The role of improvement in implementing the shift from analogue to digital

“We have brought up software that enables clinicians, using really simple software, to design their own assessments.”

“Can technology make it better for patients and for staff? And we're using wearables to test that out. It's about the democratisation of healthcare and using technology as an enabler to do that.”

“There's so much exciting stuff in that ten-year plan, but there'll be a load of people reading that who don't have a decent device, where the Wi-Fi’s not working, they can't get any phone signal when they're in the hospital, you know, all this kind of stuff. So I think there's really something about saying: ‘We're going to get the basics right, here’.”

“That whole purpose of the NHS Turn Your Plan of putting something, the doctor in your pocket, the NHS acting as the front door, I think is the really promising bit.

Penny Pereira

Hello and welcome to Leading Improvement in Health and Care.

Matthew Taylor

And if you haven't guessed from the teaser clips, in this episode we're delving into the role of digital technology in the government's 10 Year Health Plan.

Penny Pereira

Digital is one of the three core pillars of the recently announced plan. So how can improvement methodologies enable NHS leaders to implement digital transformation successfully?

Matthew Taylor

This particular podcast measures on system approaches to improvement. 

I'm really pleased, Penny, that we're going to be hearing from people in the mental health and community sector and who are working out in the community, that the three shifts in the ten-year plan, left shift, prevention, digital, they need to support each other. And yet when we talk about digital, we too often focus primarily on the acute sector. It's really important. They've got the most money. That's the kind of most tech heavy. It's really important that we think about digital in a community context.

Penny Pereira

Yes, this podcast feels like it's always about spanning silos, spanning boundaries. Helping us with this episode as roving reporter is Tom Hardie, who's the Senior Improvement Fellow here at The Health Foundation.

Tom's been speaking to Sadia Khan, who's the clinical lead for innovation at West Middlesex University Hospital, but also to Abigail Harrison, who's executive director for digital estates and improvement at Lancashire and South Cumbria NHS Foundation Trust.

First we're going to hear from Abigail. Tom started by asking for her take on the approach to digital transformation in the ten-year plan.

Abigail Harrison 

There's loads of good stuff in there and lots of kind of ambition and exciting stuff that's really good to see. I think the three key things that I thought were most promising that I was really pleased to see. So firstly, just some of the stuff in there that's kind of bringing forward some of the basics. So just really making things simpler and easier for people, releasing time to care. I always find that's a really good way just to engage staff. They really want to know that digital technologies are just going to make things easier for us, whether that's a single sign-on or for patients in terms of accessing their information in kind of simpler ways. So it's good, because I think we need to get those basics and those kind of foundations right first. So that was really good to see. 

I think the second big thing that I thought was really promising is this kind of real shift to a focus on neighbourhoods and trying to understand, guess, what the digital enabler is to that and really shifting that focus onto kind of patients and them being empowered to have access to the information they need, the services they need, but at a kind of neighbourhood level. And that's something that I'm really passionate about. And I've done a lot of work around trying to understand how you kind of wrap digital data and technology around somebody within a neighbourhood. 

And then the third thing I guess is this kind of focus on optimising our data and that kind of being part of this journey towards moving towards prevention and kind of keeping people well at home. And I would really want to see that going back to the neighbourhoods move beyond the NHS, because this is about NHS, but also social care, voluntary sector. So how do we kind of really enable that at a kind local level?

Tom Hardie

What key service shifts do you think we'll need to avoid simply digitising what we do already?

Abigail Harrison 

The most important thing is that we really start to get better at focusing on the kind of whole pathway. And I think what often we do when it comes to technologies, we start to just think about individual kind of opportunities to digitise or put technologies in. I think in terms of the way that we look at our services and the shift will be to really focus on the whole pathway and really focus on whole pathway improvement first. And then the next step is to kind of map the digital opportunities onto that. 

So it might be that actually there is some digitisation of the status quo, some kind of simple automation and digitisation, or it might be that we have technologies that enable a kind of new approach, a new way of delivering care, a kind of something more transformative. Or we shift again to something really radical and a kind of innovation that might totally change our thinking about what is possible in terms of how we deliver that care. 

But I think the first step is really to look at that whole pathway, really think about where the value lies in that pathway for our patients, where the value lies in that pathway for our staff. What is the bit of this that is really meaningful to our patients and our staff before we start to kind of layer in the technology. And I think often what we do is look at kind of one technology at a time for individual bits of pathways and patient journeys rather than looking at the whole journey and kind of mapping it all the way along. So that'd be the biggest shift, I think, in terms of how we think about our services before we move to that digitisation.

