AI slop picture of a fictional IT trade show added to help game the linkedin algorithm (sorry)
Over the last week I’ve had three discussions in entirely different contexts that relate to a similar theme – how to get vendors of software products to tesselate effectively with state-run digital services.
Here’s a pattern that I see play out all the time, and have done for the last decade.
Supplier of fancy new software (typically involving AI these days) which is big in industry, or another country, meets senior person/people in a public sector organisation. The leadership gets excited and says “This is brilliant, we need this everywhere. Make it so!” Connections are duly made and this eventually filters to the poor delivery teams who are already up to their eyeballs delivering other things.
This is where shiny idea hits reality. Because then you have to figure out things like:
Can a specific product be quickly bought in a way that complies with procurement law? (Usually not, which is why suppliers offer products for free to get a foot in. And by the way – no shade at vendors for doing this, I’m sure I’d use the same playbook if that was my job.)
Is it compliant with all relevant standards from ISO27001, to DSP Toolkit, to MHRA regs to clinical safety standards?
Is this a point solution, in which case what will it take to integrate it into one or more other workflows so that it actually saves time rather than creating a copy paste swivel chair nightmare?
Does it manage data according to agreed standards that enable interoperability, and mitigates against lock in to a particular product set?
Does it solve a genuine problem?
Most importantly is this a priority against all the other thousands of things that the team are being asked to deliver? If so, why? Does it actually matter more, or is it just that an important person is asking for it? Is it really worth pivoting the teams away from their core work to focus on?
Getting convincing answers to these is non-trivial, so what then usually happens is lots of polite conversations are had but ultimately all parties end up disappointed. Senior leaders think their teams are intransigent and anti-innovation. Suppliers think government is impossible to work with. And delivery teams are left in the middle; managing the noise and soaking up the disappointment from all sides. In some cases, leaders really dig their heels in and the teams have no choice – but unless there is genuinely a good fit this rarely leads to good outcomes.
I’m afraid I don’t have a brilliant solution to this repeating pattern. Seeing it though the lens of procurement specifically, I suspect the key is in active and ongoing market engagement that builds relationships between vendors and delivery teams and enables vendors to respond to emerging need, rather than have to shoehorn square pegs into round holes.
Indeed, the most successful digital and AI products fly off the shelves not because leaders are bashing their businesses or consumers over the head to use them, but because they meet a need brilliantly and are great value for money. Government and the NHS needs great industry, needs great software, and needs great ideas. But if we don’t get the docking points right we will continue to disappoint.
In 1998, a year after the last Labour landslide, the NHS Executive published ‘Information for Health: An Information Strategy for the Modern NHS 1998-2005’. Among other things it promised lifelong electronic health records for every person in the country, round-the-clock online access to patient records and seamless patient care through GPs, hospitals and community services sharing information.
While the technology at our disposal has changed immeasurably since 1998, the 10 Year Health Plan for the NHS in England, published today by the Department of Health and Social Care, has similarly and necessarily bold ambitions at its heart, including a much-needed shift from analogue to digital. Alongside a commitment to making all hospitals fully AI-enabled and a range of enhancements to the NHS App – including to enable remote mental health support – we also see a familiar commitment to a single patient record for all citizens.
There have been some tremendous successes with respect to digitising the NHS over recent history. The NHS App records over 50 million sessions per month. Platforms like NHS login take the pain out of signing on to multiple consumer systems, alongside the App itself. Some trusts have been paperless for many years, and have been able to optimise pathways for safety and convenience. The OneLondon shared care record and care plan now provides a single digital view of important health and care information supporting faster, safer decision-making.
But one question that remains is: if the goal of a digital NHS has existed for nearly 30 years, a time in which compute and storage has become faster and cheaper beyond comprehension, why can we walk into many NHS trusts around the country and see paper everywhere, double keying, endless logins, endlessly spinning cursors of doom? It’s certainly not for the lack of ambition or strategic attention; every government since 1997 has pinned its hopes on NHS digitalisation. Neither has it been a lack of investment, with countless billions spent on NHS technology in that time.
