Learning lessons – why co-production is the "secret sauce"

It could have escaped no-one, that since Matt Hancock’s appointment as the new Secretary of State for Health and Social Care, he has proven to be a strong advocate for the use of IT – he wants to use digital to support the transformation of Health and Social Care. We’d heard parts of Hancock’s thinking from moments such as his speech at NHS Expo. He issued a stark warning to health IT suppliers that they risk losing business with the NHS if they don’t fully embrace data-sharing by adopting common standards.

Now with the announcement on the 17th October of a digital vision for Health and Care we can see his comprehensive plan on paper, we see his thinking fleshed out in more detail. There is much to be celebrated in Hancock’s ‘Tech Vision’, but as someone who has worked in this field for 15 years, I have been thinking – is this vision new and is it enough?

Nearly 10 years ago the straight talking IT analyst Boris Evelson wrote a searing blog called Healthcare Industry BI Groundhog Day (which I encourage you to read) after visiting HIMSS 2009 in Chicago. In it he compares attending the show to being in the film Groundhog Day, living the same day, same date and never able to get to tomorrow. And here we are nearly 10 years later asking the same questions:

  • Where are the open technology standards?
  • Where is the transparency?
  • Where is the common sense that business requirements, not vendors, dictate the rules?

Of course this sound familiar! But then, as he points out, these things had never existed in Healthcare. Because these things had occurred in nearly every industry Evelson described how he subconsciously believed it must have happened in Healthcare too.  He called out many of the things in his blog that are contained within last week’s digital vision for Health and Care, and at the time he was genuinely optimistic that the market was changing.

So why have things not moved on? Why was Evelson’s prediction not come true? And why has the NHS and Social Care needed this cogent, well organised vision from Matt Hancock’s team in 2018? 

We know that a great vision is a pre-requisite for transforming anything:

  • It needs to be clear, concise and understandable to a broad constituency
  • It needs to inspire those who have to execute it

In my view, this vision has this in spades, but as Thomas Edison said, “Vision without execution is just hallucination”.

Visions for IT in the NHS, with various levels of ambition, have come and go. Now more than ever, it is in our interests to make digital transformation successful – it is vital for the service, for patients and equally importantly tax payers.  We applaud the honesty where the vision document says, “We don’t have all the answers – this should be the beginning of an open conversation about how we can iterate to best achieve what is needed and work with the many brilliant, forward-thinking people in the system to get it right.”  After all, we’d agree that the problems with digital technology over the last 15 years are far more about execution than vision. 

Ideas from the 2015 Robert Wachter review “Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England” are reflected in the vision. But what I believe is far more useful, and relevant today, is that the Wachter review also said Health IT entails both technical and adaptive change –  implementing health IT today is one of the most complex adaptive changes in the history of healthcare, perhaps of any industry.  

Adaptive change involves substantial and long-lasting engagement between the leaders implementing the changes and the individuals on the front lines who are tasked with making them work.

So, what does this really mean for us?

I am indebted to Professor Joe McDonald, Director of The Great North Record who provided this amazing 15 minute presentation on what makes eHealth projects succeed (or fail), given at the International eHealth Conference in Bologne in July 2016. Success or failure is all about implementation.  

You may try “Top-Down”, “Bottom-Up”, etc. but fundamental to success in implementing adaptive change across multiple organisations is the need to deal with some key issues:

  1. Organise and agree – how do you convince parties you have no direct control over to join?
  2. Diverse interests and priorities – there has to be negotiation to get everyone you need on board.
  3. Project Management – How can you co-ordinate the activities, keep them on track and to keep everyone bought in, especially as short term demands typically always take precedence?
  4. Costs and Benefits – There is an unequal distribution of these. Some parties may incur great cost in doing something that provides benefit to other parties and not themselves  known as “Collective Action Dilemmas”. These are so prevalent in Health and Care, how do we overcome them? (This takes us straight back to my last blog 2 weeks ago)

So if you don’t address the four issues above it won’t just matter that standards have not been defined in enough detail to accommodate the wide variability of end points across Health and Care, with their large number of different systems that need to be joined-up. We also have to consider that different organisations or health economies have different priorities and they are at different levels of maturity and capability to implement solutions.

In light of the above, there’s no question as to why Top-Down approaches are not suited to solving these adaptive problems and why all previous attempts have failed.

techUK is an active part of INTEROPen because we believe that co-production with NHS England/NHS Digital, Professional Records Standards Board, the Service, Suppliers and Standards groups is the only way to succeed in solving the adaptive change needed to crack the interoperability problem.

In INTEROPen

  • We work together in an honest, open and collaborative way. 
  • We constantly test and challenge each other in managing conflict, finding solutions and as a group we always come out stronger as a result.
  • We have a governance structure and board and co-ordinate activity and a collaboration infrastructure to manage our work day to day
  • None of us just look at the problem from what it means for our individual organisation, or the group we represent. 
  • We are all part of the solution and we owe it to frontline staff, patients and tax payers to solve this

We believe it provides an excellent model for Matt Hancock to look at for implementing all of the adaptive change needed in the vision. techUK and the supplier community wants to work with you and to take up the gauntlet that has been thrown down. Industry working collaboratively with all parties to solve these “wicked problems”.

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