We have heard lots of people mention the ecosystem when discussing digital products and services. It can mean different things to different people and may vary depending on the perspective. The ecosystem is not really one thing but is ultimately a collection of clinical, policy, regulatory commissioning, purchasing and technology environments.

There are probably other things too that make up the ecosystem and there will be other factors that evolve in the future. Like any ecosystem all the elements exist within a balance, that balance exists at a macro level where high level policy makers, government ambitions and national plans may influence them; it also exists at the meso level between the national actors, regional agents and providers; and it exists at the micro level where patients, providers, suppliers and clinicians interact.  The ecosystem is influenced by as many known and unknown factors.

Confusion around what the NHS wants or needs

Small to Medium Enterprises (SMEs) coming into the NHS see the digital ecosystem as their opportunity to enter a market that has often been difficult to break. There has definitely been a step-change, with barriers to entry lowered – but they still exist. Technological barriers remain one of the biggest challenges – whilst there is clear direction in terms of the "open-market" approach and the the evolution of standards, open APIs and other enablers of interconnectivity to help drive system integration; SMEs find the pace of change slow and not in keeping with their AGILE or enterprise culture which relies on speed of execution for business survival. 

There is also a reported ambiguity of outward messages from different parts of the NHS in terms of the future view and what the NHS needs or wants. In some ways, differing views may stem from what SMEs perceive to be a culture within the workforce of not wanting to change or innovate, or simply the parts of the system that are so risk averse the ability to experiment or try new things isn’t there. 

A further substantial barrier is how the NHS commissions services – our rigorous structures are aimed at protecting and ensuring value for money – but do they support digital commissioning and our need to take a flexible approach and deliver at speed in order to drive innovation for the future? These are only a few of the barriers or challenges, and all play into the culture complex - but ultimately all SMEs just want is the right conditions in order make a valuable contribution to the future digital ecosystem. 

National policy playing a key role

A key influencer in maintaining an equilibrium and balance across the digital ecosystem in the NHS undoubtedly is national policy. Formulation of dynamic national policy for digital health in the NHS, however, sometimes is laden with justifying and managing the burden of past investment – human as well as capital in legacy nationally built technology systems. The inhibited technical and enterprise architecture exacerbated by the magnanimity of these systems restrict us to patchy improvements rather than a fundamental overhaul which indeed may be needed for ensuring system design that is fit for purpose to support the emergence of health delivery for next fifty years.

Despite these challenges, the ecosystem is evolving to complement nationally treasured systems with locally driven innovative solutions. The symbiosis to be achieved through the Local Health and Care Records Exemplars (LHCREs) and role of Summary Care Record (SCR) is a good example of policy recognising the potential of the vibrant marketplace now available to the NHS.

The emergence of universally adaptable and agile referral systems and patient facing appointment booking solutions highlights also the gulf that remains despite the successful contractual clause implementation of full use of NHS e-Referral service. The digital growth and success of the private online pharmacy ventures further exemplifies how the small and medium sized enterprises are working with local leadership to fill in the digital gap for users despite the robust central infrastructure of the national e-Prescribing system.

Sending clear signals to suppliers

Managing any ecosystem is hard, encouraging and growing an ecosystem is even harder. There will always be a tension between different policy makers and differing perspectives. However, if we are committed to digital ecosystem within the NHS, then this requires a strategy that is designed to promote this approach where it makes sense to do and also to send clear signals to the market.

Multi-vendor delivery is as much part of this ecosystem, as is having a buoyant supplier market that can work in partnership to solve health system problems. A strategy needs to take into account the factors that will either enable or inhibit a broad ecosystem and consider outcomes that are beyond health outcomes alone. At present, technology suppliers are waiting to help the NHS solve problems but the mixed policy environment can sometimes seem like a barrier to a successful ecosystem.

Dr Sam Shah, Conan O'Neill and Radhika Rangaraju are the NHS England director of digital development, digital delivery lead and head of integration for digital urgent and emergency care, respectively.