Dispatches From the Frontline #2

Practical ‘rules of the road’ advice on how to implement innovation and get things done from combat-hardened healthcare leaders.

Welcome back to Dispatches From The Front Line, a series of interviews with healthcare professionals who have managed - perhaps against the odds - to deliver innovation in a healthcare system. The aim of these interviews is to inspire, inform and instruct other healthcare professionals, policymakers and stakeholders about the importance and impact of putting human needs and experiences first in order to deliver meaningful healthcare innovation and delivery.

Our second Dispatch comes from Chris Fleming: a partner at Public Digital, a digital transformation consultancy, where he oversees the healthcare practice. In this dispatch we discuss barriers to meaningful innovation (the "heptagon of horror!") and we touch on topics such as leadership and how to set up for success. Chris also shares an example of innovation best practice he was involved with, and we note how short-term, project by project approaches can produce fragmentation not transformation. Last, we explore why making it easy for staff and patients to be a part of the solutioning process early is critical to adoption and ongoing usage. Enjoy!?

Thank you, Chris, for joining us as the second participant in our series of interviews on digital innovation in healthcare, where we get to delve into your experiences and insights regarding the implementation of innovation. First things first, can you introduce yourself please?

My name is Chris Fleming, and I'm a partner at Public Digital, a digital transformation consultancy. I oversee the healthcare practice, essentially co-leading a team of five consultants who support projects for health and care clients. Our client base includes NHS Trusts, provider organisations, national government agencies like NHS England and NHS Digital, as well as local authorities, county councils, charities, and health-adjacent organisations, including pharma companies.

Before joining Public Digital, my background revolved around product leadership roles within the NHS. This included serving as the program director for the NHS's flagship mobile application, which provides access to healthcare records, appointment booking, and medication management. I also have experience in urgent and emergency care services, focusing on the development of essential digital infrastructure.

?And before all of that, my first career was not as a digital specialist but as a policy person in Whitehall and in the Greater London Authority. What that means is I find myself at the intersection of bureaucracy and digital delivery. So my specialism, if any, is helping bureaucracies create conditions for innovation and strong digital delivery.

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It sounds a bit like putting a theory into practice: looking at policy, looking at what's on the ground, and then helping make sure that things get done, is that right?

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I think so, yes. I mean, the typical approach of Whitehall policy officials centres around your agreement. Essentially, it functions as a super secretariat for ministers. So, for instance, if you're the minister overseeing a particular topic, your role as a civil servant entails comprehending all the issues pertaining to that area, grasping and representing the perspectives of all stakeholders concerned, and sometimes allocating funds towards initiatives aimed at addressing a specific problem.

Now, the required skill set for this role is often described as that of a generalist. A policy generalist is a familiar figure within Whitehall; a group of individuals who are proficient in a variety of areas but aren't experts in any one field, or jack of all trades, master of none. In my opinion, over time this system - along with some of the specialist skills required to come together as multidisciplinary units to solve problems - has led to a surprising lack of innovation and has had a negative impact on our problem-solving capabilities.

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Given your current position and your experiences in your field, what do you consider the primary obstacle to the integration of new technology by healthcare providers, whether they operate in the public or private sector?

There's a slide I have, which I call the "heptagon of horror." It delineates what's hindering better digital innovation in the NHS. Around my heptagon, I've identified commercial, HR, data security, finance, clinical safety, IT infrastructure, and legacy IT and interoperability as key factors. These elements collectively impede digitally enabled innovation in healthcare settings. If I had to distil it down, I'd pinpoint culture and complexity as the primary culprits.?

Addressing complexity makes progress marginally easier, but intricate data models and organisational structures pose significant challenges. Essentially, innovation involves finding new ways to better meet needs, and that often entails data integration. This dual challenge of complex data and landscape specialists complicates projects and raises barriers to entry for new vendors. Moreover, acquiring the requisite skills, including clinical and design expertise, is hard within a healthcare setting.

?Culturally, healthcare often inadvertently hinders progress through its actions. These issues bleed across various domains due to the highly regulated nature of healthcare, impacting both the NHS and private sector. I recently authored a blog post which discussed the challenges of implementing a single shared patient record, and it highlighted how bureaucratic processes and policies have proliferated and led to misinterpretations. For example, while legislation allows data sharing for direct care purposes, bureaucratic interpretations often impede such sharing.

