Health Warning

The cyber attack on the NHS demonstrated its resilience but highlighted where improvements can be made

During the widely-reported worldwide cyber attack in May, which infected more than 230,000 computers in over 150 countries, 47 NHS trusts were ambushed by the WannaCry ransomware, leading to cancelled operations and patients being turned away from A&E. It is now important to cast a critical eye over the event, review how the trusts dealt with the threat, and see what can be done in future.

Global problem

At the outset, three issues need to be mentioned. First, the breadth of organisations and countries affected show that this was not a targeted attack on the NHS, and nor was it only NHS trusts whose IT was breached.

The list of major corporations affected was extensive, including FedEx, Renault, Telefónica, China National Petroleum Corporation, the Indian State Police and Deutsche Bahn, and contained organisations that spend considerably more time and resource on technology and cyber security than NHS trusts can.

The scale of the attack reveals it as a global problem and shows just how difficult it is going to be to defend against the constantly developing and often sophisticated methods of attack. Merely blaming NHS managers, as some have been doing, is clearly way off and demonstrates a lack of understanding of the root problem.

Plans in place

Second, it was also evident that the NHS was ready for a major crisis. Business continuity and disaster recovery plans kicked in where appropriate across the country, as they were required to, as the extent of the attack became clear.

This varied from closing down potentially comprised systems in some trusts, to full-on silver command in others. What was clear is that the NHS is actually well placed to deal with issues of this magnitude, in part due to the fact that any numbers of major incidents are just around the corner for any given trust.

Our best asset

Third, we also saw that the old saying about the NHS's crown jewel being its people is true. Despite the myriad of issues for large parts of the NHS workforce, the staff involved went above and beyond to ensure patient safety and care were not compromised.

The attack showed how different parts of the NHS work well together, as clinical and support staff battled to minimise the impact on patients and restore IT systems. Among all the headlines showing a stretched and pressured service, this was a timely reminder of the million-plus people who keep the NHS running.

Lessons learned

However, any major incident, whatever the cause, requires a cold hard look at where future improvements can be made.

In this instance, the first lesson is the fact that there will inevitably be a future incident to manage.

Cyber crime is not new, but it is developing at an alarming rate so is therefore an extraordinarily difficult risk to mitigate. We will continue to ensure we do all we can to stop attacks, through security measures and staff awareness, but we cannot eradicate it.

Understanding this places as much emphasis on a trust's business continuity plan as it does on its approach to preventing cyber crime. Clearly these plans are already in place, but now they have been used it is time to evaluate and understand areas where they can be improved in the future to be ready for the next attack that gets through.

Reliance on email

There are some lessons around communication, both within the NHS and with the wider public. Internally, there is heavy reliance on email as the main tool of communication.

In reality, this is also the case across the corporate landscape. Although those in the technology sector have been sounding the death knell for email for some 10 years, it is still the predominant and most widely-used tool in organisations.

There needs to be significant thought given to what future communications channels are used within trusts, throughout the whole health and care service, and nationally to ensure communication is still possible during any future attacks. For some trusts and organisations, email was down for a considerable length of time, so alternative communications channels are key in the future.

There is also some improvement possible in how the NHS communicates with the public. On a trust level, plans are always in place to communicate with patients and the local population, but there needs to be more thought given to how the bigger picture around these incidents is communicated.

Capital investment

Finally, this major attack has shone a light on capital investment, or more accurately on how constrained this has been in recent years, and the link this has to technology. The financial constraints on the NHS have been, and continue to be, well documented, but this pressing issue has not always been linked to the knock-on effect of ageing IT infrastructures.

What is also not well understood is this is not as simple as upgrading all those trusts still running Windows XP. Aside from the fact that the most affected operating system was Windows 7, not XP, and that upgrading Windows XP is potentially far from simple, this underinvestment in technology is much wider and more complicated.

Even doing the work required to understand the cost of the investment needed is a significant task for most trusts. They are potentially being stifled because there is no indication that capital will be provided to make the required upgrades and changes. We need to understand that the impact of not investing is so great that there really is no option.

The WannaCry attack showed how prepared the NHS is for major incidents and was a timely reminder of just how good it is at coping with extreme pressures. Also, like anything that goes wrong, it offers an opportunity to understand where improvements can be made, and in particular shone a light on the chronic underinvestment in basic technology.

The future NHS really needs a significant capital investment, of time and money, to ensure it can deal with the ever-present threat of cyber crime in the future.

Ben Clacy is Director of Development and Operations at NHS Providers

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