When Nye Bevan led the foundation of the UK National Health Service (NHS) in 1948, he did so as a committed Socialist. To this day, the NHS has remained true to its three Bevanite core values: (1) meets the needs of everyone; (2) is free at the point of delivery; and, (3) is based on clinical need, not ability to pay.
Now, nearly 75 years later, politicians of left or right persuasion dare not break those three core values of the NHS. However, as we recover from the COVID-19 pandemic and grapple with new economic challenges related to the energy crisis and war in Ukraine, it is widely accepted that the NHS must be transformed. It must be reimagined. But why? And more importantly, how?
NHS Blockchain Transformation: The 'Why'
In this blog post I am limiting NHS transformation to a technology-led innovation: NHS Blockchain Transformation. There will be a number of future iterations of this content, as I talk more about the initiatives I am working on. I will be expanding upon the detail of a multitude of complementary technologies that bring this concept of NHS Blockchain Transformation to life.
From a position of Chair at a startup social care agency ten years ago, I had my first exposure to the reality of the NHS. Specifically, this was (and still is) the problem of Bed-blocking in hospitals and the lack of coherent, timely patient flow into post-hospital social care.
In order to accelerate patient flow between hospital discharge and social care, having a joined-up information system between patient, hospital, GP, local government, care agency (and sometimes other stakeholders) is a key part of the solution to the Bed-blocking problem, as expanded upon below.
Also, enabling earlier, safer patient discharge to social care at home also relies on accelerating the adoption of Remote Monitoring technologies. This is also an inherent part of the role of Blockchain in solving the Bed-blocking problem: providing secure integration with Medical Devices used in Remote Monitoring services, effectively deployed as the Internet Of Things (IOT) in 'virtual wards'.
I now see four Value Propositions emerging in health with Blockchain technology:
- Integrated Care. Working with the new NHS Integrated Care Boards (ICBs) to improve Patient Flow and reduce Bed-blocking.
- Clinical Trials. Enabling NHS and Life Sciences firms to engage in Clinical Trials earlier, faster - and at lower costs and risks.
- Predictive Analytics. Leverage the inherent assurance of anonymised metadata within a Private Blockchain Network for Population Patient Analytics.
- Patient Identity. Working with NHS Trusts and Private Hospital spin-outs to apply Wallet Services to ensure trusted access to the right Electronic Health Records.
Resistance to Change
With over thirty years of IT industry experience behind me at that time, ten years ago I naively assumed that solving the Bed-blocking and joined-up care challenge was simply a matter of cloud-based IT transformation. I believed that by creating a single Electronic Health Record (EHR) system on a modern cloud computing infrastructure I could resolve the Bed-blocking and related health and social care problems here. Then reality struck.
Yes, I was right to move towards creating a single Electronic Health Record (EHR) shared by all stakeholders - not least the patient, family members, hospital professionals, social care managers and staff. But I could see - as I had experienced 30 years earlier in manufacturing - a significant resistance to change at all levels of the NHS and local government adult social care.
I could also see, just as I saw with manufacturing in the 1970s-80s, the vested interests in the technology industry repelling the challengers and startups, like me. As with all things in large public and private enterprises, and whether by accident or design, incumbent suppliers were (and still are) protected by arcane procurement rules and 'frameworks'. Dinosaurs were (and remain) everywhere in the UK NHS.
Enabling Meaningful Change
One of the things I have learned over many years is that people do not fundamentally change: you cannot turn a cat into a dog. For as far as we can see ahead, no one - not even the Secretary of State for Health and Social Care - can suddenly turn the NHS into a swashbuckling, entrepreneurial organisation.
The NHS is, and will remain mostly led by executives who are motivated by its social aims - to uphold the three Bevanite core values established in 1948. Although I have had some successes introducing a new Salesforce Integration technology into the NHS (see Success Story. Tangle.io) I can see that integrating health and social care requires radical change in this huge organisation.
