• Every trust attempting to apply digital new ways of working is likely to face similar structural challenges that require changes in other parts of the organisation in order to maintain the desired pace and quality of delivery.
  • Procurement, recruitment, financial approvals, governance, technology decision making, communications and leadership tend to be high on the list.
  • Unblocking issues where the existing processes and culture in these areas are hindering delivery is more likely to accelerate digital delivery than pouring more resources into the problem.


If the four pre-conditions of digital transformation are satisfied - clear leadership, a team, a goal, and a burning platform -  organisations are often set for success (see chapter three). A board’s attention may then be turned to parts of the existing organisational structure that could make it easier or harder for trusts to adopt digital ways of working. 

In the UK government, digital teams working in a variety of central departments on new or redesigned digital services between 2013 and 2015 came to describe something called the 'square of despair' - four seemingly universal organisational challenges that slowed down the pace of delivery.

To these four, Public Digital has identified at least three further sources of systemic frustration. These challenges are far from unique to government, they're equally common in large businesses and charities. While every industry endures their own special dysfunctions, all of them tend to encounter some version of these seven at various points in their digital journeys. Within the trust sector some may be perceived problems and there will be varying levels of severity. Public Digital has set out seven challenges below:



Problem: The rhythms, artefacts and pace of traditional governance run counter to the needs of rapidly iterative, agile delivery teams. 

Many large organisations run according to a rhythm of monthly boards, project steering boards and stakeholder advisory committees, fed by an industry of reporting and paperwork. These meetings expect papers, not prototypes. The point of steering boards is usually to ensure every affected part of an organisation gets to have a say, not to play a part. Such meetings usually conclude with the team leading delivery taking back many comments and actions.

Traditional governance models can swamp digital delivery. For agile service development to work, the delivery team’s role must be just that - to deliver, rather than spend a disproportionate amount of time servicing the needs of boards. Each affected part of the organisation is represented within the delivery team, there to actively contribute. The project sponsors come to ‘show and tell’ meetings of live prototypes and ask the tough questions there. The role of those sponsors meetings is to give the sponsors actions; points where they need to go and unblock issues elsewhere in the organisation. This inversion of traditional governance represents a major cultural shift for many organisations and will not happen for every project overnight. When it works well, it demonstrates how boards can still receive the assurance they need through a more dynamic, ‘real time’ engagement with delivery teams.

Following good agile governance principles go a long way to increasing pace while sacrificing nothing in oversight:

  1. don't slow down delivery
  2. decisions where they’re needed, at the right level
  3. do it with the right people
  4. go see for yourself
  5. only do it if it adds value
  6. trust and verify


Funding and investment appraisal

Problem: It is as effortful to ask for a small amount of investment to try new things as it is a much larger amount.

Too many discussions about digital transformation focus on benefits as defined through the lenses applied by traditional ‘Treasury-style’ business case methodology. While quantified benefits have their use as tools of persuasion, there are several problems with this style of investment appraisal. The lengthy, bureaucratic nature of business case development encourages central teams to ask for large capital investments over many years rather than smaller, operating expenditures over shorter periods (why ask for a small amount when it takes the same effort and time to get more?). This encourages long-term speculation based on assumptions and hypotheses. This kind of prediction is appropriate for controllable, fixed environments, but translates poorly when applied to fast changing environments like digital healthcare services. It can also see central fundholders falling in love with the process of benefits realisation reporting rather than the outcome that is sought.

Financial approval processes offering proportionate assurance to risk make it easier to release funds for small, low-risk experiments, and increase the level of scrutiny in line with the size of investment. This is easier said than done in the NHS, where central funding often comes with reporting requirements. But the NHS response to coronavirus has proved that this kind of financial agility is possible, the trick is reintroducing appropriate and informed oversight without losing urgency. HM Treasury has drafted guidance on agile business cases that offers a template precedent for this model in large institutions. 



Problem: We keep contracting the usual suspects without getting significantly better results, and we’re locked-in to long-term supplier contracts.

Often, the debate about procurement in digital transformation is framed as ‘build versus buy’. This is a false dichotomy. The flaws in outsourcing all aspects of technology related delivery are increasingly well known, and have been a root cause in many major project failures. Particularly in the NHS, it does not make sense for every organisation to invest the huge resource needed for a permanent team able to build and run bespoke services.

In some respects, procurement manifests as a blocker in a similar way to funding - a set of experts becoming too attached to the outputs of a 'one size fits all' process, losing sight of the intended outcomes that require a more flexible approach. The consequences are similar, a default towards expensive, lengthy and complicated procurements that only a few players can fulfil. To support digital transformation effectively, procurement must not put up barriers to entry for an organisation to purchase the things it needs to deliver outcomes quickly and cost-effectively. In practice, those purchases are going to be a mix of commodity technology (infrastructure like hosting or WI-FI, where there is a strong and competitive market drawing down unit costs) and multidisciplinary teams of people who can build more bespoke services. Skilled digital procurement requires a shift in skillset from contract management with large suppliers through to becoming a much more informed customer of a technology market. For trusts, this can be done at the system level in order to support service integration and drive economies of scale.



