Fixing healthtech #1 - addiction to addition

I’ll be honest, seven months into a (delightful) second child and with loads of work coming in, time for my article writing has struggled.

That said I have lots to say so clearly time to pivot for a little bit…

Over the next few months I’m going to focus on shorter punchier articles under 1000 words, as part of a series focusing on the big changes nationally, and what we ACTUALLY need to fix if we’re to actually do this healthtech / medtech / AI revolution in care that we keep batting on about. These are deep topics, which I’ll go into less depth than usual so bear that in mind. 

Firstly…

#1 - addiction to addition

If you step back and look at what we’re trying to achieve in the NHS’ next iteration, it’s big.

Hospital to Community - disaggregating the care in self contained siloes, where budgets and responsibilities traditionally also sit in siloes, offering the paradox between existing services deemed necessary, and the imagining of new kinds of service.

Treatment to prevention - highly political, much squeezed, often “vital services” being maintained, vs the requirement for a huge paddle upstream to stop people out there in the world (UK obvs!) living their unhealthy lives in a world designed to make them unhealthy.

Analogue to Digital - build has failed, buy is failing, everything in between is messy. This is not a new shift, it’s one plagued by many years of hard graft on all sides, yet too few successes. We’ve seen barely any revolution, but grinding evolution.

In each of these three huge shifts we need to ask ourselves what are we building this on. Each of these three represent incredibly costly shifts, where the demand for the status quo provision is shooting up, and where the government is being clear - cut cut cut.

Whilst I’ll face on analogue to digital, more specifically healthtech, medtech and forms of AI in the NHS, all three of these face a paradox: do more, that’s never been done before with less.

The greatest risk is that we fail because, my friends, institutional bureaucracy and those who perpetuate it have a way. Just like the Mandalorian creed. Their way is additive.

Organisational debt (e.g. governance), technological debt (e.g. legacy systems) and beyond - if you go and try and introduce a new technology to the NHS, or a new process or approach, it’s highly likely that they’ll want your tech to work with every part of their existing (often un-interoperable) estate, to dovetail with every existing service element they have in place, and to go through every process they’ve been cultivating for decades.

If one borrows from (and slightly bastardises) the pizza box analogy there are simply too many variables to make barely  ANYTHING actually viable, or if it does get through it will be slow, painful and lead to disappointment.

We simply cannot keep loading shit on the wagon and expecting the wagon to function.

Change

If we look to any revolution that has taken place, it has required the sweeping away of the old in place of the new, social revolution, technological ones and beyond. There are very few examples that I’m aware of where we managed to keep all of the existing bells and whistles.

Now arguably the government has declared war on bureaucracy and red tape, which may resonate with voters, but for those in the system, one would be inclined to ask: “what exactly should I stop, cut or do differently”, and perhaps more importantly “what is safe to stop or cut”.

Should a trust just stop asking for the things it currently asks for from a governance perspective? If so what?

This is where we, and the government, really need to turn our attention to - because if we’re to try and wean our friendly professional addicts off addition, we need to be clear around what SAFETY looks like?

Cutting jobs and specific role types will absolutely not stop this problem in isolation, because the highly entrenched culture of governance, risk aversion and additive thinking will still exist. And people stuck in the commonly ascribed ‘sticky middle’ will not know how to navigate this.

I’ve spent years working with NHS providers and defence on this exact topic, and the answer is complex, but I’d like to outline some factors that should be considered when trying to fix this at the centre:

1. Transformation is just as much about reduction as addition - and the digital revolution is not new stuff - we need to make it clear that stopping things are just as important as starting things, and that funding bungs and bonuses through capital allocation are done as is the reliance on this. This needs to be empathetically communicated to everyone to help affect the current mindset.

2. What is safety - the NHS is not a safe environment, and people are more incentivised to do something safe than something bold and risky. We need to tell people that it’s safe to take risk, and help contextualise what clear examples look like. Politically the centre might want to wash their hands of this, because naturally it will lead to newspaper headlines when risk turns into serious events. But we cannot safely achieve rapid change and not reduce risk.

3. Beware of the hydra - if we stop things but people still believe then two things will come back in their place. Many leaders will be inclined to point at bureaucratic manifestations that should go, only to see a messier, varied and confused version then spring up in the future that then ends up being consolidated into the thing that came before.

4. Below the surface - Building on the last point. Bureaucracy as an activity exists because people believe it’s the right thing to do. Not because they’re lazy, and inclined to do nothing and just gum stuff up. OK there might be a few who have lost all enthusiasm and actively disengaged, but I’d still put them in the minority. Bureaucracy exists because we’ve been told by the system and system leaders in their more subtle daily requests that this is ‘the way’. To change anything we need to focus on mindsets, values and beliefs, because if we can change them, then we’re getting to the root of the problem instead of the symptom.

5. Smash the ‘addition creators’ - we know who and what they are: especially EPR and EHR suppliers. If we’re to smash technical debt and additive interop-on-top then we need to take these suppliers on and force them to actually change. For years the centre has done way too little to force suppliers to actually change, and from a tech perspective it might be one of the biggest blockers for getting shit done, as too many things become required to make anything viable. They need to know that their time preserving incumbency is done. I would also add the very challenging issue that happens in tenders, where staff are asked to list 1000 things that go into a spec, that no company can actually serve - it’s very convenient but hugely additive.

6. Build from the ground up - it’s hugely difficult to take stuff away, but it’s much easier to start with a blank piece of paper. I think we need somewhere in the NHS to create a non-bureaucracy flagship to really try stuff, rather than years of painful negotiation unpicking hillbilly wagons in every system and trust. It’s contentious but I think we need nightingale innovation sites to help create blueprints to really show what different and  non-additive can look like.

These are just a few, and this is a very complex topic. But headline - everything we’ve learnt about actual addiction is that you can’t really change the behaviours if you don’t address the cause (see In the Realm of Hungry Ghosts by Gabor Mate), why would collective or cultural addiction be any different. 

We need to help people understand why there is a different way, that there is a different way, and how it could manifest. If we just shout at vague terms like bureaucracy and sack everyone then it’s not going to go well.

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