- Combining appropriately skilled, empowered people into multidisciplinary delivery teams is the single most important step you can take towards a successful digital transformation.
- You need people who understand the fundamentals of user-centred design, agility, and internet era software engineering, working in tandem with clinicians, operational staff and others who intimately understand the organisation and the services it provides.
- You may need to look in new places and re-examine your processes to find the different skills you need, but there are existing networks and collateral from people who have done this before that can help.
- It's essential to ensure your teams are diverse and reflective of the people you are trying to reach and serve.
Teams are at the heart of much of what the NHS stands for. Hierarchies still exist - every organisation has them, whether implicit or explicit. But the concepts of multidisciplinary, empowerment, and agility are now commonplace in clinical service delivery. Digital teams are no different. Putting the right skills together and focussing them on outcomes rather than outputs delivers results. Multidisciplinary is meant here in the digital rather than clinical sense: bringing together operational, clinical and digital staff to design and implement new digital solutions. One CDIO described these as "fusion teams".
Digital organisations support their teams by being responsive, open and efficient. This does not happen by accident. Successful digital organisations put governance in place that monitors quality and coherence, but allows their teams to work at the speed of trust rather than the speed of process. Embedding this requires an acceptance of 'servant leadership' from executive teams, a recognition that their role is primarily to serve the team by first setting strategy and direction, and thereafter removing blockers to successful delivery as they arise.
In this chapter we will explore how an organisation can build and enable strong digital teams.
What do we mean by a digital team?
Whether an organisation is predominantly building or buying technology (it will never be entirely one or the other), good digital teams are identifiable by the extent to which they demonstrate a 'digital mindset'. The cornerstones of a digital mindset are:
- Agile: the team understands the power of feedback loops and iterating in short cycles, experimenting, and scaling experiments that work.
- User centred design: the team understands the role of design in delivering great products and services, how the design process works, how to conduct user research, the fundamentals of prototyping and journey mapping, and how screens can and should look. They also are able to make sure services are accessible for people with disabilities.
- Continuous delivery: shorthand for modern, iterative cloud based development techniques, sometimes called devops. The team understands how to build and operate modern internet technologies and how they can be applied.
These three elements create a virtuous cycle. Design gets to the heart of the user's need, agile provides the means to iterate and experiment, and modern technology makes that rapid iteration possible. Taken in combination, these traits should support digital teams to experiment quickly, abandoning ideas that don't work before any big investment is made in them, and scaling products and services that are successful.
Executives need to be as comfortable with these concepts as their teams. The effects of applying a digital mindset to a whole organisation often challenge many of the operating norms it has, be that in terms of how financial decisions are made, how assurance is managed, what skills are valued and recruited, and how performance and progress are monitored.
The digital function within the trust is being aligned to its four locality networks and one specialist network. The intention is for each network to be supported by a designated digital leadership team containing clinical, adoption and performance leads that are focussed on enabling each networks specific priorities. The networks will also be supported by a senior lead from the digital team who will ensure that intelligence, transformation and operational services are effectively connected into each network. The ambition is to change the dynamic of the digital services team so it evolves from an internal support service into an agile and proactive digital transformation function that is fully embedded into the trust’s frontline services.
Minimum viable digital team
The required skills mix of a digital team will depend on the circumstances, but there should be variety. Having a preponderance of one particular skill (such as strategy, clinical experience or IT) is usually a sign of imbalance. Teams should be collectively good at solving different types of problems over time.
Whether your organisation is predominantly building or buying technology may impact the overall makeup of your digital team. In many trusts the status quo is to mostly buy, often
(but not always) when it comes to larger systems fundamental to the trust's operations, such as an EPR. But it is still critical to retain the notion that you are delivering services to meet the needs of users, not just buying a 'solution'. A good digital team in a 'buying' organisation will need the appropriate skills to be an excellent and informed customer, not just during the initial procurement, but throughout the relationship with the supplier. The tail must not wag the dog. Your digital team will also do much to define working culture and how things are done and can set a trend for the whole organisation. And they are the transformation muscles to be built that will support and guide your organisation when it comes to the bigger projects.
