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Overview
The use of digital technology in health and social care can improve quality, efficiency and patient experience as well as supporting more integrated care and improving the health of a population.
Large-scale change involving digital technology, such as adopting electronic patient records (EPRs) and shared care records, is complex and necessitates attention to particular aspects of the change.
This report shares practical learning from a series of case studies where significant largescale digital change is happening.
Key barriers to successful digital change include the constraints care organisations face in their workforce, tight budgets, organisations’ attitudes towards risk and the relationships that exist between care providers and key stakeholders.
Most of the barriers can be mitigated through time and effort and by treating digital projects as change projects, not IT projects. Effective and consistent staff engagement and resource allocation to the project are key factors in success.
Map of technology and data in health and care
Our interactive map brings together case studies from across England and the rest of world, highlighting some of the places that are experimenting with and implementing new technologies to achieve better health outcomes or more efficient care.
Video overview
David Maguire and Matt Honeyman discuss the findings of the report at our Digital health and care congress in July 2018.
Why digital change?
New technology is promising to transform a health and social care sector that is increasingly struggling with the need to do more with less funding. Many providers and commissioners are looking for opportunities to use technology to improve services and cope better with the long-term demographic pressures that the system is under.
At the same time, there remains a widely held belief that health and social care struggles to manage large-scale change involving digital technology. Past attempts at NHS digitisation have, both locally and nationally, been beleaguered by failing to understand that successfully implementing digital technology is as much about managing change as about installing technology.
Despite previous challenges, the future is bright for technology in health and social care. Local care providers are digitising under their own steam and initiative. Our report aims to support other local organisations looking to undertake large-scale digital change.
In this report, we share the lessons from five varied case study sites that have made significant progress towards their digital aims. We set out the lessons learnt and tips for other organisations that are looking to progress their own digital change.
Our research
The purpose of our research was to understand the key elements of implementing large-scale change involving digital technology in the NHS. We selected our case study sites to represent different types of change and different large-scale projects. Evidence from our case study sites was backed up with a review of published evidence about large-scale digital change in health care.
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What is digital change?
Digital change is both a technical and an adaptive change, featuring unpredictable and complex interactions between the people and technology involved. Spreading digital change beyond local areas requires continuous investment in capturing and disseminating lessons from implementation, going beyond copying technical solutions.
Historically, approaches to evaluation have centred on examining the use of a technology as a single technical intervention, obscuring the importance of implementation. As a result, although evidence about the effectiveness of technology is often negative, it might be measuring poor implementation. It is important to dedicate effort to understanding how to implement change involving technology.
Our report focuses on the complexity of digital change and how organisations have adapted and found their own way to make implementation work for them. We have identified five key areas to consider when starting on a digital change implementation. Within each area are messages from our case studies about what they learnt from going through the process.
Figure 1: Key themes in successful digital change management
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Leadership and management
The most important barriers to success were concerns and anxiety borne of historic struggles with IT in the NHS and a need for education about the potential and terminology of digital technologies. Local areas used the right leaders and managed relationships carefully, considering different working practices and groups for keeping things moving. This meant finding appropriate leaders based on their skills and interests in technology, not just on who is available at the time. Leaders were motivated by outcomes other than immediate cost savings. Areas were very realistic about the speed and scale with which cost savings might be achieved and the need for space from the national bodies to realise benefits over a longer term.
Flexibility when managing digital change was a key theme, with sites changing culture where necessary, and keeping the board involved in how the project was progressing at all stages. It was also accepted that digital change requires an adaptive approach that suits the project and the staff who are going to be involved in the change. Crucially, though, users only positively engage with change when they see it as a clinical change, not an IT project.
From the case study sites
'I think the principles of change are probably the same, and I think the management principles of change are probably the same. We have our own language in the NHS and I think the digital language is one of its own... this is a language that's very new to a lot of us... it's about not overwhelming people with a lot of digital speak.
Community mental health service manager
They kept telling us not to put all the clinicians in the room. Every time people said don't do it, but we did it. And after the first couple of weeks, by the time you got to the third meeting it was like 'oh okay, these guys are serious, we're going to do things differently'.'
