The digital transformation gambit: simpler, faster, safer services?

Matthew

Hello and welcome to an edition of Health on the Line that focuses on digital leadership.

I'm sure you're going to find the conversation that I held with Tom Loosemore and Deborah El-Sayed both fascinating and of real practical value, but before we get to that, things never seem straightforward in the NHS.

At the Confed, we welcomed last week's negotiated settlement for Agenda for Change staff. Industrial action had put pressure on services and on leaders. We were proud of the role that NHS Employers has played in getting to that point. But we are far from out of the woods.

First, while we hope union members will accept the offer, there's clearly a risk that it will be rejected.

Second, in the face of the massive impact of the junior doctor's action last week, over 180,000 cancelled appointments and operations. Whilst we welcome the prospect of talks between the government and the BMA, the sides do still seem a very long way apart. So, it's going to require flexibility and creativity if there's going to be progress.

Third, even the current Agenda for Change pay offer will leave a hole in NHS finances for next year up to £2 billion. Given that the Treasury was party to those talks and must have understood the implications, it was alarming to hear Cabinet Minister Oliver Dowden imply this weekend that the funding gap would have to be found by making cuts in local services.

And then finally there is the delay in the publication of a workforce plan and uncertainty over the funding of that plan. The simple fact is that years of austerity have left us with 120,000 plus vacancies and staff who often feel overstretched and under rewarded. As the NHS staff survey shows, we have a long way to go to restore a sense of pride and confidence in the people who work for us.

There are no shortcuts or cut-price ways of reversing the damage that's been done. But surely progress has to start from a simple truth. We cannot hope once again to be one of the best health systems in the world unless we are also committed to being one of the best health employers in the world.

And now let's talk about digital leadership.

Matthew

This edition of Health on the Line is linked to the Confederation's Digital ICS programme. We're delivering that in partnership with NHS Providers and Public Digital, and the work is supported by Health Education England and NHS England.

The Digital ICS programme is a support offer, free of charge to integrated care boards and integrated care system leaders, and it offers a range of resources events, leadership sessions focussed on the role of the board in leading the digital agenda across systems. So, if that's of interest and it'll be of a lot more interest by the time you've listened to the whole of this conversation, do please visit our website to find out more.

I'm delighted to be joined in this conversation by two people who've got a great deal to offer it.

Tom Loosemore, who's a partner at Public Digital and has been around the kind of space of public sector digital innovation for many years, he wrote the UK's first government digital strategy. He served as the government digital strategies deputy director for five years and I remember lots of conversations with you, Tom, when you're in in that role. So, Tom can talk about digital and health, but he can also offer examples of digital transformation and the barriers to digital transformation in other sectors.

Our second guest is Deborah El-Sayed, who's director of transformation and chief digital information officer at Bristol, North Somerset and South Gloucestershire ICB. There can't be many people, Deborah, whose employer is got a longer name than yours Bristol, North Somerset and South Gloucestershire ICB. Deborah is going to be able to talk about ICB priorities and how concretely they're implementing changes in her own system. And Deborah herself has got a very rich background of working on digital at a national level, so also brings that perspective to it.

I'm really looking forward to our conversation. And I spoke to Tom and Deborah early this week and we agreed this is the way that we're going to do it. And it's a bit challenging for Tom. So, Tom, you go to digital boards and you offer a kind of hypothesis around driving digital change; a set of principles that you think need to be adopted to make it most likely that digital transformation will be successful.

So, what you're going to do is you're going to sell us that proposition, those principles, and then Deborah and I are going to be your kind of friendly critics in terms of reflecting on those principles, in terms of Deborah and her concrete experience and insights that I may or may not have to offer.

So, Tom, over to you. Tell us a little bit about the work that you do and then give us the first of your kind of the principles that you would present to a board wanting to think about digital transformation.

Tom

Okay. So, at Public Digital, we've been supporting the boards of trusts, but also the boards of ICSs, to go on the journey of leaders to really embrace the opportunities of digital transformation. And I want to stop there and define the term ‘digital’. For me, digital does not equate instantly to technology. I would define digital as meaning applying the culture processes, operating models and technologies of the Internet era to respond to people's raised expectations. And the order of those four words culture, processes, operating models and technologies is very, very deliberate. You start with the culture, changing the culture, and you end with the technology. The technology is fourth order and an enabler towards the end. Important, but not where you start.

