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.
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.
A few weeks ago in a planning workshop, our CEO Ben encouraged me to post more; thus gifting me a nice and straightforward NYE resolution. It’s not an unfair challenge. Little does he know last January I set myself the personal target of publishing 3 blog posts in the entire year to jolt myself back into a habit. I think I’ve managed one so far. So this is an attempt at being a whole third less useless.
Leading the health and care team at Public Digital for the last 12 months has been another of immense intellectual fulfilment, enjoyment, and pride. Tough problems with great clients. So, here’s a quick note on some of the year’s highlights to end 2023 in the way I want to start 2024.
(1) On the basis you get nowhere in the transformation of health and care without really understanding clinical practice, this year we were delighted to add a doctor to our core team. Not just any doctor though — one that also has a Masters in Design. Welcome Saw. We’ve also done important work to strengthen the technical expertise of our network in areas like population health or provider trust technology.
(2) From a previously predominantly NHS-oriented client landscape we had more client diversity in healthcare this year. And in particular have made strides in the charity space, and social care. Our team is highly purpose driven, so hearing a client report for instance that thanks to our help we “genuinely improved outcomes for children” as part of a safeguarding project we were working on will live long in the memory.
(3) Public Digital is part of a family of companies called kyu. Travelling to meet our health counterparts from the kyu various companies in New York last March was a thrill, and gave me a much better sense of the capabilities we have across the group. I already knew about the brilliant people in IDEO, but the group also has skills in urban design, public affairs, behavioural insights, development, branding and creative, and more.
Chris and Matt at the Governor’s Office, New York City
(4) Although we still do a lot remotely, getting out on the road in the UK has been invaluable to form ever better and more trusting relationships. This year we got to: Barnsley, Blackpool, Bristol, Chelmo, Dartford, Derby, Ipswich, Liverpool, Maidstone, Manchester, Middlesbrough, Newcastle, Northampton, Norwich, Nottingham, Southampton, Warrington, Worthing. And of course lots and lots of lovely old London.
Chris, Jesse, Audrée, and Saw on the road in Newcastle.
(5) This was also a year when we started to think about the intersections between some of our practices within Public Digital. To that end, I’ve been working with my counterpart Emily and her amazing team on healthcare opportunities in the Global South. This included in the latter part of the year, supporting Madagascar to examine opportunities around open source healthcare technologies. Our team was also represented at the Global Digital Health Forum in Washington DC at the start of December.
Connie and Abisola in DC for the Global Health Summit
(6) It wouldn’t be the health and care team without plenty of work in the NHS as well of course, and that has ranged from deep dive assessments into trust digital maturity, to work at the national level on products & services, and getting right back to our roots with a bit of website work thrown in too. We’ve also continued our amazing partnership with NHS England, NHS Providers and NHS Confederation on the Digital Boards program. And we dropped into a handful of the major events of the year. Particular highlights including Cate appearing on a panel with Patricia Hewitt to talk about ICS digitisation, as well as Mike keynoting the NHS Providers conference.
Cate McLaurin presenting alongside Patricia Hewitt at Digital Health Rewired.Mike Bracken speaking at the NHS Providers conference.
(7) Our client feedback has been phenomenal this year. Lots of it has been variation on the theme that we “show up differently”, and get great results because of it. I like to think of this as internet-era consultancy — borne out of the unique space we occupy between classic consultancy and digital delivery. Amongst it all, my absolute favourite was hearing that “Public Digital have made us into a team”. This outcome is something that surprisingly hard to capture as a deliverable in a statement of work, but is beyond doubt the most value we could ever leave a client.
So there you are. Plenty of highlights, but that’s not to say it’s been universally positive or easy going. The contortions at the centre of the NHS and its ripple effects have made things bumpy at times. But through those experiences, comes wisdom, and resilience. Onwards.
We are PD Health and Care. We generate momentum for radical change by:
assessing and building digital maturity
designing digital strategies
resetting difficult programmes
building exemplar services
coaching leaders
developing teams
changing cultures
transforming operating models
If you think we can help you with any of the following give me a shout [email protected].
Merry Christmas everyone. 🎄
This post was originally published on Medium on 19 December 2023.
The Department of Health and Social Care announced yesterday that NHS Digital and NHSX will be folded into NHS England. We have seen these kinds of reorganisations many times before, including in the NHS. All too often they are distracting, dispiriting and don’t deliver the intended benefits.
But that doesn’t have to be the case – providing you get off on the right foot. The reorganisation is not the story. What you do afterwards is.
We don’t know all the internal mechanics of the NHS. But based on what we do know, here are our suggestions for using this transition to build trust and continue the momentum gained during the pandemic.
Work in the open by default. Start by publishing the names of who’s in charge, and what they’re responsible for.
Make an unambiguous, technically literate statement explaining what this means for patient data.