Commissioner
'We have an electronic project group, which is chaired by our medical director and our director of operations - our executive directors [EDs]. [The chief executive] is very clear that it's driven from the top, so the executive directors drive it. It's well attended because it's ED driven...so you'll get each of the disciplines, you'll get the nurses, the medics, the OTs [occupational therapists], the psychologists, they all turn up, because they can't be seen not to be doing what the EDs want. No changes can be made without that board signing it off, so there's no click-your-finger changes.'
Chief information officer
User engagement
We heard how engaging the intended users of digital technology in the change is critical to success. Done badly, engagement can feel like ‘rubber stamping’ and sow the seeds for low adoption rates or significant problems in implementation. We heard about varying attitudes towards change and a cultural gap between technologists and clinical users that had to be overcome.
Engagement needs to start early and be continuous to overcome some of these issues and get the right people on board. Technology itself can be part of the solution for good user engagement, and so it is important to explore the technology available for this purpose.
Addressing different attitudes to change and bridging cultural differences to technology is important in building a broad coalition of support for change. To do this, the support of clinical leaders who contribute to a better digital solution, as well as acting as translators between digital and clinical staff, is important. When dealing with users, it is important to avoid imposing fixed solutions by being adaptive and deciding on an appropriate implementation model that suits how staff work.
From the case study sites
'I think expectation management here is really important, that it's not put something in [10 January or 24 January say], then it's all fixed, tick, move on, because that then reinforces it's an IT project. This is a living way of doing stuff and it's never going to stop evolving and there is going to be some regular pain involved with it.'
Digital lead
'I think the thing I found very noticeable was in the pre-implementation phase and during implementation, it was almost impossible to explain to the staff, the end users, what they needed to think about. We were going out saying to them: 'What do you do, what would you like us to build with EPR?' They had no idea. They had no terms of reference for answering that question.'
IT analyst
'I do as much clinical work as virtually anybody. I ran my practice completely paperless nine months before there was any talk of trying to deploy it to the rest of the community. So what that means is that when a clinician stands up in one of those boards and says, and this is a direct quote: 'You have walked us into the Valley of Death!' by trying to get them to use electronic note keeping. I can stand up and say: 'Well, that's very strange, because I've been doing this for the last six months, and none of my patients have died. What are you doing?' Unless you've got that credibility, if you're a non-clinician, then you've got almost no defence.'
Chief clinical information officer
Information governance
The way organisations manage and safeguard the processes of collecting, using and sharing information about NHS patients can often throw up challenges. Good information governance ensures that data processes are robust and lawful and that patient information is shared at the right time with the right people. The complexity of information governance and the sensitive data that health and care organisations hold makes it hard to get right.
Our key finding is that information governance is a cultural issue, which people often try to fix with technical solutions. As a result, information governance tests trust between organisations. In this way it also acts as a canary in the coal mine for future collaboration across an area. To engender trust, organisations need to be transparent and build a positive, clinical case for sharing information. Taking time to build trust can make it easier to make changes in the long term.
From the case study sites
'There are significant IT issues that nobody was aware of at the time of letting contracts. The people who did the initial work had the concept of 'we want to share'. It's only when you get your hands dirty in the system [you realise] that we don't actually hold that [data] in a way that can be shared.'
Local authority lead
'In those areas where you do try and rush, you can undo a lot of technical work. If you don't have the confidence in your partners (a) for them to share data and (b) for that data to be used and accessed responsibly, you're not going to get the signatures on an information-sharing agreement and all of the information governance you need to have in place.'
Project manager
'People from the [system] are saying we've got this population data now, can't we do something more with it?...All these things are coming along, and there's no problem with doing them, but we've got to get the governance right on those as well. We're trying to run while we're still walking. We've not got the headroom and the space to get all the partners on board.'
Information governance lead
Partnerships
Barriers to positive partnerships included unrealistic timelines being proposed by suppliers and limited opportunities to adapt technology for local organisations. We also heard concerns that the competitive nature of suppliers and other partners was having a detrimental impact on the NHS’s ability to spread digital learning. To counter these issues, all sites put effort into building relationships and directly facilitating conversation between users and partners. Recognising that suppliers themselves are digital change management experts and finding a way of tapping into this was key to a positive relationship. Sites also fostered buy-in from their partners by getting a single vision of what success looks like across the partnership.