I have spent years leading digital change and transformation programmes and looking at the lessons of successful and unsuccessful attempts at NHS digitisation. It has made me immovable in my view, and as The Future Governance Forum regularly argues, that the ‘how’ of delivery and execution is as important as the ‘what’, if not more so. The lessons learned from decades of failed technology-enabled change are incredibly well rehearsed. Indeed Public Accounts Committee (PAC) reviews of the aforementioned 1998 strategy document them pretty well.
“End users must be identified before the project commences so that their needs are taken into account fully during design and development of IT projects.” PAC report into An Information Strategy for the Modern NHS 1998-2005.
But these lessons bear repeating often, because the evidence strongly suggests they have still not been widely internalised either by governments or indeed by many other large organisations from around the world. The NHS has seen many high-profile digital failures: just a couple of examples include the imposition on clinicians of ill-suited software under the National Programme for IT, or the data sharing programme care.data.
Here are five things the government needs to do, to successfully deliver the digital commitments in the 10 Year Health Plan:
Be bold, ambitious and focused on the problem you are trying to solve, but accept that the solutions needed may vary. Building a new piece of technology is not an outcome. The outcome is: better care, thanks to a health worker’s ability to make decisions on the best information, based on having that information at their fingertips. Although technology is important, it’s the culture, process and operating model change that will truly drive this outcome. You will need to spend at least as much on ‘change’ as you do on the technology, even if you design that technology for maximum efficiency of adoption.
Start small, test and learn, move fast. AI adoption and the move to a single patient record are opportunities to radically rethink the NHS technology approach, moving it to a modern suite of tech suitable for the internet era. But this is a truly massive undertaking. Up-front design based on untested assumptions and a big bang mentality is the pathway to ruin. There are mountains of good work and knowledge out there already to build on. De-risking this should involve letting go of the ‘one system to rule them all’ approach – instead build things which can work well together.
Fix the basics. There is no point in designing a bullet train if you don’t have railway tracks to run it on. For the NHS to get any benefit from the technology in front of them, the absolute first thing is to have wifi that works in all corners of the estate, computers that don’t take five minutes to boot up, and an operating system that provides half-decent cybersecurity.
Give equal voice to policy, operations, clinical, technology and design. Policy decisions in the absence of technical advice can create millions of pounds of unnecessary waste. Perfect technology blueprints don’t survive contact with the reality of the mess that is the NHS. The most senior clinician’s view does not represent what patients need practically or emotionally. I’ve seen the effects of all of this up close. The key is to embed true multi-disciplinary working from the top level leadership all the way through to the delivery teams.
Think long term. Some vendors will have solutions that claim ‘out of the box’ functionality to support the 10 Year Health Plan’s goals. This will appear extremely tempting in the near term especially as the desire for political wins and announceables will be relentless. But in 10 years’ time, who do we want to have custodianship of that data, and how have we made sure that the NHS retains the levers to effect change and set its future direction? This also creates monopoly and oligopoly markets. The lessons of the GP primary care market over recent years ought to be warning enough against this strategy.
People have been trying to solve the challenge of NHS digitisation for more than 30 years. While technology has evolved a lot in that time, the way the NHS thinks about tech – how it builds, buys, manages it – has not always kept pace. While the rest of the world has ridden the wave of digital era technology success, the NHS has often poured endless money into a failed model of technology. To achieve the ambitions of the 10 Year Health Plan, the NHS has to change how it fundamentally thinks about technology, to take advantage of the ability to test, learn and grow successful national scale services.
Maintaining public health and preventing (rather than treating) sickness has been part of the NHS’ mission since its inception.
The subject of health, in its broadest sense, involves not only medical services but all those environmental factors- good housing, sanitation, conditions in school and at work, diet and nutrition, economic security, and so on-which create the conditions of health and prepare the ground for it.
1944 NHS White Paper
Fast forward to today and prevention remains a fundamental plank of the government’s strategy for the NHS. A lot has changed in that time but the most significant change has been that of technology. The internet has now enabled the processing and sharing of information and data instantaneously and at increasingly marginal cost. No surprise then that alongside the shift to prevention, the health and social care secretary is also prioritising a shift from analogue to digital, seizing the opportunities that these new technologies can provide.
