This way up: 5 years into my work for the NHS

Sunshine through clouds, modern and Victorian buildings in city centre, in the foreground a constructon site
Sunset over Leeds skyline as seen from Quarry House

From the start of my time at NHS Digital, I was in the habit of publishing six-monthly updates on my work. I kept up the habit at 6 months, 1 year, 1.5 years (a special favourite), 2 years, 2.5 years, and 3 years.

Why the 2 year hiatus? It’s complicated.

At 3.5 years, I found myself at a delicate point in negotiating a move from one bit of the national NHS organisations to another – a move I posted about on social media but never quite got to write up the chapter and verse. Quite a lot of that is still in my drafts folder.

At 4 years, I was just settling into my new role off the back of a short tour of duty on a high-profile COVID-related service that I was really proud of, but less able to talk publicly about as a live issue of government policy.

At 4.5 years came another round of organisation change, bringing together my past and present employers in the new NHS England Transformation Directorate. This coincided with my line manager leaving and changes in my own directorate. The timing was never quite right to publish an update.

So here I am, 5 years into my time in the NHS, reflecting on a quote often attributed to Arthur C. Clarke or Bill Gates, but more reliably to J. C. R. Licklider:

“A modern maxim says: ‘People tend to overestimate what can be done in one year and to underestimate what can be done in five…'”

In one year

I don’t know about J.C.R. Licklider, but I’m quite proud of what’s changed in the last 12 months, even though it will take longer for the benefits to fully ripple out.

This time last year, I was still in introductions mode, learning more about urgent and emergency care (UEC) and how it all fits together to meet patients’ needs. I’ve learned a lot, thanks to the patience of colleagues who have been working on this stuff for a long time, and others who, like me, are looking at a vitally essential yet highly challenged part of the national health service with fresh eyes.

UEC has some unique functional and non-functional features. Every hour of every day, people from national, regional, and local NHS organisations are collaborating at pace to care for patients. They need and deserve digital services that support them, not ill-fitting technology that gets in their way.

At the same time, no part of the NHS is an island. We have to figure out which bits of the technology stack need to be specific to UEC, and where we should take advantage of system-wide enablers, such as the new Booking and Referrals Standard. If we get these judgements right, there can be more innovation and faster learning loops to make health services better.

I joined the team in the spring of 2021, and we were soon focused on how to support the UEC frontline – including 111 call takers, ambulance paramedics, and emergency department staff – through the following winter. Not long ago we ran a retrospective on how winter went from a national digital perspective, and how we can inform learning for next annual cycle.

Digital UEC includes some mature national digital products, but also a set of transformation initiatives that have kicked off in the past year. I was keen for them to show early signs of progress, and focused on a small number of milestones that teams met, or came close to meeting.

Setting ourselves targets for delivery doesn’t mean we’re not doing this in an agile way. As Senior Responsible Owner (SRO), my role is to make sure that real needs are being addressed, and we can only be sure that’s true once we start delivering something. Sometimes a team will need to change their focus to maximise the return on investment in their work. When that happens, we must test the emerging evidence and assumptions.

Given the nature of the work, this has to be a partnership between clinical, operational, and digital professions. I’m very fortunate to work alongside Jacqui, the deputy director and clinical lead for Digital UEC, who chairs our assurance board.

New arrivals have strengthened the small NHS England Digital UEC team.

Brin joined us as head of transformation strategy, to connect our work to the wider UEC strategy, and articulate the “golden thread of our team’s story. He does that with the support of Yvonne, as engagement manager, and Yemi, as senior benefits manager. Benefits management was commended as a particular area of strength in our programme’s recent gateway review.

Imogen has taken on a new role as head of product, working across the portfolio to create a cross-cutting user-centred view.

I’m pleased to see the culture of user research observation spreading through the team, and user researchers in product teams having a higher profile than before. Having joined during a COVID-19 lockdown, site visits and patient engagement haven’t been easy, but we’re starting to get out into the services more now.

Laura Wade-Gery’s review of digital transformation in the NHS national bodies recommended that we:

“Replace formal ‘internal commissioning’ between NHSEI and X and NHSD with joined-up business planning and a more iterative dialogue that navigates between business needs, technology considerations, and budgetary constraints.”

I’ve made it my mission for Digital UEC to show how that can work.

After a year or so of finding my feet in the role of NHS England director and SRO for a digital transformation programme, I’m rediscovering my voice on the things I really stand for: putting patients and frontline workers first in everything we do.

I also really enjoy working alongside Simon and Nayeema as part of the Digital Transformation Directorate, a genuinely blended team of NHS and Civil Service digital professionals.

In five years

Looking back on the blog post I wrote on arrival 5 years ago, my reasons for joining the NHS hold true today. From the start I was sure this would be a multi-year mission. What has shifted in 5 years? (This is by no means me taking credit for these achievements. I’ve just been lucky enough to play a small part in them.)