So, since we have a highly-conservative, socialistic culture embedded deeply within the NHS, the word 'radical' can be uncomfortable for those NHS executives who otherwise, could be empowered to sponsor such innovation.
This where Blockchain Transformation comes in as the 'what' - underpinned by Design Thinking as the 'how'.
In simple, plain English, it is the curious executives and professionals within the NHS who respond well to the concepts of Design Thinking - as expanded upon below.
NHS Blockchain Transformation: The 'What'
However, Blockchain is not without controversy and misunderstanding. It is most widely associated with a foundation for 'Bitcoin' or 'cryptocurrency'. As a cult-like movement, Bitcoin evokes strong thoughts and expressions. This ranges from those who believe it is cure for every problem the world faces to those who believe it only serves gangsters and dictators. This is hardly a benign scenario, when making the connection between Blockchain, healthcare and transformation in the NHS.
Blockchain is the software architecture for something called 'Web3': which, in simple terms, means a new transformation of the Internet, built around distributed individuals, not centralised organisations. As Open-Source software, Blockchains are created by an open community of contributors. Web3 initiatives generated on a Blockchain provide 'Non-Fungible Tokens (NFTs)'.
NFTs are the equivalent of a 'triple-entry accounting system': 'immutable' debit, credit and verification transactions'. In other words, this means digital records and data that cannot be altered or hacked. This is the inherent advantage of Blockchain as the technology foundation for integrating health and social care and enabling the other Value Propositions discussed here.
A Blockchain, whether public or private, enables developers to create software applications called 'dApps'. Early examples of these immutable applications are digital intellectual property (such as art), cryptocurrency tokens, and directly relevant here - Electronic Health Records (EHRs).
Another way to describe a Blockchain is as a 'Distributed Ledger Technology (DLT)', where a Ledger, as a EHR for medical data, patients could control and thereby transform the relationship with health (and social care) data. This ability to grant or deny permission to share a EHR also provides clinical and other professionals with a fuller picture of a patient's medical history.
With Blockchain architecture we have true 'data provenance'. No one can tamper with the data, and it is highly secure, thanks to inherently strong cryptographic features. What follows with NHS Blockchain Transformation is a healthcare ecosystem that is truly joined-up, safer, lower-cost, faster and more automated.
Since no one organisation owns the Blockchain, the NHS can explore this innovative technology knowing that the selling of health data - and all things related to the fear of privatising this institution - simply goes away. This means that patient data - stored in a Blockchain-based EHR - will be owned by the patient - not the NHS, nor some future private enterprise - just citizens themselves.
In the quest for reimagining government in general - and the NHS in particular - Blockchain Transformation is truly radical innovation. But, of course, it may be hard for NHS executives to instantly go with this notion of a 'disruptive' technology. This goes to the heart of what really matters in digital innovation - the 'how' more than the 'what'.
There are already examples of Blockchain being used by NHS Trusts in South Warwickshire to monitor the cold storage equipment used in the COVID-19 vaccination roll-out. This is now being extended to other precise storage requirements for blood, plasma and chemotherapy drugs.
Estonia has become the leader in Blockchain Transformation of health and social care. Today, Estonia is six years into a countrywide implementation of a Blockchain-based e-health technology foundation, led by the Estonian Information Systems Authority.
The NHS is currently going through organisational change. Much of this change is focused on the integration of health and social care. In England, this has resulted in the creation of 42 regional Integrated Care Boards (ICBs), bringing together NHS primary and secondary care and local government social care under what is described as 'partnership organisations'.
In the devolved regions of Northern Ireland, Scotland and Wales similar initiatives to England ICB initiatives - albeit described in different terms - has been under way for some time. The language used in these emerging ICB entities in England focuses on 'place-based partnerships' and 'provider collaboratives'.
Without dissecting the minutae of this bureaucratic speak, this is inherently all about collaboration beyond traditional organisational boundaries. In turn, this is also means building trust among and beyond the boundaries of each stakeholder organisation engaged in health and social care.
