- Digital transformation is most likely to succeed if there is clear leadership, a delivery team with a clear goal and mission, and a sense of urgency from the outset.
All trusts have carried out digital transformation as part of their response to COVID-19. For example, one trust conducted 31,000 remote outpatient consultations in the first six weeks of the lockdown, up from the low thousands the previous year.
Based on Public Digital's experience across different sectors, there are often four pre-conditions that tend to set apart the most successful and ambitious attempts at digital transformation. The first three of these are within the gift of the trust's board, the fourth is particularly relevant for the current situation.
No government has successfully embarked on digital transformation of the public service without a senior political leader at the helm to act as figurehead, top cover and chief 'un-blocker' of internal obstacles. In the corporate world, the same thing could be said of the chief executive.
While digital transformation should be the collective responsibility of the whole board, it is undoubtedly more likely to enjoy greater impetus when it is a public focus of the chair and chief executive from the beginning. This unambiguously aligns the incentives of the whole organisation towards delivering on it, rather than leaving it in the domain of one executive, or worse, none at all. This commitment, combined with a leadership style that encourages a culture of innovation and delivery, is a powerful catalyst of digital change.
Milton Keynes University Hospital NHS Foundation Trust
Establishing clear digital leadership across the board
Milton Keynes University Hospital NHS Foundation Trust provides a range of acute services in the centre of the country.
The trust's strategy for the future must address a rapidly changing local environment, with the population of Milton Keynes set to grow to 500,000 by 2050. Alongside this a large undergraduate university is set to open in the city in 2023, further boosting growth.
The board at Milton Keynes has segmented its digital agenda into three pillars, supporting patients, clinicians and professional support staff, in order to make it an integral part of all board portfolios. For example, when it comes to the trust’s EPR, while the medical director may take a lead on its clinical capabilities, the finance director is more interested in automating administrative functions. This makes the digital agenda more manageable for the board. It also means every executive is actively engaging in digital transformation, which in turn builds the confidence of the non-executives.
The expectation at the board is that digital is treated in the same way as the trust’s finances: not everyone is an expert, but it remains a core part of the board's business and a key part of everyone’s role. It is why the trust has decided not to appoint a chief information officer to the board: digital is not owned by a single board member. The trust believes leadership in action is always needed and that cultural change starts at the top of the organisation. The board encourages a no-blame culture and gives digital leaders a clear remit and enabling environment.
The board has also focused on getting the technical basic infrastructure in place first and an incremental approach subsequently to build board confidence and risk appetite.
Over time this approach has paid dividends. Sometimes this has meant having the courage to step back and not rush projects. For example, the board took the decision to delay the second phase of the trust’s e-CARE EPR rollout because in the long run they knew this would cause fewer problems. At other points it has meant experimenting with innovative partnerships, such as its collaboration with a supplier on a new patient portal which can write directly onto the EPR.
The trust's approach to digital leadership has served them well during the response to COVID-19. Like many trusts, Milton Keynes quickly adapted to support remote working, expand digital communications and improve processes for information sharing. Each board member has supported this work by continuing to lead the agenda through their own portfolio. When the board meets, executives are challenged about what has worked well and what can be dropped as the trust moves into the next phase of its COVID-19 response.
Board members need to embrace digital in the same way they see trust finances - they don’t have to be an expert but it’s a core part of the board’s business and part of everyone's role.Chief Executive Officer
Board leadership is an essential prerequisite for digital transformation, but strong steers from the board table have to be complemented by digital and clinical practitioners - doers - on the ground who can deliver something tangible by making the best use of that top cover.
A common mistake made by digital transformation programmes is that the first team tasked with delivering comes from only one part of the organisation, or worse, one specific discipline. Typically, this might be a strategy, policy or IT team. In Public Digital’s experience, the first team leading a digital transformation programme should be small, empowered, multidisciplinary and have the skills within it that make it possible for them to 'show the thing' - i.e. to build prototype services that can be used by real people. Technical architecture diagrams, strategy papers and impressive slideware aren’t enough.
Of equal importance is that the first team is not wholly dependent on management consultants or outside contractors. It is completely reasonable to use external support to cover gaps in internal capability - either service designers or user researchers. Longer term these skills may be brought in house through the upskilling and development of existing staff. This is important to do in order for an organisation to become an informed buyer from the market, regardless of a preference to build or buy digital services.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Empowering teams to deliver digital at scale
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) provides mental health and disability services and support across the north of England.
