The prevalence of duplication, dependencies, and contradiction is not unusual in large, complex bureaucracies trying to undertake digital transformation. But, to me at least, it does feel particularly noticeable in healthcare. A behemoth of a system with approx 1.7m employees this is understandable but makes it even more urgent a problem to solve.
The Secretary of State at DHSC obviously thinks this challenge needs more drastic measures. The announcement of NHSX has made clear it is going to try and tackle the strategy challenge head on.
I’m particularly fascinated to see the organisational structure they bring to bear. In the past I’m not sure those of us in the relevant delivery agencies have always helped ourselves untangling the complexity challenge; and I’ve started to think that there is something around our organisational design tendencies that is holding us back.
When I started working in digital roles one of the first things I was taught about by a valued mentor was “Conway’s Law”. This is well known in digital circles but for the uninitiated, Conway’s Law states that:
“organizations which design systems … are constrained to produce designs which are copies of the communication structures of these organizations.”
This was introduced to me during the development of a departmental intranet, where the content was organised by the various departments of the organisation in question, rather than say, something more useful like being organised around the tasks users wanted to complete.
In the world of digital, what Conway’s Law is saying is that if your organisational structure and approach to software development (which should de facto based on user needs) are not in alignment, expect problems.
In digital health, whether working at a national, local agency level or within a supplier market, there appears to be a number of different ways organisations, well… organise themselves and their departments and functions. They might:
- Organise by the user. Is it a clinician using a particular technology, or the patient? Or a commissioner or provider? For example: empower the person; or enable clinicians.
- Organise by the care setting. Primary care, acute care, or my own area urgent and emergency care? Or it could be around disciplines e.g. nursing, dental, or pharmacy.
- Organise by function or capability. Enable users to undertake booking, get prescriptions, or access care records.
- Organise by the care pathway or user journey. For example “maternity” or “cancer”.
There are probably more, and a fifth category specific to the NHS of ‘interoperability’, i.e. working on the plumbing between systems, merits an honourable mention as sometimes it’s on its own, and sometimes it’s within other buckets.
All of these are logical ways of slicing up the problems to be solved. But the problem is that we can often use all of these taxonomies all at the same time.
This then often means that perfectly skilled teams of well meaning people in each group set out to try to meet needs (sometimes user, sometimes business) in their area in a way which will then inevitably span all of the other categories.
So you might get, for example, primary care people trying to create patient facing services, and patient facing services teams trying to tackle primary care. Or urgent care people spinning up analytical teams to get the data they need, while the data infrastructure teams cast around for customers. The natural tendencies of “not invented here syndrome” and an understandable desire to reduce dependencies on other parts of the system can often make things worse. In such a mind bogglingly complex system it can often be more accident than design when these things link up.
This is further exacerbated by two other factors. First, the central agencies overall probably play quite a small role in actually delivering ‘stuff’ compared to organisations on the ground, which means the same contradictions may play out at Trust, Clinical Commissioning Group, or Integrated Care System level as well as across the national agencies.Second, there is the challenge that end-to-end user journeys will touch many settings and functions, and implicitly different provider organisations, rendering proper service design pretty challenging.
I’m not sure what the answer is, and I have no envy at all of the talented folks who have wrestled with this in the past and are probably doing so now. Maybe the response is a combination of the above: something like a top tasks strategy with a mix of user journey/care pathway teams, and capability teams. But if nothing else it underlines the need to go the extra mile to set a crystal clear strategy, including how markets should be managed, and the combination of ruthless spend control, and serious capability building. Sounds like a plan.
Originally published on 16 May 2019 on Medium.