You’re right. In some of policy documents and among some clients, there's a set of principles stating that if a patient can benefit from a certain action, it’s encouraged and you should do it. It's like a moral obligation, but yes, it's explicitly stated yet how it’s interpreted is how shall I put it, smokey. This creates a lack of trust, a climate of fear, and throws a log across any road to progress.

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Exactly. I've encountered so many instances where IG (information governance) officials are primarily focused on risk mitigation and are deeply concerned about

the repercussions of recent events. It's quite fascinating. The Department of Health engaged Chris Witty to produce a promotional video on LinkedIn , alongside the Information Commissioner, reassuring people about data sharing. You can find it on LinkedIn. It's quite good. And I think these efforts exemplify the approach they're taking to promote data sharing. During the pandemic NHSX published really clear and actionable guidance on information sharing and information governance. This went down really well with the system and seen to be one of the most helpful things NHSX did. That facilitated a more permissive environment and that highlights the complexity of the process and policy landscape in this area. it's a very, very process and policy heavy area: so much of it can be streamlined.

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This reminds me of a speech Dr. Tim Ferris delivered during an innovation event at Chelsea and Westminster. At that moment he was still the Director of Transformation at NHS England but it was clear he was pretty frustrated. It seemed that he had already decided to head back to the States and return to Mass Gen but what he said was telling.

My interpretation of what he said was that if the NHS was to transform itself, then any transformation activities must come through the NHS and through strong leadership. He urged leaders to take responsibility, to encourage more trust in patients, to enable data access and sharing, and promote digital services sign-ups. The challenge, he stressed, was on NHS leadership stepping up and finding better ways to manage risks in order to drive progress.

My question is do you think that’s true and that leadership, in respect to innovation, could be improved, or should they be treated as separate entities? And if so, what can we do to help remove those barriers - how can we overcome them to promote innovation and tackle complexity effectively?

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One of the hindrances to innovation is the tendency to approach projects in a fragmented manner, focusing on short-term goals rather than long-term objectives. Innovation - defined as finding new solutions to address needs - often necessitates collaboration across various disciplines. In contexts like healthcare, this entails assembling teams with clinical, technical, design and operational expertise.

And successful innovation involves navigating the intersection of these areas, finding the mountain ridge between those four peaks to ensure clinical safety, desirability in design, operational feasibility and technical viability. Just relying on advanced technology without considering these factors seldom leads to meaningful innovation.

So fostering an environment that supports innovation means leaders need to move away from just delivering individual projects and instead focus on offering ongoing services. And this in turn involves establishing stable, long-term teams capable of understanding user needs, iterating on concepts, and incorporating feedback with agility. Empowerment within set boundaries is essential - the motto here is 'delivery as a team'. Ultimately, innovation flourishes when teams are empowered and focused on improving everything together.

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That sounds like a sensible approach but it still leaves me wondering how we can get leaders to actually do it. Maybe some of it is linked to how leaders’ performances are assessed.

But just to return to the question of barriers: there are significant challenges to address: deficiencies in service delivery and organisational culture are prevalent issues. The current approach tends to be fragmented, and there is a lack of sharing of best practices. This is not a revelation; it's understood that incorporating diverse expertise and perspectives improves outcomes, including improved patient and staff experiences, as well as cost efficiencies.?

So, where do you begin? What strategies should be prioritised? What experiences have you encountered that offer insights into overcoming these barriers and steering us in a more effective direction?

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Here’s an example: just yesterday, I shared a post on LinkedIn about NHS login , which as you know is a platform for accessing NHS services. It’s the authentication gateway for NHS app users, and it was developed by a dedicated

multidisciplinary team at the core of the NHS. This platform has been operational for several years now, with 46 million authenticated accounts, with 32 million achieving P9 levels of personal authentication, granting access to medical records. It's a pivotal service, clocking in over 1.6 billion logins and integrated with 70 different apps and digital platforms.