Tom Hardie

What role do you think improvement approaches can play in planning and delivering digital transformation?

Abigail Harrison 

So I think the first is really thinking about how we test and co-design digital solutions. So we tend to move straight to kind of procurement and implementation, and then we find that it isn't right. So the first thing is let's look at the pathway first. So let's make sure we've got a process that is ready to be digitised, that we really understand where the value is in this pathway, that it's as kind of lean as it can be. And then we think about testing.

So testing, co-designing solutions, evaluating, that might be working with partners to do that before we go to that kind of procurement and implementation phase. So I think improvement approaches are really, really helpful there. And can really help you get your business case over the line as well, actually, because you've got much more evidence around how something works before you try and implement. And the second then is that kind of implementation as scale methodology.

So I think in improvement, you we know that it's difficult to scale. So we know that the context is different wherever you go, you know, even from one ward to another, from one team to another, have a really different context. We know that we need to work with clinical leaders. We know that things need to be really owned by a team. So there's lots of learning from improvement around how we gradually scale and implement that I think we could use much better in digital transformation. 

And then the final one for me is around thinking about to enable collaboration. So a lot of what I've worked with our digital teams has been, let's think about who can help us with this. So often a kind of digital implementation is just kind of left with the digital team, but actually I would say, you know, that could never be the right thing to do unless we're purely talking about a bit of infrastructure or cyber or something like that. And even then perhaps not, but most things that are going to impact on our frontline staff and our service users and our patients we have to work really closely together with our services. 

So thinking about approaches to collaboration, but not just with our clinicians and with our patients, thinking about the teams that can operate with you in a trust. So I think an improvement team really consists of lots of different people, procurement, for example, you know, let's figure out how to get them in the space and work with them and thinking about how we collaborate with our industry partners as well. So I think there's approaches that we can learn from improvement that help us understand how to collaborate and deliver much better than in terms of our digital transformation.

Tom Hardie

That's really interesting. And I wondered if you could talk a bit about how you and your organisation have used improvement approaches, whether that's in relation to testing and co-design or evaluation or implementation or anything else that you mentioned, really.

Abigail Harrison 

So it's really exciting for me, but what you do need to do first off is make friends with your improvement team. So let's have your improvement team as a start around the table with you. So there's a few things that we do. So one is thinking about how we create a space for ideas. So we have a forum called the Digital Ideas Drop. So if somebody's got a new idea or a thought about how we could be using technology, we create a really open space where we can just kind of bounce ideas around with clinicians or staff members, whoever it is who's come up with the idea or has some thoughts with our digital team and the various different experts. Within there, you might have development, cyber security, your CTO, you know, all those different skill sets and an improvement adviser as well, who will really help us think about trying to make this small. Because I think often we move to, well, that might cost a million pounds and we need a business case and, and, you know, it's difficult to do.

What our improvement coaches in that space really help us do is think how can we take one step? Could we do something small? Could we have a go? Could we test it? What's the problem we're trying to solve? \how could we achieve that? So creating a space where I think you have your staff members, might be patients as well, your digital team and your improvement experts and your trust can really help you have a different conversation. 

The other thing we've done is really tried to use improvement methods to deliver co-design. So we have been doing some work on our EPR and we've got a programme we've called it ‘Rio Recharged’ because like a lot of trusts, we've ended up with quite a cumbersome system. So we've been trying to kind of strip back our EPR and redesign it. And to do that, we have held sessions with clinicians where we've had multidisciplinary clinicians in the room, multidisciplinary teams, and we have literally brought up software that enables them themselves with a little bit of support from the digital team to develop themselves what they want to use. 

So we've had clinicians using really simple software to design their own assessments with the digital team and the improvement team kind of facilitating and supporting, but really putting the design onus on them. So that's been a really interesting experience and really interesting to get those different clinicians together to figure out themselves, well, you if we want this to be easy to use, which one of these 30 things that we all want in here are the most important things that we're going to add in and to have to do that themselves, but also design the kind of visuals themselves. 

But I think in its simplest way, in terms of what I'd advise people to do is just go and speak to your improvement team and have them working with your digital team. Every improvement team should have a digital person on it. And every bit of digital work that's happening should have your improvement team in the room. And I think that's just a really simple first step that anyone could take really.