To support alignment around the digital prevention agenda, NHS Providers hosted a roundtable for national, system and trust leaders to discuss the role of digital in prevention. Our aim was to help increase understanding, provide some of that alignment, and forge some new and useful connections along the way.
Here are six key takeaways from the discussion:
Prevention is having a moment The political prioritisation of prevention alongside the investment in the tools and platforms that support it, is helping move prevention from policy discussions into mainstream healthcare delivery and opening an Overton window for change that can be leveraged. Now is the time to prioritise any associated opportunities.
The NHS App will be a key tool in the prevention toolset The NHS App is emerging as one of the most powerful digital tools in healthcare — boasting more subscribers than Netflix and logging over 50 million sessions in January alone. Its potential lies not just in usage volume, but in expanding its offer and embedding it deeper into integrated service delivery and prevention strategies. Although there will always be a desire to fix everything through the NHS App given its user base, it will be important to ensure the patient’s experience through the app is organised around a coherent set of services and needs and doesn’t get too confusing and bloated.
Digital can enable a shift from transactional to relational type services There was a consensus that digital health tools shouldn’t just facilitate transactions — they should help foster long-term, personalised relationships. Much like YouTube’s tailored experience, digital health has an opportunity to be, as Rachel Hope, director of digital prevention services at NHS England put it, more “proactive, participatory, and personalised”, transforming the app from a front door into a companion on the health journey.
We need to prioritise enabling work if we want to grasp the data opportunity for prevention The quality, accessibility, and linkage of data across services will play a revolutionary role in unlocking effective prevention. The NHS App could enable self-reported data, while social and demographic insights offer new opportunities to target interventions more precisely. But this will not happen without the critical enabling work of making information governance easier, putting the right tools and platforms in place, and driving standards.
Behavioural change can be driven by design Behavioural change lies at the heart of much of prevention activity. Medicine adherence, better lifestyles, vaccination uptake are all examples. Design is an incredibly powerful lever to achieve this — whether through the gamification of physical activity goals (Couch to 5k) all the way to the simple act of providing clear enough language so that all patients can understand what is meant and what is best for them in terms of their choices. The NHS App and other tools can be a lever to drive better design into patient interactions.
National tools can be a force multipliers for local capabilities It’s a bit of a classic refrain, but where national bodies are building and maintaining scalable platforms, these must allow local flexibility or if they can’t, at a minimum should be co-designed with the front line to ensure buy-in and cultivate a sense of agency among local teams. The NHS’ famous blue lozenge and central mandates are rarely enough to guarantee take-up; products and platforms must also be designed to enable easy adoption. For instance the ability to cohort and invite users can give local teams powerful new capabilities — turning national products into huge local assets.
In my experience of at-scale transformation, the key organising principle for (and challenge to) digitally enabled change in the NHS, is getting alignment across a highly federated and fragmented system. Everyone agrees that prevention and digital transformation matter, but actually delivering it means confronting hard trade-offs and deep cultural change to create that alignment. Forming coalitions of the willing (for instance among the attendees of this roundtable), building momentum from the ground up, and keeping prevention high on the political agenda will be vital to ensure that digital prevention has what it needs to deliver on its promise.
This post originally appeared on the NHS Providers website.
As a former employee of NHS England, I am sparing a thought for former colleagues in the organisation who are facing yet more disruption.
But looking beyond what will obviously be difficult for NHSE staff, there are undoubtedly some opportunities here for the NHS.
Here’s an interesting test. Can you find anyone out there online or in the news defending the status quo?
I haven’t, and it’s clear why. The disconnect, duplication and chaos that has been generated by the current structure is having a palpable impact on the ability of the NHS to get a grip on its many problems. In addition, there has over the years been a huge concentration of staff at the national level, leaving the wider NHS system that operates on a more local level with insufficient capacity to help make change happen on the ground.
Something had to give, so although seismic, I can see the logic in this decision.
To get it right though, the changes must be delivered with care.
