NHS at 75: The huge promise of technology – with Navina Evans and Penny Pereira Episode 34 of the Health Foundation podcast

Jennifer Dixon:

In this series on the NHS at 75 we've been looking at the big challenges and opportunities ahead. We know that part of the future has got to be greater use of technology, especially with artificial intelligence coming at us really fast. So in this last pod in the series we ask, how can we best exploit the opportunity from tech to benefit patients, the public, care staff, and the taxpayer? By the way, we're recording this on the day the landmark NHS workforce plan is published, so lots in there about this too.

With me to discuss all of this I'm delighted to welcome Dr. Navina Evans, Chief Workforce Training and Education Officer at NHS England, where she's been since July '22, and very much behind the workforce plan published today. She's a doctor and a specialist in psychiatry. And Penny Pereira, who's a senior staffer here with me at the Health Foundation. Penny is an expert in process and system redesign in health care and has worked on these for many years, both with us and before that in the NHS and at the NHS Modernisation Agency. So welcome both.

I guess the first place to start is the workforce plan, which I thought it looked very sensible, lots of new staff planned to be trained over the next 15 years and retaining existing staff. So just your immediate response, it must be huge relief and accomplishment I think to see it over the line, particularly getting past the Treasury.

Navina Evans:

Yes. It was a massive piece of work and it was a collaborative piece of work with yourselves and other partners in the sector, the professions with services, with higher education, and it also builds on previous attempts at doing this work, my colleagues in Legacy HEE and with the department. So it feels like a real joint effort. And it feels like, for me, we were responding to something that, I don't want to be dramatic, but it's a moment in time when we had to I believe, otherwise it was a turning point for all of us in the health system.

Now it's scope, it's very ambitious, I believe, however, some people will say it doesn't go far enough. And I think probably that's true, but we want to be doing things that are deliverable. And the other thing I would add is that it's going to be iterative, and to me that's another huge achievement. So in 2 years' time we will have to update it and we are committed to it being made public.

Jennifer Dixon:

That's fantastic. Now I know there's 151 pages, Penny, and it was only published a few hours ago, but I'd be interested in your immediate response, particularly given your background in quality improvement and management.

Penny Pereira:

I guess what struck me is some of the things that you're saying, Navina, that I think I seem to align with some of the principles of improvement. So that focus on finding the right balance between ambition, and yet something that feels deliverable, and that principle of iteration is going to be really critical so that people can see the vision, but they can also know and adjust as this connects with the very busy and pressured reality of the health sector at the moment.

Jennifer Dixon:

Navina, my eyes were caught on the chapter on reform, particularly where technology is mentioned, because this is the third of a three-part series on the NHS at 75, and we have focused on a couple of things. Long-term planning is one and this plan is an example of that. But the second thing is the hope of technology to help reshape care and improve productivity and improve working lives of staff. So I just wondered if you had a flavour of the ingredients that you could just outline for us.

Navina Evans:

I think if I picked on three things that I want to say here is that the way we deliver care has been sort of lagging behind innovation and advances in technology. And if I think about the way we deliver other services in life, shopping or leisure or travel or whatever, we in health care haven't really kept up. And during the pandemic actually we were forced to do things and adopt technology.

Then there's the second area which is treatments and interventions that is rapid advancing technology. And so I think that's the other bit where the reform has to be in how we deliver our education and training. And so how we learn, how we teach, blended learning, use of technology in multi-professional learning. Many of the universities are way ahead in, say, engineering or some of the other courses and yet we're a bit slower in health and care. So that's the second thing I think that is about what the technology and digital and AI and all of those things which could offer us.

And then the third area is, I think, it also tells us more about how people want to live. And that's not just the population and how they want to live and how they want to use services, including health care services, but also how our staff want to live, and how they want to work, and what technology does for how they want to work. So in the workforce space, if we can't respond to that we won't be able to keep people. They'll go elsewhere, they'll do other things. They're not going to sit around, waiting for us to catch up.

Jennifer Dixon:

So just the headlines, I mean, I think everyone's familiar with the fact that technology might be able to help us shift more care into the community and help with more preventive care. Is that the main one for patients? And also for staff then, what's the kind of flex that you think that technology can help the staff?