Tom Hardie

Healthcare is fundamentally about people, it? And digital transformation is also about people. So with that in mind, how do we get buy-in from key audiences, in particular staff, to make digital transformation happen?

Abigail Harrison 

Yeah, so our digital kind of enabling plan has a number of different areas. Some are focused on cyber infrastructure, there's stuff about innovation, but the one that can always look people in the eye and really talk to them about and know that they are pleased to hear this is just getting the basics right. So I think there's so much exciting stuff in that ten-year plan. But there'll be a load of people reading that who don't have a decent device where the Wi-Fi is not working. They can't get any phone signal when they're in the hospital, you know, all this kind of stuff. So I think there's really something about saying we're going to get the basics right here and then we're going to do the exciting stuff. 

So I tend to talk about that first. Like we'll make sure your internet's good. We'll make sure you've got signal. You've got decent devices. And then the next part of that is this is about making things easier for you. So ‘releasing time to care’ is the way that we describe what digital should do. So should make us safer, should make it easier for people to access our services and it should release time to care. And if you think about how we use technology in our day-to-day life, we only use it really if it's going to make something easier. That's why we use it. 

But in the NHS, we've ended up in a scenario, I think, because we often digitise to measure. So we digitise to kind of collect data and we layer things in and we layer things in so that we can track things, so we can evidence that we've been safe and so on and so forth. And I'm not saying none of that's necessary, but I think it's created a scenario where digital isn't making life easier for people all of the time. So I think that's really the way we articulate it with staff. Let's get the basics right. And we're going to use technology just like you do at home. Think about your Google Maps and how much safer and easier that makes it to get you know, imagine now not having that. That's how technology should feel to us in the NHS. And I think that's what we're hoping to achieve. And that's the way we talk to our staff about it.

Tom Hardie

So everything that we've just discussed in mind and kind of standing back a little bit, what would you say are the kind of key things that need to be in place locally to support organisations to achieve the step change in digitisation that the ten-year plan brings about? 

And then with that in mind, what can national bodies or regional bodies do to support that?

Abigail Harrison 

So I think that we've said it does come down to kind of leadership really. I think locally, what we really need to do is to support, I often say kind of let's support just the kind of normal kind of average trust. Like I'll introduce, I always say, if I'm going to go and speak about some of the improvement stuff we're doing or the innovation stuff, I always make a point of saying we're just kind of an average trust really. 

So where are those normal trusts? Because they'll be really struggling with just procurement processes and kind of legacy infrastructure. We haven't talked about that, but that's so important. And I remember when I started at the North West Ambulance Service, I said that I spent the first six months just really trying to listen to the digital team. And as a non-digital person myself, we weren't talking the same language, but just listening, listening, listening, really trying to figure out, right, you're really worried about this. Because if they're worried about something, it will be for a reason. 

So I think focusing on getting the infrastructure right first, because that will kind of release the capacity of your digital team. They won't be constantly trying to patch things and just fix problems that aren't necessary. And it frees up everybody's headspace and imagination a bit. Once you've sorted out that infrastructure and you feel safe, you could start to be a bit more creative. You can do more inventive things. So I think that would be a kind of ask for local leaders, I guess, to just really think about that. 

And then I think really thinking about collaboration. So really thinking about how can you help foster some collaboration here and get people working in a different way, which would be quite a big change, I think, for some teams. So how do we get that improvement team and that digital team working together? 

So yes, we need kind of these core systems at a national level, which will be really helpful, but we also need the foundations. Each and every trust needs those kind of really safe foundations in place. They need the leadership in place. They need that kind of collaborative approach.

Tom Hardie

And then just to finish and just building on that, would you say there was any sort of specific actions that national and regional bodies can take to build that improvement capability that we were talking about earlier or supporting the kind of identification or sharing of it where it's already there?

Abigail Harrison 

Yeah, so I think from a national point of view, working with boards so they really understand it, which I know is happening. So I know there's the work with NHS Impact, which my chairman of our trust, David Fillingham, is the chair of the national improvement board. So we talk a lot around how do we make sure that boards understand this kind of coming together of digital and improvement. So I think there's something about ensuring that boards and kind of your exec. understand the opportunity there that the national team can really set that out as an opportunity for us in this digital and improvement space. 