Previous NHSE restructures (and I have been through them myself) have taken a salami-slicing approach – trimming a lump off all teams, so you are still left with a complete mess, albeit a slightly more meagre one. A fundamental reshaping of the organisation needs to take place that leaves the government with a workforce fit to deliver the strategy.
Through this change, the department of health must hold on to their digital skills at all costs. A shift from analogue to digital is not only a key plank of Streeting’s strategy but it also wholly underpins the two other shifts he wants to see – from sickness to prevention and from hospital to home. The digital agenda that NHSE is grappling with, and the criticality of digital to NHS reform, means NHSE can ill afford to lose further digital specialists.
This isn’t just about the use of technology but a different mindset and culture. The NHS is a highly devolved service that needs to be led rather than commanded, as previous efforts, successes and failures illustrate. That’s precisely why taking these opportunities will give the government the best chance of delivering not just evolution but the revolution that will be required to modernise an ailing NHS.
This article originally appeared on LBC news website.
An extraordinary day of news on Monday from NHS England*.
My first thought is with former colleagues and officials in the organisation who have been in almost constant restructuring for the last five years. Just when things were starting to settle, the rug has been pulled again. I am sorry for you, folks.
Looking beyond the personal toll, there are undoubtedly some opportunities in here, as long as the leadership takes the right approach. Here are some thoughts on how to get some positives out of a pretty horrible situation for those involved.
Focus on locally-led change
It’s undeniable that there is a massive concentration of people power in the centre. I don’t think many at NHSE realise just how low the capacity is in some parts of the nationwide system. Last year, I worked with one integrated care board which had a single project manager who was the point person for the entire digital portfolio: NHS App, UEC EPR convergence, e-RS, FDP and others. “Build it and they will come” does not work. A rebalancing of some delivery capacity to focus on locally-led change would be helpful. Note, I’m not suggesting product development skills should be devolved to local – the digital agenda that NHSE is grappling with, and the criticality of digital to NHS reform, means NHSE can ill afford to lose further digital specialists.
NHS as a service organisation
Previous NHSE restructures (and I have been through them myself) have taken a salami-slicing approach – trimming a little off of all teams, so you are still left with a complete mess, a slightly more meagre one. A fundamental reshaping needs to take place that leaves you with a workforce that can deliver the strategy. Within this, there is also an opportunity to fix the overall structure of NHSE. I’ve written about this before (in 2019 gulp), but the way NHSE is structured around priorities, without a consistent taxonomy, results in mass confusion and duplication. It means that everyone, everywhere, is trying to solve the same problem – but from different start points and worldviews. NHSE needs to think of itself as a service organisation i.e. one that organises itself around users and their needs, rather than internal communications structures.
NHSE needs to think of itself as a service organisation; one that organises itself around users and their needs, rather than internal communications structures.
Fix pay and recruitment
I assume it is a legal requirement to freeze hiring, while restructure and consultation takes place; this hiring freeze, however, could be an act of self-destruction. Getting new people into NHSE takes six to nine months. NHSE needs to stay on top of the new skills it will need to deliver against priorities. From a people perspective, NHSE also needs to fix pay consistency across national and local. Talented leaders are disincentivised to go out to the system because, simply, the pay is worse. The restructure must be seen as an opportunity to enhance the value proposition to attract key skills, otherwise it will make a challenging recruitment landscape even more so.
Adopt internet era ways of working
Most critically, NHSE needs to make sure that deep digital and data expertise is at the top table. Driving NHS transformation is not just about technical literacy (although it is a critical part of it) but also internet era ways of working i.e. what it means to operate as a modern organisation. This means adopting, and valuing, inclusive and open ways of working that enable trust, operational transparency, and an efficiency of communications that helps spread knowledge.
The NHS is a highly devolved service that needs to be led rather than commanded, as previous efforts, successes and failures illustrate. That’s precisely why taking these opportunities will give NHSE the best chance of delivering not just evolution but the revolution that will be required to modernise an ailing NHS.
*Two days after this article was published the UK Government announced the abolition of NHS England.
This post was originally published on the Public Digital website.