Matthew

So, Tom, before you go further, I said that I was going to let you expand on your thesis, but of course I'm going to interrupt you all the time. So, I want to start with that and, and get Deborah involved as well. I heard you say this many years ago, when you were at GDS, talking about this and about the frustration you had at the time because you would go into departments, I remember one government department in particular, and you kind of tried to explain to them that they had to re-engineer the whole of the way in which they operated, the whole of their business model, the way they delivered services, or else they just couldn't get the benefits of technological change. And I remember at the time there was quite a lot of pushback. There was a view of these people are supposed to come in and give us technological solutions; they're not supposed to come in and tell us to change our whole organisation. So, Deborah, I suspect you kind of agree with Tom, but tactically, as it were, when you go to a board and you start to say to them, this really involves profound change, I'm not here to offer you kind of technological fixes. How do you think that goes down?

Deborah

Well, I think what you're picking up on, it's not how we do things. So, it is quite difficult to say: Actually, can we stop with the solutions a minute and can we just focus in on the design process and understand what's the real problem that we're trying to solve? Because often people have come up with solutions and what they want to do is, I want to fix this problem quick and I need a solution. And actually, digital and technology tell me I can do that, and of course, we know that just implementing the tech doesn't work, but that's what people are looking for, it's a fast fix solution. So, it is difficult.

We're just embarking on a model of trying to make sure that, Tom, you'll be glad to hear this, that some of the GDS processes of start with user needs, start with the problem you're trying to solve, start with discovery, is just starting to kick in. So, I can see the green shoots of it, but it's still going to be challenging. I know when I say to people, actually, no, this isn't going to be implemented in six months, and you've got a nice, neat solution. This is something more fundamental.

So, I think the pace and the speed and the urgency of some of our changes kind of drive a real appetite for solutions rather than really understanding the problems and doing that ground up piece that Tom articulates.

Tom

Yeah, I would agree with that.

But I would also reflect on how the world has moved on and the understanding of senior leaders around what the opportunities and the requirements of changing to be a digital organisation are.

When I reflect back to those times when I was at GDS, there really was very, very limited understanding of the scale of change needed in terms of how organisations operate, you know, to put the needs of the user first, to start small, to assemble multidisciplinary teams and focus on outcomes, not solutions, all that good stuff. That is now far more frequent that we encounter senior leaders in the NHS, and beyond in the public sector, who do actually understand that, and they don't necessarily know how to do it, but they understand that is what is needed.

A lot of the work we're doing now is really around the how of making that broader operating model change rather than whether they should or not. Now, I'm not saying that's universal. It's not. But I'm far more hopeful than I was five years ago that senior leaders will go on that journey.

Matthew

So that's interesting. So, your preamble to your principles is itself of real substance, it seems to me. And I think that presumably when you talk to boards and you say to them it's really important that they don't just think this is a kind of set of words before you get down to business, but they really do understand it. And it's good that more and more do. But boards are very important to this, aren't they? Because it's the board more than anybody else who has to has to be realistic about the scale of change that is involved.

Tom

I completely agree. And even one individual on a board who is fixated on a technology solution can cause real problems. Even NEDs actually, and I say that as a NED myself. So, I think there is a responsibility to make sure the whole board has gone on that journey, not just a couple of key leaders.

I think the real narrative that tends to work is sometimes paraphrased as let’s not do a faster horse, as in, let's not just digitise the existing services, the existing way of operating. The real opportunity comes when you take the opportunity of the Internet era tools, ways of working to create simpler, faster, clearer, safer services that were previously unimaginable.

And that emotional, intellectual leap into the previously unimaginable, that is both incredibly exciting to some senior leaders, but also a little bit terrifying. But I am absolutely convinced that the real prize here is not just the bluntly digitised the analogue, but to take some much bolder steps, the sort of equivalent of let's turn off 2,000 websites that the government run and just have one website - gov.uk. Those analogous kind of intellectual leaps towards simplicity. That's where the real prize is.