Navina Evans:

Again, I think if I say so, for patients I think easier access, better treatments, all those sorts of things that we all know. For our staff I think we need better systems. People tell us how clunky our systems are, how they get in the way, the administrative burden, all of those things.

The second thing I think, we worked on Framework 15, which was a framework for long-term planning for care. And we looked into this a great deal, and there's a misconception that actually technology will mean you need fewer staff, and that's not the case, but you'll need different staff with different skills. And I heard this wonderful phrase which is, you get the gift of time. So you're releasing time for care for the human connection and that human side of care, which is so important and actually critical for people's quality of life and recovery. And that is a big win for us, that technology can bring.

Jennifer Dixon:

I think it was Eric Topol, wasn't it, who coined that phrase, that's a really good one. And just, before I turn to Penny, there's clearly, if you look at the demography and we have looked at that in previous pods, and you see the big bulge of older people that's going to come our way with, including myself by the way, eventually the baby boomers who are retiring, and the frailty and the end-of-life care, where you don't really automatically think that tech is foremost in the lives of those individuals.

What have you been thinking about the use of technology really in that phase of life, that's very sensitive and this huge frailty, huge psychological component, what's been thought about that?

Navina Evans:

I think for me the first thing is not making any assumptions about that demographic and that population. Either that, ‘Oh no, no, no, they just can't possibly do this,’ when many of them can. Or on the other hand are going too far the other way, which is that everything will be about technology and then we start excluding and creating health inequalities because there's a risk that use of technology creates even further health inequality. So we have to be really mindful of that.

And I think bringing into that is also the notion of tackling loneliness and how we prevent it, but also make sure we don't exacerbate it. Technology can be a solution but also could potentially add to it. So that's the other thing.

And then finally, I think there are lots and lots of examples in many parts of the world where people are using technology, especially in remote parts of the country. And we have a discrepancy or disparity in our rural and coastal parts of England, where we have to pay attention to the quality of care people get. And I think technology could be quite liberating at whatever stage. So I don't think end-of-life care or care for the elderly should be excluded, but we should be more sensitive in how we use it.

Jennifer Dixon:

Now, just turning to Penny for a minute. Your interest and expertise is very much in change and improvement. And I know that you did a lot of work during the COVID-19 pandemic on how effective technology was adopted by staff. In fact, you co-authored a really interesting study on that. What do we know about how effectively technology can be adopted by itself, what needs to be in place?

Penny Pereira:

There are a number of different ingredients that we know need to come together, and often one or other of those is neglected, and then you turn around and get surprised with what ... doesn't quite deliver the results that you are expecting. I'm interested in how often it's much more about the actual change process, the way, in what roles and processes and technology need to adapt together, rather than just the technology itself, which will determine the nature of the success and the output.

I wanted to build a little bit on some of the things that Navina was talking about because, for example, when we were looking at the adoption of video consultations during the pandemic, I think what we saw was that you were able to innovate at great pace and start working between people in service departments and people in technology teams in ways that we don't often see coming together well. Often you didn't have the time when we've introduced technologies to pay proper attention to staff wellbeing. And to some of them maybe quite profound shifts that technologies might mean to what gives professional satisfaction, their identity. And sometimes we give a lot of focus, say, to doctors, but we don't necessarily think about the implications for all staff groups.

So I think there are things that we can learn about a holistic way in which we need to be thinking about this. Thinking about the potential of technology, I guess we can't necessarily predict some of the technologies that might be coming down the line. That said, I think that in practice we may end up be implementing new technologies that are already existing in our services. Certainly during the pandemic, what we saw was that a lot of what was called COVID-19 innovation was actually the acceleration of technologies that people were seeing and being able to scale.

Jennifer Dixon:

So it was more spread than totally fresh innovation?

Penny Pereira:

Well, indeed. And it's some of the technology changes that actually catalyse a different kind of model of care. From digital consultations for example, or the way in which you might approach online health promotion or remote self-monitoring. So some of those things may not be hugely innovative from a technical point of view, but if they're introduced in the right way they can enable quite a significant shift in the model of care.

Jennifer Dixon:

And you can see, can't you, that if the pathway was, I don't know, theoretically 10 steps and your technology affected step seven, that all the other steps would be affected, which requires quite a bit of management, doesn't it, to be able to re-equilibrate this pathway. And isn't that quite a tall management challenge?