For starters, the NHS’s national digital channels have been transformed, with a user-centred, mobile-first, accessible NHS website, an online login available across England, and a common front door to urgent care through 111 online.

Through delivering these products, we scaled the multidisciplinary, user-centred product culture from a handful of isolated alpha teams to large parts of NHS Digital, NHSX-as-was, and beyond.

The proof of this came when we were challenged to stand up new digital services at pace in the pandemic. Teams were able to move fast because the foundations were already in place, and well-documented in the form of our design principles, service standard and service manual. None of that happened overnight: it was years in the making, and there were moments along the way when things could easily have unravelled.

In 5 years, I’ve changed jobs twice and organisation once, to get closer to a vision of a strategic capability for the whole NHS — making visible what’s valuable, and supporting creative leaps to deliver better service.

It’s still about the people

I still believe that the practices of co-creation and co-production emerging in health and social care will be the foundations for the next phase of people-centred service design – though at times that still feels a long way off.

My first encounters with the business of the NHS, before joining a national organisation full-time, were with patients and frontline staff through my service design work for mHabitat, now Thrive by Design. There I learned the power of involving people meaningfully in decision-making about their health and social care services.

I’m fortunate to have access to that wisdom now in the form of the Patient and Public Voice Board for Digital UEC. A few weeks ago, I had the pleasure of meeting some of them in person on a visit to a 111 contact centre. The tone of the visit, and quality of the learning, was significantly raised by having patients literally in the room. The whole team benefited from hearing their questions and concerns.

Something similar is true when we actively involve staff in the development of the systems they have to use for work. Many assume that frontline staff, clinicians in particular, are too busy to get involved at an early stage. This is a false economy, because a few hours from a few colleagues on an ongoing basis can prevent a team from wasting months on features that won’t be used, and at worst will get in the way of good care. I’ve found that even very senior clinical leaders will invest time with me and my team – provided they can see the relevance and believe we are actually going to deliver something for them.

I also feel as strongly as ever about modern digital ways of working. That means investing in long-lasting teams with multi-disciplinary delivery capability; using modern agile, iterative approaches through the whole product lifecycle. No one seems to disagree with the principle, but our funding flows and governance still bias heavily towards stop-start projects, over sustainable service-centricity. That’s got to change.

I still count myself lucky to work with a great and growing band of user-centred design practitioners and product people across health and care, proud of the things we have achieved together, and in no doubt of the transformation work still to do.

Half a decade is a good timespan to watch talent development play out, and that’s very rewarding to see. People I met at the beginning of their traineeships on the NHS Digital graduate scheme are now well established as experienced professionals on delivery teams, including in Digital UEC. People I first knew in practitioner roles have stepped up to be leads and heads of role themselves.

Given the past couple of years, I respect those who have done their tour of duty and moved on from in-house NHS jobs to agencies or other sectors. I hope one day they’ll return with renewed enthusiasm. We mustn’t create a cul-de-sac of health digital jobs. It’s much better to have a two-way flow in and out of the NHS, so we take advantage of the full diversity of digital talent.

There’s a massive prize to be had here: to put the digital, data, and technology professions properly at the service of the new NHS England, which has long been deprived of digital expertise because of the way the national arms-length bodies were set up in silos. Compared to other parts of the public sector, we have a lot of catching up to do, but now’s the time to create a very different kind of national organisation. I’m here to help make that happen.

On leadership

Leading in a complex, distributed, multi-professional system is hard.

I’ve certainly seen, and felt the pressure called out in the Messenger Report, ‘Leadership for a collaborative and inclusive future‘:

The sense of constant demands from above, including from politicians, creates an institutional instinct, particularly in the healthcare sector, to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user.

I’ve valued the support along the way of senior leaders who modelled the bold, inclusive styles that enable multidisciplinary teams to do their best work. I’ve learned something new from every line manager I’ve had. (Thanks to Amanda, Ian, Wendy, Ben, Iain, and Matthew!) Sadly few of those leaders have stayed as long as I hoped they would. Joe McDonald aptly calls this the “lava lamp” effect in NHS tech management.

More than 2 years since I graduated from the NHS Leadership Academy, I still wear my Nye Bevan programme pin badge with pride. I hope I am applying what I learned with my awesome peer learning set.

The Bevan Programme prompted me to explore the role of the non-executive director, and to take on an extra role as a board director for Leeds and Yorkshire Housing Association. Spending time in this much smaller, community-based non-profit is a healthy counterpoint to my role in a massive national organisation. It’s also a regular reminder that the NHS accounts for only a small proportion of the wider determinants of health.

And beyond

The habitual reference-checkers among you will have spotted my sleight of hand at the top of this post. When I quoted human-computer interaction and cybernetics pioneer Joseph Licklider, I left his actual words hanging on the half-truth of an ellipsis. His 1965 maxim actually went like this:

“People tend to overestimate what can be done in one year and to underestimate what can be done in five or ten years.

Might this five-year mission turn out to be a decade-long? It’s probably too early to say.

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