In recent years the trust’s digital strategy has been underpinned by three key principles: a mobile first approach that is embedded into service design, prioritising the development of patient facing services, and ensuring success in technical infrastructure to enable quick scaling of digital programmes.
The CNTW board is clear their role is to create an enabling environment for delivery teams and devolve appropriate decisions to the frontline. Board leaders act as digital champions within their own organisation and across their system.
The informatics team are viewed as 'transformation enablers', and so the board seeks to understand the barriers faced by this team and how they can be overcome. Crucially, the board-level digital champions understand some of the work the informatics team undertakes won't deliver instant benefits. For example, although the trust rolled out a new EPR system in 2010, the board admit it took them up to three years to fully appreciate the benefits.
Crucial to the success of the trust has also been the test and iterate approach taken to rolling out digital tools. The disparate nature of service delivery at CNTW allows the informatics team to test different digital tools in 'model teams'. Launched in 2010, these frontline, clinical teams use lean methodology to use, test and feedback on different digital technologies. This expert feedback is crucial to the informatics team, who focus their efforts on solving issues within each team before scaling and rolling out to the rest of the trust.
The 'model teams' approach gives the board practical examples of the challenges and opportunities facing frontline services. The informatics team can easily demonstrate the value of digital solutions to the trust. The board believes this approach has made digital more tangible and means they have a better understanding of how digital can enable the delivery of services.
During the trust's response to COVID-19, CNTW was adept at scaling many digital technologies across the organisation, whether it be Microsoft Teams or new reporting systems. Staff at the trust are used to rapidly deploying, testing and then scaling new digital solutions.
It’s about organisational development and continuous improvement rather than kits and wire.Chief Executive
A goal and a mission
One way to attract that first team - and for internal staff, it is often self-selecting - is for the trust to articulate a clear, compelling goal and overarching mission that underpins digital transformation.
The challenge of trying to drive organisation wide change is that the interconnected nature of problems within the NHS makes it all too easy to put forward objections or delays. "Of course, you're right that this state of affairs is unacceptable," the argument runs, "but once this project is finished in six months we'll be in a much stronger position to get started." The variant on this is, "Well, if you’re going to fix x, then of course you’ll need to fix y and z at the same time for it to be really worth doing." This tactic is sometimes described as 'collecting rocks'. It can be done forever.
To overcome this, boards need to agree on two things: a single, clear goal of something tangible the trust will deliver, preferably by a specific date. For the UK government, this was GOV.UK. a new website that replaced 1,881 others. In Public Digital’s experience, this goal should be relatively small, visible, realistic, low-risk and strikingly different from what is ‘normal’. Achieving momentum, however small the beginning, is essential.
This goal can be set within the context of a broader mission. This is best tailored around the bigger strategic aims of an organisation: to provide a world-leading integrated health and care service, for example. The mission should elevate digital from being seen as purely a tactical response, or a tangential part of the organisation, to something that is central to the overall operating model. For trusts, it will be important to plan and deliver this within their wider strategic context, in line with the ambitions of the NHS long term plan.
South Central Ambulance Service NHS Foundation Trust
Focusing on a clear digital journey
South Central Ambulance Service NHS Foundation Trust (SCAS) delivers services across six counties in the south of England.
The trust was established in 2006 following the merger of four ambulance county services. Since its inception, digital has been a key enabler for the trust’s wider strategy.
Given the breadth of service delivery at the inception of the new trust, the board had no choice but to invest in new digital systems. In short, integrating what had previously been four different ambulance services meant standardising processes and reporting systems. Digital was core to this work and the merger focused minds across the new organisation.
Since then, SCAS has continued to make progress on the digital agenda. Key to trust's success has been the clear staging of its digital journey. The first iteration of the trust’s strategy was focused on integrating legacy systems, such as telephones and computer aided dispatches, while building resilience and reliability in its core infrastructure. Digital was the 'golden thread' to the new ways of working. The second stage, although more challenging, focused on 'renew and replace', including the 111 rollout. During this work the trust began to shift its focus to how digital could support wider service transformation, ranging from decision support tools for staff, to more seamless interfaces with other providers, and expanding multi-channel access to urgent and emergency care for patients.
A key lesson the trust learned from its merger was to avoid embarking on too many business-critical changes at once, and to plan appropriately before the next initiative is started. At every stage, the board believes it is important to have an honest conversation about the organisation’s starting point, and to be realistic about priorities and pace.
The trust's strategy is now focused on delivering system working. For this the board started discussions with a whole systems perspective and worked back to determine what this meant for individual SCAS services.
