- Trust boards continue to face internal and external challenges that make digital transformation difficult and inhibit the development of digital teams.
- These include finding sustainable funding, managing legacy systems, siloed working, managing risk, visibility of traditional IT, recruitment and retention, and buy versus build tensions.
- These factors can make digital delivery feel slow and undermine the confidence of trust boards in their own digital capabilities and expertise.
Trust boards face several ongoing challenges when it comes to delivering digital transformation, both external and internal. Many of them will undermine efforts to build and run effective digital teams.
- Funding: the current approach to investment is rarely in support of the development of digital teams. In recent years, the pattern of digital investment across the NHS has tended to make large pots of capital funding available for specific programmes that trusts have to bid for. This encourages a feast and famine cycle that incentivises one-off expenditure on systems and ‘solutions’, while inhibiting long term, strategic approaches that provide sustained operational funding for teams. In turn, this has created a situation where many trusts still lack basic core infrastructure. This approach to funding is sometimes compounded by an unclear national policy environment.
- Managing multiple legacy systems: many of the benefits of digital transformation, in terms of user experience and efficiency, come from 'switching things off', as much as introducing new ways of working. Constraints mean trusts often remain reliant on legacy systems, with associated costs, such as patching, ongoing maintenance contracts and an increased vulnerability to cyber attacks.
- Visibility of traditional IT: the job of a trust IT department is often invisible, mostly about keeping the metaphorical lights on. The department’s energy is spent managing legacy systems while trying to juggle requests from across the organisation for new digital products. Some chief digital officers (CDOs) or CIOs speak of their work being like an 'iceberg', where only 20% is visible to most of the trust. If this is the case, it can be difficult for boards to appraise the work of their IT department and have realistic expectations of what they can deliver.
- Working in silos: the IT function within trusts often sits separate from the transformation, operations and clinical teams. Without proper engagement and buy in, this can lead to change that is IT-led rather than service user-led. This disconnect between technology and the rest of the organisation tends to rule out generating any significant benefit from digital transformation. Instead, adoption of digital solutions tends to be slow, or worse, service users (patients or staff) avoid adopting new ways of working altogether.
- Managing risk: digital transformation in the NHS is complicated, which makes controlling risk difficult. Implementing a trust-wide electronic patient record – the foundation stone for true digital services - for example, can easily engulf the full efforts and energies of a trust board, at the expense of other digital programmes. In many ways, digital transformation will always require a leap of faith. But as the Academy of Medical Royal Colleges has noted, there's a potential tension between a technological attitude of move fast and break things and the ethical principle of do no harm in healthcare.
- Recruitment and retention: the NHS, and the wider public sector, can struggle to attract staff with specialist digital skills. In urban areas, this might be because the NHS is competing with other industries for the same talent, while in rural areas there may simply be a skills shortage. Health Education England's wider Digital Readiness programme seeks to address this by creating an uplift of digital skills, knowledge, understanding and awareness across the health and social care workforce. NHS trusts, in common with many public sector organisations, also often lack a clear career path for digital specialists to progress within the organisation, with too few digital and technology roles at senior and board-level positions. Some inevitably choose to progress their career elsewhere. What’s more, during these initial phases of the pandemic, we know many digital specialists working within the NHS, like much of the wider workforce, risk burnout and exhaustion from several months of working long, intensive hours.
- Buy versus build: the complexity and expense of digital technologies means there will always be a need for the NHS to work with the IT and technology sector. But many trusts grapple with decisions about when they need to build their own bespoke solutions in house, and when to procure existing solutions from external suppliers. There are numerous considerations for both, particularly around costs, interoperability – both internally and externally across an integrated care system – and future proofing. Neither way is inherently right or wrong. Decisions are complicated by lack of resources, availability of skills, and the market’s tendency to over promise.
Taken in combination, these factors make establishing digital teams a difficult task for any NHS trust. Reliance on central funding and capital investment puts trusts in a reactive position, undermining efforts to build sustainable capability and deliver long-term strategy. This in turn means that board conversations can become too focused on the tactical elements of transformation, with more time spent discussing funding and fixing what is broken, rather than on opportunities and outcomes.
Creating digital teams has also sometimes been allowed to fall into the 'too difficult' category, with a concomitant tendency to outsource components of digital born of a lack of confidence and a mentality of 'not being good at IT'. However, in responding to Covid-19, many trusts have been forced to confront these challenges head-on.