Category Archives: NHS Policy

Open Digital Platform Challenge Fund

Many  will be aware of the proposal that Tony Shannon and I have been promoting to persuade the decking to allocate 1% of the money they plan to spend on an “Open Digital  Platform Challenge Fund” to stimulate the development of an open digital ecosystem based on open standards.

We have had a positive response so far and will shortly be presenting out plans to the NHS CIO and CCIO. We want to be able tell them that there are enough people and projects committed to an Open Digital Ecosystems to make good use of the money we are asking for and give then a good idea of the projects that might come forward if they take up our suggestion.

To this end we have been asking people for expressions of interest via this link . We are looking for expressions of interests from people who support the approach and the specific standards laid out in our document. In not onerous to fill in the form which does not imply a fixed commitment just a general indication of interest.

If you have not already done so I’d urge you to let us have your ideas

Full details below

 

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1) Executive Summary

An NHS open digital platform challenge fund will stimulate the development of an open platform in the NHS. Open digital platforms are independently forecast by McKinsey and Co to reduce the delivery of care costs across the NHS by 11%. They will support widescale entry and growth of suppliers into the market, injecting innovation at all levels of service delivery to support improved care outcomes for our patients.

In the context of an NHS struggling through a perpetual winter, open digital platforms present a realisable opportunity to massively stimulate new ways of working, process innovation and a new digital health and care market, based around services. This is independently forecast by McKinsey and Co who predict a positive financial impact in excess of 11% across the whole of health and social care.

By creating an open digital platform and a move towards a services market, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support transformational new models of care, radically improving the care outcomes of our patients and building a sustainable care ecosystem that is fit for the future.

There is little disagreement that platforms represent the future for digital health. Rather the present debate is about who should own them, and how and when they will emerge. The “status quo” retains the closed platform frameworks, introducing open interfaces for exchange of information. This provides a short term stimulus, supporting improvements in patient care and operational efficiencies. However in the longer term, by seeking to control the rules of engagement and restricting the mobility of data, the retention of closed platform frameworks will stifle competition, impede innovation, and continue to drive-up costs.

Open digital platforms are a radical alternative that overcome the serious shortcomings of closed platforms.
They present the most assured approach to achieve consistent, long term and affordable growth in innovation-led service transformation across the complexities of health and social care. They will enable the full competitive aspects of market supply to be exploited, with associated benefits of the injection of innovations on a massive scale. For this reason, open digital platforms are manifestly in the interest of both the NHS and its patients.

The purpose of the proposed Open Digital Platform Challenge Fund is to stimulate the development of an open platform ecosystem through kick-starting the creation of open platforms, building on work already well underway, and the development of exemplar applications to exploit them.

We propose that the fund is created through diverting 1% of the investment each year in NHS digitisation into the challenge fund. This fund would be made available via an annual open competition in the form of relatively small awards to innovative organisations (public, private and third sector). The selection of projects will be balanced to stimulate and develop an open ecosystem of shareable and reusable applications to service across health and social care. We are inviting submissions of expressions of interest into this Open Platform Fund. In so doing, we will gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding.

2) Current Situation

To introduce this bid for funding we need to review the current situation with important context on the bigger picture issues that are at play. We need to acknowledge and understand the current mediocre state of health IT, as an immature and problematic market with mixed/relatively poor value for money and results seen from billions of £ and $ of investment from the UK to the US and elsewhere.

We also need to recognise the related digitisation of the NHS has been over promised and under delivered for some considerable time. Compounding this people/process/technology problem is the ongoing and perpetual winter faced by the frontline in the NHS that is in the news.

We restate the need to continue the critical push towards more personalised, integrated care at home and in the community to meet the 2020 vision. This clearly requires an underpinning patient centred infrastructure to do so. Last February Jeremy Hunt announced £4.2 billion for NHS Health IT. In the last 18-24 months while there have been plans in the form of Integration Pioneers, Vanguards, Local Digital Roadmaps (LDRs), Sustainability Transformation Plans (STPs), there has been little/no allocated funding to date to make these happen.

In Autumn 2016 we were able to read and digest the latest review of the NHS IT, authored by US physician Dr Bob Wachter. Dr Wachter built his reputation as establishing the hospitalist as a medical specialty in the US. In recent years he has become a fearless and honest critic of the state of Healthcare IT in the US, with his book “Digital Doctor : Hope, Hype & Harm at the Dawn of Medicines Computer Age” (2015) exposing the real mediocre state of the health IT market in the US. The book and related opinion pieces on the state of health IT industry he explains some of the real problems with the current supplier market is clear. In a New York Times Op Ed piece on “Why Health Care Tech Is Still So Bad” (2015) he highlights that

“In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point…That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows”.

However in the NHS, Dr Wachter’s recent review led to funding being provided to “digital exemplars” all of which are a small group of hospital trusts in the NHS who will invest in those very same health IT monoliths. While understandable as a means to “do something”, rather than nothing, given the state of affairs is understood, it is sadly limited in its thinking and perpetuates the usual tactics that we have seen in the NHS IT for years, i.e. investing in the same 20th Century monoliths of old. We know that doing the same thing over and over and expecting different results is futile.

Simply put, if a small elite are getting the focus of funding for investments in 20th Century health IT monoliths over the next years then inequity within the system will increase, while original ideas in the sector to bring care into the modern era will decrease.

We have been left asking where has the requirement for integrated person centred care gone, that is ingrained in the other plans that NHS and local authorities have been working towards with STPs and LDRs etc.

What is sorely missing is the open patient centric platform that Dr Wachter looks forward to and that healthcare awaits. As this is a glaring omission, our paper recommends a focussed investment towards that end as part of a bimodal strategy for NHS IT at this challenging time.

3) What can be done

The changes required are radical, if we are to simply survive, yet alone thrive in the years ahead. We know we need a mix of people + process + technology changes. We know too that the leaders of the NHS understand and value the role of innovation and the crucial role of information technology in achieving same.

3.1) The role of an open platform

For some time now leading thinkers on both sides of the Atlantic, in the NHS and indeed the US has been calling for a move towards a more open platform approach. From within the US market, the establishment of Healthcare Services Platform Consortium aims to address the mediocrity of the “big 6” monoliths and the concurrent problem of the thousands of small unrelated vendors.