SCAS has now mainstreamed many of the basics of digital transformation. This helped build the confidence of the board and has increased its risk appetite, enabling the trust to focus on supporting wider service transformation through digital. The trust implemented the first fleet wide EPR and was the first to roll out mobile access to the NHS summary care record to its ambulance crews.
Since 2014 SCAS has hosted the National Pandemic Influenza Service, comprising an online and telephony self-assessment service. In response to COVID-19 the trust has rolled out the service nationally via 111, once again demonstrating its ability to spearhead new digital ways of working across the sector.
Boards need to work out their journey, based on a crystal-clear understanding of where they are now and where they are going. Everyone needs a map, but the key part is the really honest conversation about your starting point and being realistic about priorities and pace.Chief Executive
A sense of urgency
In January 2020 the NHS declared COVID-19 a serious, level 4, incident. Since then, the provider sector has been at the forefront of the NHS’ response to the pandemic. From the frontline to the board room, trusts have gone above and beyond what is normally expected of them.
The NHS' initial response to COVID-19 saw the sector galvanise around a single, clear, vital, imperative. The number of priorities for one trust IT department dropped from 30 to just two. This proved instrumental in ramping up the pace and scale of digital transformation across provider organisations. Out of necessity, many trusts changed their ways of working:
- Integration of health and care: secondary care, primary care and social care worked closely together to ensure patients were seen in the most appropriate care settings. Organisational and budgetary silos were ignored or bypassed.
- Bureaucratic pragmatism: a lighter and more flexible approach was taken to regulation that allowed the sector to adapt at speed.
- Local empowerment: trust leaders were given a clear objective and asked to do whatever they thought was best. This was cascaded down throughout the provider sector, with frontline teams being able to change how they work.
- Mobilising partnerships: the NHS worked closely with a range of partners and voluntary organisations to achieve things it could never have done by itself.
As a result, trusts were able to successfully navigate the initial peak of the virus. As one trust leader said, the NHS is good in a crisis and can mobilise quickly in the short term.
There is an enormous opportunity for digital to continue to play a critical role in the reconfiguration of services, but boards will first need to understand how internal circumstances changed in order to give frontline staff the flexibility to work well during the first phase of the pandemic, and apply this learning in the incredibly challenging months ahead.
The impact of COVID-19
Trust boards have begun to examine the ways in which digital technologies were rapidly deployed and implemented to support patients, service users and staff during COVID-19. These analyses are informing ongoing preparations and planning for the next phase of the pandemic as well as trust strategies over the longer term.
Every board will have gained invaluable experience and education in implementing new digital systems and each board member will have insights to share.
Reviewing the initial response
Boards will want to understand what worked well and what didn’t during the response to the first phase of the pandemic. This will help determine what digital solutions should be kept, what should be expanded and what should be dropped. For example, in April the video platform Attend Anywhere was centrally procured and made available to all trusts, at no additional cost to the sector. Many trusts took up this offer. However, some are now reviewing their use of the platform given the available alternatives that may better integrate with their existing systems.
Boards will also want to reflect on what patients, services users and staff have fed back on these new digital experiences. For example, many trust leaders accept that remote working, while necessary for many staff during the initial peak of the pandemic, is not sustainable for everyone and that hybrid approaches will likely be needed over the coming months.
Some boards are also in the process of reflecting on the way digital has been successfully harnessed during the pandemic response in contrast to the anxiety traditionally associated with digital programmes. A reappraisal of many boards' approach to digital risks and opportunities and appetite for digital innovation is likely as a result.
Keeping the 'how' as well as the 'what'
Across the NHS many have said there is "no going back" to old ways of working. Boards will want to lock in many of the behavioural changes within their organisation, such as the innovative spirit within teams, and even some of the changes to existing trust processes, such as virtual town halls. That said, governance arrangements will need to be proportionate to the risks faced by the organisation. These risks will vary over time and so a board’s risk appetite should not necessarily remain fixed.
Boards will also want to ensure consolidation and consistency across services. As one trust leader has said "we get the greatest benefits when we impact the greatest number of people". This may require the continued upskilling of different parts of the workforce, while some have warned there may be less tolerance of imperfection during the next phase of the COVID-19 response.
Longer term, some trust leaders have accepted that the progress and changes made on digital during COVID-19 will require them to be more ambitious with their digital strategy. Many trusts have been taken by surprise by how quickly and willing staff, patients and service users have adapted to new digital ways of working. This may suggest there is a more receptive environment in which they can advance digital services. For some this may mean recreating the conditions of the COVID-19 'burning platform' and not accepting old behaviours and attitudes to digital transformation.