- While all NHS trusts have certain characteristics and contexts that are unique, the vast majority of the challenges leaders will face are the same across the sector, and indeed other sectors too.
- The section provides a set of questions that executives in other industries - and government in particular - have used to identify strengths and weaknesses in their own digital leadership.
Based on their experience of working in (and with) governments and complex commercial businesses, the Public Digital team has compiled a set of questions every board member of any organisation could ask themselves about their own digital transformation. We believe much of this can apply to the NHS. This is not an exhaustive list, these questions are intended to kickstart wider discussions that can engage and focus whole boards and allow each member to assure themselves on digital.
1. How close are you as a board to what your users experience?
NHS leaders are used to 'walking the floor' - experiencing first-hand what their patients and staff are going through as they receive care or go about their working day. Exactly the same logic can be applied to the digital experience, in as unvarnished a way as possible.
From the first weeks onwards, teams working on programmes that deliver patient or staff-facing services should be showing their leaders ‘clickable’ prototypes and early versions of services. Scrappy is perfectly acceptable provided the early versions have enough fidelity to test assumptions about policy, operations and technology.
Strong digital leaders tend to demand sketches and prototypes, rather than papers, and ask what the team has learned by observing how users engage with them during user research sessions. They become worried if the team says there’s nothing to see other than paperwork after the project has been running for three months or more.
Another facet of this is patient involvement in the governance of digital transformation, and their representation in conversations guiding the strategic direction of teams. This form of patient advocacy can be a valuable complement to user research at the frontline.
2. Are your discussions more focused on outcomes or outputs?
Many past digital transformation efforts have fallen victim to a form of 'metrics blindness'. This is where the KPIs intended to measure the programme’s success all appear green on the dashboard, yet the service experience itself remains stubbornly poor in reality. The same charge can be made of focusing too closely on a project’s deliverables as defined by the consultancy or vendor contract, and not enough on whether the outcome is actually what was intended.
Metrics and quantified performance measures have their place as signals of progress and momentum and can provide useful warning lights on the effectiveness or otherwise of digital services. However, many leaders are increasingly treating them as necessary but not sufficient. This is partly because metrics can be unreliable. It is also because of the perverse incentives that being too led by metrics can create. This is a familiar story if we think about NHS financial targets of recent years. These have put the focus on trusts delivering impressive efficiency savings through in year cost improvement programmes, without being able to match this with the investment required for long-term service transformation.
3. Are you seeing evidence that your digital programme is delivering visible value to patients in weeks and months, rather than years?
The COVID-19 pandemic has given a powerful and timely reminder to trusts that they are very capable of delivering significant change quickly and well, with the differences being experienced on the frontline within days. Successful digital transformation that replicates this effect does not mean that leaders need to instil a permanent sense of crisis. However, it does mean taking some elements of the environment that defined the successes of a trust’s rapid response and making it possible to repeat them in more normal times.
Specifically, leading digital organisations have become well practiced in starting small with imperfect, minimum viable services, and iteratively improving them quickly based on new information. They’ve prioritised good initial projects according to things that are clear and obvious patient needs, rather than speculative technology solutions. Crucially, if things haven’t demonstrated value at the frontline quickly, they’ve not pursued the experience and instead tried something else. This muscle of 'failing fast' is a sign of digital maturity in any organisation: strong digital organisations don’t make fewer mistakes, they just make them more quickly, and more cheaply.
4. Who does most of the talking when the topic of ‘digital’ is raised?
A common theme throughout this guide is that digital transformation is a collective responsibility. This is not just true around the board table, it is equally important that a variety of different specialisms and perspectives are represented in the teams who are delivering.
Board members should be concerned if they perceive that the conversation about progress on digital transformation is entirely led by one particular ‘tribe’ within their organisation. Often this will be the IT team, but the over-dominance of any area - be it strategy, IT, finance or clinical - should be good grounds for asking questions.
Of particular worry should be if the conversation is being led not by an organisation’s staff at all, but by contractors or consultants. While both groups may play an entirely appropriate and valuable role within a bigger digital team, over-dependence on external support for the programme’s success creates significant risks for its long-term sustainability, and especially if that support is the leading voice.
5. Are teams in the trust empowered to experiment with new ways of working?
More than most industries, healthcare has a long history of experimentation that is central to its culture. A tension at the heart of every healthcare system is reconciling the need to nurture this experimentation and provide a route for scaling effective new interventions as quickly as possible, while maintaining consistency and coherence across a complex array of organisations.
This tension is one almost every large organisation encounters, and it cannot be conclusively resolved. However, an effective tactic for reducing the friction it creates is ensuring that the processes and culture of an organisation apply a proportionate attitude to risk. When the risk is low relative to the potential benefit - in terms of patient outcome, or cost, or staff engagement - organisations that carry out successful digital transformation operate with a high degree of trust in their teams. Every round of approval or piece of paperwork involved in trying something new - processes that are put in place as a substitute or proxy for trust - adds time, which adds cost, which changes the risk-benefit equation. This can lead to simple, quick wins being ignored.
The implication of embedding a more experimental culture is that it is also a more accountable culture, organisations where junior staff are empowered to act, and be responsible for their judgment. Healthcare has an advantage because this attitude is more common in medicine than many other fields. The challenge in healthcare is empowering junior staff across the system in clinical and non-clinical roles.