“EHRs are becoming commodity platforms. The winner will be the EHR vendor that provides the best platform for innovation – the most open and most extensible platform.”

In this we wholeheartedly agree and concur with our US colleagues.

We believe there is now a compelling case for a small but useful investment in Health IT from the bottom up, to the princely sum of 1% of the planned £4 Billion NHS IT expenditure, aimed deliberately at the integrated, patient centred care vision of Personalised Care 2020, based on the principle that all projects should aim to leverage elements of a common open platform.

4) 1% Case for an open platform

We are making a case for an investment of just 1% of available NHS IT funds to offer a way forward to improve the care of 99% of the population. To do so we have highlighted Dr Watchers analysis and writings to focus on the key problems and issues we seek to address;

Usability

“This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.

Interoperability

“[There are] Political obstacles to overcome, put in place mostly by vendors and healthcare systems that remain reluctant to share.”

Vision for patient centred care

“In essence, there will no longer be an EHR in the traditional sense, an institution-centric record whose patient portal is a small tip of the hat to patient-centeredness. Rather, there will be one digital patient-centered health record that combines clinician-generated notes and data with patient-generated information and preferences. Its locus of control will be, unambiguously, with the patient.”

So in order to address these real issues and support the national ambitions – usability, interoperability and patient centred care we will use the investment fund available to benefit the broader public. We wish to draw attention to that part of the population who could be better served by the NHS with an improved patient centric platform today. We are also mindful of the need to support;

  • Prevention, Self care and management
  • GP patients
  • Community Care Patients
  • Mental Health Patients
  • Social Care

We look to the leadership provided by the Gov UK Digital Service standard to highlight the principles to underpin the approach we commend.

Pursue User Centred Design & Agile Development

Leverage Open Source & Open Standards

In our work to date (on the Ripple programme and Code4Health platform based on openEHR) we have deliberately pursued these principles to useful effect and recommend them to others who wish to transform healthcare with information technology. We welcome wider scrutiny of our open platform work to date. Our work and the leading work of others (such as the Endeavour Foundation and the INTEROPen CareConnect API Collaborative) in this field, leads us to believe there is now a real, significant appetite for wider and deeper moves towards an open digital platform in the NHS.

By creating an open digital platform ecosystem, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support innovative new models of care.

We firmly believe that a small but focussed 1% investment can deliver against some of the key challenges in Personalised Health and Care 2020 on an open service oriented platform- to stimulate the public & private sector. An open healthcare platform fit for the 21st Century.

 

5) What is an Open Platform?

Platform based architectures power the internet, with the platform providing the plumbing (the infrastructure, data and services) that applications need, freeing the application developer to focus their efforts on their application without the need to build the infrastructure it needs to operate. Platform approaches speed development, make applications more robust and interoperable and open up a new services market in healthcare IT, where suppliers compete on services and the value they add rather than on the proprietary nature of their software.

An Open Platform is based on freely available open standards, so that anyone can play. As no one party can control the platform – they must collaborate – just like the Internet.

An Open Platform has the following characteristics:

  • Open Standards Based – The implementation should be based on wholly open standards. Any willing party should be able to use these standards without charge to build an independent, compliant instance of the complete platform;
  • Share Common Information Models – There should be a set of common information models in use by all instances of the open platform, independent of any given technical implementation;
  • Support Application Portability – Applications written to run on one platform implementation should be able to run with either trivial or no change on another, independently developed;
  • Federatable – It should be possible to connect any implementation of the open platform to all others independently developed, in a federated structure to allow the sharing of appropriate information and workflows between them;
  • Vendor and Technology Neutral – The standards should not depend on particular technologies or require components from particular vendors. Anyone building an implementation of the open platform may elect to use any available technology and may choose to include or exclude proprietary components;
  • Support Open Data – Data should be exposed as needed (subject to good information governance practice) in an open, shareable, computable format in near to real-time. Implementors may choose to use this format natively in their persistence (storage) layer of the open platform itself or meet this requirement by using mappings and transformations from some other open or proprietary format;
  • Provision of Open APIs – The full specification of the APIs (the means by which applications connected to the platform a should be freely available.

The key to an open platform is the definition of a set of standard interfaces (APIs) to the range of services that might be provided on a platform defined by an open process that all interested parties can participate in (like Internet standards) and that are freely available for all to use.

While it may be encouraged, not all elements in an open platform need to be open sourced. We believe that “infrastructural” components that are generic, reusable and utility like (e.g see Appendix 1 below) should be open sourced, while the overlying applications do not necessarily need to be open sourced, as long as they leverage open data models and offer open APIs.

6) Why an open digital platform?

We have seen across all sectors how platforms are changing the way people lead their everyday lives, from how we communicate and interact, how we travel and where we stay, how we manage our finances to how we shop, to name but a few. Platforms transform. An open digital platform supports:

  • Unconstrained innovation – ideas and ambitions can be shared by people across the office, street or globe
  • Collaboration – clinicians and care professionals inherently want want to share their good work with the rest of the medical world.
  • Alignment to medical science progression, been based on the spread of ideas – health IT can do the same.
  • “Publish or perish” culture of modern medicine demands that healthcare advances are laid open for scrutiny by our peers
  • Grassroots progress – Complex adaptive systems require decentralized control so people can locally innovate. Amendments and improvement can come from the grassroots and bottom up, without the bureaucracy that innovators often face.
  • A shift in the market towards a healthy, commercially sustainable, services oriented marketplace.

7) Open Platform Fund mechanism

The main aim of this Open Platform bid is;

Support the development of services towards Personalised Care 2020 –

support the development of an NHS ecosystem around an open digital platform

To be clear, while we do not currently have any secured funding for an open platform fund, our aim is to gauge interest in this approach and make the evidence based case to NHS Digital.

The fund is intended to support innovative projects that stimulate the creation of an open digital ecosystem and as such aims to support a large number of small projects that are unlikely to be supported as part of “business as usual” investment by health and care organisations. The aims are to driving innovation and transformation that is scalable, shared, flexible and adaptable and ultimately improve health IT for clinicians and improve care outcomes for patients. Winners will show that they will concentrate their efforts on usability, interoperability, patient centred care that meet the vision. To do so we suggest;

7.1) Request for Expressions of Interest

We initially invite the submission of expressions of interest into this Open Platform Fund. In so doing, we wish to gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding .

Please submit a brief expression of interest (1-3 page) via this Google forms link; https://goo.gl/forms/4SaNvAgkAe2AfLZ82 by Friday 10th February 2017.


We will acknowledge expressions of interest, collate and feedback the results of our findings, pass on related submissions and summary findings to the Apperta Foundation CIC which we believe is ideally placed to independently oversee this process and support the case for funding from NHS Digital and NHS England. The Apperta Foundation is a not-for-profit community interest company supported by NHS England and NHS Digital led by clinicians to promote open systems and standards for digital health and social care.

While the focus of this paper relates to the NHS in England, we know that colleagues in the health systems of Scotland, Wales, Northern Ireland and indeed the Republic of Ireland are facing the same challenges at the frontline, while aware of the same opportunity on offer from an open platform from a 1% investment, particularly if done openly and collaboratively. Therefore we invite related submissions towards an open platform fund on an All Islands basis – which we also will pass onto the Apperta Foundation and the UK and Ireland CCIO Networks.

7.2) Outline of Proposed Allocation

A) Infrastructural component projects

45% of £40m = £18m over 3 years (until 2020)
Open source tooling & infrastructure components – underpinning standards and compliant components that provides services useful in an open ecosystem (See Appendix 1 examples)

B) Personalised Care: Innovation Incubation and Exemplar Implementations

50% of £40m = £20m over 3 years (until 2020)

Open APIs & open data models based projects as showcases of an open platform in action. (e.g. may include open APIs (e.g. INTEROPen CareConnect FHIR based APIs) + open data models +/- open source data repository (e.g. openEHR based). Examples may include Person Held Records/Electronic Patient Record/Integrated Digital Care Record etc. related projects.

C) Oversight/Custodian of process by an independent CIC such as the Apperta Foundation

Along with the CCIO Network and INTEROPen Collaborative to oversee clinical merit and technical connectathons.

5% of £40m = £2m over 3 years (until 2020)

7.3) Eligibility

We suggest that this open platform fund is open to:

  • UK Registered for-profit commercial entities (Companies and LLPs) and
  • UK Registered not-for-profit entities (CICs,Trusts,Companies limited by guarantee and other recognised forms) meeting UK definition of an SME (In the UK a company is defined as being an SME if it meets two out of three criteria: it has a turnover of less than £25m, it has fewer than 250 employees, it has gross assets of less than £12.5m)
  • UK Public Sector bodies (NHS Bodies, Government agencies and local authorities etc.) irrespective of size.

7.4) Match funding obligations

We suggest that applicants will be required to match fund any award from the fund as follows

  • Social or commercial micro-enterprises 1
    No match funding obligation
  • Social or commercial SMEs 2
    Match funding equal to 50% of the award
  • Public sector bodiesMatch funding equal to 100% of the award

 

1 A business with less than 10 employees and (a turnover < £2 million euro or a balance sheet total of less than £2 million euro)
2 A business with less than 250 employees and (a turnover < £50 million euro or a balance sheet total of less than £43 million euro)
These are the current official definitions applying in the UK

8) Criteria

We suggest that an Open Platform fund is open to projects that stimulate and support both the creation and adoption of an open digital ecosystem which meet the definition in section 5 of What is an Open Platform.

While the main aim of all projects will be to improve NHS services towards personalised health and care 2020, the criteria by which the funding from this fund will be allocated will depend on the concurrent creation of value add in the form of;

  • Collaborative – all projects must establish open channels of communication and means of engagement with other parties in the bid at the time of their application (e.g. INTEROPen Ryver etc).
  • Transparent – all projects must be willing and evidence how they will partake in regular clinical and technical reviews. We suggest these should be in the form of bi-annual CCIO Network led review along with INTEROPen led Connectathons with a minimum of 3 out of 6 Connectathons undertaken.
  • Share Ideas, Knowledge, Experience – i.e. willing and able to openly collaborate with others in this initiative (e.g via online community building via tools such as the Open Health Hub, Ryver etc) and partake in Open Data connectathon against INTEROPen FHIR APIs

9) Judging process

Initial Bid and Review Point Principles

We suggest the related submissions into this fund will need to evidence the following as part of their bids and progress at agreed review points:

  • Clinical merit – against the Personalised Health and Care 2020 Vision
  • Technical merit – against the open platform principles outlined
  • Clinical gap / need / demand
  • Clinical Leadership – all projects need nominated clinical lead
  • User Centred Design – include/demonstrate a commitment to open publish UX design
  • Alignment with Agile Development methodologies
  • Business readiness (preparatory work, governance etc in place)
  • Collaboration with other parties in the open platform bid
  • Open Source track record

10) Conclusion

If public monies are for one purpose, they should be for the common good. Our proposal aims to ensure the efficient and effective allocation of public monies to projects that can impact the health and care of millions of citizens in England, supporting local NHS & Social Care organisations in their hour of need, while leveraging Britain’s long held reputation for industry and innovation to enable a new global open platform fit for the 21st Century.

Our proposal for an open platform technology fund aims to offer a means towards the integrated care vision of Personalised Care 2020 that is in the best interests of the NHS. In aligning patient, clinical and care needs with the investment potential offered by open platforms in healthcare, we believe there is a clear win-win on offer here.

At times of challenge and change the natural instinct may be to withdraw from risk or novel action, yet all our instinct is telling us that now is very time to embrace this challenge and seek the opportunity – which is why we are taking a public lead in getting this Open Digital Platform for Healthcare into action and welcome your interest and support in this effort.

Dr Tony Shannon, Ewan Davis
14th January 2017

Questions or Comments?
Email us at 1percentfund@ripple.foundation or tweet @rippleosi with #1percentfund

11) Declarations of Interest

Both of the authors are unashamedly proponents of an open platform in healthcare for some time. One might argue that this constituents a conflict of interest with the proposed approach. Rather we would suggest that our track record in leading the effort to disrupt the market towards an open platform, equates to a confluence of interest with the approach now required.

Dr Tony Shannon, Director – Ripple Foundation C.I.C
Director – Frectal Ltd

Ewan Davis, Director – Synapta C.I.C
Director – Handi Health C.I.C
Director – Open Health Hub C.I.C
Director – Operon Ltd
Director – Woodcote Consulting Ltd

12) Related Links

Ripple Foundation Community Interest Company http://rippleosi.org/
HANDI Health Community Interest Company http://handihealth.org/
Synapta Community Interest Company http://synapta.org.uk/
Endeavour Health Charitable Trust http://www.endeavourhealth.org/
Apperta Foundation Community Interest Company http://www.apperta.org/
INTEROPen Collaborative http://www.interopen.org/
openEHR Foundation http://openehr.org/
HL7 FHIR https://www.hl7.org/fhir

Appendix 1 – Open Platform Infrastructural Component Candidates

The aim here is to initially outline examples/suggestions of a “top 10” set of federated service components in a Service Oriented Architectural world that would be useful to in healthcare. In doing so we welcome further suggestions and related expressions of interest that would aim to provide open source solutions to plug gaps / provide enhancements towards the open digital platform movement. The fund may support the open sourcing of existing components or their development.

Identification & Authorisation
Master Patient Index
User Interface framework
Integration technologies
Clinical Data Repository
Terminology services
Workflow services
Rules engine
Scheduling
Business intelligence
Clinical content collaboration/authoring tools (i.e. openEHR/FHIR etc)

Applications for these open source infrastructure projects are encouraged to state their preferred OS license (weighting towards non copyleft (Apache 2/MIT/BSD) or AGPL licensing)

 



 

Digital Maturity Index?


It’s a good idea for health and social care organistaion to reflect on their digital maturity and understand where they are in relation to their peers.

The NHS Digital Maturity Index was a good proxy for what we all might reasonably recognise as digital maturity and potentially a great tool to stimulate reflection, benchmarking and change.

However, we seem to have forgotten what the likes or J Edwards Deming and Charles Goodhart have told us who said, respectively:

“Eliminate management by objective. Eliminate management by numbers and numerical goals,

Deming’s 11th point

As soon as the government attempts to regulate any particular set of financial assets, these become unreliable as indicators of economic trends.” have told us”

Goodhart’s Law

We’ve seen the same issue closer to home with the GP Quality and Outcomes Framework QoF which has been great at getting GPs to hit QoF targets, but not so great at addressing the crisis we currenty have in primary care.

Now the Digital Maturity Index has been linked to funding, career and organisational success people are understandably gaming it and it is ceasing to be a good measure of digital maturity, more a measure of gaming and political cunning that’s failing to deliver the organisational reflection that we desperatly need.

When are we going to learn?

Please! Not another “White Knight”


News has been leaked this week by Computing  of plans by NHS England to create a new post of Chief Information Officer/Chief Technology Officer to replace the role that Tim Kelsey will leave vacant at the end of the year.

On the face of it this seems to be a good idea, but my experience over many years gives me some concerns that such an appointment may not have the positive effect hoped for.

Over my 35 years in the sector I have seen a string of able people come and go in the top leadership positions in NHS IT. Generally they have been presented as the Messiah, someone with simple answers to complex problems, a White Knight (or Dame) with Silver Bullets that will result in IT or what we now call Digital, to enable a radical transformation of health and care.

A radical transformation is clearly what we need Digitally Enabled Services and Big Data are two of a very small number of tools available to us with the potential to make a major contribution to addressing the challenges in health and care readers will well understand. But, the answers to the complex problems we face are not simple, but are themselves are complex, and there are no White Knights or Silver Bullets.

As I said in an earlier blog

I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care, but I have concerns that a lack of knowledge and experience amongst policy makers, vested interests in the care, informatics and vendor communities and a naive belief in the Tooth Fairy. Might mean we don’t achieve what’s possible.”

Leadership is critical to success, but we need leaders with a profound understanding of the domain who can harness the undoubted skills and goodwill in the care, informatics and vendor communities and who have the confidence to resist those with vested interest who insist they have simple answers.

Lets look at the characteristics of the various people who have held the top jobs over the past 35 years? In general, and there are exceptions, but these people.

  • Are intellectually very able.
  • Have a track record of doing amazing things – Although typically they overestimate the extent to which this was due to their brilliance and much underestimate the fact that they were just lucky.
  • Manage to dazzle those that appoint them, but turnout to be human after all.
  • Have limited prior experience in health or care, particularly on the front line.
  • Suffer from various degrees of narcissistic  personality disorder .
  • They don’t do “critical friend” and thus tend to get surrounded by “yes men” and sycophants.
  • They stay for no more than 3 to 5 years – Many have had the sense to get out before the job destroys them, some have not.

What do I want to see in any CIO/CTO? Well firstly it’s probably not a CIO or CTO but rather its closer to CCIO (Chief Clinical Information Officer), although it’s not exactly any of these things. They need:

  • A profound understanding of how the UK health and care system works at the front line. This is unlikely to be achieved without at least 10 years experience of working at the front line as a health and care professional in the UK or in a role directly supporting such front line staff.
  • A profound knowledge of health policy and practice and of the research/evidence base of how this might be developed.
  • A profound understanding of Health and Care Informatics – To me health and care informatics is the science of how health and care information and knowledge can be represented in a computable format an the techniques for it processing, it is not fundamentally about the specific technologies.
  • Experience of working in a politically and organisationally complex environment with the gravitas and robustness to survive in such an environment.
  • A personal and management style that can build and work with a diverse team of people who will continually challenge what’s being done.
  • A willingness to engage with unprecedented openness and collaboration with all of those in the care, informatics and vendor communities, including citizens, carers, patients and service user.
  • Enough knowledge and experience of software design and engineering to critically appraise what others tell him, but this is not a job for someone with primarily generic CTO/CIO skills.
  • Finally, they need to understand that this job is about making the best health and care systems in the world1, better by harnessing the commitment, knowledge and experience of those in the care, informatics and vendor communities that have put us in the enviable position.

Finding someone to take this role is going to be a challenge, but it is possible. It’s highly likely that the person we need is already working in the system. The last thing we need is somebody from outside of health and care or outside the UK. No matter how able they are they won’t get to point of understanding the challenge in the time we have to meet it (2020?)

Whoever is appointed let’s make sure we don’t place impossible expectations on them. They can only succeed if they can engage with and harness those in the care, informatics and vendor communities who already know what needs to be done, their role is not to tell us what needs to be done, but to enable us to do it.

Sticking to the Knitting


I’ve written about this before, but have become increasing concerned that the pressure on NHS organisation to generate revenue outside of their core business is a dangerous distraction, acts as a barrier to the diffusion of innovation within the NHS and acts against the best interest of patients and taxpayers.

