Digital is more than just technology, it is about applying the culture, processes, operating models and technologies of the internet-era to respond to people’s raised expectations.
Across the NHS, trust leaders are wrestling with common challenges: workforce shortages, care backlogs, unsustainable workloads and the need for greater efficiency. Trusts are working with other health and care partners to integrate care, tackle health inequalities and improve population health, with access to only limited funding. Digital transformation is playing a big role in the NHS's response to these challenges. But it’s important to focus on the opportunities too. Digital technologies will help the NHS deliver personalised care, empower patients and service users, and help everyone live healthier lives.
The most successful digital transformations are user-centred and outcome-focused, not IT-led. Simply applying technology without any other changes will have limited impact. Instead, organisations that are thriving in the digital age are those that adapt their operating models, rethink services and adopt new skills and ways of working.
But technology is important too. Organisations that lack an understanding of the possibilities and limits of technology are unlikely to thrive in the digital age. And when technology fails, it can have a significant – sometimes existential – impact on organisations.
Many trust board members feel ill equipped to make decisions on technology. It is often seen as too complex, technical and difficult. In a world where technology is playing a more critical role in how trusts operate, this is not sustainable.
Board members don't need to weigh in on which specific solution to use, but they should feel confident in making important technology decisions like which delivery approach to use, which investments to make and what in-house skills are needed. They also need to be aware of the broader organisational changes needed to achieve sufficient uptake and adoption.
All board members need to be more involved in technology decisions, it should not be left to the CIO or CCIO. Public Digital has observed how organisations that fully exploit modern technology are ones with strong in-house digital teams who have the skills to make the most of it. They also have board leaders who can set the vision for what technology can unlock, and understand the changes that need to be made across the organisation to realise this. Technology literacy is becoming as important to leaders as human resource, quality or finance literacy. It's part of the toolkit of a modern board leader because technology is now a fundamental part of how organisations are run.
Boards must show the same level of interest in digital as in other areas like clinical safety and finance – after all, digital impacts every aspect of an organisation and contributes to all other agendas. Digital matters because it is a patient safety issue. Successful boards have grasped this connection.Former NHS Chief Information Officer and Advisory Board member of College of Healthcare Information Management Executives
Modern technology means a different role for board leaders
Technology is now faster and cheaper than ever before. This has opened up a new role for boards. It is now fundamental to doing business, not just an add-on.
Previously, delivering a new system was a long process that required physical infrastructure and – at the very least – months of planning. Changes were costly, so they were to be avoided. Governance was about measuring adherence to plan, rather than measuring value delivered or reprioritising. This meant the role of boards in technology development was limited to reading progress reports. Largely, IT was left to the IT team. The National Programme for IT (NPfIT) demonstrated the pitfalls of this approach. It failed in part because "there was no comprehensive strategy to engage clinicians or NHS executives to ensure they understood the reasons why NPfIT was being developed or implemented."
Technology has radically changed: things that took months and millions of pounds now take days and thousands of pounds, and the cost of change is much lower. The key question leaders should be asking is not whether a technology project is delivering 'to plan', but rather is it working for its users (i.e. patients, service users and staff), or should we invest in something else? Boards should be demanding fewer memos and more demos.
How technology has changed
Over the past few decades, there have been a series of landmark technologies that have had a profound impact on society and economies:
- The internet provided a single, global network for everyone. These common rail tracks negated the need to build your own private network.
- The web emerged as an open standard for applications and information sharing. There was no longer any need to install (or update) applications, other than a web browser. While the Internet acted as the infrastructure that connected everyone, the web allowed users to access and share information.
- Cloud computing enabled anyone to run reliable, scalable systems without investing in expensive physical data centres. Instead, users could buy services and storage on a "pay-as-you-go" basis. This lowered barriers to entry, costs and lead times. All you needed was a credit card.
- Open source software provided a lego kit for software developers to build their own systems, made available with no license fee. This enabled developers to focus on solving the problem at hand, rather than building everything from scratch.
