- Digital is not just about technology, it is about applying the culture, processes, operating models and technologies of the internet-era to respond to people's raised expectations.
- Digital is not a case of entirely replacing one way of working with another, it provides new approaches to addressing problems old and new.
- Digital disruption does not represent an existential threat to the NHS as it does for many parts of the private sector, but failing to meet people's ever-increasing expectations of service quality will have very negative consequences.
'Digital' is easy to dismiss as a vague and unhelpful buzzword. Coming to an agreed definition that the whole board and wider organisation understands is a basic but essential first step.
The mistake for all organisations to avoid is equating digital with technology. Wikipedia's own definition of digital transformation at the time of writing is "the use of new, fast and frequently changing digital technology to solve problems." This can lead to an organisational response (often supported by technology suppliers) where digital is solely the responsibility of the IT department.
The consequences of taking a technology-centred approach to the uncertain and uncontrollable environment of digital public services can be ruinous. The UK's first e-Borders scheme, started in 2003 to collect and analyse data on everyone travelling to and from the UK, was cancelled after 11 years and a £830m investment, leaving behind "highly manual and inefficient" systems. The healthcare.gov website, front-door to the Obama administration's flagship domestic policy, crashed on launch, costing $2.1bn and forcing a rose garden apology from the president.
A technology centred definition of digital is not wrong, but it is incomplete. Digital transformation is not all about technology, it is about changing the way an organisation works in response to the changing environment around it. Tom Loosemore, co-founder of the UK's Government Digital Service, summarises it as: "Applying the culture, processes, operating models and technologies of the internet-era to respond to people's raised expectations".
Undertaking a digital transformation of a trust means revisiting the operating model of the organisation - what is it there to deliver, who is going to deliver it, and how will its form fit that function - in light of how the world has changed since that operating model was first put in place. It then considers how technology and the use of data can underpin that new operating model.
CASE STUDY
West Suffolk NHS Foundation Trust
Defining digital beyond IT projects
The context
West Suffolk NHS Foundation Trust provides a range of acute, specialist and community services across the east of England.
The trust is the smallest global digital exemplar site in the country. One central ambition is to deliver a single health record that covers its whole health and care system. The trust is already linked up across Cambridge and is now joining up with system partners in Suffolk and north east Essex.
The challenge
West Suffolk's digital journey reached a critical point when it was suddenly confronted with a patient administration system (PAS) that urgently needed replacing. The board understood from the outset that this was not simply an IT project and that it had to deliver wider service benefits. Alongside the new PAS system, a new digital strategy would be crucial in terms of improving the quality of services. Such a strategy would stand or fall on the effectiveness of engagement with staff and patients.
As a result, the trust has focused on considering the potential of digital to every aspect of its wider strategy, but in a way that puts people first, and the technology second.
In implementing new digital technologies, the trust always seeks to engage the 'key influencers' within individual services. Delivery is focused on improving staff and patient experience. Sometimes this involves getting the best out of what already exists so that it works better for users. This can mean time is spent sorting out low level gripes, for example by introducing voice recognition for clinical note taking. At board level, the medical director and nursing director have an important role in ensuring clinicians lead digital transformation within the trust.
Going forward the trust will continue to balance the risks and rewards that come with an increasingly ambitious digital strategy. For the board this means discussions remain strategic rather than technological. For non-executives with digital backgrounds, this might mean resisting the urge to become too close to the details.
The impact
The board's confidence has grown as it has learned more about what is possible. In many cases it did not fully foresee some of the benefits of the digital tools it was implementing.
It has focused on improving the enabling environment within the trust to help staff exploit the opportunities digital provides. This means more ideas are being shared, risks are being discussed more openly and clinicians are speaking up earlier.
The biggest challenge now is to think 'system wide' about digital programmes. The board understands that the real benefits of digital transformation lie beyond the organisation. The focus is on spreading this learning within their integrated care system.
The board needs to be clear that it's not about IT, nor replacing your PAS. It’s about transforming the quality of your services and engaging your staff in that journey, recognising that it can be a bumpy road.
Former chief executive
Like many businesses, universities and government departments, NHS organisations were set up in an era before the internet and computers. NHS processes, organisational structures and ways of working were designed for an analogue world. Much as trying to work in a new way without using modern tools will cause problems, overlaying new technology on old processes results in a mismatch.