And I was delighted to hear Patricia Hewitt in conversation with you on the last podcast talking about the emergence of ICSs and ICBs offering that kind of step change possibility. Not easy, but possible because there is malleability there, there is difference there and, you know, a shift from competition to collaboration and inversion of the pyramid. These are all you know, singing my hymn sheet in terms of how to get the most out of digital.

Matthew

Before we get into kind of exploring the kind of particular kind of key kind of principles or key elements to an approach, I just want to stick with this point you've made because I have kind of personal pain here. And I wonder, Deborah, whether you've got examples as well.

I'll tell you exactly what happened. I ran an organisation called the RSA for many years, and throughout that time we had people on our board who were representatives of fellows and they were activists, so very active and they kind of assumed that every other RSA fellow wanted to be very active. And so, each time, and this happened three times, they'd come along and say: We need to create a platform where fellows can talk to each other.

And I would say to them: Look, there isn't much evidence really, that if you just create a platform that fellows do just want to talk to each other, it's not, you know, they're busy people. They've got all sorts of other things going on. That's not what gathers people together, just creating a space. And if you do create a space, I can tell you what will happen - it will get full of people who are old and grumpy and who want to run the RSA and see this as an opportunity to moan about things.

Now, the reason I'm telling you this story is I had that argument three times. I lost it three times and three times we spent a lot of money and time creating a platform which, surprise, surprise, not many people used and soon became only the refuge of grumpy old men who wanted to run the RSA.

I'm interested, Deborah, when you think about engaging boards, engaging other colleagues on the executive, on your executive, not your executive now, but more broadly, are there particular kinds of misapprehensions, mistakes that come up again and again that you have to particularly watch out for?

Deborah

I think there's the bit about simplicity and obviously one of the big important parts of the ICS is about integration and integrated care and bringing the services around the person, wrapping the care around the person rather than what we've done for many years of putting people onto a pathway and hoping they get to the to the right place.

But of course, one of the things that comes up constantly is, well, we just have some interoperability. And because people don't understand some of the complexities about actually that does mean that you've got to define bits of data that link to another bit of data in another system, and that complexity that is there. Even before, I mean Tom's point about the design side of things, even before you've designed what needs to happen really in each place and thought about it differently. So, things like that, there are technologies that have become part of common parlance that we just get some interoperability, we'll sprinkle some AI over the top and that will magically analyse the data.

I think there are things that people are because it's in our lives, technology is a golden thread through our lives. We don't pick up our phones and think, I'm just going to do something technical now we just live this way. So, we are all becoming much more au fait and comfortable with technology, but it also means that there are some misnomers in there that people think that they understand it. And actually, there's some complexity and some things we need to do before we consider interoperability.

I think one of the things in your point about understanding what people want, there is a catalogue of situations where we think we know what the problem is, and it's only once we invest the time to do the insights piece of work and really talk to people and ask the question why? So, we don't end up with the Henry Ford faster horse scenario, that we actually need to spend the time to do the insights to understand.

But also, one of the things I'd love to ask Tom is, that we struggle with is, what people say they want, i.e. I'd quite like a faster horse, please. And what they actually need, are two different things. And I think sometimes we've got into a space of if we do the user insight and people say, you know, I'd like a platform and I'd like it to have a purple header and I'd like to have a conversation in that space, we need to get down to what is it that actually people need rather than what they say they want.

And I'd just love to hear from Tom. How do we get over that and help them help a kind of board understand this isn't delay tactics. This isn't extending the life of a programme, this is doing the fundamentals that will mean we do it once and we do it well.

Matthew

There you are, Tom. You're in the board meeting. You've kind of told people, I'm sorry, this is going to be a bit deeper and a bit more complex and maybe a little bit longer term than you imagine. You've dealt with the board member who says, but hang on, isn’t just about interoperability? And can't we just do AI? And you've dealt with those questions, and you've got people to kind of recognise it's a bit more than that. So okay, now the chair turns to you and says, so what do we need to do? What are the key principles that we need to apply?

Tom

Okay, so the key principles. Let's go there. I will answer your questions specifically, Deborah, in a moment.

