Where’s our National Health Digital Service?

Technology is often seen as the solution, but so often it’s really just another huge problem.

I have the unfortunate task of visiting our local hospital King’s College more often than I’d like at the moment. Nothing too serious, my wife fell down a few stairs in the middle of the night and broke her ankle. She’s on the mend, thanks for asking.

The NHS is a phenomenal beast. Most of the time, you’re just along for the ride, “go to the X-Ray, then come back here, don’t go to the front desk, come straight to us” a nurse tells us, “have you been referred or are you a self referral?” asks the assistant at the desk, “you’re not on the list, sorry” says a nurse practitioner. You have to give yourself up to the system, let it carry you along it’s digestive system. You have to remind yourself not to second-guess or doubt the nurses and doctors because they trained a very long time to be able to treat you at this moment. But at a rough guess, I’d say pretty much 50% of the experience in a hospital is what John Seddon would term ‘failure demand’ of some sort, or what Bob Deming would have called rework. Everyone there is preoccupied with coping with the system.

When you succeed, you do so despite the technology, not because of it.

The NHS is one big edge case, it’s a system made entirely of edge cases. Everyone in there is an edge case, they are all outliers, nobody wants to be there. Yet the way the system works seems designed only really to handle cases perceived as ‘routine’. As an example, I had a letter with a barcode, which stated our appointment time. There’s a kiosk type of thing in the X-Ray place where you can go and scan your barcode and check yourself in, like you would in an airport. Except, there’s a friendly man who is assisting people. The friendly man is the interface for the machine, they don’t even let you see the machine’s face. The friendly man is the interface. It’s welcome assistance because when he scans the letter for me, the machine bleeps like it’s slightly miffed but it offers no real explanation. The friendly man explains that we’re two hours early for our appointment. I tell him that the consultant asked us to come at 8.30am not 10.30am so that she could see us first and my wife wouldn’t get barged about in the rush that happens around 10am. The consultant had improvised and created her own priority for her patients, except the formally procured system didn’t really allow for this. Why should it really? These kind of technical solutions have been purchased through a rigorous procurement system which doesn’t put patients first.

Another example, after we saw a nurse on our first visit, we were given an appointment card detailing the time and place, with a handy little map to show exactly where we needed to be. I was pleased that it had a map. Except, when, as instructed, I took the card to the reception (they didn’t explain why) they took the useful card away from me and replaced it with a less useful object- a piece of paper with the same information, except there was no map.

It’s relatively easy to write off the problems as simply a result of its vast complexity. But it’s obvious to see why the problems exist. They exist precisely because of technology.

You can see where the technology works and where it doesn’t. My experience of plaster casts was previously limited to what I’ve seen in Carry On movies. I thought it would take forever to set but it didn’t. They have an incredible synthetic product which behaves like a bandage, but once wet, it sets very hard, very quickly. Now that’s a technology solution that works. Also, the X-Rays are no longer plastic sheets, they are sent between departments as high-res images on the computer with something that looks a lot like email. Walking from department to department, the X-Ray results seem to follow us around in the cloud. And also, there’s clear wait times displayed everywhere, which seem pretty accurate. So it’s not all bad.

But the failures of the NHS aren’t just within our hospitals, the NHS is the National Health Service, not a collection of hospitals. You can see the failures of our system on the streets begging for change, shivering a pale- our systems are failing to pick up and treat mental health and addictions that lead to homelessness.

For NHS hospitals, most problems seem to come about because of the interfaces and IT systems put in place by a vast array of different providers, mostly fixes that fail, systems that don’t evolve towards their purpose.

When will the Department of Health conceive of a digital strategy as strong as that of the Government Digital Strategy? We need a set of principles for the National Health along the lines of those created for the Government Digital Service. We need a strategy that…

  • … puts patients before The Trust, for example by using Plain English, not the language of the system. I have no idea what a ‘self referral’ is.
  • … works iteratively by not procuring expensive and useless technology systems sold by the private sector which never improve and only get in the way of people doing the work they need to do.
  • … makes things open so that systems and departments can communicate together more effectively

Where’s our National Health Digital Service?