I think focusing on procurement frameworks, there's something in the ten-year plan around kind of innovation space in procurement. I can't remember exactly how it was described. It wasn't very specific, but that was hopeful. How do we support people to work together to share improvement results? Because I think it's all there. It's just about how we work together and start to not see those organisational boundaries. So I think that's where the regional teams can really help.

Matthew Taylor

So Penny, that was of course fascinating. Let's just talk about a couple of the kind of key things that I drew out of that. 

The first is the importance of getting the basics right in the sense that a lot of people in the health service have had mixed experiences of technological innovation and digital. Often it hasn't lived up to the promise. So for Abigail, absolutely being sure that this is really going to help people, these tools are going to make people's lives easier, it's really interesting that she focuses on that.

Penny Pereira

Yes, and those simple things are often where the trust and confidence that both staff and patients have in technology starts to erode. And that provides no foundation for then really getting people to get excited and invest in that transformational change. 

One of the things that I think we've learned through our work with Q Lab is actually, what are the specific factors that will influence people's trust and confidence in technology-enabled care? And given that, actually how people use tech, is really critical to its adoption, quite often we're dealing with relatively little information about that dimension of the change process when we have huge minutiae and huge amount of detail on perhaps the technical specification. 

So I guess the things that we know are perhaps the basics of people trusting the tech that they have around them are really knowing that it's actually going to make a difference, positive difference to the care pathway, for example, so it's not going to get in between the patient and the clinician is actually going to enhance that relationship. 

And then there'll always be some particular risk factors associated with the use of technology within any particular pathway. And so really understanding that is going to be really important. 

The other things that we've picked up are, for example, like people really want to understand that health inequalities are being properly addressed and that the way that patients are trusting technology will really influence the way that staff are trusting technology and vice versa.

So I guess getting the basics of tech implementation and technology right is partly about the basics. Does your IT and your Wi-Fi work? And it's also about some of those foundational basics of change and what it takes for people to trust in the processes that are being built around them.

Matthew Taylor

And there's a couple of themes in the conversation between Tom and Abigail that we're going to hear echoed, I think, in the conversation with Sadia. And that's firstly, don't use digital simply to digitalise existing processes if those existing processes have got problems, you know, it's an opportunity to rethink that process. So they both want to talk about being patient centric and having technology is built around patients’ needs, understanding patients’ needs.

And then another theme we'll hear from, we've heard from Abigail, we'll hear from Sadia, is around empowerment and engagement of staff in the process of designing, testing and refining digital solutions.

Penny Pereira

Yes, and it's really interesting that people we're speaking to here, who we reached out to people who are interested in the implementation of tech, and yet our interviewees are taking this in such a kind of bigger picture. So really pushing us to think about the whole pathway view and of the three shifts, they seem as energised or as much talking about the shift prevention, the shift from hospital to community.

I think that reflects some of the things that we've seen as being needed in this transformation work, that we're thinking about technological innovation as something we pull in to specifically address the gaps that we've identified in pathways in order to enable the big shifts, as opposed to implementing technology because we're excited about the specific potential of that particular bit of kit. 

I think the ten-year plan has a bit of a mixed record on that. I'd be interested in your reflections. There's quite a lot of excitement around the pure potential of individual technologies and then some good things in there about the wider view of neighbourhood health, of moving from hospital-based care to alternatives that draws on technology and digital.

Matthew Taylor

So Penny, we're going to hear now from Sadia Khan, who's been leading on two projects supported by Q's lab - wearables and digital inclusion. Just before we hear from Sadia, just summarise that lab project and the outcomes from it.

Penny Pereira

Yeah, so the lab is Q's approach to supporting people to make progress on complex challenges. So, you know, the lab process supports people really understand issues systemically. And, as you'll hear, this has led to an approach where, for example, the team in Chelsea and Westminster reached well beyond the hospital to form collaborations with local authority and with community groups. We talk a lot about this. I think the lab method and what we'll hear from Sadia starts to explain how you do that in practice.

Sadia Khan

From the wearables work, there are two key areas that we've really focused on. And they basically span the whole part of what I would regard as a patient pathway from the outpatient to inpatient, from the inpatient to the outpatient. 

So two projects we're currently running. One is a piece of work looking at the use of wearables in the ward area. So can we make patients safer, particularly if you look at the evolution of what's happened inside hospital wards? I've seen over the course of my career, which hasn't been as long as other people might think, but I've seen over the course of my career, real shift in terms of what we look after in our general bed bases. I think that was really brought to the fore during the covid pandemic when we saw a huge amount of pressure on every single bed, particularly the general beds in hospitals and subsequently a pressure on staff. 

