Delivering any digital healthcare service is always a balance between organisational goals, clinical needs, user needs and technical constraints. If your trust has decided to invest in a digital service or IT system, it's likely that there's a clear organisational goal behind this: perhaps efficiency, clinical safety and quality or improved communication.

However, no matter how strong the business case is in theory, the promised benefits won't be realised in practice until the service is properly adopted by staff, patients and service users. Unless the digital service solves a real problem for these users – not one assumed by leaders or digital teams – it is unlikely to succeed.


Business requirements aren't enough

The traditional approach to IT often involves project managers or business analysts working with stakeholders to define how a new system should work. These requirements are then passed on to a software development team to be built, or form the basis of a procurement where suppliers are assessed against these requirements. It is rare for actual users – staff, patients and service users – to be involved in this process, and clinical experts are often side-lined, too.

This is an outdated approach to designing digital services, but it is still common in many organisations. The best way to meet the expectations of staff and patients – and avoid costly mistakes – is to establish a clear understanding of clinical or user needs from the start of any new digital initiative. This requires researching, observing and testing what these users need, not just asking what they want. It also requires understanding of digital inclusion: how will your service work for patients who lack digital skills or access to the Internet?

For professional users like clinicians a co-design approach works best, where subject matter experts work closely with digital teams to design the service. The challenge is to properly resource this time to ensure that it is not simply squeezed into an already busy day job. Some trusts are exploring whether digital co-design can be incorporated into job specifications and annual appraisals.

Adoption of digital technologies is always better when there is a collaborative process between clinicians, IT teams and the vendor that allows clinicians to co-design, steer and shape the technology into what they want and need.

Andy Carruthers    Chief Information Officer, University Hospitals of Leicester NHS Trust

Validate assumptions early

By the time mistakes are realised it is often too late. Contracts may have been signed, systems built and changes too costly to make. A common reaction to failures like this is to blame the requirements defined at the start of the project: the specification wasn't clear enough, or detailed enough next time, we'll invest more time on this planning phase. However, this ignores the bigger problem: the lack of a meaningful user feedback loop throughout the development process that enables you to course-correct – it's almost impossible that you'll get everything right the first time. Boards should expect their digital teams to be able to articulate what assumptions have been made, and how they're going to test these assumptions early on to avoid wasted effort and spend.


Beware of solutions looking for a problem

It can be tempting to assume that digital services are the answer to every problem in your trust. Perhaps there is national funding available that can only be spent on a specific digital solution; or a supplier is pushing for a pilot of their new software – maybe even for free. These initiatives may deliver some value, but too often can be a distraction from the business of fixing the basics and solving real problems for your users – patients and staff. Whatever the origin of the initiative, it has the potential to be successful if a user-centred, iterative approach is used.


Key questions for boards:

  • Do you talk about your users' needs or the business' requirements?
  • How regularly do your digital teams get feedback from users?
  • What's the riskiest assumption your digital team has made?


Case Study

Delivering meaningful change at Cambridge University Hospitals NHS Foundation Trust (CUH)

Most NHS frontline staff aren’t here to be ‘digital people’. They want to deliver high quality care for patients. Therefore during any digital transformational change, you need to ensure there is a freeflow conversation about work, prioritisation and pain points.

Afzal Chaudhry    Chief Medical Information Officer, Cambridge University Hospitals NHS Foundation Trust


Cambridge University Hospitals NHS Foundation Trust (CUH) is a healthcare information and management systems society (HIMSS) level 7 site with an advanced electronic patient record (EPR) system. It is considered one of the most digitally mature trusts in the country, and has extensive experience introducing new digital services and Epic EPR modules. But this success has only been achieved following years of learning how to deliver change effectively.


CUH's leaders recognise that on a day-to-day basis there is limited bandwidth for change within the workforce. And crucially, most staff will find workarounds if they feel a new process or tool is inhibiting them from doing their job well. Therefore, a significant amount of effort must be taken at a leadership level to understand how changes to behaviours and ways of working are delivered:

  1. Start with the problem and then form a vision around this. It may sound like a cliché but the vision provides the board and the organisation with a single sense of purpose which will become crucial during the minutiae of implementation (and when inevitable problems arise).
  2. Understand the workflow and describe what the ideal circumstance will look like: the who, the what and the why. Only then look to see how digital can support this new process from start to finish.
  3. In the run up to 'go live' or implementation, the trust's leaders start doing the hard work around harmonising, aligning and reducing variable practices across services. When the switch is then made to a digital process there is less time and money spent on the change management piece which has already been done upfront.

In working this way, CUH's leaders have developed a mature digital culture within the trust. Below board level, changes are discussed monthly by speciality leads with senior level oversight. The digital team itself now comprises nurses, pharmacists, allied health professionals (AHPs) and junior doctors.

This way of working takes time to embed but the board is now reaping the benefits. There are few digital sceptics within the trust but more interestingly, the digital teams are receiving fewer trivial requests and instead are engaged in conversations with clinicians about redesigning entire pathways.