The types of roles that are essential in a minimum viable digital team are as follows. These are inspired by the teams outlined in the Government's service manual.
Product manager: product management as a specialism is one of the most important digital era roles. Product managers are leaders who care deeply about solving problems for users and achieving outcomes for the business. This vision is combined with the right technical and design understanding to be able to determine at a high-level how this can be done.
Delivery manager: a key role to ensure that the team has the right environment to successfully deliver. They remove blockers to delivery, and use a variety of agile techniques and tools to ensure the team is happy and delivering value.
Designer(s): There are several types of designers that are important to digital teams. An interaction designer focuses on providing clear and consistent user experience. They specialise in how users interact with digital products and services. A service designer is responsible for the end-to-end journey of a service and focus on ensuring that a user can complete their goal. A content designer is responsible for creating, reviewing, and iterating the words used across services and digital products. Content design is particularly important in health where language and concepts can be difficult for people to understand.
User researcher: responsible for helping the team understand users and their needs. They regularly test products with users, and ensure that the team understands how the feedback translates into changes to the digital product or service they are working on. It is important to actually observe users trying and often failing to use a digital product, because what users do is different to what they say. This concept isn't new to the NHS and is similar to the work done by trusts to understand patient journeys and staff shadowing.
Lead developer: the lead developer writes, adapts, maintains and supports the computer code underpinning your service. When you have more than one developer in the team this role is often then referred to as the tech lead or architect. The tech lead works with the team to help understand the best way to technically solve particular problems for users.
Lead clinician: this is particularly critical when the focus is on the delivery of good clinical outcomes and therefore needs to be clinically led. And while it is not always the case that you would be delivering a clinical service, clinicians are nonetheless always vital champions and stakeholders for any type of healthcare transformation. Your lead clinician should have an interest in technology and the basics of user centred design.
One word of caution however, it can often be the case that a clinician involved in a digital project becomes de facto "in charge". Unless that clinician also has professional product management or service design skills, this is a mistake. Clinicians are highly skilled individuals, but delivery of digital services is a specialism in its own right. In this situation pairing a clinician with an experienced product manager leads to the best results. A new generation of clinical product managers represent a compelling new hybrid.
A complete set of job descriptions for the key digital roles (with the exception of lead clinician) are available online.
As well as having a diverse skill set, it is important to ensure there is true diversity of thought and experience within your team. If trust leaders consistently seek answers to problems from people who look the same and think the same, the answers will remain the same too. This tends to be a challenge in the wider technology sector, where only 15% of the workforce are from Black, Asian and minority ethnic backgrounds and women comprise only 19% of the workforce.
Diverse teams are more effective teams. There is strong evidence to suggest that a more a diverse workplace improves innovation, efficiency, productivity, staff engagement, wellbeing and retention, and decreases staff absenteeism and sickness. In the NHS it has also been shown to improve patient care and better patient outcomes.
Establishing digital teams that reflect the diversity of the community you serve is also critical as trusts grapple with the challenge of ensuring digital services are genuinely inclusive. Diverse teams are more likely to seek out a wider range of user experiences and viewpoints that have traditionally been overlooked, designing services and delivering outcomes that better meet user needs as a result.
This is equally about diverse leadership. Around 20% of the NHS workforce is Black, Asian and minority ethnic and 77% are women. However fewer than 10 women of colour are in senior digital leadership roles across the trust sector. And at board level more generally, only 7.5% of executive directors are from Black, Asian and minority ethnic backgrounds. It is the board's role to lead from the front: set out a compelling vision, be clear on the interventions, and establish an accountability framework to measure success. When recruiting digital teams specifically organisations will need to:
- Review your recruitment practices: many organisations are already strong on the basics of diverse recruitment. Make sure these are covered, doing things like checking job adverts for language that is biased towards particular genders, to widen the pool of people applying for roles.
- Actively find new networks: several networks (such as the Shuri network, led by women of colour in digital health and care including CIOs, CCIOs and aspiring leaders, or OneHealthTech, a volunteer group that promotes under-represented groups to become future health innovation leaders) are helping connect under-represented groups. They will be valuable sources of advice, guidance and potential team members.