So what we're looking at is can technology make it better for patients and for staff? And we're using wearables to test that out. 

The other thing that covid did, in my career, is I ended up leading what was called covid virtual ward for our organisation. And at one point during that covid pandemic, I had three wards full of patients I was looking after with covid in the community who otherwise would have been in the hospital bed. And from that beginnings, we've managed to create a virtual ward programme. And again, we use technology to support people. 

So effectively a combination of remote monitoring, so helping people monitor their own health using technology that we then have some degree of oversight over to a true virtual ward system where basically we're effectively looking after you as if you were an inpatient, but whilst you're in your own home. And that's all enabled by technology. 

So during covid, through the Q Lab system, the Q community was putting out a call for teams to be involved in improving staff and patient confidence in the use of technology in healthcare. I knew that we do digital inclusion really, really, really badly. I can't tell you how many really should go into that conversation. 

So I got an idea thinking, well, there's someone out there who's within my local network who does that much better than I do. So what I did was persuaded our hospital director at the time to reach out to his colleagues in the council, because this was the beginning of that sort of neighbourhood type approach to healthcare. So they'd started to do some work together and covid I think really accelerated that too, because we recognised that actually no single public-facing institution was going to get through that pandemic unless they work together.

So in that space, there was a relationship building. So I leveraged that, persuaded my colleagues at local authorities to apply for that programme. And that's really influenced how we've worked on the digital inclusion piece. 

For me, the bits, the most promising about the technology piece is nothing to do with technology. It's to do with people. It's about the democratisation of healthcare and using technology as an enabler to do that. 

And when we come to talk about, which I'm sure we'll come to talk about, I see as the challenges with the ten-year plan. I'm worried that we're using technology to fix a people and process problem. And my experience suggests that never works. 

I think the ten-year plan is very, very NHS focused. But actually, if you look at what happens in people's everyday lives, the NHS, yes, it's an important part and it's national institution, long may it remain so, but it's just a part of people's lives. They have to be able to live the rest of their lives around it. 

So that whole purpose of the NHS ten-year plan of putting something, the doctor in your pocket, the NHS acting as the front door, I think is the really promising bit because actually we start to think about how is healthcare and particularly preventative healthcare, population behavioural change, population-level health metrics, how do they fit into people's lives as individuals and to communities as a whole? Unless we recognise that actually we have to fit into all of those spaces, we're not going to achieve the benefits for our communities that we'd like to see. 

So one of the bits of work that came out of the community project we did was we did some focus groups really trying to reach out to people who traditionally perhaps wouldn't have spoken out on healthcare needs and wouldn't have been heard in the traditional way that we run engagement in healthcare. And one of the things that, to be honest I was I'm embarrassed to say I was surprised about, is the sort of stuff that came back about well you're always changing digital tools why can't you just leave it alone; I don't know what to trust; you're always putting stuff out there everybody's asking me for the same information in different ways.

So trying to make our front doors the same, so health and social care, for example, local authority services where people need to access stuff like childcare, after-school clubs, whatever it is, we need to start thinking much more about how people's lives work across all of the systems, not just health or not just health and social care. 

What we often see is someone has an idea, we put a service change in place, but actually no one really knows what it does, how to measure what it does, is it value for money? Is it better than the thing that we had before? And that's where, when you were asking me about improvement, I think that's where improvement approaches really add value here. 

So we've been set a vision or an ambition, if you like, but we need to now go in and paint in the detail into that vision. So actually this is how it can be delivered. And from my perspective, we need to do it in a way that doesn't reinforce the problems we already have in the existing models, like excess demand for things that perhaps could be managed better in the system, poor communication, lack of trust, I get from everyone who's using healthcare because actually they've seen the standard of care that they seem to be receiving be different to what they were expecting or hoping to get. And also those elements of essentially a different model of care that fits into what people need to receive and not a model of care that the system says this is how the care will be delivered, therefore this is what you get.

Tom Hardie 

So just kind of building on what you were saying there, I mean, what role do you think improvement approaches can play in kind of planning and delivering digital transformation?

Sadia Khan

So I think I'm probably as guilty as everyone else of I have a problem, therefore I've already decided what the solution is and I'm going to implement it without really thinking it through. 