Whether you’re using a national product, eConsult, clinic services, or specialist apps for various conditions, with NHS login you can have a seamless single sign-in authentication process. This eliminates the need for individual companies to construct their own account, ID and authentication infrastructure, it streamlines user experience and reduces redundancy.

This required a multidisciplinary team, clinical input, ID experts, technical team, agile approach, a strong vision and political will. And a clear strategy that paved the way for success.

One key aspect of the strategy was ensuring a positive onboarding experience for suppliers, with comprehensive resources available online for testing and integration. The user experience for patients and citizens was also optimised, with streamlined processes such as automated ID verification and human intervention where necessary.

So it's a really slick process. And a good example of effective collaboration and user-centric design in delivering essential healthcare services.

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Coming back to leadership then, who was at the forefront of this, and what was their background? What kind of experience did they bring, especially in public sector healthcare? Were there any other factors or cultural viewpoints that played a role in the conversation?

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The leader of this programme is Melissa Ruscoe , a brilliant digital leader in NHS England. The delivery involved employing actual user researchers, design researchers, service designers, technologists, and developers in-house, alongside teams of policy officials and clinicians, rather than outsourcing everything to a company like Fujitsu.

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Big ouch! The Fujitsu case is many-layered and certainly people at the delivery end were not listened to and ignored. That's my point: in order for that space to be opened up and for that team to be integrated into that space, we require a significant level of buy-in towards human-centred design. We're aware that even now, despite the errors of the past, current initiatives often lack substantial service end user experience consideration and consultation. So - and yes I am biased - was there a human-centred design champion? Was this approach integrated earlier in the process, rather than being an afterthought just before going live?

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The challenge with off-the-shelf products is that you have limited control over the user experience with the exception of configuration. But that's a really good question, and there are a couple of reasons behind it, to be honest. Firstly, there was a nascent community of people who were advocates of those methodologies. They weren't in leadership positions, but they were around in the organisations that mattered, even if they weren't the majority in the workforce. Another factor that played a role was the influence of the Government Digital Service's adoption of service design standards, which kind of set a precedent. It had a ripple effect, influencing the adoption of such practices.

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And that's highly valuable when combined with ISOs and similar frameworks. These provide us with a human-centred design standard, which can then be aligned with technical standards as well.

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Sure. The point here was spend controls were tied to firm requirements, not just issuing guidance. When it comes to managing spending for organisations that operate at arm's length from the government, there are strict requirements to follow regarding how services are designed and business cases are approved. While these standards may not extend to the broader NHS, there's ongoing debate about implementation and relevance. Some parts of NHS England and NHS Digital have historically opted to overlook spend control, leading to conflicts over who has authority. But citizen-facing services developed by NHS Digital are subject to these standards. Despite initial resistance, you now find teams actively engaged with the process: they're using it as a way to encourage better practices and behaviours among their own leaders.

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What I'm stressing? is the importance of being human-centred and those familiar with the benefits of such an approach, such as usability, will understand its value. I'm pointing out the difference between just having a team that talks about this idea and genuinely fostering a whole culture around it. In the end, it comes down to identifying who initiated this shift and who granted the authority to implement it. It’s all about understanding this process and the key players involved.

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When I joined NHS Digital, various services such as app service design and online platforms like NHS websites began adopting design standards and agile methodologies. Leading this charge was Juliet Bauer : she's a trustee at Chelsea and Westminster, as well as a prominent figure in digital health. Juliet's approach was refreshingly rooted in real world in real world digital service experience. She brought with her expertise from the consumer product space, and stressed the importance of user-centric design. Although there were occasionally some clashes over framing and terminology, her primary aim was fixed on enhancing user experiences, which I think everyone could get behind.

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That's the 'bigger than just us' point and something to always consider - the end goal is behaviour change in humans. Learning from various sources is great, but the ultimate goal is to drive behavioural shifts. If these efforts result in the desired change, then that's excellent. The key is ensuring that the change aligns with what you want, which, in this case, is encouraging people to engage with health services more efficiently and cost-effectively.

?When we focus on the outcomes, it's simpler to get everyone on the same page with a shared goal. And, let's not forget the importance of responsibility, leadership, and performance frameworks… Leaders have to own up to getting results, as this really affects how people behave and whether they're open to trying out new ideas. Do you have any insights on how performance metrics and outcomes influence behaviour and innovation implementation?

