Competitive edge in the NHS – Commissioning Support Unit CIO interview

When film director Danny Boyle wowed the world with a glorious opening ceremony at the London 2012 Olympics, England’s NHS was thrust centre stage. Enshrined by the 1946 National Health Service Act and described by Boyle in the official programme notes as “the institution which more than any other unites our nation”, some 600 NHS staff danced around hospital beds to Mike Oldfield’s Tubular Bells to revere the history of Great Ormond Street and our National Health Service.

The cruel irony of the evening was that the creeping privatisation of the NHS has been happening for two decades and is continuing under the Conservative-led coalition. While Great Ormond Street itself receives significant funding from owning the rights to JM Barrie’s Peter Pan, Boyle’s NHS celebration was brought to you by McDonald’s, Atos, Samsung, Visa, Coca-Cola, BP and G4S.

As such the NHS has become a political pawn, CIO for the NHS Yorkshire and Humber Commissioning Support Unit Mark Dundon told CIO UK recently.

“It’s a very difficult area to operate in,” Dundon says. “The market context is one of an ever increasing population size, which is older, living longer, with more conditions – and the budget has to go even further.

“Funding the NHS is a highly sensitive political topic in times of austerity.”

Indeed, while Chancellor George Osborne was announcing a fund of £2 billion a year to the frontline of the NHS in last week’s Autumn Statement, US arms dealer and defence giant Lockheed Martin was one of a number of private companies weighing up a bid of £1 billion for an NHS contract to run GP services in England – one of the biggest put out to tender – and one described by chair of the British Medical Association Dr Mark Porter as “another worrying example of creeping privatisation of the NHS”.

The Commissioning Support Units are themselves operating in a competitive space. Set up in April 2013 as part of the government’s plans to devolve healthcare planning and commissioning to local GPs, Primary Care Trusts are being replaced by Clinical Commissioning Groups (CCG) – that consist of GPs and healthcare professionals – who procure their commissioning support from CSUs.

“In April 2013 there were 23 CSUs across England; that’s now condensed to nine,” Dundon says.

“I was recruited into West and South Yorkshire and Bassetlaw CSU. We merged with North Yorkshire and Humber to become Yorkshire and Humber CSU – we are now responsible for six million patients across 23 CCGs.

“It’s an example of consolidation across the marketplace of CSUs. Some weren’t strong enough.

“If a CSU does its job and services its customers and patients right, the customers will stay and the CSU will be financially sustainable and win business from other CSUs which aren’t doing that. It’s a competitive landscape,” Dundon explains.

NHS competition

A CSU thus has a natural habitat in commissioning to its local area, but there’s nothing to stop a CCG procuring services – whether that’s IT, a laptop, WiFi, business intelligence, mobile devices or medicine management tools – from wherever it can get the best service.

“A CSU is an arm’s length body from the NHS on a roadmap to privatisation at the start of 2016,” Dundon explains.

“We need to make sure we are in a position to become competitive and sustainable financially.

“It is a very competitive, very commercially-focused area. The CCGs are learning to become very demanding customers – they do not accept below-par, sub-standard delivery timescales because of the pressure they are under in managing a budget to deliver patient services or manage patient outcomes. They need the best bang for their buck and expect a lot from a CSU.

“It puts a lot of pressure on the staff at a CSU to get it right, and where they don’t it exposes them very quickly which leads to merger, acquisition and consolidation,” Dundon says.

The IT, technology and intelligence landscape in the NHS is one which really excites the former Plusnet CIO who believes the greenfield landscape of the NHS has “so much untapped potential”.

“There are lots of basic, simple opportunities to take advantage of, and our board is a strong mix of NHS leadership who know the service inside-out with great commercial acumen, and three of us who came out of the private sector.

“Ultimately we want to become a private business. We need to become profitable so we can invest that money back into services and improvements which go back to benefitting patients.

“I suspect when CSUs become private in 2016 it will be a social enterprise model. It will need to make a profit which will in turn be invested back into patient care and services which benefit the community.”

Business intelligence

The Yorkshire and Humber CSU’s Big Data and BI initiative is one of the projects which Dundon is most enthusiastic about after the newcomer spent large chunks of his first six weeks on the job visiting all 23 CCGs in the region, an area of more than 6,000 square miles.

“One of the big things which struck out was that there wasn’t a business intelligence strategy from the CSU,” he says. “BI was previously done by PCTs in an ad hoc local way where they did dashboards and reporting with nice graphs but that was much it.

“Eventually it was all put into one area but there was no real improvement or economy of scale. There was no strategy and they weren’t getting the intelligence they needed.

“Everyone’s interpretation of BI in the NHS was different – nobody was speaking the same language so I went away and defined a strategy, working with the CCGs and their needs and with our team to find out our capabilities.

“Eventually I got a board member from each of the 23 CCGs together at a meeting at the end of the summer. There I outlined a baseline of what BI is and what the options were.

“We’ve got the strategy and now we are really focused on the delivery,” he says.

It’s this collaborative ethos and orchestrated stakeholder management which Dundon believes offers the NHS some of its biggest opportunities in terms of saving money and improved processes.

The value add of the CSU in all the CCGs is that if one area suffers from particularly high rates of diabetes and another cardiovascular or cancer, the CSU knows what’s going on with a “virutal team and intelligence capability” pooling it all together, he explained.

“Other CCGs can then take intervention to save themselves huge amounts of money later on which we can share with everyone else,” Dundon says.

“CCGs can learn from each other, big and small, but this works best if everyone is together.

“It’s not about how big the data is. The big isn’t in the data, it’s in the outcome; what positive impact is there, what’s the benefit that comes out of the work?

“People get caught up on how much data they have crunched, but I don’t really care about terabytes and supercomputers. If that floats your boat technically it’s fine but I want an intelligent outcome from it.