A distraction because NHS management has challenges enough without targets to generate revenues, trivial in comparison to the budgets of the services they manage, form activities which are peripheral to their core business.

A barrier to to the diffusion on innovation because NHS organisations hang on to intellectual property, in the hope of selling it, rather than making freely available to other NHS organisations and the broader UK health and care sector.

Against the best interests of patients, because it distracts people from doing their day-job and denies patients the benefits of innovation from elsewhere in the NHS.

Against the best interest of tax payers, because in many cases the target customers are just other NHS or public sector bodies which at the very best in a zero-sum game but in reality much, much worse because of the cost of sale and the massive opportunity cost from the slowed diffusion of innovation.

Those involved in the system understand and resent the situation, but politicians and policy makers don’t and have created incentives and penalties in the system that force rational people to behave in what are a sub-optimal ways.

I’m all in favour of exploiting public sector IPR to taxpayer benefit and while there are examples of such opportunities at significant scale (most often in pharmaceuticals and biotech) in many more cases the small scale of the opportunity and the disbenefits to patients and taxpayers mean we really should think again.

Supporting New Models of Care


“I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care, but I have concerns that a lack of knowledge and experience amongst policy makers, vested interests in the care, informatics and vendor communities and a naive belief in the Tooth Fairy. Might mean we don’t achieve what’s possible.”

There are two things it is certain that we need to do to help address challenges that an ageing population creates for health and care. Firstly, we have to get much closer integration of health and care and move care nearer to the patient. Secondly, we have to leverage digital technology to support this change using both big data and small data to deliver more appropriate care more effectively.

I’m pretty certain that the health informatics community know how to create the open digital ecosystem we need to support the emerging new models of care and that there are examples of successful approaches that we can draw from. However, I have a number of concerns, that:

  • Policy makers don’t have sufficient knowledge of the available options or the technical understanding of Informatics and digital health and care to make informed decisions.
  • Informaticians and technologist from outside of the domain don’t have sufficient understanding of health and care to provide good quality advice to policy makers and worse believe that they have.
  • Organisations on the ground also lack sufficient knowledge and technical understanding which means they are not able to critically appraise proposed solutions from vendors and may be tempted to implement solutions that appear to address immediate priorities but which are not scalable or sustainable and which create vendor lock-in.
  • That many in the NHS, vendor and digital health communities have existing positions and conflicts of interest which disincline them from taking the radical steps necessary to work towards the creation of the open digital ecosystem we need.

The imperatives outlined in my introduction are recognised by policy makers and are the thrust of the approach outlined in NHS England Five Year Forward View Central to policy is the creation of new models for the delivery of health and care and policy makers are, rightly in my opinion, facilitating and encouraging various approaches to create new organisation and structures to deliver care. At the heart of all of these is the creation of some form of accountable care organisation (ACOs) with total responsibility for the health care of a given population. ACOs could emerge from various directions including General Practice, NHS Trust, Local Authorities ,the private and third sector. Yesterday NHS England announced 29 Vanguard sItes   to implement 3 approaches These are: multispecialty community providers (or MCPs), primary and acute care systems (or PACS), and enhanced health in care homes. We also already have work around the Integrated Care Pioneers  with the initial 14 now expanded to 25 and work under the Prime Minister Challenge Fund to improve access to GPs also has relevance and finally we have the ambitious plans announced for Manchester, which are likely to be replicated elsewhere.

All of these initiatives have massive implications for new and existing digital technologies, both to mobilise data and to enable the digital delivery of services to citizens. It will be necessary to create interoperability between existing systems across health and care and changes to make it easier to implement and integrate new digital services and apps. This integration requires interoperability both of data and workflows to allow the sharing of both information and tasks across multiple actors in care communities and needs to liberate information in open and computable formats to facilitate big data analytics to help us understand needs, what we are achieving and how we might do it better.

All of this has to happen in an environment where privacy, information sharing and governance issues are addressed but while this is in many ways the biggest challenge, it’s something that I’ll leave for a future blog.

There are many companies developing new and existing products to meet these challenges and while many of these have a more open approach than has traditionally been the case most are still based on solutions tied to particular vendor or technology. My view is that such approaches which give a small number vendors a dominant position are unlikely to have long term sustainability and even where they do create a degree of vendor lock in that is against the public interest. As far as possible we need to create solutions based on open standards independent, of particular technologies which allow multiple vendors to play allow the easy replacement of any single proprietary component to avoid vendor lock-in.

If we are to achieve progress policy makers need to recognise their lack of knowledge and be aware that those advising them both public sector IT specialists and vendors may a have vested interests which mean their advice must be critically appraised. This can only be achieved by a more open, collaborative and transparent process. All of us have our own agenda seeking some mixture of money, power, sex and glory with concerns about how we pay the bills. No individual or organisation can offer informed and impartial advice and it’s only if we are all honest about our motivations and concerns and debate the options openly that we can make progress – I’m in it mainly for the glory, have paid off the mortgage but could still use a bit more cash and a gentlemen never tells.

I outlined one approach I think has great promise in my previous blog

For more about ACOs see:

Kings Fund http://www.kingsfund.org.uk/publications/accountable-care-organisations-united-states-and-england

 

Let’s do it like the Internet


There is much talk about “Standards” following the publication of the NIB Framework “Personalised health and care 2020: a framework for action”.

Standards are of course a self-evidently good thing, but only if you do them right which is far from the way the NHS has traditionally done them or looks like doing them in the future.

I ask those who challenge this view the three questions:

  1. Do you think the Internet has had a significant transformative impact over the past ten years?
  2. How does the Internet do standards?
  3. Why doesn’t the NHS do standards like the Internet?

So far only Mrs Trellis from North Wales has answered “No” to question 1 for the rest is the reaction is a resounding “YES – Why would you even ask”.

In relation to question 2 the answer is generally “I’m sorry I haven’t a clue” and certainly those who really do and know how the Internet does it are not those driving policy on standards in the NHS.

The answer to question 3 is usually “Well we probably should – Why don’t we?” for those who do raise an objection their answer can often be more honestly be restated as “because I’d be out of a job if we did”

I written a lot about standards and I explain my view in more detail in my blogs “Farewell to ‘Ruthless Standardisation” and “Standards are a Barrier to Innovation”

But the short answer is: The Internet does standards on an agile, collaborative, voluntary basis as a trailing edge activity with those who use the standards doing them. Internet innovation doesn’t wait for standards, they simply follow to secure it as business as usual. The process and outcomes are messy and like much of the Internet in theory can’t possible work, but do in practice.

