Back in May 2020 the National Audit Office (NAO) released its report on the state of digital transformation in the NHS. You can read their report here. The purpose of this report was to describe the current state of digital services within the NHS and to examine the readiness of the NHS to deliver digital transformation.
A key part of the overall strategy for digital transformation in the NHS was to set up NHSX as an oversight group that would develop national standards and monitor the activities of individual trusts against these national standards but to allow each trust to develop its own overall approach to digital transformation guided by the standards. You can read in detail the defined purpose of NHSX here. This approach was different from previous attempts in that it gave individual trusts far more autonomy whilst showcasing and funding best practice from those trusts that were able to implement digital transformation successfully.
The report from the NAO built upon previous work – in particular the Wachter Review. This review was published in September 2016 and highlighted at the time that the objective of a paperless NHS by 2020 was unrealistic and proposed that a digitally mature NHS could be achieved by 2023 but only with additional funding. This previous review also made 10 specific recommendations – you can read this review here. From this the NAO has pulled 6 problems that it believes were identified back in 2016 and against which progress should be have been made subsequently.
The report has some interesting findings – findings that aren’t just interesting for the NHS but for any organisation thinking about digital transformation in general. Rather than focus on the specific detail of the fundings relating to the NHS I have tried to pull out findings that can be generally applied to any digital transformation programme at any organisation.
Lessons from the NHS
Digital Transformation is hugely challenging
The report identifies that the introduction of new and complex ICT systems requires significant financial investment, and changes to process and staff behaviour. Because of this digital transformation at large organisations is in very nature hard to complete successfully. Digital transformation is made more difficult at organisations that have a large technology deficit – for example at organisations using older software and hardware.
Digital Transformation will fail without adequate funding
Ambition to complete digital transformation without the accompanying funding will cause problems. NHSE&I recommends 5% expenditure on technology but for many trusts the figure is less than 2%. Without proper funding digital transformations will stall before they really get moving – consequently the costs need to be properly understood up-front and then the required investment made. Digital Transformation is likely to cost more than anticipated not less.
Digital Transformation isn’t always infectious – but it needs to be!
The Global Digital Exemplar (GDE) programme is intended to fund digital transformation in trusts that are good examples. It does this in order to further accelerate their transformation programmes in the hope that other trusts will follow their examples. But at present the NAO says it’s not clear that good practices will spread to other trusts.
I guess the point I want to take from this is that ensuring good practice spreads is almost as important as ensuring there are examples of good practice in the first place. Speaking when no one is listening is pointless!
Digital Transformation is hindered by legacy systems
It might sound ridiculous but anyone who has worked in any large organisation will know there are systems that “cannot be changed” – systems so embedded in how an organisation works that they cannot be replaced. It could be that extracting the data is too hard, or the system has too many hooks into other systems, or changing is too expensive, or that other organisations in the health-care environment link into that system. Whatever the reason these systems exist and they act as blockers to change.
I think in order to mitigate this risk there is a real need to identify the applications that are likely to act as blockers to change and why. Then, once you know those applications, to plan how you will handle them. Personally, I believe that the problems these applications cause will only get worse over time, as will the cost of maintaining them or removing them from the estate. So my recommendation would be to identify what will replace them, what the replacement process will look like and schedule this activity as soon as possible.
Digital transformation will fail without an owner at the most senior level
Several times throughout the NAO report the authors mention that funding is unclear, or that oversight isn’t in place, or that there is confusion around who locally (i.e. within an NHS trust) owns responsibility for the implementation of a national initiative within the organisation. I think this illustrates the need for a senior responsible owner for any large digital transformation programme – someone who has responsibilities for the budget for the programme and freedom to change how that budget is spent – but who also has accountability for the delivery. Because of the amounts of money involved this surely requires a board level staff member?
In the NHS I think this situation is further complicated because of how the NHS is structured – local trusts having their agenda driven strategically through organisations like NHSX. I think this is right but it is also challenging. Trying to apply this to a broader audience, I guess large multinationals might have similar problems where different business units are independently trying to head in the same direction based on directives from “head office”.
Digital transformation must involve improved interoperability
Interoperability is the principle that systems must be able to talk to each other across business and organisational boundaries. It is made challenging for several reasons:
Historically vendors have desired to make it difficult to extract data from a system or integrate into other systems without using paid for integration tooling from the original system vendor.
Often there are no common data structure standards defining how a particular set of information should be formatted. In the NHS this has been patient records – but in other organisations this can be any employee, customer or business data, e.g. HR records, training records, customer service information, etc
Lack of defined and well documented APIs. An application program interface (API) is a structured method in which software components – or even different pieces of software – should communicate with each other in code. Interoperability is made much easier when a published and documented API exists. Without a structured well documented API it is very hard and costly to get systems to integrate.