Penny Pereira:

Indeed, and often managers haven't been equipped with the support to be thinking about innovation or digital innovation. They don't necessarily have a lot of confidence in that. But perhaps more significant, pressures on the agenda at the moment means that people are so focused on the operational here and now.

I think when you think about it, Scotland has a nice model where they show how you need to be thinking simultaneously about the way that roles will change, the way that processes change and the way that technology evolves, and how that develops iteratively over time. And just as Navina was saying, thinking about that from a point of view of the individual populations that you're seeking to reach, without necessarily making assumptions. I think Scotland is a great example of how video consultations, for example, accelerated far faster and have reached a far greater scale than we've seen in England. Partly because they had more comfort with what was necessary in a quite rural environment in a lot of Scotland.

In Newham, for example, where I was working before I joined the Foundation, where the Health Foundation's done a lot of work on the adoption of video consultations, I was also reminded how actually some of the assumptions you might have about comfort with technology can be disrupted quite quickly. There we had a population who might not have had access to a lot of resources, but actually you had people who may be quite comfortable with using Skype and other technologies because they were regularly communicating with relatives abroad. And so their adoption of certain technologies that were then going to be useful to different models of health services, was actually ahead of some other parts of the population, and indeed, some of the staff who were working in the hospital.

Jennifer Dixon:

There's two big things that I took from what you were just saying. The first was breaking down the impact on staff by categorising the impact on roles of technology, of the process of care and of the bigger service change or pathway change, which I think is very helpful because clearly the bigger the change, the more the management load.

And then the second is the impact on patients and the fact we need to skill up patients as well or help support them, give them confidence to use some of the technology, which after all may require more responsibility and more activation in terms of managing their own health. Is that right?

Penny Pereira:

Indeed. And that's why initiative approach is so important because actually that growing confidence of the patient population and the staff population needs to grow together. And I think what we saw during the pandemic is that a lot of people, both patients and staff, ended up using new technologies for the first time and actually found, yes, sometimes there were a lot of glitches, but actually they found that they could make things work. And the opportunity to be able to try things out and maybe accepting they won't be perfect first time and then iterate from there is going to be I think the way in which we'll achieve a lot of benefits at the pace that we need to. I think we should be thinking in that mode of change, rather than the major IT programmes that are 5 years in the planning and then a big bang launch.

Jennifer Dixon:

Navina, that sets us up very nicely for asking you a little bit about preparing staff first for these new technologies, whether they affect their role and mainly just their role, or whether it's a bigger process or whether it really is the whole service pathway. Can you say a little bit about that? There's a lot about that in the workforce plan, which is very helpful.

Navina Evans:

Yes. NHS England and Health Education England as was, as it happens for a ... well, I think 2021 pulled together a digital workforce plan, which was two-pronged. One was about the capability of the experts if you like, or people with the digital technical skills and roles and things like that across, because there's a lot of variation across the NHS. But the second actually doing a kind of assessment of capability of existing staff and senior staff, but also how we build into the curriculum for all of our clinical staff. What are the digital, technical, capabilities, skills that are core to every single professional? And especially professionals who are patient-facing or whom traditionally you might not have thought would need this kind of support.

And so we started to implement that and embed some of those findings in our work. But I think we absolutely need to go faster and further, otherwise we'll have service models, we'll have treatment pathways, we'll have innovation, that we don't know how to deliver. And I just remember the days when we introduced the electronic patient record in my trust years ago. God, you would've thought the world was going to end, but actually it was because so many clinicians had been so used to the files and paper and paper records, became really anxious. And what was clear to me was that the way we implemented it could have been a lot better. We didn't prepare enough, we didn't support people to understand. It was sort of, ‘Right, we don't need paper anymore, we'll go to this. And we've got six months to make the change.’

So I think that's just an example of things that we need to be mindful of. And just listening to Penny earlier, I think what I heard was there's a lot of behaviour change, culture shift, helping people to feel confident, which is really required.