Times article this morning on the Health Secretary’s desire to enable people to book GP appointments online (linked in comments). Some quick thoughts:
It is currently functionally possible to book GP appointments at any time of the day through the NHS App. This works via API access to the EMIS/TPP clinical software that runs GP practices. However, the user experience varies from practice to practice because GPs can configure what appointments (if any) they make available to book via their internal clinical systems. The reason for this is that GPs, reasonably, would like some control around what how appointments are being allocated, so that constrained resources are directed in the right place. Another challenge is that there are different types of appointment but no agreed standards for describing them so the way they surface in the app is confusing to users. Serious plumbing work is needed but never sexy enough to prioritise.
But ‘online appointment booking’ is a red herring – not all patients will actually need the GP appointment they think they do. Instead, a wider concept of ‘digital access to GP services’ through the App, which takes a more nuanced approach to meeting patient needs, would provide a better experience for patients and practitioners. This should include digital triage: in preceding years, NHS England has encouraged a “digital first primary care” policy in which GPs are encouraged to use digital tools to gather initial information from patients that then allows them to be triaged (such as e-consult, Klinik, or Accurx). This works pretty well in a lot of places depending on which product you have integrated. I’ll try not to name faves. Triage is well used in A&E and 999 – so why not primary care.
Rather than demand GPs release appointments, a successful policy would demand integration of triage and communications tools into the NHS App, with strictly mandated data and design standards using the NHS design toolkit to ensure a good experience. This could be further extended to different care settings. But barriers to this, and necessary reforms to overcome them, lie more in traditional models of care, commissioning and payment, and managing software vendor markets, as well as technology challenges.
P.S. I do appreciate a lot of this is happening behind the scenes. I’m just tackling the article 🙂
Public Digital is growing. And through growth comes inevitable change. One of the consequences of that change is that the health team is expanding to encompass local government and charity work too. This is an exciting step forward but also means the end of a small but perfectly formed team of some incredibly talented people.
At Public Digital we celebrate starting things – and we celebrate stopping things too. We always make the space and time to reflect on what has passed – what went well, what could have gone better, and what we’ve learned.
So last week, we spent an afternoon reminiscing about our work over the last four years, so we could give the team a good send-off. This short scrapbook captures some of our memories.
Chris was the first into the team joining Public Digital in late 2020, ostensibly to work on the NHS Providers Digital Boards programme. The image below shows an artefact from Chris’s first week – a sort of ‘mind map’ of key concepts in digital transformation and the GDS story. Essentially a one page version of the PD book Digital Transformation at Scale. It has proven a faithful ally and useful prompt over the years for pithy insights on various aspects of digitally enabled change.
An artefact mapping key concepts in Digital Transformation at Scale
Digital Boards is a programme we still support today. In fact it has just relaunched for a new phase this week. It’s had fantastic feedback from participants, and has taken us and the brilliant NHSP team all over the country.
While PD colleagues were flying to Nigeria, Washington DC, Guadalajara – the health team took in the delights of…
…Scunthorpe (it’s always sunny in Scunny)……Ipswich in Matt’s Mother in Law’s drop-top fiat 500……many many trips to Norfolk…… and Chesterfield, where we delivered a session in a tinsel-bedecked room even though it was July. A hangover from on-and-off lockdowns in the early days.…a Stoke-on-Trent Travelodge and its limited real ale selection…Delivering a Digital Boards session takes a serious IT rig. Here’s a glimpse of Connie’s set up circa 2022.
Beyond NHS Providers we’ve had many other memorable client visits and experiences in the healthcare sector.
User research is a key part of much of our work. Which includes not just things like usability testing or semi structured interviews but also meeting people where they are. The below photo is from the installation of a GPS pendant for an elderly lady suffering from dementia, the start of our work in the care sector.
Some of our projects tested our artwork skills to their absolute limits. Working on a project with NHS England, we were asked to facilitate a retrospective using the “anchors and engines” structure i.e. what will weigh us down and what will propel us forward. Although we are blessed to work with many great designers in Public Digital, we don’t always have one on hand. 10/10 for effort Matt.
Like the rest of PD, the health team is also blessed with many highly gifted speakers and presenters who represented PD at a whole range of different events. A couple of honourable mentions
Cate speaking alongside the Rt Hon Patricia Hewitt.