6. Is the trust set up to support scaling up of successful experiments across the organisation?
While having a culture of experimentation at individual and team level is necessary, it is not always sufficient for sustaining transformation. Teams may perform heroics in changing existing practices to deliver something with better outcomes for patients, but they may be doing so in a way that cannot be maintained. Sometimes this is because they are having to go at full tilt to do it and face burning out. More typically, it is because they fall foul of the innovation trap, where scaling the work up requires them to navigate processes - investment approvals, governance processes, national sign off, recruitment, procurement - that are ill-designed to maintain the pace of delivery, or assess their efficacy against a sufficiently broad definition of value.
Successful digital organisations have to develop a muscle for scaling their most successful experiments. In part, this will require them to challenge whether the existing ‘sausage machine’ for approvals is really fit for purpose, but it also demands a greater degree of ruthlessness in stopping experiments that aren’t delivering. Every new project absorbs resources and leadership bandwidth, having too many on the go at once can leave an organisation with lots of impressive stories, but not enough improvement in outcomes. Prototypes that spend too long proving themselves solely in rarefied conditions that don’t reflect the reality of frontline healthcare offer diminishing returns. Scaling up is about cutting losses as much as allowing the best bets to thrive.
7. Can you explain what your digital strategy has not prioritised, and why?
The principle of selectivity applies to strategy development as much as selecting innovations for scaling. Most digital strategies end up as a shopping list that provides comprehensiveness without direction. The worst examples amount to a long list of untested hypotheses, sprinkled with technology trends, and bookended by implementation timelines grounded more in hope than well evidenced expectation.
Good digital strategies share three qualities. The first is that it should be inseparable from the organisation’s overall strategy: digital at the centre of an overall vision. The second is that it should be very clear about what it has decided to prioritise in terms of focus, and in what order it plans to deliver digital transformation. For example, there is little point setting grand ambitions for applying artificial intelligence to patient care unless your data architecture is built on strong foundations. Implementing new digital services of significant complexity may be less of a priority than a simple, well written text message appointment reminder service. Any strategy will involve trade-offs, the best organisations can articulate clearly what sacrifices they’ve chosen to make, and why.
Finally, when people hear strategy, they think of a weighty document written before any actual delivery takes place. Good digital strategies are short and written after having tested as many assumptions and trade-offs as possible in reality, a summary of what has been learned so far to inform a trust’s choices about the future.
8. What have you turned off, or stopped doing, as a direct consequence of your digital transformation?
Good digital transformation is fundamentally a destructive process as much as a creative one. To get the most of it, you have to turn things off. The value in doing so is two-fold. Most obviously, turning things off - be they old systems, bureaucratic processes, redundant skills, and so on - is a tangible, measurable driver of efficiency savings within an organisation. These can be banked as savings or free up resources to be invested elsewhere. Just as importantly, the other compelling argument for turning things off is that if an organisation fails to do so, all a digital transformation programme can do is add another layer of activity, process and technology on top of the existing layers. This creates more complexity, confusion and frustrations with transformation programmes that don’t appear to change anything much, other than creating more work for everyone.
9. Are you confident you have access to real-time feedback on what patients, staff and other key stakeholders need?
To build services that are capable of being iteratively improved upon, organisations need ready access to real-time feedback. Negative or unsolicited feedback tends to be the most valuable. The government digital service paid close attention to analytics on the citizens advice service website, as it was a good proxy indicator for issues with government services, for example.
The most effective organisations have put in place strong mechanisms for gathering qualitative and quantitative feedback. Strong qualitative feedback comes from structured user research, often conducted as ethnography with service prototypes. Quantitative feedback, in the form of web analytics, can also be invaluable in informing service design. Indirect feedback - where one watches what people do, rather than what people tell you - is significantly more reliable and powerful than direct feedback. Even in focus groups and surveys, people have a tendency to say what they think you want to hear or provide insights that are difficult to turn into actions.
10. Is the organisation taking opportunities to copy and adapt learning and work from other trusts, the centre (NHS Digital/NHSX) and other industries? Is it openly sharing its own work?
The comforting thing about digital transformation in the NHS is that every mistake or problem encountered by any trust will have been faced by several other organisations before. Sharing of advice and experience between peers across the healthcare system, and from other industries, can be an invaluable source of insight and confidence. The Global Digital Exemplar blueprinting programme was set up to facilitate much of this shared learning. Within the ICS/STP framework trusts are working closely to progress digital capabilities for all system partners.
Even more helpfully, there is a wealth of practical, open source tools available on the internet that trusts can adapt and copy in order to build their own services and prototypes. Code design patterns, guidance on the practicalities of ways of working are all readily available to pick up and use. The great advantage of these is they are the distilled essence of many years of false starts. Borrowing from others allows trusts to outsource years of mistakes, so organisations can get on with making (and learning from) new ones. Even if you were to only borrow from others to build prototypes that are thrown away based on context specific feedback, validating assumptions about where your context is unique and where it is not can save a lot of time and money.
Equally, trusts have a responsibility to be good contributors back into that pool of knowledge. The single quickest way to share this knowledge widely is to publish it on the web. Working with other central curators in the system - such as the team running the NHS service manual - will help make sure what is learned locally can help the collective effort across the NHS to use digital to transform health and care.