Penny Pereira:

Yeah. I mean, I think that confidence is so critical. Again, it's something we see across our work. I think staff need to feel that the technology is going to enable high-quality care, and actually sometimes there's some questions about that. They may not be able to see the route to how this is going to enable the quality of care that they want to provide and what mode of working that will give satisfaction to them and their colleagues. So I think that vision needs to be sometimes clearer than it is at the moment. And that, even if they can see that vision, the experience of the implementation of technology in the NHS will mean that we're often starting with a degree of cynicism from among staff because their experience hasn't been great in the past.

I think some of the things that can help us build that confidence is to involve staff through the process, rather than them just get new technology, new process at the point of implementation. We need to be thinking about how we co-design the approach to new pathways, new technologies, with the whole range of staff that are involved. And when we're thinking about training, for example, I remember my first experience in the health sector a long time ago was introducing booked admissions from GPs to hospitals, and then from allowing patients to book the date of theatre. That involved quite a lot of use of basic technology and process change. We spent an awful lot of time thinking about what this would mean for the doctors and nurses and we didn't really think about the kind of training and role satisfaction implications for the admin staff, whose roles were perhaps more impacted than others.

Jennifer Dixon:

Navina, that sort of relying on undergraduate training or medical school is quite a slow moving thing, isn't it, and yet this technology world is very fast moving. So this implies constant on-the-job training of some sort, doesn't it? I haven't read the fine detail of the workforce plan, but is that the ambition?

Navina Evans:

Yeah. The detail isn't in the long-term workforce plan, but it makes a reference to other plans that we are carrying out. And so that is the digital workforce plan for example, is about paying attention to the fact that it's a lifelong learning process. As Penny says, the importance of just not assuming, and we're all a bit ... Clinicians or people who've been around a long time, it's a bit embarrassing to say, ‘Do you know, I don't understand and I don't know how to do this.’ You hear people who are proud of saying, ‘Oh, I'm really bad at technology. I don't know how to share my presentation on Teams because I just can't do it.’ But we say it as if it's something to be proud of. ‘I'm too old. I'm too old to learn.’ And then I remember someone saying to me, ‘No, just learn it. Learn and you can do it.’

But I think sometimes I know I said, ‘Oh, I'm too old to do it,’ but it's because I was afraid that if I tried to share my presentation on the screen, I'd get it wrong in front of 15 people who are terribly important, they'll think I'm stupid. Or even worse, I'll share the wrong thing and they'll all see my emails or something.

Penny Pereira:

I think part of the solution here is recognising that the nature of changes we need in the health sector now, I mean, they're beyond what people digital innovators can achieve on their own or process improvement of people or managers.

Actually, what we need is, a multidisciplinary transformation team. We talk about multidisciplinary team working in the health sector all the time, and actually I think we need to use a similar paradigm for thinking about change. And what that means is that, yes, everybody might need to have a little bit more knowledge around the potential of technology, but you can look for the people with the expert digital skills. They need to be able to work much more confidently with people who have the process design skills and the project management skills and the patients who can bring lived experience to the work.

Jennifer Dixon:

So it's a mindset change. And I guess, I can imagine quite a few staff listening to this thing feeling, ‘This is a bit rich. I'm writing up my notes in my pyjamas at night because there's just so much I've got to do.’

So there is a question there, isn't there, about how we can free up time to help staff innovate constantly, as we all will have to do I guess in future to make the most of these technologies, because they'll come thick and fast. So is there a tactical question, Navina, about prioritising time-releasing technology first?

Navina Evans:

Yes, I think there is. From where I'm sitting, and I'm not an expert so I listen and I hear, this seems to me that we are in some places so far behind that there's so much that we could do to improve, and also, there's so much variation across the country. That's another big thing that we have to address.

And for me, I think, how do we use our existing structures? How do we use the power of the ICB, the power of the provider collaborative, to start to make these changes happen? Releasing time for care really, isn't it, is what you're talking about, and how technology can do that. I was immediately taken back to my QI roots, and one of the things that persuaded me most to really, really push to embed improvement methodology in the work that we do, is because if you practice a mindset of continuous improvement, you are always asking yourself, ‘Actually, why am I doing this?’ And can we find a safe way, using data and using measurement, to actually make the best use of our time and getting value out of our time?