Tom presenting at Digital Health Leadership Summit having brought odd shoes. Odd as in, from two different pairs, rather than simply ‘strange’. No one noticed thanks to judicious concealment behind the lectern.
Tom presenting at Digital Health Leadership Summit
As a proud north-easterner by heritage it has perhaps been no coincidence that we have had the privilege of doing a fair bit of work in Newcastle, Durham and Teesside over the years.
One of our meeting rooms in PD is called the Calvert room after Margaret Calvert one of our CEO’s heroes. In the picture above you can see the Calvert Typeface on the Tyne and Wear Metro. Distinguished by its block serifs.
A night with clients in a Newcastle comedy club. Possibly ill-judged in hindsight but gosh it was memorable.No visit to the north east is complete without a pit pony sighting
As well as stotties in Newcastle…
We’ve also eaten cobs in Nottingham……pie barms in Blackpool……and parmos in Middlesbrough.And we’ve run off the calories in New York.We’ve sponsored brilliant unconferences like Healthcamp……found our colleague Saw’s spiritual home……and even given Santa a base of operations when he needed one.We exhibited the strongest of scarf games.And just look at this suit.The health team has always had an eye for a natty bit of clothing. Believe it or not these autumnal hues were entirely uncoordinated in advance.
We’ve had some memorable moments with clients over the last four years. We’ve seen a CEO of a several hundred £m organisation fall asleep in our workshop. We’ve travelled hundreds of miles to reach clients only to be uninvited on arrival. We’ve cringed our way through a fair few car crash meetings. But through adversity comes strength and the excellent moments have vastly outnumbered the bad.
Here are just a few of the things our clients have said:
“[PD’s work] really inspired us as a team and gave us a language to use together to lead transformation.”
“Thank you so much… you are making such a big difference to people’s lives doing this.”
“Public Digital are genuine subject matter experts, passionate about the digital agenda, and interested in getting to the root of the real problems.”
“I get lots of consultancies telling me that they want to do ‘meaningful work’ but I’ve never come across one where every single person so actively, genuinely and obviously means it like the Public Digital team.”
“This is not a deck that tells us what we’ve told you. It’s full of practical things, starters for 10, and we can all see a clear path for what we need to do next.”
“We really appreciate all the remarkable work that has gone into the report. Your team has shown genuine care for our organisation and the individuals who you have met. It feels that you have put your heart and soul into the project to provide us with the insights and recommendations to move us forward as we further develop our services for those in need of our support.”
And our favourite of all time.
So goodbye then to the loveliest team any of us could have asked for.
And on to the next chapter.
This post was originally published on the Public Digital website.
Another political administration, another commitment to putting technology at the heart of NHS reform and medical records in the hands of those that need them. If you think you’ve heard this one before, it’s because you have. All of the preceding Conservative Secretaries of State for Health have made similar commitments on NHS digitisation. As did their Coalition and Labour predecessors.
In fact, the story of digital technology reform in the NHS starts all the way back in the 90s with the introduction of the NHS’s first Information Management and Technology strategy. Which said some entirely sensible but eerily familiar things.
“Staff will enter data once and share where needed. Information will be secure and confidential. The NHS will share information using common standards and an NHS-wide computer network.” (Source: Mark Reynolds, 2023, Digital Health in the NHS)
In a complex network of institutions such as the NHS (the NHS is not one single organisation contrary to popular public belief), sharing data about a person to ensure their continuity of care is self-evidently an essential part of delivering a good service – if it was merely a matter of political will, wouldn’t it have been done decades ago?
The real reason that we haven’t achieved this is due to a series of extremely tricky technical, design, commercial and policy challenges all made more difficult to tackle by misaligned incentives.
How the NHS App displays medical records today
The authors led development of many digital products and services within the NHS, including leading on the NHS App, so are both familiar with these problems as well as invested in its success.
The NHS App already does a number of things but this blog post is particularly focused on the access to medical records.
The NHS App uses APIs to connect to GP Systems, of which there are two dominant market leaders in EMIS and TPP. These APIs existed long before the NHS App, indeed without them the App wouldn’t exist.