But number one as a leader is real clarity on what outcome you want to achieve and focusing on outcomes, not solutions and outcomes that you can measure while not being obsessed with the measures.

The second principle would be, and Deborah's already alluded to this, is to be obsessed about the needs of your users, be they patients, be they your staff, more than the convenience of your organisation and user needs trumping organisational convenience is a phrase that you as a leader should say as much as you possibly can, and user needs are different from user wants, which I'll get on to in a minute.

The third principle I would be pushing for is the thing that really changes the world is always a small, empowered team and the very best teams everywhere, but particularly in the NHS, are multidisciplinary, not just clinically multidisciplinary, but also organisationally, administratively and technologically multidisciplinary.

So as a leader, clarity of outcome focus on the needs of your users, not the solution. And how do I set up and empower, invert the pyramid, become the servant leader of multidisciplinary teams that are going after those outcomes.

And I think the final principle is that digital transformation, the speed of it, is determined by trust. Digital transformation happens at the speed of trust. So as a leader, your role is around building trust within your organisation and at the ICS level between different institutions within that entity. And trust often comes from alignment. Be that alignment around organisational incentives, alignment around outcomes, alignment around how the money flows, alignment, how the how the data interoperates or doesn't, as the case may be.

So, I think they would be they are typically the principles focus on outcomes, focus on user needs. You know, multidisciplinary teams change the world and, you know, a focus on developing and improving trust within your purview as a leader.

Matthew

What hits me about that, Tom, is you've described four challenges, which are challenges for the health service, full stop. Forget digital, if we could do all those things in everything we did, we would be a better health service than we are now. So that underlines this cultural shift. So, Deborah, what I want you to do is to go through these principles and just talk about what that practically means and the challenges that are involved. Or of course, if you disagree with the principles, tell us that as well – we’re are all up for a lively conversation. So, the first one I think is define your outcomes, Deborah. Talk to us about that.

Deborah

So, I do agree and I think taking time to. Understand not just the outcome we want to achieve, but also really understanding the problem.

And so, a real life example: when we were developing our place-based partnerships, which lots of people have got different approaches, but this is the integrated team at neighbourhood level. We went through this process.

We spent seven weeks going round talking to people to understand and synthesise and synergize the problems that we were trying to solve. This probably covers off the bit about trust and alignment as well, because what we found was we needed to find the places that we had shared common goals. And we talk about this a lot, don't we? In terms of why does things really work in covid? Because we had a shared common goal.

But I think there's something about how we use that to our advantage. But knowing that we need to invest time, effort and energy in doing that. So, we were really fortunate. We had a board that got the fact that we needed to do this discovery and we needed to do it properly.

But it is about taking that time to walk the boards and get out and talk to people and not just take the first answer of the outcome, the outcome is we want a better start for all our children. Yes, we want that outcome. But what does that actually mean? How do we break that down? Because sometimes our outcomes are too broad to do anything tangible with or to really understand the areas that we need to consider. In terms of our design.

Tom

I would really reinforce that, the danger of having an outcome, just one outcome that's too high. You need to nest your outcomes, make them measurable so you can give them to teams to focus on at the right level of granularity. I think that's a really important point.

Matthew

And this isn't a smooth process in the sense that this isn't about discovering a hidden outcome like hidden treasure. You just need to find it and open the box and there it is. People will have different views about what outcomes they want. So, this is a small political process as well, isn't it Deborah?

Deborah

Totally. And what you understand in that process is where you don't have alignment, where you have got people with a vested interest for things not changing. And until you get to understand all of that in terms of the partnership and the work of the ICS, you can't kind of move on because you haven't understood everybody's vantage points and they are so diverse.

If we think about digital, for example, the digital leaders in our local authorities are also responsible for the road signs and traffic lights, and it's not just about health and care. So, for example, one of the things that we're doing is making sure that we're working with the West of England combined authority to understand the bigger digital strategy and make sure that we link in with those.

It does take time to make sure that, you know, you've really understood where you've got conflicts as well as where you've got alignment and how you can address them.

Tom

I often use a phrase that, you know, successful digital transformation as a leader is more about your diplomacy skills than your technology skills.