A charge often laid at the door of digital - and many other forms of 'change programme' - is overzealousness, a tendency to dismiss old ways entirely and throw the baby out with the bathwater. The point of digital transformation is not to replace one orthodoxy with another. Many processes, cultures, models and technologies used by trusts for decades remain the best tools for a particular task.
Successful digital transformation should not swing the pendulum from one extreme to another, it provides leaders and their teams with another set of tools that are better suited to tackling certain kinds of challenges. These challenges tend to involve meeting new needs, how to deal with the increased service expectations of patients, for example, or how to capture and use huge volumes of data. Addressing these challenges may require new technology, tightly coupled with new practitioner skills (those who deliver in code, design and research), project management techniques, forms of financial appraisal, and approaches to governance. As these are capabilities that span across the full range of a trust's activities, accountability for their successful implementation therefore has to be the collective responsibility of the whole board, rather than one isolated silo.
It can be helpful to think of digital transformation in terms of addressing three questions, where the answers are often in tension with one another:
- If you started with the cultures, processes, business models and technologies today, what would the operating model of this organisation look like?
- How do we pivot an organisation with cultures, processes, business models and technologies that may be three or four decades old towards this, without over-burdening leaders and teams tasked with keeping the healthcare service running day to day, and without jeopardising patient safety?
- How do we retain our organisational flexibility to change, and avoid getting stuck into a new status quo?
While it may be tempting for leaders to look at the successful examples of Amazon and Netflix for lessons, it is essential to consider those organisations in the appropriate context. Trusts were not born on the internet, like Google and Ocado. Like almost any organisation set up before 1997, trusts are now 'on the web, but not of the web'. Successful digital transformation for any organisation that pre-dates the internet-era involves riding two horses at once, building something new while maintaining the old, and carefully managing the risks in transitioning from one to the other. When that leap is made too quickly, or in one fell swoop rather than a series of incremental steps, things often fall between cracks.
As an industry, healthcare has not ignored the implications of digital change. Unlike some sectors, it actually faces a much lower risk of falling prey to the existential disruption some organisations have already experienced. Writing of media companies terrified by the insight that broadband might end up killing traditional TV, a former BBC executive compared them to being pursued by a giant snail. It's not a fast mover, yet they cannot get away. "The snail! The snail!" they cry. "How can we possibly escape?" As he points out, "the problem being that the snail's been moving closer for the last twenty years one way or another and they just weren't paying attention". Many large organisations have watched the internet approach their sector and refused to adapt their operational model in order to survive. Kodak, Blockbuster and Toys 'R' Us, among others, learned the hard way.
This won't happen to the NHS. Digital's disruptive pressure on public services is different. Rather than go out of business, governments and public bodies bear the cost in different ways. One is failing to make the best use of finite resources, but the most profound is loss of trust. A clear and obvious trend in public attitudes throughout the internet-era is the growing expectation we all have of our 'service experience'. We have all got used to the ease and convenience of well-designed online banking, or shopping on Amazon. People do not expect their experience of public services to be any less effective at meeting their needs. For some public sector organisations, failure to live up to their expectations damages institutional trust and credibility. In the NHS, there is a risk that failing to harness the opportunities of digital will hold back improvements in patient care and experience, and worse, lead to missed chances for saving lives.
The Covid-19 pandemic further increased public expectations on the health and care sector. According to Ipsos-Mori data from April 2020, just six weeks after lockdown was announced showed:
- Almost three in five people reported having used streaming and video services more than they did a month ago,
- over half indicated they have used social media more than they did a month ago,
- around one in six used video to communicate with family and friends for the first time,
- one in seven used video to communicate with work colleagues for the first time,
- 7% were participating in community and religious activities by video for the first time,
- around one in four downloaded fitness apps, almost one in ten for the first time,
- one in ten searched online for what is open/closed near me for the first time,
- and 6% of people used a banking/mobile app for the first time.
In the weeks immediately following the start of the pandemic, the crisis response proved that NHS organisations were capable of delivery that would have been considered impossible in normal times.
During the pandemic, the spotlight was on the frontline healthcare more than ever and trusts had to bear much of the burden of these increased expectations. There was also greater scrutiny of comparison between countries and between trusts. That scrutiny, fair or otherwise, is unlikely to account for nuances of context if an organisation's digital response is perceived to be poor. While the immediacy and focus of Covid-19 has diminished, the heightened service expectations that patients, clinicians, and staff have of the system will not. Meeting the needs of all these different stakeholders - in a sustainable way - is a challenge only a successful digital transformation can address.