available to the public and our health and care partners, we developed a framework to allow the recruitment of third-party organisations as approved assessors of apps and invited six to join the process in May 2019.

Much of the work of Citizen Health Technology is about enabling clinicians and members of the public to work together. This changes the balance of the relationship between clinician and patient and creates opportunities for completely redesigning services.

Our Personal Health Records programme is at the heart of that work and is working closely with local areas to ensure innovation at the grass roots is joined up and supporting overall NHS improvement. In May 2018, we published NHS-wide standards and guidance for personal health record access. 

We distributed a toolkit to help local organisations align with national process and worked directly with key areas to ensure they were connected seamlessly with services like the NHS login, NHS App, and the NHS Apps Library.

The National Data Opt-out Service also puts individuals in control. It was successfully launched on 25 May 2018, giving people a clear choice about how their confidential patient information is used for research and planning by the health and care system. 

They can simply state their choice once on-line or through our contact centre and are then able to change their minds whenever they wish. By giving people more information and more control, we expect to increase trust in the use of data to improve treatment and the effectiveness of services.

The NHS Long Term Plan relies heavily on the use of digital technologies to empower patients and change traditional models of care, but it also stresses the importance of ensuring everybody is able to access this in the future “from the most digitally literate to the most technologically averse.”

Since March 2017, our Widening Digital Participation programme has supported over 167,000 people from excluded communities to access and use digital health tools and services. This year we delivered six digital inclusion pathfinder projects  to develop and test new ways  to support homeless people in Hastings, older people in  care homes in Portsmouth and people with sensory impairments in West Yorkshire.

In May 2018, we also published the Digital Inclusion Guide for Health and Care to help commissioners and digital teams across the NHS ensure their digital services and products are inclusive and accessible to everyone. 

Next year, we will deliver a further six pathfinder projects to help people with dementia in Leeds, those living with cancer in Nottingham and  to improve the digital skills  of nurses in Cumbria. By March 2020, we hope to have supported 280,000 people from deprived communities to access and benefit from digital health technology.

We are working with local organisations across the acute, emergency and mental health sectors to use digital technology to support new models of care.

A handful of core electronic systems are transforming how patients access health services, allowing us to get people the right care quickly and relieve pressure on frontline services.

NHS 111 online is now available across all of England. Anyone with an urgent medical concern can visit 111.nhs.uk, answer questions about their symptoms, and find out what to do and where to go. The process usually takes about two minutes and in most places users can have a clinician or out-of-hours GP ring them, if needed. The service is also available through the NHS App.

NHS 111 online was used nearly 800,000 times in 2018-19. By November 2018, the service had met its 6% uptake target, five months ahead of schedule. A national publicity campaign at the start of 2019 prominently featured the online option. During this time, 111.nhs.uk accounted for 10.5% of NHS 111 triages.

The NHS Pathways and the Access to Service Information (A2SI) teams are both working to improve the tools used by clinicians and NHS 111 and 999 call handlers to assess, triage and direct patients to the right urgent and emergency care services.

We are constantly updating the service’s algorithms to ensure individuals get the right care in the shortest possible time. This is a continuous process of questioning, re-evaluating and improving the way we handle a wide range of symptoms and situations, from how to help emergency callers conduct CPR to providing advice on emergency contraception.

By January 2019, all Pathways providers had deployed a major update including a new triage pathway to help ambulance services manage major incidents such as road traffic accidents or terrorism attacks. Among a range of other improvements, we are providing a safer and faster response for children complaining of chest pain and introduced new options for mental health crisis teams and next-working-day pharmacy referrals within Pathways.

Our Access to Service Information (A2SI) is improving the Directory of Services (DoS), the core application that holds information about the availability of local health and care services in England. It is used by call handlers and clinicians to find the right care services for patients. 

In October 2018, we started a private beta of new functionality providing users with live information about current wait times for emergency departments and urgent treatment centres.

We are also testing a mobile search capability for paramedics and pharmacists, allowing them to use the directory while on the move.

By March 2020, we expect all healthcare professionals to be able to directly book appointments for their patients through the directory.

The Urgent and Emergency Care Digital Integration team is working with suppliers to improve the flow of patient information so that patients do not have to repeat information and tests as they move between care settings - and to ensure that professionals have the information they need to make prompt and safe decisions. 

