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Professor Robert Wachter (pronounced Wokter) is well known in the NHS IT sector. In late 2015 Jeremy Hunt announced he had tasked Dr Wachter to lead a review of the digital future of the NHS. The resulting Wachter Review was published in September of 2016 and this issue we’ll summarise the salient points.

Who is Robert Wachter?

Dr Wachter is a Professor and Associate Chair of the Department of Medicine at the University of California. He is also a best-selling author, having written The Digital Doctor, an insightful book about the state of IT in healthcare. I can personally recommend the book and it is very relevant to anyone involved in moving to an electronic based healthcare system. The review team included a significant number of US and UK clinicians and transformation experts.

Ten recommendations

The full version and executive summary of the review are available at this shortlink:
Below are the main 10 recommendations from the review:

  1. Carry out a “thoughtful, long-term national engagement strategy.”
  2. Appoint and give appropriate authority to a national chief clinical information officer.
  3. Develop a workforce of trained clinician-informaticists at Trusts who are treated as senior managers.
  4. Strengthen and grow the CCIO field and health IT and clinical informatics more generally.
  5. Allocate more national funding.
  6. While some trusts may need time to prepare to go digital, all trusts should be largely digitised by 2023.
  7. Link national funding to a viable local implementation / improvement plan.
  8. Organise local / regional learning networks to support implementation and improvement.
  9. Ensure interoperability as a core characteristic of the NHS digital ecosystem.
  10. A robust independent evaluation of the programme should be supported and acted upon.

Changing strategy

Some of the recommendations mean a change in the strategy to date. Until the review, the official plan was ‘paperless NHS by 2020’. The review states: “We believe the target of ‘paperless by 2020’ should be discarded as unrealistic. The goal is not paperless – it is improvement facilitated by having information where it is needed and when it is needed.” Another relevant quote from the review is “Regarding timing, we have set 2023 as a reasonable date to have robust clinical information systems in all NHS trusts.”

Points 5 and 7 above hint at increases in funding. In line with point 7, the community is expecting further funding rounds in the future. It is expected that Trusts that show positive moves toward digitisation and have involved their workforce will be able to attract a greater share of funding. Jeremy Hunt has already announced an initial 12 Trusts that are considered exemplars ( These Trusts will receive a share of up to £10m, with more Trusts to follow in time.

People are the solution, not technology

In the list of recommendations above, and far more clearly in the text of the review, Wachter makes it clear people are the most important factor. Chief clinical information officers (CCIOs) are considered pivotal and Wachter recommends they are put in place in all Trusts and are suitably upskilled. He even goes as far as saying that the CCIOs should report to the board or CEO. Wachter describes the current UK CCIO workforce as “very thin, very small and not particularly professionalised.” In his own hospital in the US (similar to a large UK Trust), he describes over 20 doctors and nurses having advanced training in informatics, spending 30 to 80% of their day working on connecting clinical work to IT systems.

Some of these recommendations have already been achieved (appointment of a national CCIO) and many are being pursued. For instance, an equivalent of a Royal College for CCIO staff is in the works. Training and accreditation, along with appraisal will likely be rolled out sooner rather than later.

One of the points Wachter stresses in his book, the review, and presentations on the subject is technical change versus adaptive change. He feels IT systems often fail in healthcare because they are treated as merely technical changes (plugging in a system and switching it on). Wachter describes healthcare IT as requiring adaptive change, where people themselves need to change. People are considered as both the problem and the solution in adaptive change.

Another frequent expectation of digitisation is increased productivity. Wachter describes a ‘productivity paradox’ in digitisation, where increases in productivity are not realised (at least initially). Wachter feels the way to tackle this productivity paradox is two-fold. Firstly, to ensure clinicians are fully engaged to re-imagine how work is delivered, not just mirror existing paper based systems. Secondly, the purpose of digitisation should be considered to improve quality, safety, efficiency and patient experience. In other words, the purpose is not primarily to digitise or increase productivity. Although productivity increases may come in several years, they should not be used to drive implementation of systems.


The above recommendations have been very well published within the UK NHS IT community. As clinicians, knowledge of this can be useful when hoping to engage with an IT department or board members about innovations in IT. There has clearly never been a better time to get involved. Many Trusts still don’t have CCIOs and more still have them, but they are not given sufficient resources, training or power to enact meaningful change.

Ophthalmology is a difficult challenge for the IT departments. The field doesn’t fit any existing moulds well, and is quite isolated clinically. Without significant involvement from clinicians we could end up with nothing more than scanned paper notes, rather than the data rich digital record that is clearly possible.

Talking to your IT department is a good first step. Heads of IT (often called CIOs) are usually the most appropriate people to contact. There is also a strengthening community network of CCIOs and 
national conferences and training 

The author has no proprietary or financial interests in the products discussed.





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David Haider

Bolton NHS Foundation Trust, Royal Bolton Hospital, UK.

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