Problem: We cannot afford to hire the digital skills we need, and even if we could, they would not want to work here.

Many organisations - particularly in the public sector - take it as a given that they will not be able to hire specialist digital skills they would ideally like, simply because they do not pay enough to persuade them to leave better remunerated positions elsewhere. Strikingly, these same organisations are often those most dependent on contractors working on expensive day rates.

While there is a pay differential between the public sector and others competing for the same digital talent, the public sector (and the NHS) has one huge advantage - it offers talented people the chance to apply their skills towards making an enormous difference. Careers in the NHS also offer good job stability, which is particularly important in the current climate. Many trusts already understand that the NHS arguably has one of the strongest hands to play in the world.

Several factors may be preventing public sector organisations from making the most of this advantage. This can sometimes come down to a gap in self-confidence and communication of this unique opportunity for digital recruits. It is also important for potential recruits to believe that they will be put in the right organisational environment to make the difference they crave, regardless of how appealing the mission is. Being able to convincingly communicate these messages is often the best way to recruit new digital talent.



Problem: We cannot work in the open, and share best practice (as well as code, design patterns, user research findings).

A defining cultural feature of digital transformation is working in the open. Day to day openness - publishing blog posts about what a team has delivered this week, for example, or publishing regular social media updates - plays a very different role to traditional organisational communications. Whereas the traditional comms world tends to be the broadcasted, occasional pushing of messages from the top with minimal right of reply, digital comms is conversational, responsive, regular, and about ‘pulling’ people in. It is the difference between publishing a blogpost and emailing a document. ‘Publish, don’t send’ is a good maxim. 

A lot of corporate communications can be fundamentally about risk management and tend to be tightly controlled. For digital transformation programmes, this method too often lacks speed and authenticity. It also makes sharing best practices and scaling the story across the organisation much harder. Even so, switching to working in the open is a cultural challenge, because it requires the organisation being comfortable with speaking in new voices and on new media - and with different, lighter editorial safeguards. That said, if GCHQ can manage it, very few other organisations have an excuse. In recent months many trust leaders have adapted to new forms of communication techniques, publishing online board updates or holding town halls via Microsoft Teams.



Problem: Security says 'no' all the time, frustrating our attempts to design for usability, and we do not know what technology choices to make, when.

Underlying technology is obviously a major contributor to the speed and success of any digital transformation programme. For trusts, the most important considerations are likely to be some combination of dependency on old legacy systems, interoperability with the wider health and care system and security and legal risks.

Large scale technology projects often induce anxiety around a board table. As one senior trust leader admitted, mishandling a ‘big bang’ electronic record system launch remains on the list of things that can get a chief executive sacked. Beyond the NHS, the root cause of technology disappointment is often that technology has been thought of as a hygiene factor of the organisation - essentially, another part of the planning - and therefore not considered as integral to the organisation’s overall strategy. Leaving technology as an add-on can be a recipe for trouble. The same can be said of security. Usability and security are not inherently incompatible, what is incompatible is fully designing a service, then thinking about security as a separate piece at the end, at which point all the necessary protections ruin the design (and badly designed services lead people to use more insecure workarounds.)

The other hindrance to effective consideration of technology is seeing it as a homogeneous category. In the healthcare world especially, technology is shorthand for a dizzying array of different things. Some of these things are established and well understood, such as telemedicine and remote monitoring, others are at the very cutting edge, such as artificial intelligence and population health. Taking the same approach, with the same people, in the same organisation conditions, tends to end in failure.



Problem: Senior leaders do not engage with the digital transformation programme, or perceive it as purely operational, rather than of strategic importance.

While the energy and expertise to deliver tangible outcomes from digital transformation will come from the practitioner levels of an organisation, the effort as a whole cannot succeed without strong, diverse and inclusive leadership.

Almost all digital delivery teams should, by definition, be challenging the norms and defaults of the trust as they make progress in building new services. For them to move quickly, they will need to feel they have ‘top cover’ from leaders who have empowered their teams to get on with overcoming those obstacles, and - as a rule - expect them to seek forgiveness rather than ask permission. Providing this mandate requires a relationship of trust and a particular attitude to risk. It does not mean that leaders allow teams to go rogue, it is about giving the right group of people a clear mission and considering the risk of delay or maintaining the status quo as being greater than the risks inherent to challenging it. The more permissive environment in the NHS in response to COVID-19 has demonstrated how much more quickly change can happen when staff feel empowered to act. It is important leadership is representative of patients, service users and the wider workforce. This reduces decision making bias and supports staff engagement, which will ultimately improve performance and innovation within digital teams.