Digital initiatives can suffer from short-sightedness: a 'quick win' delivered to satisfy a need today, without a clear view of how it joins up with other services. Piecemeal developments such as these can cause more problems than they solve adding to a 'spaghetti architecture' of technology systems and confusing experiences for staff and patients. At a time when NHS organisations are working towards integration at system level, it's critical to think about the long-term consequences of major technology decisions made today.
On the other hand, some digital initiatives let 'perfect be the enemy of the good' by trying to solve every use case at once – sometimes taking years to deliver any value to users. Although these attempts are often thorough and well thought-through they can fail under the weight of their own complexity. By the time these initiatives make it into users' hands things have moved on – technology has progressed, needs have evolved and user expectations have raised.
Trusts should aim for the best of both worlds: a clear digital strategy combined with incremental, iterative delivery.
Where possible, trusts should avoid mega-projects that only deliver value at the end of a long development cycle – the only digital service of value is one that is being used by staff and patients. Rolling out improvements to real users every few days or weeks – rather than once or twice a year – is a good habit to build. Not only will this speed-up the realisation of benefits, but it will also reduce risks by helping to spot problems early. It will also help build trust with users and stakeholders by demonstrating how progress is being made. Where this isn't possible, make sure you have the feedback loops in place to let you know when something is going wrong.
Build an environment that enables this approach
Shifting to a long-term mindset for digital transformation often requires changes to how work is organised, funded and governed. Funding temporary projects can lead to short termism 'feast or famine' cycles of investment and systems that never improve beyond the initial implementation. Project-by-project funding can also result in siloed and narrowly focused initiatives, rather than digital teams working together to solve problems.
Equally, adopting an incremental approach to delivery can be hampered by existing structures. Long-winded business case, procurement and change approval processes can encourage digital teams to design large, waterfall, single vendor projects to avoid going through bureaucratic processes multiple times. This approach increases the risk of delivering digital services that don't meet the needs of staff and patients and reduces the ability to make changes without incurring significant cost.
Fund teams and services, not projects
Many organisations have found that funding digital teams is more effective than funding project-by-project. This approach 'moves the work to the people' rather than 'moving people to the work', enabling teams to maintain momentum rather than resetting each time a new project team is formed. While this may not always be possible, trusts should design structures and processes that promote long-term thinking, incremental delivery and ongoing improvements – discouraging siloed, linear, stop-start delivery of digital services.
Key questions for boards:
- Are your digital initiatives working towards a 'north star' vision?
- How frequently are you able to release improvements to patients and staff?
- Do your funding, governance and procurement structures encourage incremental delivery and ongoing improvements?
Incremental EPR delivery at Kent Community Health NHS Trust
It is the human bit that matters the most. As a board you have to be aware of the cumulative impacts that change has on staff. It is important not to overburden people with too much change all at once. Pick projects that will give the biggest benefit and do it in a phased way that lessens the burden and allows you to learn and refine as you go along.Acting Chief Executive, Kent Community Health NHS Foundation Trust
Implementing a single EPR system at Kent Community Health NHS Foundation Trust posed a challenge because there was a legacy system that had been implemented differently in different services. The trust began an incremental roll-out of their RiO EPR system in October 2020 with the aim of releasing clinical time, enabling joined up care and improving clinical outcomes.
The trust realised that it was important to look at their processes and standardise their IT. This would help to meet the needs of multiple services by identifying commonalities between teams and consolidating divergent systems. The trust then took a phased approach during implementation, launching the EPR in children's services first, followed by adult services. The board began deploying the new system in services that they knew would be less complex so they could learn and iterate their approach for those where roll-out was expected to be more challenging.
During a period of increased operational pressure the phased roll-out allowed the trust to lessen the overall burden of the EPR launch on staff and allowed them to see the improvements earlier.
Board level learning:
- The business case process requires a lot of input. Don't just read and review. You need to properly understand if the proposal is realistic.
- Make sure you can draw on real life experience. Kent Community seconded an IT director from another trust who had an existing relationship with their new supplier.
- The chair and chief executive need to ensure the board has an effective approach to assurance which utilises the varied experience around the table and avoids a division between executive and non-executive directors