Conflict between data protection / GDPR concerns and interoperability – interoperability requires data to be passed between systems, whilst GDPR concerns itself with which systems hold which information about an individual, why the information is being passed on and who owns the system processing the data. Unfortunately it’s possible for the need to document the information required for GDPR compliance to block or delay interoperability.
Underestimating the costs associated with interoperability and time required to get the documentation in place can easily derail a digital transformation programme.
Digital Transformation requires commitment to a plan with timescales and milestones
The NAO states in its report
“NHSX does not have a timeframe for achieving interoperability and its plans are under-developed”
“Digital transformation is essential to the NHS… and will need a high-quality implementation plan… However, there is no digital implementation plan”
For a digital transformation programme to be successful it must have objectives, milestones, and timescales – I.e. it must have a proper programme or project plan.
Digital Transformation requires people with relevant skills
The NHS has a shortage of staff with digital and cyber skills. The NAO report notes that
“Specialist skills are in short supply”
However, since the UK overall has such a shortage this issue is not unique to the NHS but of concern to the whole of UK business.
This is surely obvious; but if you plan on migrating to a new system, or to start working in a new way, you need staff who have the required technical skills to assist you in successfully completing the migration. This could be the staff / partner who will design and implement the new system, but equally important are those who will train, mentor and model how to work in the new way for your own staff. Also – it’s not merely technical staff here, you will need programme and project managers who understand digital transformation programmes. You will need staff who can build technology adoption plans and staff who will be willing to champion the new technology who are trusted by all the other staff. You will need staff who will work together to become a centre of excellence for digital technology. You will need specialists in change management. This isn’t an exhaustive list but hopefully you get this point – the staff required aren’t merely those needed to technically get the solution working.
To avoid low levels of technology adoption and an erosion of the trust in your ICT function due to repeated failures, you need to plan to recruit these staff early rather than later. If you don’t bring them onboard early enough you won’t achieve the predicted benefits of your digital transformation programme.
Digital Transformation must be built upon lessons learned
Almost everyone has a story that starts “Do you remember when…[insert ICT system] … didn’t work?” When hearing complaints of this nature I always wonder if the associated organisation’s ICT function knows why and has acted to prevent a recurrence? The NAO is aware of this problem and notes “we are not convinced that all the lessons [learned] are being applied now.”
I think there are a few things to think about here:
Have you learnt the lessons from previous large ICT projects? For example do you have a list of what went wrong and what you’d do differently in future from when you last upgraded Exchange, last replaced a pair of firewalls, last upgraded SAP, or last did a WAN replacement?
Were you totally honest about what went wrong in your lessons learned? Sometimes it’s possible to perform a lessons learned exercise without really wanting to document what really went wrong because it will damage departmental reputation within a business. The problem is that, in this instance, the point of the exercise is totally sidestepped and thus the benefit is lost.
Last time you ran a major project did you integrate the lessons learned into the requirements document? Did you review the lessons learned before you went to tender? Did you discuss the lessons learned with your preferred supplier?
Will you review the lessons learned against your digital transformation programme and work out how and if they apply?
Applying the lessons more broadly
In conclusion, I believe that all digital transformation programmes can learn from the lessons highlighted above – these have been pulled largely from the NAO report on the state of Digital Transformation in the NHS. Some of them seem obvious but the mere fact that the NAO has mentioned them or alluded to them suggests they still need to be “learned”.
To summarize then:
Digital Transformation is hugely challenging – so don’t underestimate how complex it will be!
Digital Transformation will fail without adequate funding – so make sure you understand the true costs upfront.
Digital Transformation isn’t always infectious – but it needs to be! – So make sure you notice and publicise successes.
Digital Transformation is hindered by legacy systems – So make sure you identify which systems are likely to act as blockers to progress and how you will deal with them.
Digital Transformation will fail without an owner at the most senior level – so make sure you appoint someone senior enough to own digital transformation.
Digital Transformation must involve improved interoperability – so make sure you understand what interoperability is and how you choose systems that have open APIs and get up to speed with your obligations under GDPR.
Digital Transformation requires commitment to a plan with timescales and milestones – so make sure you know what your objectives and milestones are, and when you need them delivered.
Digital Transformation requires people with relevant skills from the start – so make sure you know what skills you will need and how you will ensure adoption.
Digital Transformation must be built upon lessons learned – so make sure you know in detail what went wrong during your last few major ICT projects and how you will prevent the same things going wrong again.
If you are thinking about or have already embarked upon a digital transformation project why not give us call and have chat – we’d be delighted to help you.