We are supporting interoperability between patient information systems and clinical decision support systems through adoption of our FHIR-based standard across urgent and emergency care settings.

Our Trust System Support Model provides direct, practical help to trusts taking on major technology projects. We work with NHS England and NHS Improvement to offer trusts access to specialist expertise and national best practice on subjects including technical infrastructure, testing, business change, service management and clinical engagement. 

We provide business case and strategy reviews, support before deployments to ensure trusts are well prepared, and, if necessary, get involved after deployments if challenges are being experienced.

We worked with NHS Improvement and trusts to review eight major digital business cases. 

We have also supported trusts using the Lorenzo electronic patient record system under the Department of Health and Social Care’s contract with DXC Technology, with four trusts selected as Lorenzo Digital Exemplars responsible for demonstrating how the system can support integrated care. 

We worked with the Chief Information Officer for Health and Social Care to establish a strategic relationship- management function for key suppliers into secondary care and have put service improvement plans in place with suppliers where performance has been an area of concern. 

The Global Digital Exemplar (GDE) programme, which we run in partnership with NHS England, is supporting 26 acute, ambulance and mental health trusts in pioneering the use of digital technology and data to deliver exceptional care against international benchmarks. These exemplars are working with 24 ‘fast follower’ trusts to develop best practice evidenced by improved outcomes that  can be shared. 

In 2019-20, we expect to accredit the first cohort of full GDEs, meaning they will have met the standard of world-leading use of digital technology. We have produced 34 GDE blueprints, clearly describing what was learned in specific projects and setting out systematic approaches to implementation elsewhere in the system. 

Cambridge University Hospitals’ work to develop a Global Trade Item Number (GTIN) database to tighten up medicines supply and administration is just one of the new approaches developed by the GDEs that look set to have a major impact.

The database will allow much better tracking of medicines, helping to ensure compliance with the Falsified Medicines Directive and, ultimately, safer treatment for patients. 

The programme is working with the Local Health and Care Record Exemplar programme, the Academic Health Science Networks and the Building a Digital Ready Workforce programme to use the learning networks developed by the GDEs to support improved sharing of best practice across the system as a whole. 

We have introduced a portfolio and programme management tool, called ‘Project Vision’, for all GDEs, which is being used by more than 50 trusts to help with GDE reporting. It has been so well received that some have elected to use it to manage other project portfolios.

It has allowed the central programme to efficiently showcase and report on trusts’ progress across a wide range  of themes – saving time and money and also improving quality.

The programme continues to expand, with £200 million funding announced by the Secretary of State in September 2018 to create the next wave of GDEs, including the first community trust exemplars.

User researcher Jeanette Attan works with members of the public to shape the new NHS 111 online service.

“It is about talking to people and observing how they actually use your product and then changing things to suit what they need – not what you thought they needed,” says Jeanette.

NHS 111 online allows patients to enter symptoms and answer a structured set of questions to identify what healthcare, information or guidance they require. Answering questions online is different to speaking to a call handler. There’s no opportunity to ask for clarification if you don’t understand.

“When I first started working on 111 online,the system asked: ‘Do you feel severely ill with a new rash like bleeding or bruising under the skin?’ This two-part question was difficult to answer. One woman said, ‘I didn’t have a rash, but I did feel severely ill, so I am going to answer ‘yes’.” 

That answer would have resulted in the woman being told to call the ambulance service, because the question was checking for severe sepsis symptoms linked with meningitis. Answering incorrectly can result in unnecessary load on stretched services. 

Jeanette’s research provided evidence for  splitting the question into two simpler parts and has fed into a wider review about how  such questions are asked across the whole NHS Pathways product. 

“The work to improve the site is continual. The whole 111 online team regularly gets to observe users navigating the site and testing  new pages. Doing this helps everyone understand users and how to make sure the site works for them.

“People are unpredictable and have a whole range of experiences, so there are always ways in which we can improve.”

Primary care is under unprecedented strain and yet is critical to the future of the NHS. A growing and ageing population with complex multiple health conditions must have access to responsive and integrated primary and community care.

The NHS Long Term Plan pledged to finally dissolve the historic divide between primary and community health services in England. Investment in these sectors will grow faster than the overall NHS budget over the next five years, the equivalent of at least an extra £4.5 billion in real terms for local services by 2023-24. 

The focus is on creating integrated and flexible primary care networks involving GPs, pharmacists, district nurses, community geriatricians, dementia workers, physiotherapists, social care providers and the voluntary sector, which will give patients more choice and better targeted care. 