We must follow the way IETF and WC3 do technical Internet and web standards and need look no further than Wikipedia for a model for clinical content development.

Finally, to those who are worried about their jobs if they support these new ways of working I say, that given the shortage of those with skills in health informatics you need never worry about being out of a job as long as you are willing to change, learn and embrace new opportunities. If you’re not the sooner you go the better for us all, maybe you can get a job walking in front of cars with a red flag?

We really do need to do things like the Internet does.

Farewell to “Ruthless Standardisation”


“Ruthless Standardisation” was the failed mantra of the NHS National Programme for IT. The Programme is dead, but in some places this view still persist but it is time to consign it to history as something else that “seemed a good idea at the time”

In a previous blog I said “Standards are a Barrier to Innovation” and I have taken to repeating this statement which tends to get a strong reaction often supportive but sometimes not.

This statement is of course deliberately provocative and those who read beyond the headline will find that I not saying that standards are a bad thing, indeed I believe that applied appropriately that they are probably a good and necessary thing.

It seems I’m not alone in these concerns and I was recently introduced to  a blog from Prof. Enrico Coiera from last November which asks “Are standards necessary?”  This is essential reading and provides a more erudite and evidenced perspective than my own in which he proposes a  new ‘Malthus’ law of standards “That the fraction of standards produced that are actually complied with, will with time asymptote toward zero”

I’ve also been much influenced by discussion with my friend and colleague Dr Ian McNicoll who has spent more time in the standards swamp than me and who introduced me to the idea of a “Distributed Doocracies” as a new approach to developing clinical content standards.

I conclude that to make progress we have to.

  • End (or at least ignore) the religious wars amongst the Standards Tribes  for the one true way and adopt a more polytheistic and pragmatic approach
  • Learn from the processes that have allowed us to create the Internet, the Web and Wikipedia and apply them to health informatics.
  • Apply the “Four Freedoms” of open source to the standards making process to create a “Shared Commons” of clinical content.
  • Promote new ways of creating the accommodations we need to deliver interoperable digital health systems, based on distributed doocracies, which are accessible to and driven by frontline clinicians, supported by techies and informaticians.

In this blog I want to talk about the process of standards development and how I’m led to the conclusions above.

I’ve become increasingly convinced that the process as currently applied to digital health and care is not fit for purpose and it is this rather the process that standards themselves that are a barrier to innovation.

There are two problems with the process. Firstly, it’s too slow, changes are not possible in a responsive way forcing people to “do their own thing” to meet operational needs. Secondly, it opaque and inaccessible both to clinicians and innovative SMEs.

Before considering these two points I want to differentiate between the technical and contents aspects of standards. The technical aspects deal with the format of data and might use representations like CSV, XML, JSON, etc. These are generally not a problem. If the content is equivalent it is usually easy to write mappings or transformations between them. The content aspects are where the problems lie, what do we mean by a blood pressure, an allergy, a diagnosis, a prescription? What elements make up these things and how do we represent them in ways that are unambiguous and computable. The domain expertise to answer these questions lies with experts in the clinical domain to which these concepts relate i.e. clinicians. Specialist clinical informaticians can support this process but even if they are clinically qualified they are rarely the domain expert. If you want expert input on, say, visual acuity you need to ask an ophthalmologist specialising in visual acuity.

The problem is that the current process for standard settings and many of the tools that support it are not likely to engage the required domain expertise as those best able to provide it are generally more interested in clinical practice than learning the technicalities of things like UML, HL7 or RDF or sitting in interminable standards meetings waiting for the few minutes where they can make a valuable contribution.

So the first problem is that we have to make the process accessible to frontline clinical experts. This means managing the process so they can engage only on those matters of specific interests to them and supporting them by tools that feel intuitive to a clinician with minimal training in their use.

The second problem is that we have to make the process agile so that required enhancements to content standards can be made available in hours-days, rather than months-years. This requires two things: A move from top down control and a shift to a continuous process (rather than one based on review and publication cycles) this is analogous to what is known as continuous integration in the software development world.

The third problem is that we have to make the process open, too many standards making bodies operate behind closed doors or raise barriers to participation by way of the cost of participating in the process or obtaining outputs. It is a scandal that formal standards from the likes of BSI, CEN and ISO which are funded by taxpayers are not freely available on the web and I was appalled to be asked to sign a NDA by BSI before joining a committee to develop standards for apps (I declined). The fact that it costs £232 to buy a copy of CEN 13606 from BSI is hardly going to encourage a microenterprise to find out if it might to be helpful to them (even if they can get it at half price by joining BSI for £189 pa at the microenterprise rate) –   Standards development needs to be like open source software and licensed in a similar way to grant the “Four Freedoms”

So how do we address these issues? Well the answer as ever is to follow the Internet which provides us with two great  open, distributed models for reaching accommodations.

The first is the way core Internet standards are developed, which is by way of RFCs. The clue to the approach is in the name “Request for Comment” Internet standards are those things, which for the moment, nobody is moved to make any comments about. RFCs cover “many aspects of computer networking, including protocols, procedures, programs, and concepts, as well as meeting notes, opinions, and sometimes humor(sic)” – The last is essential when trying to set standards. – Read the page my link points to it’s short and stuffed with wisdom.

The second is the Wikipeadia editorial model and it’s a simplified version of this we need for clinical content and this is illustrated in the diagram below created by Dr Ian McNicoll.

Distributed Doocracy

This specifically relates to proposals for the creation and curation of clinical content models in the form of OpenEHR archetypes, but is equally applicable to any similar process.  It has a number of key features.

Archetype development is an open process that anyone minded to can watch and/or participate in.