I remember, we used to do stuff like breaking the rules and every so often assessing how many of the meetings do we have that actually add any value, or how many of our processes really make a difference and can we stop doing them? What would happen if we did? And I think we all have to constantly do that, and I hope that technology can help us to ask those questions and answer those questions safely.

Jennifer Dixon:

You've got a very strong pedigree, don't you, Navina, in quality improvement, as you say. And meantime we've, in another part of the forest in the NHS, there's been the Eden Review, which is really trying to up the amount of quality improvement and quality management systems to get them more systematic across the NHS, and leading to something called NHS Impact.

I mean, I thought the workforce plan was really good, but if I was to say there was a gap, I didn't see the dots joining on that bit, is that fair or have I just missed it in the quick skim?

Navina Evans:

I think it's fair to say that I don't think there's a sufficient emphasis in it, because the work on impact and embedding improvement is probably still being shaped, in early days, because I think it was only this year that we had the consultation and got the commitment to change. Because again, it comes back to changing behaviour and changing leadership. It's got to start from the very top, and we've got to change our mindset around tolerating. And again, how do you embed improvement, as opposed to green, amber, red?

Jennifer Dixon:

Exactly. Not blaming, not judging, but actually encouraging learning. Because we have to do that because the technology trial will mean failure, which is a learning point. And we're not going to get very far if everyone's too scared to try anything, even if they've got the time.

Navina Evans:

Yeah. And we all have to change our behaviour across, from NHS England and leadership and everybody, because we are pressurised to hit targets, that's part of the business that we're in. But we need to find a way to do that with a quality improvement or a continuous improvement lens.

Jennifer Dixon:

And I'll just turn to Penny here because I know your background is partly in this, isn't it, Penny? You work for the Modernisation Agency and you've also been advising on the Eden review as well into quality improvement. What would you like to say about the connection with the workforce plan here to try to aid the and smooth and speed up the testing and confidence in technology?

Penny Pereira:

Yes. I mean, as you say, these big policy developments, they take some time to then weave together and work out how they connect. I think that sense making across these piece of work is going to be important so that the service really knows what that means. So perhaps that's a next step to help draw out the particular implications. For example, if we're thinking about board development, what are the board development considerations for workforce development? How do we connect that with, for example, what boards are learning around how to use digital technology? And then, the commitment to board development that will come around improvement. For boards, as with every level of staff, people need to see this feeling joined up so that we're focusing our effort effectively and it makes sense.

I wanted to just build on what Navina was saying about the different levels of change that are needed to make the most of technology and to release the benefits quickly, because there are some changes that need to happen across integrated care systems, the macro redesign or major pieces of infrastructure, they're going to unlock some of the big changes. Those are really, really critical, but they're going to take some time. And therefore we also need to be doing a lot of the continuous improvement, the incremental front-line work, where actually the leadership and management mode, we need to enable staff to feel like they have permission and have the support and a bit of time to introduce changes.

I think that requires what we're thinking about as a sort of ambidexterity. So people need to be able to both make progress on some of the long term, the big picture stuff, and some of the things that are short term and can be more immediate.

Jennifer Dixon:

And on that, we talked about reducing the bureaucratic drudge, you did, Navina, earlier, that's driving staff wild at the moment, the bureaucracy. It's a question of I guess where are the big voices on the non-clinical innovations that are probably quite boring, that can really help lean some of those, I would say ... I'm not just talking about back office functions, but I'm also talking about things like natural language processing that can just reduce the need for the keyboard and the screen. I don't see the national backers of those sorts of things. You see the John Bells on the life sciences and innovation that way and AI in the clinical sphere, but not really on that side. Is that accurate do you think?

Navina Evans:

I think you are right, Jennifer, because as you were talking I was thinking, ‘Oh, I remember that happening here or there.’ It tends to be from the point-of-care. We hear a lot of these being used at the point-of-care because they're helping people to do their jobs, so it does mean that there's quite a lot of variation in how technology is used to help with these interventions in the back office spaces and things like that.

But at a national level, I think the things that I can think of at the top of my head are HR recruitment systems, from point of days to recruit and working out that actually the system it takes ... There's so much variation, and actually if we put in a good technological solution, actually that really brings it down and could help a lot in the HR world. Now that is something we are looking at. And I know that our commercial director, Jacqui Rock, is looking at in the procurement world as well. But actually, in terms of every day making people's lives easier, I think that we see a lot more of it from service in rather from top down.