In some places the NHS App also has integration with providers of secondary care records such as Patients Know Best. Access to these records is highly dependent on which products and services have been procured locally, and therefore it is not uniformly available across the country.
Given that the GP record is intended to contain your entire medical history, and the fact the NHS App is already connected to all GP records in the country, in one sense this is a solved problem.
But it doesn’t feelsolved.
The challenges of the current model
The reason is perhaps that aspects of this solution really don’t work well enough – or they don’t work well enough all of the time.
Firstly, in order to access the full details of your GP record via the NHS App, your GP records needs to have a setting set on the GP’s own system to enable “Detailed Coded Record” access. Without this you will see just a very summarised version of your record in the NHS App. Theoretically from 2023 this setting should be enabled by default, but it’s clear that this isn’t the case with many GPs. To enable this setting on your GP record, you have to contact your GP surgery and ask for it. When we’ve tried to do this for our own records we’ve found that the surgery staff had no idea what we were on about.
There is also a huge usability challenge to overcome. Medical records at their core are designed for professional clinicians and not laypersons. As well as being hard to read due to the technical nomenclature, there are genuine patient safety and usability concerns around presenting uninterpreted data to patients, especially when it comes to diagnoses or test results with significant consequences for patients.
Example of how the Pfizer COVID vaccine shows up in the app.
Furthermore, simply presenting data in lists doesn’t necessarily help a patient understand the journey they are on, or which information is most relevant for their current situation. The same is true for clinicians, who often have to wade through screens of ephemera before finding what they really need.
In the examples above you can see the change in design language when jumping between different systems. This is jarring for users. Joining up user journeys across all the different products sold by different vendors is extremely hard to get right, and requires a muscular approach to shaping the NHS software market that has sadly been lacking.
Under the hood, the interoperability is still not good enough, both in terms of the mechanisms for accessing data, and the modelling of the data itself. The data is pulled into the NHS App via something called IM1, which is a pretty ancient set of API standards that have limited utility.
Better APIs into the core clinical systems do exist, but the vendors charge for access. This is where you run into the politics. EMIS and TPP have their own “patient portals”, and also support an ecosystem of vendor partners that do similar. This is a key part of their business model. So in effect the NHS App is competing with the offers that the 3rd party “patient app / patient portal” suppliers are providing, and many GP surgeries are still using them as their front door and default patient data platform.
In too many cases a ‘let the software market decide’ assumption runs deep within NHSE. Such a posture is in direct opposition to the alignment required to join up patient records.
How to solve these problems
A foundational question in all this, which was the source of some debate on X this week, is “is it possible to solve these problems without fundamentally ripping up the core technical infrastructure at the heart of the NHS and starting again?”
Is it better to work with the model we have, an archipelago of medical data with a central shared view pulling data in from the multiple sources, or is it better to do something radically different where we re-engineer the existing model and create a new national record infrastructure based on data being pushed into a consolidated record which is made available through dedicated API services?
Both models need more analysis, and those analyses should be published so the public can appropriately scrutinise the hundreds of millions that will need to be spent in either context. They must also include a hard look at the existing significant investments in NHS data infrastructure and technology, and resolve any duplicative or conflicting approaches.
Regardless of the technology approach, this challenge won’t be solved through the creation of the perfect architectural diagram.
Whichever route you take there are some other fundamentals that also need addressing:
Embedding deep experience and technical knowledge in the Centre of the NHS, particularly at the very top table driving commissioning and strategy conversations. This is lacking at present.
Committing to a long term plan (no, not that one) that remains consistent and is inoculated from political change and cabinet reshuffles.
Radically reshaping vendor markets. NHSE has too often let the market decide. Enough of that.
Properly funding and taking a coherent approach to data and open information standards, with a coordinated approach to working with vendors.
Publishing a clear strategy and roadmap, explicitly linking strategic aims, the work that will contribute to them, and the aligned incentives that will support their success.
Once we see the announcements that will achieve these fundamentals we can look beyond the headlines and get some real hope that things may just be different, this time.
Cowritten with Matt Stibbs and originally published on the Public Digital website.