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As a consultancy one of the first questions we ask?clients is around the outcomes they aim to achieve. We often team up with digital and technology departments in organisations, checking how well they line up with the overall goals and strategies of the organisation.

To what extent does the work belong to the digital team? Or the people working in that space and organisation? How closely intertwined are they with the overall outcome? Or the strategy of the organisation? That's an important thing to solve early on. Regarding performance, I'm not sure. Personally, I see performance frameworks as closely linked to individual contributions within these teams.

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An example could be the DNA or ‘did not attend’ rates, for instance, or ‘time to diagnosis’, or ambulance response times. These are the concerns directly linked to what frontline staff - including those at street level - are likely contemplating regarding their performance reviews and overall effectiveness. But these individual concerns ultimately contribute to the team's, unit's, or department's performance and, consequently, the hospital's overall performance.

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Sure. If your hypothesis is that digital and IT teams in hospital provider trusts are working on a basis of “can we implement this piece of technology like an EPR,” as opposed to "how do we help that team meet a specific outcome like getting those times down" - then you're correct.

This issue of not being outcome driven is rife, from what I've seen. IT departments often function merely as technology procurers and installers, and then they wash their hands after implementation. Silos exist between the IT function, clinical and operational teams, and other teams like quality improvement or transformation teams, each focusing on different priorities.

So again, the way around that is picking your outcomes and then forming multidisciplinary teams around those to find the innovations.

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Yeah, I understand where you're coming from. It seems like you're envisioning a cohesive approach where different departments collaborate effectively, all aligned towards achieving common goals. The focus appears to be on performance metrics that span various disciplines, aiming at tangible outcomes. And that encourages a broader team mindset, with each member contributing their expertise while also considering the larger objectives.

?For example, let's consider the scenario where the IT team ensures a machine functions properly, connects to Wi-Fi, and has robust backup systems. But then, it's equally important that end-users are proficient in using the equipment, it's calibrated correctly, and its usage optimises both operational efficiency and clinical outcomes.

Have you encountered similar multidisciplinary metrics or approaches, perhaps referred to as Northstar metrics or similar concepts, in your experience?

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We have this project I can think of, a local authority and which is in the safe-guarding space. Essentially, it's a multi-agency unit representing a partnership between the police, county council, education, and health. If you're out on duty and you have a safeguarding concern, you can call the unit. But over the years, the partnership wasn't functioning well. Queries took a long time to be dealt with and it was generally a dysfunctional situation.

They brought us in to fix that problem. As always, we started the conversation by discussing the outcomes they wanted to achieve and the user needs, and we found opportunities to operate more effectively. For instance, offering a triage service for various forms of support beyond safeguarding, and enabling them to assist users earlier in the process.

We got them all physically in the same place so we changed their rhythms around the way they were talking to each other. We introduced agile practices such as retrospectives, to evaluate what was working and what wasn't, thereby enhancing team performance. But we also of course examined the outcomes the team aimed to achieve, and the measures they would use to assess their progress.

?If we look at the number of Section 47 meetings, which are about taking children into care, and the number of what are known as strap meetings, which are multidisciplinary gatherings to determine the consideration of Section 47, we begin to identify these metrics. If you improve the service, then you should start to see these numbers drop. The service transformation and focus on needs also surfaces the need to alter our data capture methods to accommodate a new process flow and enhance readability, particularly for online submissions. Our focus wasn't solely on technology; rather, it stemmed from the necessity to streamline the end-to-end process.

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It seems like there's a focus on determining outcomes and measuring success, as well as identifying the processes and models necessary for achieving those outcomes. From a technical standpoint, there's consideration for the role of digital tools and data in supporting these processes and outcomes. It's an outcome-first approach, right?

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Exactly, which is so vital, because it's the antithesis of what was happening all the time. Especially in sectors like healthcare and local government, there's a huge amount of hype about AI. Personally, I am highly sceptical of many of the use cases. But dismissing AI entirely misses its potential role in improving service delivery. At some stage, it might be acceptable. When we possess a sufficiently large dataset, there's a possibility of deploying a machine learning tool that comprehends the correlation between a specific form and its associated outcomes. So we can accelerate that process.