“So it’s about getting the right technical level of data – and again I don’t care if if’s big – as long as it’s the right data applied to a local context of the needs of the customer to give them the right intelligence they need to make the right decision and spend the right money in the right place.

“That’s where the big is and that’s where the benefit is.

“That excites me because it’s not really happening in the NHS – it’s mostly around service delivery and reports but I intend to really push the boundaries on this and I’m hopefully leading this organisation into a position of strength and if or when the CCGs realise this, they’ll want to work with us,” Dundon says.

Digitisation and collaboration

Another focus for Dundon and the NHS are the opportunities provided by the consumerisation of digital technologies being used in a number of other industries and organisations but not yet the NHS, and a more flexible and collaborative working culture often associated with them.

“One of the first things I noticed was basic communication and collaboration capability and tool sets were way behind the curve,” Dundon says.

“Email and telephone was the crux of it. When you talk about digitisation email is great, but the way people work now is incredibly different; it’s not necessarily the best for sharing documents, viewing patient records or providing feedback.

“We are introducing videoconferencing and unified communications tools and instant messaging. There’s a huge appetite for this because people are using it in their private lives but in their professional lives they are not used to it – our problem is just keeping up with the demand.”

GP videoconferencing

The consumerisation of technology and the possibility of leveraging the unified comms infrastructure to improve services is something Dundon is investigating in Yorkshire and Humber, and typically could also be accelerated due to commitments made by parties in the political space.

“Some statistics say 70% of patients could be dealt with via videoconferencing,” Dundon says. “There are quite a lot of forward-thinking GPs are willing to use videoconferencing while others are more reluctant, but that’s changing.

“A directive is coming down from government, there was a promise from Prime Minister David Cameron that everyone will have access to their own GP and will be able to access them 24/7.

“It comes down politically because they want to win votes but it obviously it seriously impacts on GPs.

Dundon says that in practice it is possible that videoconferencing could help assess and diagnose patients, much of which could be done with smartphone apps and peripheral hardware hooked up in real-time to a GP, as well as wearables which could monitor the condition of a patient throughout the day and negate the need for constant check-ups.

“We are looking at the opportunities for this and they are endless, but we need to get the basics right first while having these conversations around innovation and research,” Dundon says.

Telehealth

This move towards ‘telehealth’ is one which Dundon believes is not just more efficient – whether that’s cutting down on waste, either time or money – but also meets the patient needs.

“We are trying to change the culture of what people think is normal,” he says.

One of the major catalysts for this could be Apple’s move into the health market, Dundon says.

“When Apple released iOS 8 it had a dedicated app in the operating system for health. It’s not necessarily always the case that when Apple does something it grows but largely when they do something everyone else follows and already I’m starting to see other players,” he says.

“Apple are behind it, health is a growing market digitally and there will be lots of innovation over the next two or three years because their market penetration is so big.”

Strategy and structure

There are two principles which Dundon says strikes through all of his plans and strategy at the Yorkshire and Humber Commissioning Support Unit – take care of you staff and take care of your customers.

Previously while the organisation lacked a clear strategy and vision, there were also gaps in accountability, responsibility and financial control, and with people not being managed in the right way.

“We needed to change; I mapped out what I needed to take the organisation forwards to where it needed to go,” he says.

“The strategy and planned structure creates clear accountability across functions and positions. I’m very big on empowerment and very big on accountability.

“I’m also very big on setting strategy direction and leadership to help deliver services – with staff and customers always the focus – but if something’s going really well I want to be able to give a high five or slap someone on the back and say well done, and if something’s not going well I want to be able to point to someone and ask the question for assurance and find out their plans for overcoming those challenges.

“I want to get behind the people and have a proper structure before them.”

Getting buy-in

One of Dundon’s biggest achievements in his nine months at the NHS Yorkshire and Humber CSU is bringing 450 staff together shortly after his arrival to outline the vision and strategy.

“We got them all under one roof and I did a keynote at Elland Road,” he says. “From the staff’s point of view they were all from different organisations and previously part of different PCTs.

“They’re not joined up and going through a merger and are worried about change, and then this new guy comes in and they haven’t got a clue who I am, what my values are, what I stand for, what my strategy is and what my leadership style is.

“Unbeknown to me they also got in touch with my family, and my wife filmed my kids answering questions about me while we were on holiday before I started.

“The people at Yorkshire and Humber CSU got to know some personal stuff as well as me professionally, but I articulated strong values and ethics of what I expect, and in the afternoon was all about them and their own development, a bit about culture and breakout sessions of how they could help with the strategy.

“People went away knowing who we are, what we are trying to do, and what the strategy is. There was a buzz for a good few weeks afterwards.

“As we know being a CIO isn’t about being a technology geek – it’s about using technology for commercial benefit, and in the NHS it means using it to improve patient outcomes, and how you can value people and get them on board, get the best out of them and deliver to patients and customers.”

Working to deliver better patient care while being a pawn in a game of political chess is something which Dundon has come to realise is the reality of working for the NHS, and part of the inherent dichotomy of the CSUs – supporting groups of clinicians but competing with each other until they are ‘externalised’ in 2016 as the market of CCGs dictates the winners.

“The NHS is a constantly changing landscape. Before I came into the NHS I had a perception of how politics changes things every few years and you can’t do anything about it and that’s true,” Dundon says.

“But the more I think about it, it’s about the customers – there are always things outside your control which change the dynamic of your customers’ expectations whether I worked at Plusnet or HSBC.

“When the government comes out and says GPs need to be contactable 24 hours a day, seven days a week, yes it’s a political thing but in some ways it’s no different to other demands. We now need to think about how we help CCGs help themselves to become 24/7 – and hopefully at no extra cost.”