  • Archetypes can be used at any point a user considers them stable enough and fit for their purposes, but become standard at the point of “publication” at which point they become subject to strict version control and configuration management.
  • The work and decision making is delegated to Editors working with a small number of reviewers and is fine grained operating at the level of a single archetype or small group of related archetypes. While anyone who wants to participate can at this level there would typically be a small number of active participants (<10 often fewer) who have  specific expertise and interest
  • Publication is a decision of the Editor who operates as a “benign dictator” subject only to the risk of a coup if they fail to satisfy the needs of users.
  • There can be competing archetypes and archetypes can fork if users feel a need, but the aim of the Editor should be to create an “accommodation” that allows a rough consensus (the maximal data set + restraining template approach of OpenEHR makes this relatively easy to achieve)
  • There is some loose overarching governance to enforce general principles and deal with dictators who cease to be benevolent, but there is no central body controlling the publication and approval of archetypes.
  • Professional bodies and standards organisations are encouraged to provide guidance, nominate appropriately expert and interested individuals as editors and reviewers and to provide formal secondary endorsement of published archetypes but are not required to approve publication.
  • There is a high level of vendor engagement, as these are the people that need to make archetypes work in the real world.
  • Archetype and project Editors are supported and coordinated by a team of expert informaticains acting as Clinical Knowledge Administrators.

This general approach is proven as successful both in the very diverse world of Wikipeadia and the specific world of OpenEHR.

Making this work requires the existence of an engaged community, appropriate governance and supporting tools. Here again OpenEHR provides a great model. Available tools like the Clinical Knowledge Manager are easy for clinicians to learn and use and provide an online community that can engage global clinical expertise and allow debate and discussion to support archetype development. The online approach removes the need for costly and time-consuming meetings and allows individuals just to engage in those things in which they have a specific interest. The OpenEHR tools as provide the facilities that the Techies need in a way accessible to them without the need for detailed clinical knowledge, provides the technical artefacts they need and supports good software engineering practice in relation to version control, configuration management and backward compatibility.

So we know what needs to be done and have some proven examples of how to do it. So lets just do it.

 

 

 

 

 

 

 

 

Code4Health

The  Code for Health initiative and the idea of teaching doctors to code (disambiguation: I mean write computer software not learning to apply clinical codes to health records and other health data) is in my mind a really good idea but something that is capable of being badly misunderstood and misapplied with the potential to seriously back-fire. In this piece I’ll try and explain why I think it’s a good idea and how we can ensure it delivers that which its’ protagonists hope for and also some other ways which may be more appropriate for HCPs to become involved in designing digital systems and services.

In this blog I use the term HCP (Health and Care Professional) as shorthand for any professional group whose primary domain of expertise is health and/or care rather than IT. This group includes doctors, nurses and other clinicians, clinical scientists, social workers and other social care professionals as well as managers and commissioners, particularly those working at the frontline.

I conclude that it’s a good idea to teach those HCPs who wish to learn to code – not so they can become or replace professional developers and designers, but to create a more meaningful discourse between HCPs and digital professionals and to enable them build simple tools at the user interface level, while digital professionals concentrate on building robust systems that make this safe and easy. I also suggest that for many HCPs, engagement in the design of digital systems and services may be more appropriately achieved by enabling them to contribute their expertise in the development of clinical content and the user experience rather than teaching them to code.

So what’s my rationale for these conclusions?

Amazing things happen when you get people with different skills, ways of thinking and insights in the same problem space working together.

I’ve seen this many times in my career. In the early days of GP Computing in the late 70’s and 80’s more recently in the NHS Hack Days and  on many occasions in between See this previous blog

I’ve tried to make it happen at other times and places and have both failed (as I did working inside the NPfIT) and succeeded (as for example with HANDI ) and I’m increasingly focusing my efforts in areas where I think I can help create hybrid vigour or heterosis

Central to the generation of heterosis is the creation of mutual respect, shared perspectives and common language to enable a meaningful discourse between the parties.

In the development of digital health and care tools and services there are five critical groups of actors who we need to engage in a meaningful discourse in the design and creation of digital health and care tools and services:

 

Actors
Actors

To facilitate this discourse we need to create some boundary objects – things of which each of the participants has some common understanding. The first and most important boundary object is the citizen/patient who in my model is both an actor and a boundary object. This is possible because all of the actors are citizens and have direct or indirect experience of being a patient and so from the outset can engage in a meaningful discourse about what a citizen/patient might want from digitally enabled health and care services. I’d also suggest that there are other boundary objects that it is useful to create. These allow each of the groups of actors to gain insights into the domains of the others, facilitating a meaningful discourse, building mutual respect and hopefully creating heterosis. There are many potential boundary objects that can be developed I’d like to concentrate of these:

  • Software
  • Care pathways
  • Clinical content
  • User interfaces and user experience

Code for Health is concerned with the first of these and is useful as it creates a boundary object between HCPs and the other groups of actors facilitating. Its aim should not be to make HCPs software engineers, but to help them develop a common language and understanding so that each understands and respects the contribution the other can make and to enable HCPs to be meaningfully engage throughout the life-cycle in the design, development and implementation of digital tools and services.

Next, creating an understanding of the issues associated with maintaining well-being and treating poor health and in particular the care pathways which we hope digital technology can enable and support will help those other than HCPs better understand the challenges to which they can apply their skills. So, for example teaching engineers to deliver care is equally as valuable as teaching HCPs to code.

Clinical content is perhaps the most promising boundary object with which we can most usefully engage HCPs in the creation of digital tools and services.

Clinical content represents the information and knowledge required to deliver health and care and consist of information models, care pathways and decision making rules The primary experts in this domain are the HCPs, the experts in the construction of the artefacts required to represent these things and the informaticians, while those with the expertise to build the tools to enable HCPs to engage in ways which hide the technical complexity are the engineers and designers.

Historically, the formalisms that enable clinical content to be represented in a computable form have been impenetrable to those without substantial training in information modelling and/or knowledge engineering (just look as things like ProformaArden Syntax RDF or the Hl7 MIM ) making them inaccessible to frontline clinicians, and HCPs while many of those with the technical skills to use these things lack the clinical understanding needed to use them to best effect. The result has been that the control of clinical content has been left with a few High Priests versed in both the dark arts of Knowledge Engineering and Medicine who are often too remote from the front line to know what’s really needed. However, this is now changing with the creation of tools that allow mortals to engage in ways that are accessible to an ordinary IT literate clinicians and HCPs. Great exemplars of this are OpenEHR www.openehr.org and OpenClinical www.openclinical.net which provide intuitive tools to allow, respectively the creation and maintenance of electronic record and clinical decision support components by frontline practitioners while dealing with the technical complexities essential to the production of the technical artefacts needed by the engineers and designers to produce digital systems. This new generation of tools allows people to concentrate on their core competences knowing that the requirements of others will be met and provides boundary objects, enabling an ever more productive discourse between domains supporting effective user centred agile design by multidisciplinary teams.

