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.
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.
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
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
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
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
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
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
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.