MY VIEW - Digital by default or digital by strategy?

VIEW - Karen Day, Fellow of HiNZ and senior lecturer health systems, School of Population Health, Auckland University 

The NHS recently released its Fit for the Future: 10 Year Health Plan for England. This View compares their digital approach with New Zealand’s Health Strategy.   

This tale of two countries delivers different views on much the same thing: How a country fires up its health system to engage in the future while standing on the shoulders of giants from the past. 

Society is at a tipping point where artificial intelligence (AI) is pushing us into a digital-first world, triggering the fourth industrial revolution (remember the printer that started the first one, and steam trains that introduce the second, and the Internet of Things for the third?). 

Both countries’ strategies are vested in transformative change, i.e., significant ways in which our respective health systems become different to meet 21st century health needs. Will digital do it by default (UK) or by serving values and culture (NZ)?  

Health system priorities  

When reading these two strategies side by side, I was struck by their similarities. They both aim to improve equity and health outcomes. They both want to start the changes where the need is greatest. 

Te Pae Ora Act (2022) laid the foundation for structural changes in New Zealand, and a combination of legislation and the 10 Year Health Plan have laid the England NHS foundation.  What is striking is their different takes on the role of digital technologies, skills, capabilities and capacity as can be seen in this table. 

The England plan layers financial commitment and benefits into every priority, while the NZ strategy is silent on investment.  

Health care is about people 

Our two countries have different and similar population profiles. NZ (with a population of just over five million) does not have the same capacity to scale up digital implementations that the UK has (with a population just over 68 million). 

Culture and values matter in NZ, with a commitment to Te Tiriti o Waitangi, resulting in a different strategic gaze. The two strategies agree that people need help to be well, avoid illness, and get well, and preventative health via digital technologies plays a role in the survival of a universal healthcare system.  

The UK emphasises ‘digital by default’ assuming that patients and healthcare professionals should move from analogue to digital for survival. NZ has emphasised voice (people) that supports and represents the future of communities, cultures, and safe access to, use, and provision of health services. 

Neither document fully addresses the effect of digitisation on invisible people (disabled people, neurodiverse people, those with difficulties using devices, and those struggling with life in general). 

Both imply seamless information flows within and among different organisations, but neither addresses the elephant in the room – interoperability. Both emphasise innovation (yes, NZ is a nation of innovators, long live innovation) and they each indicate a mechanism for commercial collaboration for digital design and implementation.  

A future workforce 

I am disappointed to see the emphasis on doctors in the England strategy, and little acknowledgement of the diversity of healthcare professionals. The NZ strategy acknowledges a broader range of professionals and goes further by indicating that new roles will emerge for which educators and the health system in general must constantly respond to. 

Both strategies cover leadership in a range of settings, but the UK has the courage to ‘out’ poor leadership and indicates ways to reward and address excellent and poor leadership respectively. 

It is not enough to equip healthcare professionals (typically doctors, nurses and allied health professionals) to use digital tools as part of everyday work, e.g., robotics, ambient and scribing AI, genomics, and predictive and preventive analytics. What is missing is the digital health specialist workforce and the workforce that keeps the computers running so that clinicians can do their work. 

The emerging digital health specialist workforce provides expertise spanning the past and the future, makes innovations implementable, provides data science services, and evaluates strategy successes and failures. The England plan includes transparent quality improvement, which implies evaluation resulting in improvement responses.   

In conclusion, since these documents are strategies, it is our obligation as implementers and leaders to fill in the blanks, add detail, design implementation plans, and evaluate achievements. 

Emphasising digitisation (UK plan), or not (NZ), creates a pipedream if politics and insufficient financial investment get in the way.  

Image: Karen Day, Fellow of HiNZ and senior lecturer health systems, School of Population Health, Auckland University 

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