- Mobile put huge computing power into people’s pockets, combined with sensors, always-on connectivity and cameras.
All of these technologies have become commodities, much more accessible than ever before. For many organisations, technology is no longer an expensive bespoke activity exclusive to large corporations.
Getting technology to work in a reliable, secure, scalable and useful way is still hard but these changes make it a lot easier.
Board leaders need to have an appreciation of the ‘health’ of their current IT and network estate - both the ‘gaps’ and ‘opportunities’. Risks occur when boards do not translate this into a clear digital strategy and roadmap which outlines how any existing and future digital improvement can best serve their patients, staff and organisation.Non-executive Director York and Scarborough Teaching Hospitals NHS Foundation Trust
The NHS is still at a transition point
While every trust has at least some experience of the big technologies of the past few decades, the NHS still lags behind other sectors in adoption.
Many of the systems in place today pre-date these technology changes. Data centres in hospital basements and private communication networks like N3/HSCN are still commonplace. Few health applications were designed natively for the web or mobile.
This is largely true for trust-wide electronic patient record (EPR) systems, too. Very few EPRs take full advantage of cloud computing or mobile technologies, for example. And implementing an EPR across a trust is a huge undertaking that will still take many months and significant investment to achieve.
Therefore, operating in the world of NHS technology requires pragmatism: an awareness of modern technology approaches combined with a realism about what technologies are available – and useful – in health and care today. Many modern technology practices – user-centred design, agile delivery, multi-disciplinary teams – can be applied to good effect, regardless of the technologies being used.
Promoting collective board ownership at Milton Keynes University Hospital NHS Foundation Trust
“We know as leaders we will sometimes get it wrong. The challenge to the board is how they will come together to respond to failures, pick themselves up and get it right in a different way. It is the responsibility of the whole board to have the confidence to invest in technology and create this space for innovation.”Chief Executive Milton Keynes University Hospital NHS Foundation Trust
The trust understood that digital success would stem from strong leadership at board level. Rather than appoint a single digital leader to the board, the board set about restructuring its governance model to encourage collective ownership of digital amongst all board leaders.
All board members are expected to contribute and discuss digital at board level. Digital initiatives are grouped into four categories which makes it easier for directors to navigate the digital agenda:
- Infrastructure: Includes getting the basics right, such as wifi, devices and ongoing work on the electronic patient record. The ambition here for the trust is to become totally paperless.
- Patient technology: Focuses on giving patients more autonomy and power over their data. It tends to be spearheaded by the board’s governance lead but operational and clinical leads also take a significant interest in empowering patients with insights and giving them greater flexibility. For example, the trust's MyCare portal is now used by over 100,000 patients, allowing them to change and cancel outpatient appointments on their phone, as well as receive clinical letters electronically.
- Staff technology: The trust's vision is to enable staff to do as much as possible on their own devices. This includes staff training, bank staff scheduling, booking leave and accessing pay slips. It also means weekly incidents can be pushed to staff phones, and more people can be set up to work from home. HR and finance leaders often drive "staff tech" initiatives.
- Clinical technology: Led by the executive medical director to encompass any technology innovation driven by clinicians or that simply improves care delivery. The board tries to never say "no" to clinician-led innovation which helps foster ownership and excitement. For example, Milton Keynes was the first trust to use surgical robots for major gynaecological surgery. The trust's ambition on "clin-tech" is also helping services attract new staff.
Key considerations for boards
- Think about the long term: Systems in the NHS tend to stick around for a long time. That means if you’re implementing outdated technology today, it will be even more outdated in a few years time. Is this the right option for your trust?
- Be pragmatic: You may not always be able to adopt systems that make the most of modern technology, given the options available in the market.
- Look outside of the NHS: There may be technologies you can use that are not marketed specifically for use in the NHS or healthcare, but will work well for your trust. You may find that your needs are not as NHS-specific as you think.