With NHS Blockchain Innovation, I am engaging with tech startups and challengers, building relationships with NHS and local government early adopters to form unique collaborations, known in the jargon as 'Decentralised Autonomous Organisations (DAOs)'.
This means a NHS ICB creating a 'DAO venture' as a member-led community, where neither centralised government nor NHS England determine rules and structure. Decisions are made collectively, since there is no traditional hierarchy.
Although this is truly radical, a DAO is totally in keeping with the Bevanite thinking of NHS 1948. But it needs time to build receptivity, rapport and trust among many buyside and sellside stakeholders for this to work effectively and in a timely manner. I now turn to the 'how'.
NHS Blockchain Transformation: The 'How'
I am focused on helping tech startups to identify, engage and monetise early adopter customers (including our Success Story for Salesforce Integration referenced above with the NHS). I have placed great emphasis on the wisdom, yet simplicity of a five-step Design Thinking method created by the Hasso Plattner Institute of Design at Stanford University (the d.school). This has provided the foundation of an innovation method for tech startups and challengers: Design Thinking Applied.
Design Thinking In Sales is not just a way to transform the sellside, it is also a way to change the buyside approaches to radiical innovation built on new technologies. This focus on the 'how' is crucial. We are dealing with an inherent inbalance between, on the one hand, startup and challenger tech entrepreneurs - and on the other hand, the World's largest healthcare organisation.
As I will explain below, the focus on a more open conversation between buyer and seller is key to success here. We must realise that buyers do not know all when it comes to NHS Blockchain Transformation. Equally, sellers must empathize deeply with NHS and social care professionals to truly understand the significant challenges related to hospital bed-blocking and patient experience. In this situation this is the discharge process from NHS to social care - at home, or in a care home.
If Blockchain Transformation is to be successfully adopted by NHS ICB (and related) organisations, then we have to avoid the 'do-or-die' approach that has often bedeviled IT initiatives within the NHS. In the current economic environment, investing in tech innovation is best done by embracing the Stanford d.school Design Thinking mindset of 'start small and if failing, fail fast'.
At Being Guided I am bringing Blockchain experts together with our Design Thinking method, to make it easy for NHS ICB and others to engage in radical innovation - yet ton do so in affordable, safe steps, where value is measured, early and often. This becomes the tangible beginnings of what will emerge as DAO entities within NHS and local government health and social care.
As the NHS emphasise with their new ICB organisations, collaboration among all stakeholders is key. In turn, the five steps of Design Thinking are crucial to building receptivity, rapport and trust among stakeholders that goes beyond the boundaries of individual organisations. This means that the iterative cycle of Empathize, Define, Ideate, Prototype and Test must provide meaningful value outcomes with any NHS Blockchain Transformation and new DAO venture.
NHS Blockchain Transformation: The 'Who'
To bring the Blockchain Value Propositions to life, the infographic above introduces a number of key technologies - Blockchain and public cloud platforms - that come together for step-by-step NHS Blockchain Transformations.
At the heart of this is the Patientory Blockchain Network and Services: a US-headquartered startup, with significant funding and many early adopters, including the Moderna Phase 3 Clinical Trial for its COVID-19 Vaccine.
As illustrated above, think of Patientory (and its Neith dApp) as the Anonymiser and Aggregator of patient data from Electronic Health Records (EHRs) delivered via the Tangle.io Integration Platform (including HL7/FIHR interoperability protocol) and also where Google Looker acts as the Analytics Platform.
I am blending Blockchain with public cloud solutions built on the Salesforce Lightning Platform plus the Tangle Integration Platform - see Success Story in NHS. As illustrated above, we see Blockchain coexisting with a broad range of apps. This relates to the specific 'Use Case' or Value Proposition - e.g. Integrated Care; Clinical Trials; Predictive Analytics; or, Patient Identity.