Our Primary Care Technology teams are linking up the fragmented IT systems in primary care and providing  the secure and flexible access to records, care management tools, and data that the Long Term Plan’s new model of care requires.

We run the contracts for the provision of clinical IT systems to every general practice in England. These are essential to safe and effective primary care and support more than 300 million patient consultations every year. 

We are replacing the old GP Systems of Choice (GPSoC) framework, which limited GPs to four principal system suppliers, to a much more flexible arrangement offering more choice, more innovation and greater interoperability. Over the past year, we consulted with GPs, practice managers, IT suppliers, clinical commissioning groups (CCGs) and commissioning support units (CSUs) and we will transition to the new framework by the end of 2019. 

Like the old framework, GP IT Futures removes the burdens of procurement from practices, but a new digital marketplace, called the ‘Digital Buying Catalogue’, allows buyers to compare products and services from different suppliers, assemble the right mix of technology for their needs and add new capabilities.  

It will make it easier for small suppliers to enter the market, increase competition and drive innovation in important areas such as clinical decision support systems and online consultations.

Meanwhile, the GP Connect programme has been breaking down the barriers between existing suppliers’ systems and connecting care. 

We have been working with suppliers and the NHS to test view-only access to patient records across all GP systems. Our pilots are demonstrating the benefits of such access for clinicians.

Dr Geoff Hall, Chief Clinical Information Officer at Leeds Teaching Hospitals NHS, who is involved with the Leeds Care Record, quoted one example from his own clinical practice. 

He had been able to see a GP diagnosis of advanced pancreatic cancer for a patient he saw on call and get full details of what the patient had told the GP and what their family knew. 

We expect to make view-only access to the GP clinical record available across the country in 2019 and we are already well advanced on the next phase  of improvements. Enabling GPs or NHS 111 staff to book and change appointments in partner organisations’ systems will  help get patients the right appointments more quickly and at the times that are convenient to them. 

We also want to allow the secure sharing of medications and allergies information from the GP record into partner systems, cutting the number  of times patients have to  repeat information about their medications and allergies to staff, reducing the risk of error, and supporting efficient collaborative working across primary care networks. We will be piloting both improvements and expect to make them available across the country by the end of 2019-20.

The GP Connect team has also been working on a ‘writeback’ function that will allow clinicians in one GP practice to send a consultation update back to the patient’s registered GP, helping close the loop when a patient has been seen in a federated practice or at a weekend or in an evening. 

We are leading the implementation of SNOMED CT as the single, standardised terminology for use in all electronic health records in general practice. This is another critical step in integrating IT  and data flows across the sector. Having one terminology will allow digital systems to share information more effectively  and will allow us to unlock the power of the data produced to support clinical decisions and improve planning and research. 

Complete adoption of SNOMED CT across the sector was not achieved by our target date of October 2018 as not all suppliers were able to achieve this date. However, all four principal suppliers of GP systems do now have systems in place to receive and send items using SNOMED CT through the GP2GP patient transfer system and the Quality and Outcomes Framework (QOF) extract reports. 

One of the suppliers, TPP, has achieved full SNOMED CT compliance and the remaining three principal suppliers are on course for full compliance in 2019.

We are improving the capability of the General Practice Extraction Service (GPES), which collects information about practice activity that underpins vital services such as GP payments but also helps us respond to growing demand for data for planning and research. This data is feeding directly into better care. 

For example, the diabetic retinopathy screening extract was used to improve the screening process by ensuring patient information is correct and up-to-date, allowing faster and easier creation of patient registers for new screening programmes. These early interventions can be critical to protecting sight.

We also implemented the first national collection of appointments data from practices in England, providing comprehensive data about the availability and use of appointments across England. This provides valuable new management information for the NHS and we also provided a dashboard to all practices, giving them easy access to  their own information.

In May 2018, the Secretary of State for Health and Social Care announced a serious failure in NHS breast screening programmes. We provided support to Public Health England and other partners to resolve the issue.

We continue to provide technical expertise to support the NHS’s screening programmes and provide systems to support breast cancer screening, cervical cancer screening, bowel cancer screening and abdominal aortic aneurysm screening. 

We are supporting the introduction of the Faecal Immunochemical Test (FIT) for bowel cancer screening. FIT will give more sensitive  and specific results and replace subjective human judgements with numerical results that will reduce error.