In the wake of reports linking IT flaws to deaths of patients and the recent cyber attack on pathology services in south east London, Chris Fleming calls for radical change to make digital safer and more effective
Digital technologies and ways of working have huge potential to transform our healthcare system and alleviate some of the pressures facing the NHS. But only if we do it right.
So how are we getting on? Last month, the BBC reported on IT system failures that have been linked to the deaths of three patients. And in the last fortnight a pathology system supporting some of our biggest hospitals has been taken offline, and an entire healthcare system’s digital infrastructure was reported to have collapsed.
We need to change. We need to improve the products we ask our staff and patients to use, insist that the market modernises alongside us, and recognise that digital is not the same as IT – it changes the way healthcare is delivered. It is essential to get this right, to tackle the risks of digital systems and prevent patient harm.
Reshape the market
It’s tempting to bury the reasons for this failure behind issues of complexity. And in fairness to my colleagues working in the sector, the federated nature of the NHS, and the inherent complexity of medical data and medical practice, are undoubtedly contributing factors.
But the complexity is not a sufficient excuse.
There are three things we can and must do now to mitigate future patient harm and make sure we are leading digital change in the most effective way we can.
Firstly, we must take market shaping seriously to drive drastic improvements in the products we use every day in the NHS. We need to act on rent-seeking behaviours and give new players who are shaping the market in a positive way a boost. Given the general failure of the market to respond to this design challenge (with a few exceptions) we might, as Digital Health’s editor-in-chief Jon Hoeksma points out, be rather better off building some of our own systems.
Secondly, we need to take the development, coordination, and enforcement of open standards in interoperability and cross-institutional communications seriously and underpin it with the resources that reflect its importance. It is an unglamorous topic, but this plumbing is vital for the future of the NHS. The Data Protection and Digital Information Bill, which had provisions for interoperability between vendors, fell down in the wash-up period after the general election was called. If they win the election, as looks likely, Labour should revive the provisions in the Bill, to give the NHS teeth to force interoperability without being scared of the response of the market.
Thirdly, we need to recognise across the NHS that digital health is not about funding ‘IT projects’ but a fundamental rewiring of the way healthcare is delivered, requiring requisite buy-in from the whole organisation both at national and provider level.
Digital at the top table
All of which will require a well-informed and muscular centre playing a servant leadership role with the system. Digital and technology experience should be at the very top table of NHS England. Clear architecture and commercial strategies should be developed in conjunction with the wider NHS CIO community.
NHS England needs to focus on a long-term approach to funding and should build (or fund the scaling of) world leading open platforms that are designed for adoption that can take pain away from the system and prevent the front line from having to constantly reinvent the wheel.
The Wade-Gery review recommended “Putting data, digital and tech at the heart of transforming the NHS”. I know many fantastic people in the local and central NHS who get it and are succeeding, in spite of the challenges. We need to break down the barriers, unblock things for them, and let them deliver.
The complexity of the digitisation of the NHS and social care is such that it is not an area where major systemic change can happen over the short term. This has been proven many times in the past. Any incoming administration would be advised not to underestimate how hard it will be to deliver their technology commitments – especially those involving patient data, as the operational changes are huge.
But if we do not at least start with a radical rethink of how to go about these challenges, history will be doomed to repeat itself.
Developing digital services in health requires all sorts of assurance processes – clinical, technical, information governance and so on. I’ve seen assurance that can range from highly effective and supportive, to being a complete drag on innovation, quality or pace. It all depends on how it is executed.
The worst form of assurance is when teams have to go begging to a governance board of high-and-mighties who have zero knowledge of a product, its users, the research and the tech and design trade-offs made to get the product to where it is. Assurance in this case is just not meaningful, and often defaults to the strength of the relationships between the requester and assurers.
The absolute best form of assurance is when experts are considered part of the delivery team, sharing the same vision and outcomes, and assuring as they go as part of an iterative ongoing process. They can still report to higher-ups, but the decision remains closest to where the knowledge is.
My experience was that during the pandemic, all assurance of the digital services I worked on was the latter by necessity. But it shouldn’t need a pandemic. Experience from across many sectors in Public Digital shows this is a better way.