Matthew

So, let's go to your second principle was that you've got to be in service of the needs of service users, patients, the public, not in terms of the convenience of the organisation. That's a challenge as well and again, a challenge for all that we do in the health service. I think it is still the case for far too many people that it feels as though they have to fit in to the health service rather than the health service fitting around them.

Tell us about that kind of challenge, Deborah, of people seeing digital, genuinely wanting to see it in the context of giving the public and patients the service which fits them.

Deborah

Some of it is we have to talk to people more than we do. We talk about co-production a lot, not just in the digital space, but right across.

And so, when we were doing our digital strategy, we did some open to the public. Anybody could join in a massive Eventbrite publications. And one of the things that I was fascinated by was that there were so many people who things that we think are digital products in health that we just use, people didn't know, people still didn't know about 111 or 111 online or can I actually get my records from the GP? I didn't know that.

So, I think there's something about we have to continue and this isn't a one off exercise. We've got to continue to engage with our population, which again, really important part of the ICS using all those levers and assets across our local authority partners as well as in health, to actually really understand what matters most to people.

And we did some surveys recently, and I'm sure lots of other areas have done these. But the things that matter most to people are, at the moment particularly is, I want to be able to access health care when I need it. So those kinds of things help us to try and gauge where we prioritise our effort and energy and it means that it's not just only about digital. It can't be. It has to be the integrated approach to transforming things that use digital.

And I'm kind of agreeing with Tom again but using digital as the tools and enablers to make some of those things happen, that enable people to get faster access to the services they need or potentially empower them to be able to self-serve like we see in so many other parts of our lives.

We don't ever go to the desk to get a boarding pass anymore. That's all done as a self-service. So, starting to think about those types of things that we can actually enable people who get quite frustrated about having to go through many processes.

That point you made, Tom, earlier about simplicity, really starting to design for simplicity is again one of the tenets that I think the ICSs and the ICBs bringing together partners. We can start to do some of these design pieces because it isn't about single organisational design anymore. It's about how people interact with their health across their life course and across the breadth of their lives.

Matthew

So, Tom, how do we how do we get right this principle on the one hand of wanting to build services around the way that patients want to receive them? But on the other hand, you made this point about giving people what they need, which is not necessarily the same as what they want. The way that we engage the public is surely very significant in this?

Tom

Completely. And I think this is one area where, there are elements of, of bits of public sector outside the NHS that are maybe a little bit further ahead.

And that's really applying what’s a relatively new discipline of observational user research; to get under the skin, by observing how service users, our own colleagues, actually behave when presented with new opportunities about how things could work.

Not necessarily listening to what they say, because you really usually do get the faster horse narrative back from people, as Deborah alluded to earlier, but trying to unpick what they're really struggling with.

I'll never forget watching people trying to apply for lasting power of attorney. These are these are normal people, not solicitors and saying, yeah, this is dead simple. this is really simple, this is brilliant. And watching them make really terrible mistakes because actually the service hasn't understood the specific needs of their family in that kind of circumstance.

And bringing to bear some of the skills of user research that are now gradually maturing across the public sector, down to the trust level, there are some very good skills in the entity formerly known as NHS Digital. Now obviously in the transformation directorate, but there's kind of bits stuck in the middle when you really want. I think some of those user research skills spread more broadly across ICSs.

But if there was one skill set I'd encourage ICSs to hire that's new, and I know we're not in the world of hiring lots of new people right now, it would be people who understand kind of anthropological user research, the observational side of user research, rather than interviewing people and asking them what they want.

Matthew

Well, that takes me, Deborah, to the question I wanted to ask, which is the skills.There I was at the beginning thinking well ahead of digital, you need to know how technology works. But I think so far, we've recognised that to lead a digital strategy you need to understand how the technology works, but you need kind of emotional intelligence; you're going to need kind of political organisational skills; you're going to need or at least know how to engage with people with kind of anthropological, ethnographic service design kind of skills. These are kind of Renaissance people that we're going to need. How confident are you that that in our 42 ICSs we're going to have the kind of skills that we need to lead the digital transformation we want to see?

