What does the merger of NHS Digital and NHSX with NHS England mean?

Following the announcement that NHS Digital and NHSX is to merge with NHS England and Improvement, Digital Health’s editor-in-chief, Jon Hoeksma, explores what the consequences will be for the NHS IT community. 

NHS Digital and NHSX staff deserve a lot of sympathy this week. Having worked tirelessly throughout the pandemic, their reward is to be told the axe is to fall on their organisations, with many facing uncertainty surrounding their jobs.

News of the axing of NHS Digital (6000 staff) and NHSX (around 900 staff and contractors), was sudden and was delivered via a staff announcement from NHS England and Improvement CEO, Amanda Pritchard.

While a rationalisation of the many duplicate roles and responsibilities was widely expected, the full-blown take-over of NHS Digital caught many by surprise.

By making NHS Digital its in-house tech team, NHS England and Improvement will almost doubles its 6,500 staff overnight, in the short-term at least. There is a strong suspicion that the sheer size of NHS England and Improvement could lead to more job cuts.

One experienced NHS CIO told Digital Health News that changes ultimately made sense.

“There’s currently loads of duplication of very senior roles in NHS England and Improvement (CIO, Cyber, Data, programme etc) and more architects [digital and data] than in Norman Foster Partners, this will take time to settle.”

Back to the basement

While there is a widespread recognition of the need for rationalisation and greater clarity, there is a concern that in the name of embedding digital to the core business (like Tesco [Wade-Gery] or Jaguar [Bolton]), it will be relegated to a support function.

The news that Simon Bolton has been appointed the new NHS CIO, reporting to NHS England and Improvement’s director of transformation, Tim Ferris, also suggests that following the Wade-Gery review, digital is simply no longer at the top table in the way it was under Jeremy Hunt and Matt Hancock.

Another trust CIO commented: “There is a sense that with these changes digital, for all its achieved during Covid, has been demoted back to IT and sent packing back to the basement”.

What does the future look like?

A number of key questions are beginning to emerge, including, how much will the reforms cost and will there be an impact on current programmes and initiatives? To pick one, what’s the future of What Good Looks Like? To pick another, with Health Education England being abolished, where next of informatics workforce development? And finally, who now has responsibility for cyber security?

The consequence of most mergers is that organisations enter a period of introspection and naval gazing while people seek to make sense of the new landscape, structures, rules and hierarchies.

The move is also clearly a major piece of centralisation, even though Wade-Gery says otherwise, combining agencies that already often struggled to effectively work in partnership with and understand the pressures facing local NHS organisations and teams.

The Wade-Gery Review is in many respects a centralisers manifesto, with a vision of the natural primacy and desirability of a centrist organisation calling all the shots on digital and data.

This sits badly with some local leaders. One commented: “I’m a bit deflated that in the detail of the review it yet again talks repeatedly to “central” teams have all the expertise, around implementation, design, procurement and always infers non-central teams don’t – yet there never ever seems to be any actual evidence of this”.

An alternative approach would be to devolve and really commit to build up significant regional capabilities, putting teams much closer to trusts and ICSs, and ultimately spread knowledge, best practice and implementation expertise.

Need for a coherent strategy 

Another NHS IT leader spoke of frustrations about the tendency in senior circles to conflate digital and technology with transformation and treat them as though they are interchangeable.

One NHS CIO said that the way Bolton’s appointment as the new NHS CIO was announced was “incredibly disrespectful of Sonia Patel, the current NHS CIO at NHSX”.

One seasoned observer added: “Bolton’s role will be absolutely pivotal. Who he gathers around him in the next stage will tell us a lot about the likelihood of future success”.

In a series of twitter posts since the news broke Bolton noted there had been a lot of comment and defended the mergers saying it would create cost savings by removing duplication.

In another he said: “I don’t know a successful organisation anywhere in the world that would countenance having tech strategy and operational strategy set in different places”.

While in a third he added: “The NHS needs coherent, consistent leadership on technology if it is to survive and thrive”.

Few would disagree that the NHS needs consistent leadership on digital, however there has been a merry-go-round of re-organisations, changes in direction and inter-agency rivalries.

Not given enough time

It is just three years since NHS X was established by Matt Hancock as a dedicated unit to accelerate NHS digitisation. Arguably, the main problem with NHSX is that it didn’t have enough time to become established and therefore have an impact, particularly with the past two years dominated by the pandemic.

Rumour has it that former NHS CEO, Simon Stevens, was no fan of Matt Hancock’s new creation, and it now looks as though that his successor Amanda Pritchard has taken the opportunity to bring it back into NHS England and Improvement.

The rationale for taking over NHS Digital looks far less clear. How will NHS England and Improvement do a better job of managing the delivery of critical operational infrastructure and data flows? Is the axing of the agency perhaps a prelude to selling off more lucrative parts of its work?

There are also a host of unanswered data privacy and information governance questions about NHS England and Improvement taking over NHS Digital’s responsibilities on extremely sensitive data processing. This may well quickly prove a lightning rod issue for privacy watchdogs.

NHS Digital is big, unwieldly, often bureaucratic, but it does an awful lot of important operational stuff, particularly provisioning NHS national IT infrastructure and services and data flows. Much of this is business critical to the NHS.

Along with NHSX, it’s 6000 odd staff and contractors also represent the biggest single pool of expertise in NHS informatics. Yes, that expertise is uneven but like the proverbial curate’s egg, it is likely to be very hard to separate good from bad.