I think improvement has some really key bits in terms of the process that really needs to be followed here. So that engagement piece, we've already touched on it, but engagement means more than just I run a focus group and someone gives me their ideas and then I go ahead and do whatever I was going to do. And in the NHS ten-year plan, see something from the Patients Association about true co-creation that I think needs to be front and centre here. 

The other thing that Improvement does that really does well is that issue of actually starting with the problem and being expansive before you start. Don't set the solution before you really understand the problem. 

The third thing that I think Improvement does is that measurement, and that measurement doesn't need to be the just numbers, that measurement is about people's stories and their experiences. So these would be the three key sort of threads that I'd love to see running through the implementation piece.

Tom Hardie

I was just interested to know how you give staff the kind of time and space to work on innovation and improvement.

Sadia Khan

Actually, I think here we're really blessed by our hospital charity. So our hospital charity is called CW Plus and together with the trust, they actually jointly fund the innovation programme, which is called CW Innovation. And what they've done is, for me on a personal level, but also for staff at large, is really support that innovation and improvement programme. And they do that through a number of mechanisms. 

So we have the communications and engagement pieces. They run events, they help match make with companies and other organisations that are engaged in innovation and improvement and they will provide grants to staff to enable them to run projects and they also fund, joint-fund the innovation team who help support all of this work. And I think we've been really blessed to have that. I'm honestly not sure how we would do without that support. 

And I think that speaks to one of the things that the wider NHS needs to do much better is how do you not only create the headspace for staff to be able to think about these things, but the practical nuts and bolts. And often the investment isn't large. We're not talking about huge sums of money to run these projects. But small sums of money that let people learn their skills, be able to share what they've done and achieved and learned, and then be able to grow and develop their careers in this way.

Tom Hardie

Whether we can deliver the ten-year plan ambitions is obviously going to come down to people, isn't it? And, and getting their buy-in. So how do we get the buy-in from key audiences, in particular staff, to make this happen?

Sadia Khan

So I think they're all challenges obviously, if you've worked in the NHS for a little while, you see lots of cycles of change come in. And often I think sometimes it feels like that change is being done to you rather than with you. So that engagement piece is really, really critical. 

And I think the other thing that's really critical is investment in staff. So you asked me about how do we create people capacity and capability, well part of that is when we invest in developing their skills so that actually the skills of the workforce meet the visions of the health service that we have. 

And the last thing I think is that recognition systems that doesn't necessarily always mean about money, but it's about how do you make staff feel valued for the change in work that they do.

Tom Hardie

Thinking about that in the context of Chelsea and Westminster, how do you get that buy-in from staff and that kind of enthusiasm from staff to ensure that you're able to put change into practice successfully?

Sadia Khan

Actually, I'm going to be honest and say it's difficult everywhere in the NHS at the moment and I hear a lot of people who are really struggling with what's happening on a day-to-day basis in terms of the workload and the post-pandemic burnout and everything else. 

I think the key things are about the values and the culture that the organisation has. I think those are really important. And the other thing I think is the belief that actually we can make a difference and we have a way of delivering that.

Matthew Taylor 

Well, that was again, fascinating Penny. And I want to pick up a couple of things in particular. The first is, didn't we always used to hear that we mustn't forget the lessons that we've learned during covid; difficult lessons, but also good lessons, things we did well during covid. And we don't talk about that so much now, but isn't it interesting to hear that the virtual award programme that has grown and is now seeing examples of this in many places. But this was initiated during covid. It was necessity. It's a reminder, isn't it, of that old phrase, it's necessity as the mother of invention.

Penny Pereira

Yes, I was lucky enough to spend the pandemic helping track and support the work of 50 people across the UK who were introducing virtual consultations, so telephone or video consultations. I mean, that was something that had been happening actually in a small pockets for around ten years. And then during the pandemic, we saw really, really rapid uptake. I mean, our involvement over that time was to really understand what is it that made that rapid uptake possible and how could we migrate to business as usual healthcare, some of the benefits that you get from video consultations? 

I think looking back at this point, I think we've had variable success. So, you we knew back during the pandemic that there was a different balance of risk and reward in terms of the kind of clinical environment and the range of things that we were trying to do felt very different. And I think there was also a sense that the culture was different. We talk about they're being top-down clarity bottom-up agency in a way that we seem to have lost a bit since. 