Deborah

I think talent in any arena is a challenge. But one of the things that I think is going to be really important is the Renaissance people, those people that get up in the morning and care about this stuff are the kind of people that we want to attract. The more it's clear that this is how we are going to be doing things in the NHS, in ICBs, in health and care systems, the more we will attract people, because they are out there.

And I think it's also the other piece that you talked about is the overlap of leadership skills. And the reason that I'm a joint director, I’m CDIO and a director of transformation, is because in our ICS, ICB, we believe that actually those two things are really deeply connected together.

And in the same way, as you know, in the past, we would never have leaders, senior leaders in our NHS or in our local government organisations who said: Oh, I don't do people or I don't do money. I think we need to think about this new approach to leadership, which is about having those skills. And it isn't just about knowing what a technical architecture looks like or what new products Cisco are bringing out.

It's actually about understanding how these elements of technology and data as well will actually enable us to redesign and reshape the way that people experience services, both in terms of delivering them and in terms of being on the receiving end of them. I think there is an optimistic view, but it does require us to think quite differently about how we attract talent and how we develop talent from within.

Matthew

And Tom, what's your view about this kind of way that the role of the senior digital leader has evolved and the skills we particularly need to forefront in that role?

Deborah

I think Deborah really nailed it there that the merger between the CDIO role and the transformation role, they are one and the same in my mind.

They are people who are fundamentally alliance builders, trust builders, diplomats, ability to create confidence and safe spaces for their teams to really do great work. Those skills are as, if not more important, than understanding what technology now makes easy and what technology still makes hard.

I think in terms of attracting those people, there's a set of hygiene conditions that an ICS will need to create to attract those people in the first place. To some degree that's salary, but more it's about the fact that they’ll be able to work the way, the way that they know is best.

And so, the more we can have these kind of conversations, the more we will be able to attract people, who bluntly will be absolutely invigorated by this kind of challenge.

If you're looking for those Renaissance leaders and I know this from having seen how many were attracted to government once the messages got out there in the mid-2010s that government was changing to be more user centred, to allow more agile, iterative, user-centred working. We had a queue of amazing leaders wanting to join, but you have to create confidence that those conditions exist for those kinds of leaders to thrive. And I think that messaging is vital.

Matthew

I think that's a really interesting point that, that boards might sit there and think, Yeah, we'd love to do this, but we don't quite have the right leadership and answer to that is the messages you send out, the ambitions you have, are the ones that will potentially determine who you can recruit and whether you can retain talent.

Now that we've had a deep, thoughtful, psychological, sociological conversation, not one of those kind of trivial tech podcasts you have. But, you know, I'm going to end with some trivial tech questions because it's the end of our conversation. I'm going to put you on the spot and I'm going to ask you to do two things.

I'm going to ask you first, to tell me what you think is the kind of low-hanging fruit. That's another phrase that you probably get a bit tired of hearing. But what are the things that we could and should be doing pretty quickly in the digital space that would make a difference?

And then the second question is, is the opposite almost, which is: is there something that in ten years’ time we’ll go, my goodness, it's completely different now. And we, I think the quote is attributed to Bill Gates, but various other people, which is that we overestimate what technology will do in a year but underestimate what it will do in ten years. So, what are we underestimating in that kind of ten-year time frame?

I'll ask you first the kind of low hanging fruit question. I'll start with you, Deborah. What's the kind of the relatively easy, straightforward stuff that we should be kind of grasping now?

Deborah

I think it's more in the data space. And I think the really important things for ICSs and ICBs is our investment in population health management and embedding that way of thinking to be able to make better value based and allocative decisions about where we invest our considerably scarce resources. And we know that we're going to have increasing demands, a great thing, but we're an ageing population. We're all living longer. So, I do think it's that investment and we're already seeing some of that around the country, but it is putting that into the hands of decision makers, I think is one of the most important things that we need to start to do to really start to build those foundations to shift the dial.

Matthew

Great, and Tom?

Tom

I would add to that I think outpatients and the notion of patient initiated follow up, like empowering patients to manage their own care with guide rails that that feels genuinely exciting and possible with within the organisational constraints we all face.