- Speak to others: many parts of the NHS have learned from their own initiatives to improve diversity on what has worked (and not worked for them). Share ideas with peers.
- Use commercial levers: The NHS' commercial processes allow for a cultural fit score to mark potential suppliers, this can be used to incentivise more diverse practices among suppliers.
How to hire digital professionals
To build your first team, you may be able to start with the networks of your existing digital staff. If not, the first steps will be to find where digital professionals meet. At technologist meetups and hack days product managers, design and coders can be found everywhere. These are rooms full of people who have given up their free time and scarce skill to work on problems you want to fix. It's not a bad place to start.
It's important not to forget that there will be exceptional people already in your organisation whose job titles may not match the ones you're looking for. The best will adapt to specialise in these new roles if you invest in their skills. The Topol review outlined how the NHS can support these changes through training programmes, continued professional development, sabbaticals and secondments, as well as board level focus on creating a culture of learning and development.
All roles in the trust's digital portfolio now include Tom Loosemore's definition of digital in the job description: "All members of the digital leadership team will strive towards applying the culture, processes, business models and technologies of the internet era to respond to people's raised expectations." Recruitment practices are therefore closely aligned with the trust's digital vision.
If you would like to find out more about Kettering General Hospital NHS Foundation Trust's case study you can do so by visiting their website.
Regardless of an organisation's existing digital capabilities, there will always remain a need, at times, for contractors, either independent or via agencies. This is a useful approach to get started or deliver self-contained projects that require more people to implement. However, it's important to ensure the most critical roles, especially product management, are filled by your organisation. It’s also possible and indeed sensible to pair more junior members of your digital team with more experienced contractors to expose them to the relevant techniques and skills.
The trust has committed to creating a pipeline of digital talent nurtured within the organisation. Over a number of years through inclusive leadership, flexible recruitment and succession planning they have become a magnet for good digital staff. The trust's IT directorate has even employed a developer who now works primarily from Portugal. The trust tries not to be over reliant on one or two stand out individuals to deliver digital. At the same time the team isn’t afraid to bring in contractors on short term contracts when work needs to get done.
As the NHS strengthens its focus on working across integrated care systems (ICSs), many trusts are beginning to think about what digital team capabilities they need to operate across a system footprint. Some trusts are beginning to pool resources and establish shared ICS digital teams. These teams tend be hosted by one organisation but work to transform patient pathways across multiple trusts, as well as primary care, social care and the voluntary sector. We know that harnessing digital opportunities at the system level opens even more opportunities to improve patient outcomes, quality of care and financial efficiencies. But as with the wider system agenda, trusts are having to work through the implications for joint decision-making and governance to ensure these teams can help realise this potential.
The Wavelength leadership programme develops collaborative digital leadership across the ICS. Clinical, operational and digital staff from system providers, commissioners, and local authorities are brought together and supported to collaborate on digital transformation across the ICS and enable better alignment of digital strategies.
If you would like to find out more about Frimley Health and Care Integrated Care System's case study you can do so by visiting their website.
Going to market
While you absolutely need to have some core leadership digital skills in house, in a competitive marketplace it is not always practical to hire every new role on your team, particularly if you need to scale quickly.
While there is a strong tradition in health IT to go to the market to buy products, you shouldn't forget that you are perfectly able to go to the market for digital skills. The various call-off frameworks brigaded under the Digital Marketplace (G-Cloud, Digital Marketplace) have played a critical role in breaking the dependency on large IT suppliers and diversifying the digital supplier base and are very easy to use.
As with any temporary hire, there are of course risks: a focus on short term delivery that can be determinantal to longer term strategy. Boards will need to seek assurance that these risks are being properly managed.
In addition to your first delivery team you will also need people who can clear a path for them. These are the insiders who want change and know how to get things done. Transformation is, by default, going to need to circumvent some existing legacy processes and approaches – no mean feat. The key job of the board and leadership team is in legitimising workarounds, making it ok for the teams to take a different approach. This does not mean a carte blanche to ignore or rip up the current rules - rather it means empowering them to question the intent of rules that may have made sense once but need rethinking for the internet era.