Penny Pereira:

It made me think about whether partly this was a feature of the messaging that's been coming out around the gap in management capacity in the health service, and perhaps we're seeing a parallel here. So if the health sector is under managed, then we're not putting enough time and attention on some of those less glamorous, less patient-facing stuff. But actually, that ends up having just as much impact on patient care because actually clinicians and nurses are still bearing the brunt of those things not being addressed.

Could I just say that I think to a certain point it makes sense to distinguish between some of those back office things and then those that are more patient-facing. But I think actually using improvement methods, if you map the systems and processes, you realise there's a lot of interdependencies that you need to pay careful attention to. And for example, you see people deciding to centralise certain activities or functions, be they clinical or managerial, administrative. But because they don't think about it from a pathway process of care point of view, they end up having knock-on consequences that are actually pretty disruptive to quality of care.

Jennifer Dixon:

That's really, really helpful. Just turning now to patients, because obviously there's a big training iterative, ongoing revolution for staff that's needed as we face wave upon wave of new technology. There's also preparing the patient, isn't there. And you might say, well, patients, many have had smartphones for a long time and they do stuff in other parts of their life, but you just think through happened during the pandemic. Suddenly patients weren't seeing their GPs or going to their primary carer, they had to do things virtually and go to NHS 111 a lot more.

And I think now we've snapped back after the pandemic, people are almost expect the same service back again because we haven't really prepared them for a journey that they are on as well with everybody else. And for example, I don't even know what I'm supposed to be doing with my GP surgery at the moment, apart from using the NHS app, I just don't know what to expect. So it strikes me there's a big piece of work to be done there, don't you think?

Navina Evans:

Yes. I think primary care is doing a big piece of work in this space because a lot of scrutiny about face-to-face appointments. And I think one of the things that they were really clear about is what we've understood since the pandemic, was people want different things. Quite a lot of people want face-to-face, but quite a lot of other people don't want face-to-face. Some want telephones, some want virtual. And again, as I think I said this at the beginning, the health care system isn't catching up with how people want to live, or isn't keeping up rather, whereas retail and leisure, they're doing it all the time. They're keeping up with their customers and what their customers want. Whereas we are like, ‘Oh God, this patient's really demanding and being really difficult.’ Well, no, we are the customers. I'm talking about myself as a patient.

So I think one of the things that NHSF, for example, Joe Harrison is leading a piece of work for NHS England, which is around actually looking at the app and making it really user friendly. And taking into account the fact that some people don't want to be able to do everything on it, some people do, and so how do we make that happen? That's something I think for us in terms of the leadership community in health and care sector about keeping up with what our service users expect and need and have a right to.

We need to do that in training education as well because our trainees want to train flexibly. They want to have the ability to have time out and then come back. Or they want to stay in the same place and some of them want to rotate, some of them don't want to rotate, and all of those sorts of things. In the workforce plan we try to reflect that for workforce. So coming back to patients then, I think there's a lot we could learn from the cooperative or John Lewis or Sainsbury's about how to respond to what people want.

Jennifer Dixon:

But how does it work though, Navina, when people are just seeing a sum total loss? ‘I absolutely want to see my GP,’ and it just doesn't make sense for that to happen. I mean, I guess you can make things more convenient by saying you don't have to see your GP, you can do this virtually or some other way. It's almost preparing people for saying ,it's all right not to see the GP because this can be done better. But where is that narrative, I guess? Is that something we need to work on?

Navina Evans:

I think it is something, and again, we see a lot of variation. And my experience is that where people really honestly use their patients or the public or the communities that they serve to design their services. I'm coming to co-production because I'm a big fan of co-production. We say we do it, but we don't really. We're quite good at maybe doing a bit of consultation and getting feedback and maybe people involvement, but we don't really do co-production, because then you have ownership of the service with the service users.

And I think I'd look at Kaiser Permanente, they have members, they call them members, don't they? And they are actually the ... The patients are their members, and they co-designed their services because it also changes the payment model. So they have a financial incentive to change the way they behave and how they use their services. Now obviously we don't have that system here, but there are some of those principles which you can do. And I think in some parts of the country where you have the primary care, you have the social services, you have the community centre, you have the local hospital, it's like an anchor system that is about learning, training, education, but also how people use the services. So I think that's where we should be going.