I also wonder around, and I know enough to be dangerous here, so I'm being a little bit glib. But I look at discharge and the data sharing opportunities between institutions, between the healthcare side and the social care side around discharge and data sharing there. And I look at that and think there must be ways to improve that. If you can get the trust and the alignment right between those two sets of institutions.

Deborah

Could I come in on that.

I just think it's so important that piece about discharge.

The data is there, and what we've got to remember is that data is only what we've chosen to write down about what happens in reality. So, the data is there and can be there to drive that. And I think Tom's right. There are a few systems out there that do some of this stuff, but what's more important is getting people to share that data and to feel that no one's going to prod them or there's going to be somebody who's going to be battered because their data says that they should have had more capacity. That trust is a critical part of making sure that that works.

But I just think I just want to amplify that because it is really important that we get that data and we connect it, because we're impacting people's lives. People staying in hospital too long is not good. We know that and making sure that we can do the things that we can do in other industries about connecting and need, and by this, in this context, I mean, you know, my individual care needs with a kind of service or a collection of services that will wrap around and give me that support.

So that, you know, that matching algorithm, that capability is there in spades in so many other industries. And I think it's really important that we use some of that to be able to drive that critical agenda for health and care and for the people we serve.

Matthew

I'll give you my contender for the kind of ten-year shift.

My contender would be the diagnostic revolution and the kind of notion that in ten years’ time, for most people, we’ll live in a world where you find out that you're ill before you have symptoms. Not for all illnesses, but for many illnesses. Cancer in particular, but others. The use of clever diagnostic tests, blood tests, wearables, whatever, will mean we'll move to a world where a lot of people understand that they've got a problem that needs to be attended to before they've even got symptoms.

And that will become part of the just the way we live in a day-to-day way. Taking those having those tests, making those checks. So that's, I think, something that's going to be revolutionary. And obviously Digital's very wound up in that in all sorts of ways. But Tom, what's your kind of big leap over ten years?

Tom

I think it's not dissimilar to other sectors in that, you have the death of distance, and the Internet allows you to escape the constraints of geography. And I simply find it odd, having looked a little bit at something like ophthalmology, that specialist ophthalmologist skills are still constrained by the geography of individual trusts when actually those scans can be whizzed around the country at will.

And having an organisational model or an institutional design that allows you to bring the very best specialist to bear on your individual needs as a patient beyond the constraints of your organisation that is bounded by geography feels like what you would do if you were going to invent the health system again given the internet. And that feels exciting to me.

Matthew

And it's really fascinating as well, Tom, because, you know, I was talking to somebody from a specialist provider the other day who was railing about the dangers of devolution to systems because they said I could provide most of my services from a basement in Dublin. Yet I'm being encouraged to think about myself as a geographical service provider beholden to systems.

Now, we're not going to get into that whole debate, but in a way, it does underline, doesn't it, the way in which these issues, these digital issues are very much wound up with some other very, very kind of challenging questions about the distribution of power and authority and money within the health service. But,

Deborah, what's your kind of ten-year shift?

Deborah

I think it builds on both points that you've made, which is, as we start to wrap the technology around the home, it exists in homes. And I was around many years ago when it simply wasn't. And when we're using, you know, IVRs and various ways to try and collect data about individuals with really clunky technology.

But the whole idea that we haven't got a workforce that will meet the needs of our population, both health and care, it seems one of the things that we have to do is to ensure that technology enabled can, and I don’t just mean telemedicine, but there's massive advances in things like telepresence and robotics, but thinking about how that wraps the care around the person so that almost the concept of going into a hospital becomes something that is confined to, you know, the history in the same way as the Betamax video debacle.

But that we start thinking about the first place that somebody experiences care of, you know, varying degrees of complexity is in their own home and in their own bed.

Matthew

Well, that's a really exciting point to finish our conversations.

Just to remind people that this podcast linked to our Digital ICS programme that we're providing here at the NHS Confederation along with NHS Providers and Public Digital and as I say, supported by Health Education England and NHS England. And I think that our conversation over the last 35, 40 minutes shows how rich the work that we can do with boards can be. So, Tom, Deborah, thank you so much for joining me.

Deborah

Thanks, Matthew.

Tom

Thank you, Matthew. Thank you, Deborah.