3 years into my work at NHS Digital – part 2: Responding to change over following a plan

Desktop with newspaper showing "coronavirus tests for essential workers", notebook with sticker that says "teams before tech", torn up sticky notes, laptop with Miro open in browser

I hate emergencies. Some people thrive on drama, on spontaneously pulling improbable triumph from the jaws of a terrible situation. Personally, I’d much rather we didn’t get into that situation in the first place. I knew this about myself before I did the Nye Bevan Programme, and my learning on that programme confirmed it.

Leadership for me is the long, thoughtful, steady progress of building capability in individuals, teams, and organisations. That’s why I joined the NHS. When I read back through the previous six-monthly reports in this series, those are the things of which I’m most proud.

As I proposed in part 1 of this update, there are no shortcuts to digital transformation, but there are moments that illuminate how far we’ve come.

The frontline

I never much cared for the military metaphor of the “frontline” in relation to our colleagues who deliver direct care for patients, but I’m sure at times that must be how it has felt for them. I hope we in the supporting functions have done everything we can to back them up.

There’s some survivor’s guilt in knowing that others have worked long hours in literally life and death situations, while I’ve suffered nothing worse than the inconvenience of an occasionally flaky internet connection.

I feel like I’ve lived a charmed lockdown. I can comfortably work from home and our children are all teenagers who keep to their own devices. It has been very different for many others – those with younger children to home-school, those who are vulnerable, those touched personally by the horrible new coronavirus. The two-dimensionality of the laptop screen conceals it, but whenever any group appears together, there’s something different going on for every person on that call.

And yet, incomparable though it is to the direct delivery of in-person care in a pandemic, there is a digital frontline in this crisis, and there my colleagues have delivered heroically.

That frontline is the first result people see when they type “coronavirus symptoms” into Google and see structured content pulled automatically from NHS.UK. It’s the rapid updates to 111 Online and the Pathways algorithm to reflect growing understanding of covid-19, and make sure that people know what to do at time of extreme worry and stress. It’s the hundreds of thousands of people needing “isolation notes” to show their employer if they can’t go to work.

Our teams did all this while, as James, one of our product leads put it, “sticking to our UCD guns.” It has been a long haul and there’s more to go. For some of our teams, the hard work began long before the clapping, and has continued as we gingerly descend the hill from April’s sorrowful peak.

Testing times

The need to respond rapidly to changing user needs and contexts of use has shone a light on areas where we’ve achieved some agility and user-centricity, and areas where digital transformation still has much further to go.

As might be expected, the teams that rose fastest to the challenge were the ones that were already working well together before the crisis. They’ve proven the pattern of giving high-performing multi-disciplinary teams new problems to solve, rather than disbanding and reassembling resources from scratch every time. Nevertheless, the volume and variety of new problems to solve all at once meant we had to do some of the latter. Those squads found their feet quickly and also delivered some great work.

While our NHS Digital teams have been demonstrating what they’re capable of in a crisis, we have been joined by reinforcements from other government departments and suppliers. On the whole, we’ve been able to act as one team. When it comes to digital delivery and user experience, the gap between public and private sectors is narrower than sometimes portrayed.

Many people in the Digital Services Delivery profession that I lead are relative newcomers to health and care, and we still have a lot to learn. I remind myself that it’s only 3 years since I moved from consulting, and before that 12 years in telecoms. All the same, I have sometimes found myself the most experienced person in the virtual room when it comes to how our health service works, and what patients and the public expect of us. I hope I can still strike that tricky balance between knowing enough to be effective, but still looking at the unique problems we face through fresh eyes.

Different perspectives are more important now than ever before. In our constitution, we say that the NHS is for everyone, yet this crisis has thrown pre-existing inequalities into sharp relief. In the coming months and years, we must reflect on how, at key moments in our response to the pandemic, our blindspots and biases affected the decisions we made and the services we delivered.

In response to this realisation, some of our user researchers and designers have begun to expand our definitions of access. We need to move beyond our necessary but narrow focus on digital accessibility. We need to design for the wider range of barriers that prevent some people and groups in society getting the care and service they need. Until recently, I saw the wider aspects of inclusion as important and adjacent to, but not part of, our core practice of user-centred design. I’m grateful to the colleagues whose clear-thinking and determination has changed my mind about that.

I feel fortunate to be working with leaders in several of the national health and care organisations who see this too. They have held the space for teams to do their best work, to understand the real problem we have to solve, resisting the temptation to revert to less effective methods of command and control. All this has taken place with our work under a level of scrutiny I have never previously experienced, and closer to the boundary of policy and delivery than my colleagues and I usually get to operate.

What now?

As the focus has turned to the next phase, we have to strengthen and evolve the new services we built rapidly, while folding some of them back into the everyday work of the health and care system. What have we learned that can help us with that task?

First that the amazing people of the NHS can rise to a challenge of unimaginable proportions, and reconfigure whole services in a matter of weeks when they have to. Let no one ever say that health and care workers are incapable of change. But we cannot count on their heroism alone. That’s not a sustainable basis for digital transformation.

There are risks coming out of the pandemic, present before, but now even greater.

  • On one hand, we must guard against complacency arising from the gratitude people have for the care, and their love of the idea of the National Health Service.
  • On the other, we have to restore the sense of our hospitals and other healthcare settings as safe places. Having majored on a message to “stay at home”, which was essential at the time, we need to make sure no one now stays away from the help they need out of fear.
  • So much has been put on hold as the service focused single-mindedly on weathering the storm. True innovation requires some slack in the system, safe space to try new things, acceptance that sometimes we’ll fail and learn from our failures. These things will be hard to protect when there’s so much catching up to do.

Those challenges are undoubtedly systematic ones, with solutions as likely to come from communities, places and local government as from NHS organisations in the centre. The peculiar set-up of “commissioning” in the NHS has been challenged and is changing rapidly in local systems. I sense the same pressures will come for our national services too.

User-centricity and the wider skillsets of my profession have a vital role to play in determining what kind of service we become. How – to borrow some principles from accessibility – might we make the whole system more perceivable, operable, understandable, and robust for everyone who needs it, and for the people who keep it going?

If we’re not careful, generalisations about some parts of public service may collide unhelpfully with the development of genuinely multi-disciplinary delivery teams. For example, it is often observed that the science and engineering struggle to be heard in the upper echelons of politics and policy-making. I know from my telecoms experience that the solution is not to create a science, technology, engineering and maths (“STEM”) monoculture, but to nurture balanced teams, with mutual respect at all levels. Social scientists and creatives play a crucual role in channelling and amplifying the impact of talented data scientists and software engineers.

I’m cautiously optimistic. Whatever my impatience at the slowness and the setbacks – among which having to respond to a global pandemic must surely be one – we regroup and press on.

Objectives for my team and me in the next phase:

  • Continue to mature user-centred design practices across our Product Development directorate
  • Grow the digital delivery skills the organisation needs for the future, including our present and future user-centred design leaders
  • Make sure all our colleagues understand barriers to access to our products and services, and always consider the equalities implications of their work
  • From doing all the above, demonstrably deliver value to the wider health and care system.

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