Organisational and professional barriers within our healthcare system – between social workers, care providers, pharmacists, GPs and hospital clinicians – not only make it harder for professionals to do their jobs, but waste hundreds of millions of pounds a year. Such barriers make it more difficult for the public to get the seamless and personalised care and treatment they have a right to expect.

We are providing products and services that break down these barriers. The objective is to allow information to flow securely with the individual as they move through health and care and to give professionals the tools they need to work effectively.

The NHS e-Referrals Service is one of the most important digital systems in our health service. It handles about 400,000 referrals every week and saves the NHS about £50 million a year. 

We have been steadily improving its usability for both patients and clinicians, while increasing use across the system. In March 2018, about two thirds of GP-to-first-outpatient appointments in England were electronic. By October, we had increased that to more than 90%. Our ‘paper switch-off’ campaign trained over 1,000 users and supported 150 trusts and hundreds of GP practices in making the transition.

We made a series of improvements to the service through the year. Patients can now save appointment information from our ‘Manage Your Referral’ website to calendars such as Outlook or Google Calendar.

We have also improved the accessibility of ‘Manage Your Referral’ for visually impaired people by better supporting screen-reading technology. In January, we improved the letters sent to patients from the system, replacing two separate messages with a single letter that more clearly sets out all  the key referral information. This makes it easier for patients to log in and manage their referrals and reduces printing costs for GPs.

We also released a range of application programming interfaces to allow third-party IT suppliers to integrate with the e-Referral Service, allowing clinicians to make and review referrals without leaving their preferred systems.

More than a third of  England’s 11 million children are considered at risk of avoidable disease and harm. The health and care system is spending about £39 million nationally on child health information services but failing to adequately integrate children’s healthcare. Much of the information about children’s health is still held on paper in the 20-year-old ‘red book’.

Our Digital Child Health Programme is getting children’s information off paper and into fully interoperable digital systems.

In December 2018, we published an information standards notice requiring all care providers and IT suppliers to standardise the information they collect and record about children’s health so it can be shared between systems effectively. 

We have also completed the first phase of the development of the National Events Management Service. This system will track all children’s contacts within the Healthy Child Programme.

Phase one is already live in the North East London Foundation Trust, allowing basic demographic and birth data to be shared among the trust’s more than 400 staff. It covers more than 600 births a month. By March 2020, we expect to have introduced a ‘digital red book’ in London, Lancashire, Bristol and North Somerset and South Gloucestershire.

Our Digital Maternity programme is linking up digital maternity records so they are more accessible to parents  and their healthcare teams. 

We published a maternity record standard in December 2018 describing the professional clinical record to be adopted  by maternity system suppliers. 

This provides the basis for standardising and connecting records and transforming models of care in line with the National Maternity Review’s ‘Better Births’ report. By March next year, we expect to have offered over 100,000 people access to their own digital maternity care records. 

We also assessed and reported on the digital maturity of all 135 trusts in the 44 Local Maternity System areas and provided a toolkit, advice and workshops to help local areas prepare to support a fully integrated pathway. 

We have updated the maternity guidance available through the NHS website and the other apps and websites syndicating its information.

The Child Protection - Information Sharing (CP-IS) service provides a vital link between the IT systems of social care teams and those of emergency departments, minor injury units, maternity units and other unscheduled care settings. It flags young people with child protection plans or with looked-after child status when they attend health settings. This alerts health workers that they may be dealing with a protected child and ensures that social care teams know that the child has required unplanned medical attention.

During 2018-19, the number of health sites live with CP-IS increased from 52% (593) to 92% (1,035). 

The number of local authorities on the system has risen from 68% (104) to 91% (138). All local authority IT system suppliers and the top seven unscheduled healthcare system suppliers are now accredited. We expect to have 99% uptake in both sectors by March 2020 and we are preparing to extend the types of health settings covered by CP-IS from 2019-20, in line with the March 2023 target in the Long Term Plan.

The Electronic Prescription Service (EPS) is another crucial link in the health and care system. By making all prescriptions digital, we are not only saving time for prescribers and pharmacists and making life easier for members of the public, we are also transforming our ability to monitor and control the medicines supply chain and assess the effectiveness of prescribing.