But without grasping the fundamentals: the nature of the service, the value proposition, and the desired outcomes - what are you offering people? What are the outcomes you're chasing? Just focusing on the technical - the AI aspect - is a distraction. It's like looking through the wrong end of a telescope.

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Let's focus on what we want to achieve here. Firstly, it's pretty clear there will be positives with much of what you're saying. I recently had a conversation about volunteering in the ED, in Kings, where we encounter a wide range of people, including mental health patients. Ensuring those individuals don't end up occupying space unnecessarily is an ongoing challenge. Bringing various teams together - police, social services and hospital staff - to address this issue is crucial. While some efforts have been made, they've been limited. Are you suggesting starting with an initial consultation and then working towards your desired outcomes, figuring out how it's all going to work and putting that plan into action?

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Yes, that was the concept behind 111 online: to establish a national Urgent Care Service. The idea was to encourage individuals to seek advice before physically going to a medical facility. This approach aimed to distribute the load more evenly throughout the healthcare system by offering guidance earlier in the process.

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The issue here is that implementing load-balancing requires the system to handle the increased demand. With primary care services stretched thin, urgent cases are prioritised based on medical urgency rather than practicality. When I was there, we hadn't quite resolved the issue of aligning primary care based on symptoms with the current demand. Private care is also struggling to keep up. One effective solution, especially for out-of-hours needs, is services like the Clinical Assessment Service. It acts as an urgent care centre but operates virtually, allowing people to consult with medical professionals over the phone and get emergency prescriptions if needed.

While this system has shown success, it's not without challenges. The current service model for the NHS places GPs at the centre of care, but there is clearly a capacity issue which makes this unsustainable. But it is clear that ?investment in online services can help ease pressure on A&E departments and reduce call volumes. We analysed the 111 online service thoroughly and regularly surveyed users to understand their experiences and what they would have done without it. This helped us estimate the overall benefits, like the cost savings from redirecting people from A&E to our service.

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Everything is bound by constraints. Certainly, there are huge capacity issues to contend with.? But if we can streamline how we initially deliver our services and cut down on costs, that's definitely a win. It's crucial to acknowledge that challenges will always crop up, and we need to be flexible in how we respond. Even if resources are limited on both the GP and ED fronts, we've got to work with what we've got. By reducing the number of people who need assistance at ED and handling triage virtually at a lower cost, we might be able to help some folks out. This could mean fewer people relying on GP or ED services and opting instead to visit their local chemist, for example.

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It's about ‘Shift Left Testing’, throughout the different cases. Triage is a compelling topic because of its deep integration within emergency department contexts. We're only now seeing triage in terms of primary care, over the past five years. The process entails assigning appointments based on the urgency of patients' needs. But nowadays, many practices have developed their own systems to gather patient information before allocating resources and appointments. This evolution has to be a positive development.

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I think what you're saying is that coding and related aspects are improving. So, the final question: a hypothetical scenario… Imagine you're leading a service that you're really passionate about. You're thinking about introducing some new technology that could bring a lot of benefits, as we've discussed. How would you make sure it's implemented successfully starting from next Monday? And once it's up and running, how would you ensure that it's being used effectively and delivering the expected value?

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Well, to begin with, I wouldn't approach it from that angle. If I was forced to consider a particular technology, I'd start by examining our existing operating model and service design, pinpointing the known pain points, and assessing whether the technology aligns with our needs. If there's no match, I'd decline.

If there is potential, then I'd look into pre-market external evaluation. First, I'd consult with the team managing the affected service to ensure buy-in.

Then, I'd review user research to understand the issues at hand before exploring available solutions. This would mean engaging with vendors to understand their offerings, including commercial terms, integrations, testimonials: are they living elsewhere? What's their reputation? What's the feature set?…. Following this, I'd involve key stakeholders - senior clinicians and operational leads - in evaluating whether the technology's fit for our service and conduct small-scale tests, if possible, before committing to any long-term contracts. If a vendor refuses to allow testing, it's a clear signal to move on. Thanks, but no thanks.

Finally, it's just all about good practice: effective change management practices to guide the implementation process.