For Patient Data, we are holding only 'metadata' in the Blockchain, where either existing EHR systems or say, a new app built on Salesforce Lightning Platform will securely host data in Amazon Web Services (AWS), where in the case of the NHS, provides the assurance of UK Data Residency.
In the Blockchain we can create simpler, faster Clinical Trials (in ventures between NHS and Life Sciences organisations), or enable Predictive Analytics for 'population health' in a particular NHS ICB region. As shown in the infographic above, Patient Identity is delivered as Wallet Services within the Blockchain, including the IrisGuard Biometric option.
In this latter example for Patient Identity, the Wallet Services can be integrated with existing or new EHR systems, to ensure the right Records are shared with the right Patient (and who the Patient allows such data to be shared with).
Introducing Mutual Value Discovery
While NHS Blockchain Transformation means focusing hard on collaboration and trust - it should also embrace the revived UK government spirit of 'Action This Day'. For the supplyside of Blockchain technology and innovation, this means engaging with the NHS buyside in a more open way than we traditionally see. This is Mutual Value Discovery.
The problem with formal procurement programmes is they are not effective for tech innovation, such as NHS Blockchain Transformation. For radical innovation, the buyer does not know all, and cannot simply create a set of 'Requirements' in the form of a 'Request For Proposal (RFP)', subsequently asking for a multitude of suppliers to respond at arm's length with written Proposals, followed by robotic scoring of potential suppliers in a cold, abstract way.
As the name implies, Mutual Value Discovery should generate win-win outcomes for all buyside and sellside stakeholders. It is not a soft option. It demands clarity, accountability and transparency. For a conservative NHS organisation, it is vitally important that this is done - and seen to be done - in the right way. This is, after all, tax payer's money.
Introducing concepts of Non-Fungible Tokens (NFTs) and Distributed Autonomous Organisations (DAOs) and the creation of Blockchain-based Electronic Health Records (EHRs) requires a highly interactive, open approach between buyers and sellers. This means human conversation, discovery and validation - not RFP followed by scoring of arm's length written Proposals.
Through the first and most important step in Design Thinking - Empathize - buyers and sellers can come together to explore Blockchain Transformation. For the supplyside this means a judgment call on what can be done that is non-chargeable 'pre-sales' activity and what and when this has to be paid for, initially as a Proof-of-Concept engagement.
For the NHS buyside, engaging in non-tendering Mutual Value Discovery requires responsible, effective use of a Procurement Policy that allows for a reasonable spending limit without formal tendering or, in the jargon, a 'Single Tender Action (STA)'. In practice, within the NHS this ranges from £25,000 to £150,000 per transaction.
Of course, we saw at the height of the COVID-19 pandemic the negative impact of STAs when purchasing critical supplies or pushing through new processes. In these negative cases, the underlying issues here were both the sheer scale of spend (measuring many millions of pounds) and often, a total lack of transparency and trust.
My approach here with NHS Blockchain Innovation is to engage with the NHS by keeping this discretionary spending to relatively small sums of money and to do so early and often. This can be done in highly granular 'sprints' - but crucially, underpinned by maximum levels of accountability and transparency.
In UK, the Government Digital Marketplace G-Cloud procurement framework works well for Mutual Value Discovery with NHS Blockchain Transformation and a STA procurement. This works well by following three Design Principles: Meaningful Journey; Fierce Reduction; and, Progressive Disclosure.
Following these Design Principles readily provides the ability to allow small steps to be taken on what becomes a Meaningful Journey of discovery and validation. With economic challenges in mind, Mutual Value Discovery engagements should embrace Fierce Reduction to generate a More For Less outcome. And finally, in order to make this work for an inherently cautious, conservative culture within the NHS, a steady Progressive Disclosure of value realisation is key to success.
A Work-in-Progress. To Follow ...
This blog post is intentionally written as a work-in-progress. Over time, I will be adding important detail to the people, the technologies and the progress being made here with this important topic: NHS Blockchain Transformation. More to follow ...