When Jeremy Hunt commissioned the Wachter Review in 2015, it was to find out how the NHS could upgrade and transform through the effective use of digital working hand in glove with education. Sam Shah, NHS Clinician and former Director of Digital Development at NHSX, talks to Johanna Hamilton AMBCS about the challenges of transforming the world’s fifth largest employer.

The NHS is over 70 years old, with more than 1.5m workers, deployed across over 30,000 different organisations in four different countries. With so many cogs in such a huge machine, where does the digital revolution begin?

Looking at such breadth within the NHS, where does transformation start?

‘The NHS is incredibly complex. As well as having organisations within the NHS, some will be private companies providing care and operating independently. Just to give an idea, the NHS in England is made up of almost 30,000 or so organisations, including GP practices, dental practices, optometrists, pharmacists, ambulance services, out of hours providers and hospitals - that’s an incredibly complex and challenging environment.

‘An organisation like NHS Digital has to be there to provide support at an infrastructure level across the system. These are, of course, national organisations and, in some ways, supporting policy might be an easier place to start. What's more difficult is the next layer down, which is where it gets more complicated, but at the same time where most of the change happens - we’re talking at the regional or local level.

‘We have to first recognise that the pace of the change will not be the same in all parts of the country. It requires leadership at a regional level to bring people together for a shared understanding, focus and outcome. This requires some development between local organisations that are delivering services. However, change has to span from commitment at the top, at a ministerial level, through to the very centre of the health system.’

Do you start with the big picture and work down, or the minutiae and work up?

‘One of the things that we should always start off with is, what is the user need? Why is this change coming about? What's the problem we're trying to solve? Because all too often, it becomes about the technology. For some of those people out there, the barrier is real: they end up using something that might be technology or digital but actually makes their life and their work more difficult; it contributes to burnout, it means that they're spending more time doing something rather than less time.

‘We start off with the need, then focus on the experience the users of the systems, products and services will have. We think about what sort of interfaces they might have to engage with to do that job. Sometimes technology is forced upon people. Sometimes there's a few people who might have designed something with the best will in the world but when you actually land it in a live environment, it doesn't necessarily have the desired outcome.

‘A classic example of that is the NHS referral system. The idea to digitise referral was great, but when you get into the detail, you realise that some of these things can add more time and burden to a clinician's processes - and they don't always result in a better outcome. So, it's really important to work with users to understand what the issues are, what problems they are dealing with and then how digital technology might solve them.

‘We want interfaces to actually cut down on work, reduce the burden and give back time.’

The Wachter Review says: ‘Getting it right requires a new approach, one that may appear paradoxical, yet is ultimately obvious: digitising effectively is not simply about the technology, it’s mostly about the people.’

How do you get the people onboard?

‘The NHS Digital Academy was borne from the recommendations of the Wachter Review. It has been designed to promote change, by developing both education and digital leadership skills. Those leadership skills include being a champion for change, but also understanding how to make decisions.

‘In some cases, individuals might go through that programme to become better at making decisions. In other cases, individuals might use the Digital Academy programme to become the future leaders of digital with a whole new skillset.

‘The Digital Academy is a really good way of supporting individuals to progress and become leaders and agents of change, so they can operate at local level, board level and across other parts of the system, focusing on a range of things including data, service design and a strategy for change.

How important is it to have a governing body, such as FEDIP, for data professionals?

‘When embarking on any form of accreditation process and creating any form of register, you have to think of the risks and the benefits. On the one side, the benefits are improving the standard and the quality of the system and creating an environment in which there will be individuals that demonstrate that standard and deliver it in their work.

‘On the other side, there is an environment where workforce is already a challenge, which might limit the skills pipeline. So, the standard probably has to grow and the accreditation mechanism probably has to grow over time so as not to completely damage the workforce and the pipeline.’

If data is being used to help diagnose and prioritise cases, then how can you protect an individual’s right to medical privacy?

‘I think what we should be doing is moving to a place where citizens are the owners and controllers of their data and we create transparent mechanisms demonstrating the benefits of sharing that data in a certain direction. We should give citizens the ability to consent for that data to be shared.

‘Certainly, the research generally indicates that where society is shown the benefits of sharing that data and the wider benefit it would have to creating new products and services that will benefit other citizens, there's a greater willingness to share. This might result in more medical breakthroughs in the future and also a lower cost burden in healthcare.’

According to Forbes, 90% of the data on the planet was created in the last two years. Big data and, more importantly how we deal with data, is becoming a big issue - not just for storage, but for privacy.

How is the NHS dealing with big data?

‘Following on from the Forbes findings, the NHS is approaching the advent of big data, including machine learning and the application of augmented intelligence, in a number of ways, both at national and local levels.

‘My worry is that it’s early days and that decisions could be made using relatively small samples of data. At the moment, the machine result is supported by a clinician, but as iterations happen, the AI could run more autonomously.

‘The skewing of data is an issue, not just for us in the NHS but in all sectors. Especially when you understand the bias in data sets and you realise that data sets are often taken from fairly homogenous populations. That means that they don't contain the heterogeneity that is needed for widescale application and there is a risk that decisions are made because the data from their underlying phenotypes or even the types of cases are quite narrow. For that reason, it's important at this stage that that type of AI isn't simply allowed to make decisions on its own because there is a risk of skewing. It has to be taken alongside clinical context and clinical decisions making.’

You were voted 4th most influential BAME leader in the digital sector by the Financial Times in 2019, for your work at NHSX. How important do you feel it is to shine a light on diversity in IT?

‘I think it starts the conversation and makes people think. Shining a light on it doesn't always create a diverse team but at least people start thinking about it, start questioning it, looking at their own teams.

‘What creates those diverse teams is much more than that. It's creating a cultural environment where people accept diversity. Even if the team aren’t diverse, at least if they've got the best thought capabilities and they know how to include the widest range of views, which might lead to better outcomes.

‘Shining a light on gender or ethnicity won’t necessarily create a diverse team on its own, but at the very least it will be a good start.’