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OK, so now imagine you find yourself in a scenario where you've taken a stance, say, within a particular framework and you've established your current approach which is proving effective with the smaller groups you've introduced it to, and the clinical teams are satisfied. Now, how would you expand its reach? What steps would you take to scale it up?

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Scaling is about a few key aspects. Most importantly, it involves being open and transparent about your process, often referred to as ‘working in the open’. When you're experimenting with new methods on a small scale, it's essential to share updates and insights openly, so?others can see what you're doing.

I also believe it's important to connect opportunities back to our overall strategy. I never view this solely through a technological lens; instead, I focus on driving efficiencies across our services. It's not just about implementing new technology; it's about fostering behavioural and cultural shifts within our organisation.

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Once we've got the solution sorted and out there, people can start using it, trying it out, seeing what it's all about. And it's important to make sure it's smoothly integrated within the hospital environment, maybe teaming up with others in the trust to make that happen. But then, what's the plan for taking it to a bigger stage, or rolling it out nationwide? Whether its the NHS or big players in the States like like Kaiser Permanente, the road to spreading and diffusing innovation is barrier-strewn. How do we make that happen? It's definitely going to involve some strategic manoeuvring within the trust and beyond, so what's the strategy for that?

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Well, the two scenarios you've mentioned are quite different. Take Kaiser, for example, they're a full-stack provider of primary and secondary care. They can just decide, "Okay, we're doing this now," and it's pretty straightforward. In a fragmented system like the NHS, though, things are more complicated.

Here, if you're a national agency rolling out something new, you've got a bunch of options at your disposal. You can use policy changes, incentives, or even mandates, like sending out detailed instructions and letters.

The key is designing for adoption, making it as easy as possible for people to start using your product. Plus, if it's funded nationally, like through the NHS, and it's free for users, that's a big selling point. So if you're a trust or a provider who's come up with something valuable, like a new technology, you're basically in the business of selling software, in a way.

So, essentially, the software doesn't completely solve the service redesign puzzle. You see, organisations will still need to tackle that aspect. And that's where public digital initiatives come into play.

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Exactly. You can't just rely on a one-size-fits-all approach like "land and expand" or "lift and shift" because every situation is unique. Digital maturity levels vary, so you've got to tailor the approach accordingly. From talking with some insiders, Kaiser and other big non-UK healthcare providers all have these problems too.

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Yes, if you look at the software products that have had enormous adoption in the NHS, some national services have seen huge adoption rates, thanks to strategic levers. Then there's stuff like Accurex, a GP messaging software. What really boosted its success was its smart product design. They made it super easy for GPs to test the product. You could go onto their website, set up a dummy account, send a text message - either using their templates or typing your own - and then receive the message. It was simple, but it made a huge difference in adoption rates.

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It's what Ben and Jerry's used to do with their new ice cream flavours. Back in the late 90s or early 2000s, Ben and Jerry's had a clever, grass roots activist approach. Instead of relying solely on their own ideas, they tapped into their customer base for inspiration. They'd reach out to their loyal ice cream fans and ask for suggestions on new flavours. Then, they'd test these ideas by inviting people to come in, taste the flavours, and give feedback.

This process involved thousands of tastings and adjustments before they hit the go button and went to market. In fact, the last few flavours they introduced were all suggested by their own community. It's a smart way to ensure that your product resonates with and is championed by your target market. And it's not just about creating a product; it's about creating a community culture and alongside that a product that people truly want. We all want to belong. We all want to do something cool. Very clever.

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Yes, so now they've got this panel of GPs they use for research and development. My point was a bit different, though. It's about making it easy for people to understand how the product works, giving them an immediate sense of what it does. This helps build trust and confidence, making it more likely for people to adopt it, you know? Think about it, with most products out there, if you want to try them out, you'd have to go through the hassle of contacting the sales team, maybe signing a contract first, all that stuff getting in the way. But with these guys, they're so confident in their product's quality, they're like, ‘Sure, go and play with it.’ There's hardly any barrier to adoption that way.

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Fab. So Chris, we're right on time for this and I know we both have to run. But big, big thanks – a great session - and see you soon!

If you found this article interesting and would like to make contact, please email me at [email protected]

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