Deploy expert multidisciplinary teams (design, technology, clinical, operations) at all levels of decision making and delivery. Make the most of NHS Digital’s specialist capability in design and technology.
Explain which platforms are needed across the NHS, based on a thorough look at what exists now.
Show how this organisation change is meaningful by delivering something quick, visible and helpful to the system as a truly joint team. Such as an MVP platform for ICS websites, or new clinical calculation APIs, by next April.
Use the practice of working in the open to manage dependencies and duplication, instead of relying on spreadsheets held by Programme Management Offices. Get senior leaders to publish weeknotes.
Fix corporate basics to reduce friction for staff: make the website clear, put everyone on the same email system and directory, modernise the most important internal tools.
Do less so you can deliver more. Use the change to stop doing what is no longer needed or isn’t delivering value.
Most important of all – don’t let this distract from the core mission of making the NHS better for everyone. We need it, especially this winter.
This post was originally published on the Public Digital website.
As part of our work with NHS Providers (supported by HEE and NHSX) on running digital board sessions for trusts, we often get asked, “Can you tell us what good looks like?”. So it was great to see that NHSX is working on this very question, and even better talking about it openly on social media.
When Trust leaders ask us this question they usually are coming from a place of “tell us what the latest technology is” or “paint us a picture of the modern digital hospital”. My response is always the same. We could do that, but is that really what you need?
Historically, digital advancement in health settings has been taken through a predominantly technological lens. The most obvious example of this is HIMMS. But I worry this approach has been pretty unhelpful overall, because as anyone with experience at the sharp end of digital transformation will tell you, it’s not just the technology but the culture, processes and operating model you need to worry about if you want to genuinely change. The risk of painting the picture of an internet-era clinic is that you are not giving a trust any tools to help them get there.
With that in mind, here are some thoughts about what good looks like
Having a clear mission everyone understands. Digital strategies that are 40pages of shopping lists are hard to remember. Make it clear to people what you are trying to do, or they wont come on the journey with you.
Relentlessly focus on your users’ needs. If you aren’t actively focussed on understanding and addressing the clinical, practical, or emotional needs (Ht Janet) of either patients, clinicians, or other staff people won’t use your services and you will never see any benefit.
Talk about services not projects. Services start at go live, projects end at go live. Your digital services should be seen in the same way as any other service you offer- to be supported ongoing, iterated, improved. The NHS Service Standardhas all the advice you need.
Invest in skilled teams – with internet era capability covering not only engineering but product and design, and pair these with clinical and operational staff. Work together, don’t chuck requirements over the fence. And please please try not to design things without some design expertise!
Use modern cloud based technology. Don’t lock into long contracts. Work with suppliers who want to collaborate with you as one team. Stop putting tin in the basement.
Be agile. Focus on the minimum viable product based on valued delivered and iterate when you learn more. Minimum viable governance that is proportionate to the need. Show the thing, don’t hide meaning in 2″ inch-thick board packs.
As a board, be servant leaders. Take collective responsibility for your digital transformation, put it at the top of your agenda. Ensure you have the right technical knowledge in the room where it happens. Unblock things for your teams. Move authority to information not information to authority.
The title of this blog post is ‘What good looks like for digital transformation in health’ but the same principles apply in every sector. None of this is news. It’s all already in the Public Digital book, blog, and in other places like the digital maturity scale my colleagues developed with Harvard Kennedy School. Many of myformercolleaguesand others all around in the health and care system have been saying similar things.
A common picture for what good looks like is beginning to emerge across the NHS. In some places, it is already more than just words – you can see it, and so can patients. But that’s not true everywhere. What comes next must be the harder discussion about what makes good so difficult to achieve, and so hard to scale. Because the answers are likely to be rooted in the topics that all too often fall into the ‘too hard to fix’ category: money and power, legislation and legacy, the rules and tools of the game.
If you’re interested in this work and want to continue this conversation you can find me @e17chrisfleming.
This post was originally published on the Public Digital website.
“Depending on where you look, digital capability might mean one of four things. The ability to use a computer. The ability to tweet. The ability to do something requiring specific deep knowledge, like technical architecture, user research or front-end design. Or the ability to see how digital technology enables the transformation of an organisation to focus on user needs, and make that change happen.”
The digital community aside, civil servants in many departments are far from settled yet on what is meant by digital. The post of ‘digital officer’ is being advertised right now at one of the big departments as a job in a communications team. Too often in my previous policy experience, digital has been lazily characterised as ‘whizzy’.
But getting a common understanding of this taxonomy is vital. Pursuing perfection for each definition requires different skills, strategies, and organisational design. And obviously will lead to different outcomes. It’s much harder for government to pull together in one direction when the name of that direction is not yet commonly agreed and understood.
I’m later to the digital party than many. No doubt lots of effort has been put into getting this message across. But I have arrived before quite a few too, and can safely say the job is far from over.