I think the key lesson that I bring from that work into this is that whatever technology-enabled change you're introducing, whether it's video consultations or any of the multiple ideas that are in the ten-year plan, that actually you do need to get into the detail of what are the factors that are likely to mean that this will work in practice.

And those people who are directly involved in delivering and receiving care in those areas, they're going to want to see that you have paid attention to those specific things. 

So in relation to video consultation, for example, we identified like ten clusters of things that needed specific attention. And the problem is that at the end of the pandemic, often we moved so quickly on to all of the myriad other things that we weren't necessarily doing the follow-up work to make sure that you actually had the assurance and the training implications that you were actually paying attention to all groups being able to access services. 

And then what we see is that the pace of adoption starts to slow. So with the ten-year plan and the things that are being introduced now, we kind of need to get ahead of that with the more granular understanding, specifically what are the things that need to be understood and addressed in order to enable the implementation of this change. And then improvement can really help that. 

So improvement can map those issues. They can map the stakeholders. They can map what's needed. And then you can put your investment in a much more confident way to address the specific key factors that will mean that you actually get the benefits out the other end.

Mattthew Taylor

So, Penny, when I was young, I remember a friend telling me that I had a very irritating habit which was going to parties at other people's houses in the days of record players, tells you how old this story is, and then finding the records I already had and putting them on and say, why didn't you look for novel experiences rather than simply confirming your biases? I'm afraid I've never changed. 

And that's why there were a couple of things in Sadia's interview which confirm my biases. And I was grateful for them in that regard. 

So first was Sadia's emphasis on the importance of working people beyond the health service, particularly, if we want to be patient focused, neighbourhood focused, we do need to think about how we work with others. We know that part of the problem with health services is about access, but the other is over medicalisation. We too often look for medical solutions to problems which could be solved by other agencies, voluntary sector, parts of the public sector. 

It's hard enough to make digital work in the NHS, but if we don't get that kind of greater interoperability, sharing of data, we're really not going to reap the benefits of digital, are we?

Penny Pereira

No, and one thing that struck me was that in relation to really understanding what's important to patients, we need to do that at multiple levels in order to get into the territory that you're talking about. 

So, tech innovators tend to be pretty good at user-centred design, so really thinking about how the technology will work for an individual user. We need more of that. We need patient involvement in the specifics of how any technology is going to be used. 

We also need to be thinking about that at the level of overall services. So might still be in the zone of patient engagement in relation to the entire service pathway. But even that is nowhere near enough. So if you're a board leader, if you're a strategic commissioner, you need to be thinking about digital technology in the context of how whole populations and communities will be understanding their digital engagement with public services. 

And that's a really very different approach to engagement and co-production that needs to complement the specific patient involvement in tech development or in quality improvement.

Matthew Taylor

Absolutely. And then I'm now going to come to my other thing that I was delighted to hear Sadie say, which is, one of my favourite quotes is from Abraham Lincoln. And he said: “If you gave me six hours to chop down a tree, I would spend the first four sharpening the axe”. I mean, I think I'd say the first five actually. And, you know, on a bad day, it does feel like we spend a lot of time in the NHS hitting trees with blunt axes. 

So Sadia's emphasis on really understanding the problem. I cheered when I heard that.

Penny Pereira

Indeed, and it's the lesson that's come back again and again from the teams that have worked with us on the lab. I mean, the lab works with teams. They come in with an idea, with a problem. They've almost always believed they know what the problem is. They know what the solution is. We take them through a kind of three-month process or so, and almost invariably, they will change their mind once they've actually done some diagnosis and spoken to people about what the actual issue is and where the opportunity lies.

And yet that is so, so rare in the NHS. And when we think about how tight resources are, when we think about how mission critical it is that we do actually have a successful path to implementation, I think it's a really false economy to be jumping to implementation because I'm sure we're going to make all sorts of false starts.

Matthew Taylor

Great talking to you, Penny. That's all the time we have in this episode. I'm going to thank again our guests, Sadia Khan, Abigail Harrison, and our roving interviewer, Tom Hardie.

Penny Pereira

There's a really great long read if you'd like to learn more about what we've discovered about improving staff and patient confidence in technology. And the Health Foundation and Q has a wide range of great outputs now on the adoption of technology specifically. 

There's details in the show notes. 

If you like what you heard, please share this with others or get in touch and let us know what you think. See you next time.