Jennifer Dixon:

And in fact, patient centred care is the phrase that came to mind.

Penny Pereira:

I mean, indeed. Co-production, patient centred care is a pretty critical part of improvement work. And yeah, for example, the adoption of technology that we saw in Scotland, co-production was embedded there in a way that I see much more scattergun in the health sector in England.

I think one of the lessons here is that actually we maybe introduced technologies very quickly, we particularly did that a lot during the pandemic. And we maybe saw certain things like telephone or video calls to primary care or to outpatients. We saw them have quick uptake. I think it would be really disastrous for policy leaders and managerial leaders to present that as job done or think that you can simply scale from there. Because actually, what we're saying is that we do now need to go back around the loop and make sure that we are doing the detailed work that understands, ‘Okay, which patients in which scenario will this be the right thing?’

And then think about making sure that we have high reliability, because actually people are used to working in systems that are not very reliable. And that's why patients and staff are constantly building in duplicative processes, just because they're so worried about patients getting lost in the system.

Jennifer Dixon:

Very good point. And it links back to what Navina was saying earlier about inequalities and different communities having different needs and different ways of approaching health care, and different levels of confidence too.

Penny Pereira:

I think what we've heard very strongly is that actually paying proper attention to equity in relation to access and experience, that's not just really important for the quality of outcomes that we get, but it's actually really important to buy in from staff. So we're hearing people are blocking the adoption of new service models and new changes, unless they can see that actually proper attention is being paid to equity.

Jennifer Dixon:

Very interesting, thank you. Perhaps if I just finish with one question, which is, how are we going to keep track of this vast landscape strategically to make sure bits don't get out of kilter, given the interest of the commercial sector? How are we going to track that and iterate in the way you've both said?

Navina Evans:

I just want to go back to the simple basic principles. It's really exciting. It brings an awful lot of hope, which is fantastic, and we want people to be innovative and we want people to be free to have great ideas and make things happen, but at the same time we want some discipline and some rigour around this, otherwise it could be very costly. So my solution is embedding improvement methodology. It's my answer to everything. The discipline and rigour of improvement methodology is just something that's simple you can apply to virtually everything, but it's hard to do because it's a discipline.

Jennifer Dixon:

Thank you. And, Penny?

Penny Pereira:

Obviously to agree with Navina, and there that stitches together I guess the workforce plan with NHS Impact and the opportunity for us to be using the improvement ideas and approaches as the way in which we're delivering on some of these big goals. I guess that idea of having some simple principles to guide you through complexity is a key improvement principle and I think would work for us well here. So I guess if we make sure that we're always starting with the need or the problem, the priority for patients, rather than starting with the technology and the product, and making sure that we're holding likely the pressures from technology providers in that.

And then making sure that we're funding and supporting the change process in totality, not just the technology, because that's going to be critical to realising the benefits. I tend to find that slightly cheesy analogies work for me when things are complex. If you think about innovation as a light bulb, that's often the icon that's chosen, it's very easy to get blinded by the shiny end. But actually it's the screw bit, it's how it will fit in, and then it's the light fitting, it's the power supply of the resources and the time, that's actually going to be just as critical to lighting up whatever benefits that you hope to see in service.

Jennifer Dixon:

Well, I don't know about you, but I really enjoyed that conversation, but sadly we must leave it there. Thank you very much to Navina and Penny for their insights today. And that concludes our NHS at 75 series for now. But don't fear, we'll be returning to these and lots of other big issues in the months ahead, so stick with us.

Meantime, thank you very much for listening. Thanks to Kate, Sean and Leo at the Health Foundation, to Paddy and colleagues at Malt Productions. And it's goodbye, until next time from me, Jennifer Dixon.

• The Health Foundation (2020). Understanding and sustaining the health care service shifts accelerated by COVID-19.
• The Health Foundation (2021). Securing a positive health care technology legacy from COVID-19.
• The Health Foundation (2023). Five principles for implementing the NHS Impact approach to improvement in England.
• NHS England (2023). NHS Long Term Workforce Plan.