We took a major step toward an entirely electronic prescribing system in February, with the start of the roll out of schedule 2 and 3 controlled drugs on EPS. These are drugs, like morphine (schedule 2) or flunitrazepam (schedule 3), that have legal controls on their storage, production and supply to prevent misuse.

We also began to remove the need for patients to nominate the pharmacy that prescribers need to send electronic prescriptions to. Instead, the prescription is still sent electronically and held on the NHS’s IT systems. Rather than its destination being predefined, the patient presents a token that includes a barcode that is then scanned by the pharmacy. That scan sends a message to the NHS IT systems and the electronic prescription is retrieved.

These two major changes are expected to increase the proportion of prescriptions sent by GPs that are electronic from about 67% to more than 90% by 2020.

During the financial year, we continued to introduce EPS into integrated urgent care settings such as NHS 111 call centres. This allows patients to have emergency acute prescriptions sent directly to an available pharmacy of their choice after phone consultations with out-of-hours clinicians. 

Our implementation teams are working with service providers to introduce this functionality. At the end of March 2019, 24 urgent care providers were using EPS, with many more to follow during 2019.

In collaboration with the Professional Records Standards Body, we created standards to allow clinical services offered to patients at a pharmacy to be digitally captured and securely transferred to their GP. In practice, that means, for example, that a patient’s GP can be informed electronically that they have had a flu vaccination without the need for letters, phone calls or emails.

The Falsified Medicines Directive (FMD) says that all medicines packs must have a barcode that can be scanned when received by pharmacists, GPs, hospitals and other prescribing environments. This scan sends a message to a national database managed by an external body that contains all details of legitimate medicines packs. The scan is checked and sends a message back to the user to confirm the medicine is  genuine  and  safe to prescribe. We have worked with NHS organisations to define guidance to  support FMD implementation and tested it in pilot areas to ensure it is fit for purpose.

A complex commissioning and delivery environment has contributed to lower levels of digital maturity in some parts of the adult social care system than in healthcare. We are increasing the availability of NHS Digital products, implementing new digital systems to make transfers of care between health and social care safer and more efficient, and working with providers across the sector to improve information governance, data security and digital maturity.

In July 2018, we launched first-of-type sites for acute discharge to social care. This allows people to be discharged more efficiently and gives them access to the care they need more quickly, often avoiding unnecessary returns to hospital.

In early 2019, the suppliers of LiquidLogic and Mosaic, two of the main case management systems used by local authorities, developed functionality to exchange assessment, discharge and withdrawal notices with hospitals using the NHS’s secure messaging systems. These functions are in line with NHS Digital’s Target Operating Model standard and are now being user tested in local authorities across the country. Plans for wider adoption are being developed for delivery over the next two years.

We have also committed to support more than 60 local authority and care provider projects to explore how digital technologies can improve services. The Social Care Digital Innovation Programme, run in collaboration with the Local Government Association, funded 12 projects in 2018-19. Projects ranged from investigating public reactions to the use of exoskeletal devices to help carers in the Isle of Wight to developing the use of wearable biometric devices to improve support for people with autism on the Wirral.

Named Nurse for Safeguarding Children at Surrey and Sussex Healthcare NHS Trust, Sally Stimpson, says the introduction of the Child Protection - Information Sharing service (CP-IS) has been invaluable in sharing child protection data automatically between children’s social care and the NHS.

“Recently, a teenager attended the emergency department with a complication of early pregnancy,” says Sally.

“Her social worker was alerted via CP-IS, immediately after she had booked in for unscheduled care.

“They were then able to make contact immediately to inform us she was a looked after child (LAC) who had been missing and had been identified as at high risk of child exploitation.

The Trust was one of the first in the country to use the integrated CP-IS service, which links IT systems across health and social care to ensure children’s services will be made aware of every young person under the age of 18 who attends for unscheduled care and is either subject to a child protection plan or is a looked after child. This has been particularly valuable in ensuring the most vulnerable 16 and 17-year-olds who are routinely seen in the adult emergency department are automatically identified.

“Effective sharing of information across agencies nationwide is vital in protecting children who are at risk of neglect or abuse,” says Sally. “Early intervention makes it possible to prevent further harm by working with children and families.

“We were getting an increasing number of calls from social workers to the point where we have a dedicated email address to deal with enquiries about children on their caseload who have attended.

“CP-IS provides an additional level of protection for the most vulnerable children and young people in England and supports cross-agency working to achieve the best outcomes.”