Successful working relationships required clear roles and responsibilities for respective partners to be set at an early stage. In scoping potential partners, sites looked for suppliers that were open to sharing data and at how different local health and care organisations could work together to get a good deal from partners. They also recognised that it was important to aim for self-sufficiency in the medium term by building in-house capability for managing ongoing change. All these considerations require organisations to think ahead when choosing partners.
From the case study sites
'This artificial competition piece really gets in the way. So academic health science networks won't speak to me in some areas. The CSU [commissioning support unit] won't share stuff with other partners because they treat stuff as intellectual property...we couldn't be tripping ourselves up more if we tried. And playing into the hands of suppliers.'
Digital transformation director
'Without doubt the reason that we did it in the timescales was because the [supplier's] culture is that you will do this by that date, you will do this by that date. Have you done it? Right, carry on... Their build notes that they had for us to follow, all of that, it was very precise, very specific. As a company they'd done this so many times, and we went live on time.'
Chief clinical information officer
'We started to work out how to stop the same types of organisations getting charged twice for the same thing. For example, we've got two [organisations on the same EPR supplier] in our system. We said: 'We want this developed once. Cap your costs for development.' Because everyone knows they're not going to develop it twice. That's something that's not normally done before. We had central money we could fund the development costs from; so we could make it clear... we were only paying once.'
Chief information officer
Resourcing and skills
Digital transformation is about more than financing, it requires organisations to have the right people, assets and skills and a clear but adaptable plan for deploying these. The current pressure on NHS finances and its workforce means digital projects can be driven by short-term concerns and limit the scope of what can be achieved.
Planning the deployment of resources at key points in a digital change project is key to mitigating risks. This will mean thinking about who in an organisation has the skills needed to manage and facilitate a digital project as well as about the incentives that change and maintain the evolution of digital projects. Acquiring the needed resources is easier with a good track record for undertaking large-scale digital change.
Case studies invested in their people, equipping them to support technological change and motivating them to take the challenges seriously. This also supported taking transformation further, with the goal of continuous improvement. Evaluation is key to recognising success and failure and understanding the truly complex changes that digital technology brings.
From the case study sites
'I think many projects fail before they even have a chance to deliver because of the number of things we set out to try to achieve. In this particular context of digital there's only so many things that the exemplars can do at the moment because they're scattered across the country and there has to be some element of allowing catch-up as well.'
Digital leader
'I think one of the key lessons for me is the amount of ongoing support both financially and people resource support that the hospital needs to optimise its investment in both the hardware and the software was insufficient and it remained insufficient. And I suspect a common failing, which is to not recognise the real cost of ongoing support if you want to really implement change for the long-term future.'
Digital leader
'This isn't about what we're investing now. This didn't start last week, last year, two years ago, this started back in PCT [primary care trust] days. Hospitals invest in some of their technologies and then the commissioners through contracts identify it as a priority area. [We] historically invested an awful lot in digital.'
Chief clinical information officer
Taking digital change forward
Digital change shares many similarities with other forms of clinical change, but it is also uniquely adaptive, taking a technical problem and layering it with cultural complexity. Case study sites in our report show that the challenges of digital change in health and social care can be overcome from a wide range of starting points.
As the sector moves towards integrated care, organisations that provide care will need to share information with more clinicians across more care settings. Implementing large-scale digital change and removing the need to move paper copies of records around a care system is an important step on that path. Digital change will gain momentum and legitimacy by being locally led. Current national policy has been somewhat supportive of local goals, but it needs to ensure that it continues to allow digital initiatives to bloom from the ground up.
To start a digital journey, local organisations and areas should:
build a group of clinicians and managers who are interested in exploring new health technologies and who meet regularly to identify clinical problems and the technologies that could solve them
use this group to identify a wider group of users who can be involved in the design process as early as possible and are a source of potential leaders for change
give tasks to people who are interested and able to undertake them rather than letting role or organisational affiliation stand in the way of matching the right people with the right task
choose external partners that will be able to provide both change management and technical support
plan realistically for the peaks and troughs in a digital change process, recognizing that digital change demands flexibility. This will involve a balanced approach to resourcing, investing in cultural change to ensure that implementation goes as smoothly as possible.