Finally, creating functional and desirable user interfaces and user experiences is critical as without this good underpinning clinical content and well engineered components will not be enough to properly support the process of care. The key experts in this area are the designers and human factors specialists, but they need to work in close conjunction with HCPs who understand care processes and their supporting business processes. It is also important to work with citizens and patients who should be the beneficiaries, but are so often the victims, of digital tools that get in the way of HCPs trying to deliver safe, convenient and compassionate care. So this again is a key area where we maybe can make good use of HCPs as well as teaching them to code.

So in summary, we need heavyweight informatics, software engineering and design skills to deliver an open health and care ecosystem which allows HCPs to do much more for themselves in the creation of clinical content and at the user interface level without having to understand the technical complexities which have to be satisfied to allow them to do this safely, securely and easily.

This means teaching HCPs to use these tools and looked at this way, Code for Health is not just a good idea but essential.

 

 

What makes an Open Source community?

There has been a lot of interest in the role of Open Source software in the UK over recent months, initially stimulated by NHS interest in the American VistA Open Source EHR, but now taking on a broader scope including some of the exciting home grown initiatives.

Included amongst these are a number of projects that started in a closed source environment, where the IPR owner has decided to shift to an Open Source model. From a narrow technical perspective making software Open Source is easy – You just make release it under a recognised Open Source licence and make it freely available for download. However, Open Source is about much more than the licensing model and much more needs to be done to achieve the benefits of Open Source than what the Open Source community disparagingly call a “Code Dump”.

Open Source is about an approach and philosophy that at its’ heart believes that by creating a community who can freely use and contribute to a product that we can create better software and release new commercial and social value not available from other approaches. Open Source enshrines some import  freedoms and principles which defined and maintained by the Open Source Initiative  that also provides guidance on licences that meet these principles.

To be effective an Open Source community has to be diverse and well supported; containing all of those stakeholders needed to ensure a sustainable business model for the products’ ongoing development and use in which no single entity has effective monopoly control and requires governance structures around a particular distribution or version of the source code (often called a “Distro” in the Open Source world) so that users can have confidence in the safety, security and quality of that Distro including changes and new contributions made to it by the community – Something that is particularly important in context of health and care software.

Stakeholders include:

  • Those that gain financial value from the existence of the Distro – These might be organisation that use the software or the data it generates (like the NHS, researchers and other health and care commissioners and providers) or organisation that sell services to community made possible by the existence of the Distro (including developers, implementers and maintainers) – It is this group of stakeholders who will be the main source of resources to sustain the development and use of the Distro.
  • End users of systems and those who they seek to serve using the software – It is only by involving end users in an agile user-centred design processes that we can build systems that truly unlock the potential of digital technology – Too often the poor design of tools that people are expected to use is a barrier to doing what’s important. In the context of health and care this means involving frontline clinicians, other health and care professionals, managers and administrators – Their needs are often not well understood by policy makers, senior management and IT departments. Most important of all it means working with patients, service users and their informal careers who are too often the victims of poor service resulting from poor design.
  • Academics and technologists who are able to educate the community with regard to those things they know that might enable the community to improve the Distro and/or the effectiveness of its deployment and help the community critically evaluate it use. This might include ensuring that the community is aware of existing and emerging standards, technology and theoretical frameworks of potential value to the community.
  • Policy makers and senior management who need to understand how the Distro can be deployed to improve services and how such use can both shape and support policy.
  • A vibrant market of individuals and organisations who can provide a range of services to support the development, implementation and use of the system as well as relevant add-on products and services. This market should ideally include individual consultants and contractors, SMEs, social enterprises and large global system integrators. It is vital for the health of the community that there is a competitive market in the products and service needed to improve, deploy and exploit the Distro so that user organisation have a choice of who they contract to provide these service.

The Distro needs a custodian, owned and controlled by the community, who will promote nurture and protect the Distro, provide mechanisms to encourage, manage and quality control changes and improvements to it by the community and commission the delivery of enhancements and other services on behalf of the community.  The custodian needs to set and maintain source code and documentation standards and ensure that documentation is available of a sufficient quality to enable a competent developer without prior knowledge of the product to work with the source code and ideally should be able to provide additional guidance and training to enable those who want to work with the software to be able to so as quickly as possible.

A key aim of the custodian is to try and keep the community together on a common Distro. Too often, short-term pragmatism results in changes to source code somewhere that breaks something somewhere else creating a “fork”in the source code tree. While some limiting forking might be healthy if too many users “fork off” the benefits of Open Source are diminished. Avoiding this requires that the custodian provides support for people to make changes to meet their needs without breaking things important to others, in a rapid agile and responsive way. However, making changes in this way will still be slower, in terms of achieving immediate local priorities, but doing so has damaging medium and long-term sequelae. The custodian has to close the gap between the two approaches and educate developers about  the benefits of doing things for longer term benefit.

Additionally , the custodian has a role in providing assurance and warranties to users that deployments based on the Distro support by organisations accredited by the custodian will be safe and secure to deploy in live health and care settings.

Enabling the custodian to deliver its’ responsibilities will require that it is funded by the community to do so. To facilitate this the custodian is probably best constituted as not-for-profit Community Interest Company (CIC) whose control is vested in the community such that no single class of stakeholder can determine its’ actions.

If we can build effective communities then the wider introductions of Open Source software in the NHS as part of a mixed economy alongside proprietary products will help drive better value and front line user engagement and commitment  across the board, just dumping source code under an open source licence (or worse some bowdlerised licence) will not.

 

 

 

Food England?

Listening to the Nuffield Health Policy Summit http://www.nuffieldtrust.org.uk/live/health-policy-summit-2014 Lots of interesting stuff from Phil Collins of the Times. Talking about “command and control”, “integration and competition” and “patient centred service design”

Perhaps it would help to think of the NHS as a supply chain?

Supply chains are complex adaptive systems which consist of a large number of participants of very variable size and power. There is little or no overall control or management of the system (although individual elements may be and should be tightly managed) and the participant simultaneously compete and corporate.

Left alone supply chains just work, tamper with them and they break in unexpected and unpredictable ways. Consider how the UK food supply system works without “Food England”.