Roundtable: How can APIs drive effectiveness and interoperability in the NHS?

Application programming interfaces (APIs) have a hugely important role to play in the sharing of healthcare data but too often fail to gain traction. A Digital Health roundtable, in association with Cognizant, discussed how the NHS can get more from APIs and ensure they promote interoperability

System owners often approach an API project with a ‘build it and they will come’ attitude. The reality can be quite different. As last month’s in-person roundtable at Digital Health’s Rewired in Birmingham made clear, there is real enthusiasm for APIs in the NHS but it is tinged with frustration. Instead of enabling systems to talk to one another, APIs can sometimes add another layer of complexity to an already complex healthcare landscape.

The roundtable discussion, held on the first day of Rewired in association with Cognizant, brought together a range of NHS digital leaders, many with a clinical background, to share their thoughts on the current state of APIs and provide insights on how to release their potential.

To encourage everyone to speak freely, participants were informed that while their presence at the event could be noted in this report (see below for a list of some of the attendees), their quotes would not be attributed. The discussion was moderated by Will Jackson, head of API management and platform engineering at NHS England, who made it clear he was there to listen and learn how best the centre can support the people who use APIs at the frontline of the NHS.

Early in the discussion, one CIO from an NHS trust echoed the generally positive mood in the room by saying good use was being made of APIs: “We like [APIs] a lot – we just need to tidy them up and enforce them on everybody,” he added. “My bugbears are others not using them.” He described people turning up to meetings and not knowing the basics as “a real kick in the gut. We need a lot more support centrally”.

As things stand, he explained, referrals made through the NHS e-referral service reach him in multiple formats: “…an MP3, a jpeg and 25 others”. He said the centre should not allow such a free for all: “Just come up with a few you are going to support and give a timeline for the end of life of the rubbish. Pick a few, standardise, send out notes and draw a line in the sand.”

Need to mandate and apply standards

Another trust CIO said there was a reluctance to attempt enforcement: “The real issue is we are not mandating and applying the standards and the API and the way of working. We’re just letting people off.”

“How does data move?” There is no standard now,” said one participant. “NHS England could start the discussion.”
An NHS digital leader said: “In terms of the vendor side, we’ve got to recognise that sometimes the maturity of the vendors in the healthcare sector is not very good”. He wondered whether a maturity model or “trust mark” awarding “stars” for integration would help incentivise suppliers to make improvements: “They could get scored.”

“There’s a lot of commerciality around this and protectionism from vendors making sure their systems are not completely open because that impacts on their commercial model,” said a digital leader from a different trust.

Several participants suggested that more openness was needed, with one describing APIs as “a bit of a coping mechanism for the fact that we haven’t got open data, open systems”. The number of APIs was also an issue: “When you have lots of APIs that’s huge complexity and cost. When you do any form of upgrade that’s an absolute nightmare. Where do you do your testing? Where does it start? Where does it end?”

Economy of scale

A more streamlined market would deliver clear benefits, said one participant: “Vendors can only really invest in APIs if there is an economy of scale behind it. If it can be used in Dorset [and] it can be used in Wales, that’s when the vendors get behind it, because otherwise it is too niche.”

“A little bit of enforced standardisation would make clinical lives easier,” added another attendee, who gave the example of clinicians who want to prescribe expensive drugs having to input large amounts of information which already exists on a different clinical system.
This prompted an NHS digital leader to comment: “If I had to prioritise APIs, given the financial pressures we are under, it would be anything that reduces costs in the short term – 2024-5 – and anything that hands back clinical time.”

There was a lively debate about the need to “reinvent” a role for text messaging. “Text messaging used to be available to everybody in the NHS and lots of trusts made use of it. And [the centre] withdrew it because it was too expensive and only left it with primary care. It was a nice and easy method to use – that’s very frustrating,” said a participant, reflecting the mood of many at the table.

The ideal, it was suggested, would be a centrally managed API that handles delivery of messages to the intended recipient. This should seamlessly support newer technologies, e.g. push notifications, but also be able to revert to traditional text messages. “Let’s use text messages differently, rather than trying to get rid of them,” said one CIO.

Put consumers first

A strong theme running through the discussion was the need to ensure API consumers are “front of mind” and that development reflects their needs and priorities, without being unnecessarily “held up” by concerns about clinical risks and safety. There is clearly a balance to be struck between security and ease of use. Cognizant’s Manuel Reyes (a roundtable participant) wrote blogs on this issue last year, including one on how to improve API adoption and another on building a user community around APIs.

More “dev direct” – development working groups in the NHS rather than working through vendors – could help to speed up development and ensure it delivers for consumers without being unnecessarily cumbersome, it was suggested.

The centre could usefully focus on certain areas, such as data and tech integration -– mandating a level of consistency – and be “light touch” on clinical issues which would be more effectively handled by the end user and their supplier, it was proposed.

There could be a clinical assurance core, beyond which there would be freedom for local NHS digital leaders to work with suppliers to “contextualise” the system and foster an “engineer experience” mindset, ensuring that engineers can connect easily to APIs.

Ultimately, all the work around APIs needs to deliver benefits for clinicians and, above all, for patients. “This is about the patient journey,” said one CIO, as the discussion drew to a close. “What the patient wants and what the professional wants are generally quite different but [all their needs] have to be met. We need information that flows freely, rather than having to reinvent the wheel.”

Roundtable participants included: