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What if the word "solution" is generating more problems than it solves?

In this revealing conversation, Rachel Hope, Director of Digital Prevention Services for the NHS, challenges our fundamental thinking about technology and transformation in healthcare.

Rachel is building the architecture for a new kind of health service - one that's digital-first and prevention-focused. With stark statistics showing a 19-year gap in healthy life expectancy between the most and least deprived areas, and 40% of the NHS budget spent treating preventable conditions, the need for radical change is clear.

The conversation digs into the role of human-centred design in creating effective services. Rachel explains how research has transformed their understanding of user needs, revealing unexpected insights like the importance of enabling couples to book vaccination appointments together. By embedding digital specialists alongside policy and operational teams, they're breaking down traditional silos and creating more responsive, intuitive services.

Rachel envisions a future where digital services are so intuitive that "you don't even notice how great they are, unless you remember how bad it was before" - making healthcare as accessible as online banking while freeing up clinicians to focus on care rather than administration.

Whether you're working in healthcare, interested in digital transformation, or simply care about creating more effective public services, this conversation offers fresh insights into how we can rethink our approach to complex problems.
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Transcript

Sam: 0:01

Wouldn't it be ironic if the word solution was actually generating problems and holding back change? Yet we've spent decades buying technology solutions and expecting them to fix bigger systemic problems. Language shapes how we think and in complex systems, the wrong word can drive the wrong decision, so maybe it's time to replace the word solution can drive the wrong decision, so maybe it's time to replace the word solution. Today's guest argues that in a world where the pace of change keeps accelerating, what we really need isn't solutions or products. It's services that can evolve alongside technology and needs over time. Hello, this is Problems Worth Solving, the podcast where we meet people transforming health and care through human-centred design and digital innovation. I'm Sam Menter, founder and managing director at Healthia, the collaborative service design consultancy. If you enjoy listening, you can subscribe to this podcast and the accompanying newsletter at healthia.services.

Sam: 1:11

Today, I'm joined by Rachel Hope, director of Digital Prevention Services for the NHS and one of the system's most quietly radical thinkers. Rachel is in a unique position. She leads work at the intersection of two of the three big shifts the NHS is aiming for in the 10-year plan: a move to digital and a pivot to prevention. Her team is building the architecture for a new kind of health service, digital first and prevention focused. Rachel's background spans policy making and delivery. She brings insight into both the strategic intent and the messy real world complexity. Rachel's background spans policymaking and delivery. She brings insight into both the strategic intent and the messy real-world complexity of actually making change happen. Today, we're talking about everything from AI-powered health coaching to the impact of human-centred design, from designing for behaviour change to rethinking what digital leadership really means. Rachel, thank you so much for joining us today.

Rachel: 2:08

Thank you very much for having me.

Sam: 2:09

How would you summarise the big problem that you are trying to solve?

Rachel: 2:18

Let me just describe what we're doing in digital prevention services and then the big question of why. So in digital prevention services, like you said, we're building digital services to support the prevention of ill health, and that brings together a few different areas. So we have digital services to support screening, so earlier detection and trying to make sure we give clinicians more time for care. Digital services to enable people to get the vaccinations they need. We have a new digital health check, which is a heart health check and helps people understand their cardiovascular risk, and we're building a broader personalized prevention service, which it makes it easier for people to understand their risks and find the services that will help them to stay well.

Rachel: 2:54

Now, why are we doing all these things?

Rachel: 2:56

So we have quite a significant problem in the country.

Rachel: 2:59

So we know that there is an average gap of 19 years in healthy life expectancy between the most and the least deprived areas.

Rachel: 3:08

We also know that long term sickness is pushing people out of the workforce, with a near record 2.8 million people now economically inactive due to long term sickness and a mountain challenge, quite frankly, because we have 4.1 million people in work, but with a work limiting illness, and that is an increase of 1.4 million over the past decade.

Rachel: 3:30

It's quite a lot of stats there, but essentially we've got a lot of people who are struggling with their health and alongside that, if we look at what that means for the NHS, we know that 40% of the NHS's budget is spent on treating preventable conditions. So when we first set up digital prevention services, we talked a lot about the case for taking bold and ambitious steps, and we talked about the reward being the triple dividend. We all want healthier people, but we also need a healthier economy and healthier finances, and by trying to pull that demand curve and keep people healthier for longer, it is not only for people in this country, their family, their friends and social justice, but it's also the thing that's needed to maintain the sustainability of the NHS into the long term.

Sam: 4:18

What's the cost of doing nothing to people and to the health system?

Rachel: 4:21

It's huge, isn't it? We all have seen the impact of ill health on friends and family, so we know what it means to individuals. And then the cost, when you start putting pounds and pennies, is quite significant. So the cost of cardiovascular disease to the economy is £25 billion. The cost of cancer to the economy is £13 billion. These numbers are really significant and I think in the 10-year plan it talked about, the NHS today accounts for 38% of day-to-day government spending and that figure is projected to rise to 40% by the end of the decade. So there isn't really a world where we can do nothing, but we're on an unsustainable footing and that's having real world impacts to the people all around us. So we need to get a grip and we need to help people to stay well rather than just treat them when they become ill.

Sam: 5:10

You've talked about lots of very important numbers in there the impact of this but I wondered if you could share an example of something that's made this problem very real for you. Was there a moment that something hit home, made you realise we need to do things differently?

Rachel: 5:29

Yeah, I mean there are many moments and that's actually the joy of this job we're constantly making progress and it's certainly there are key points in my day to day that you go, wow, the status quo is really not a defensible position. I was listening to a playback the other day of some user research about how the child's health information systems are being used and there were conversations around how, when data was being transferred, one organisation would pick up the phone and check it had arrived with the other organisation because they weren't comfortable with the secure links between the different systems. There was a great moment where they talked about how they uploaded some of the information from paper forms onto the system and it involved the line. I then shout to Carol across the office and she uploads it and you think this can't be happening where we are today, all the way through to looking at the impacts of some of the things we're launching. So we introduced the RSV vaccine for older people and pregnant women in September last year and we've already seen in the older cohort a reduction of 30% of hospitalisations due to RSV just since then.

Rachel: 6:32

So you have these moments from day to day where you see and hear how things are happening on the ground and you can just see how things can be better.

Rachel: 6:39

And then you see some of the big national stats of when we've taken action and I think they're all those moments that make you step back and go, wow, we're having impact, but how much more could we do?

Rachel: 6:51

I think if you also just look at how we're spending our money as well, I think I have some real eye-opening moments. Then we replaced a third-party system that had been procured with an in-house digital service where we could iterate and make sure it really worked but also really look at the cost base of running that digital service and year on year, we're already saving £15 million a year from making that transition. So I think it's some of those moments as well where you take a step back and say we're making the process better for clinicians and the administrative teams. We're helping people stay well and to prevent hospitalisations in the case, better for clinicians and the administrative teams were helping people stay well and to prevent hospitalizations in the case of the RSV vaccine. But also we can save money in doing this. This isn't all about spending more for more. We can really change what's happening out there through new approaches.

Sam: 7:38

How would you describe the state of technology and software across the health system right now?

Rachel: 7:43

It's quite eye-opening when you lift the stone and look at what's going on underneath. I think for the last 15 years progress of digital in healthcare has been slow. It's been uneven and certainly piecemeal. There are many successes which I'm sure we'll come and talk about that's out in the system. But overall I think those last 15 odd years has left us in a world of under adoption. I know 45% of all NHS services have no digital option. We have fragmentation. Nhs England alone runs 50 plus different CRM systems and we know that there's instability too. So there are around 100 and I think it was actually in the digital state of government they announced there were 123 serious software outages in 2024. So we've got quite a mountain to climb to give staff and the public the services that they now expect in other parts of their life.

Sam: 8:42

Healthcare and NHS England is really one of the most complex and challenging areas of public services. I'm interested in your background and what drew you into this world.

Rachel: 8:52

Yeah, I mean I've had a wonderful career. So for anyone listening who thinks going into the public service, certainly do it. So I always wanted to work in public service and I actually joined the civil service graduate scheme, the fast stream, which was brilliant and it gave me access to a huge number of different roles across policy and research and analysis and I learned an incredible lot. But I was really struck by how out of touch policymaking really could be from the average person's experience. Particularly when I started, we wrote a lot of consultation documents with a lot of very well thought through but not necessarily always realistic views of how people's lives would operate. And I think a really great example of that is if you take the world of tax credits, for example. In tax credits which is a benefit, used to be a benefit for people we used to ask for people what their average childcare costs were. Now most people heard the word average and they didn't think of the mathematical equation they had to calculate. They thought roughly what's roughly my childcare costs? And later down the line they were saddled with huge amounts of error and debt as a result of inaccurate forecasting of their childcare costs, which is incredibly difficult anyway, but sitting in Whitehall. That felt like a very credible position to try and work out what we owed people.

Rachel: 10:12

So I think I had these experiences where I watched policymaking not work for people on the ground and actually caused quite considerable harm. And this distance from human experience meant that when I found digital, largely through serendipity, I discovered how it gave me the ability to get really close to how people were interacting with government, to empathize with them, to understand and appreciate the richness of different people's lives and, from that, not just to build great services but to create policy that really met diverse needs. And so I became a real champion of the move away from functional models where digital folks sit in one team and policy makers sit in another, and to move to a space where all professions sit in single teams. Whether you're working on policy or running the service, you come together to have a shared view of the problem and then you make the changes needed, whether that is an implementation challenge with a digital service or otherwise, or just fundamentally change the legislation rather than find all the workarounds.

Sam: 11:13

And is that an approach you've been applying in NHS England as well?

Rachel: 11:16

Very much so, and the NHS is huge and we're still on a journey. But what's really brilliant is what we've been able to do in terms of embed digital teams in alongside operational teams and policymaking teams. So, for example, the vaccinations and screening directorate, who make a lot of decisions about what vaccinations and when or what screening happens and to who. I sit on their senior leadership team, alongside those who worry about the supply chain for the vaccines, the operational demands, those who worry about the policy and the strategy, and we can all share and bring our own unique perspectives when we talk about problems. There's more to go to get us integrated throughout the system, but I think it's a start.

Sam: 11:56

What drew you to public service?

Rachel: 11:58

I think I'm addicted to big problems, problems worth solving, is the honest answer. I've been thinking about it over the years and I've always stayed with an organisation where I found the problem to be really challenging, really wicked, but where there is an opportunity to make huge change. I used to work at the Department for Education, which was brilliant. It was all about realising the potential of children and we made some really, really significant moves and when I left I said, well, the only place I could go next has to be the NHS, because when you're not realising the potential for children, the only other thing you can do is save lives. So I've always been attracted to this idea of trying to make the country better for people within it and to really tackle some of the biggest problems, of trying to make the country better for people within it and to really tackle some of the biggest problems.

Sam: 12:49

I'd love to know a bit more about your background. Can you tell me a bit about what you were interested in as a young person and how that led into the work you're doing today?

Rachel: 12:57

So I grew up in rural South Wales on a sheep farm, which is my dad's sheep farm, but previously my grandparents and all my family have been in the farming community and that gave me a few useful life lessons.

Rachel: 13:14

One was the value of community and community spirit and always helping each other out. Farming can be incredibly unpredictable. Whether it's a change of government policy to a change in the weather, there's always hardships as well as successes, so it really relies on a community approach. The second part of it was we weren't very affluent at all in rural south wales and actually looking at the government's initiatives to support people I was around going through at a time when tony blair was talking about education education that was incredibly important to both my future career as in it supported me to go to university and those around me, and it really enabled me to understand the levers that government can pull to really change the outcomes of the children of today, and I think that made me incredibly ambitious for what else could be changed and made better. And then I think, finally, just growing up on a family business, you're constantly thinking about ways you can iterate and improve what you're doing and, quite frankly, a little bit of hard work and getting up early gets you everywhere.

Sam: 14:20

Has DEFRA been an interest of yours as well as the Department of Education?

Rachel: 14:24

I've always been slightly wary of going into DEFRA just because I'd open up a can of worms with the family. My dad still watches DEFRA Question Time in Parliament at home, so I'm sure we'd have some fierce debates. I'm not saying never, but I quite like having my own space to understand and lead with him.

Sam: 14:44

You studied at Saïd Business School at the University of Oxford. What was this like and how has it influenced the way you approach change?

Rachel: 14:53

Yeah, that's another brilliant example of the opportunities offered by the civil service. So I studied there as part of the Major Projects Leadership Academy, which is a requirement for all SROs to go on, and it's a two-year program that's delivered by the University of Oxford and it gets under the skin of both the theory and the application of leading major government programs. So we were in various cohorts with other SROs. So I was with SROs of defence, so launching new warships. Sros in transport there was lots of people talking about new train lines coming in SROs across HMRC, which had some quite similar big challenges with technology and beyond, and that was fantastic because it gave me a real perspective of how you apply different tools and techniques to different problems and, quite frankly, just a wonderful WhatsApp group to message when we need a bit of support.

Sam: 15:55

Let's go back to the problem that you're working to solve and let's talk a bit about some of the things that you're doing to tackle this problem. How are you putting digital at the heart of prevention?

Rachel: 16:06

I think the really interesting thing with prevention compared to dealing with people who are unwell is who you're actually talking to. So if you think about people who are unwell and need treatment, that's a finite number of the population. When you're talking about prevention, you're talking about the whole population. You're talking about prevention. You're talking about the whole population. You're talking about population health. And when you start to think of it like that, on the 60 plus million people in the country, you realise that you can't operate just through the face-to-face channels or the paper channels that we've been operating through and achieve the level of change that's set out, for example, in the 10-year plan. You need to be using digital interventions to reach as many people as possible, as cheaply as possible, so then you can free up the face-to-face support for those who need deeper and more sophisticated care.

Sam: 16:55

The Tenure Plan talks about AI-personalised health coaching and a doctor in your pocket. Can you tell me any more about this?

Rachel: 17:02

Yes, the Tenure Plan is quite heartwarming in that it sets a real ambition for the health system and there's quite a lot of different initiatives that are set out within that. There's some aspects of the Tenure Plan which is about let's get the basics right. The tenure plan, which is about let's get the basics right, so it talks about the single patient record, enabling people to see all the information about you regardless of care setting, which, quite frankly, my granny and others think that happens already. So it's something we just need to do. No more repeating your story or repetitive tests or inaccessible data. We need to get that sorted. So some of that in there as well. Then there's other ambitions, which is starting to harness some of the new technology around AI. Like you say, the AI health coach and doctor in the pocket Now, particularly with the AI health coach, this is about supporting people to navigate to the services that will best support them.

Rachel: 17:57

At the moment, or at least in the past, actually, there's been a tendency to share things and that people will come, but we forget that people have incredibly busy lives. We don't know what we don't know and it's really hard to go out there and find the services we need, whereas actually, if we can have a conversation, whether it's through an AI enabled health coach or otherwise, we can describe a little bit more about what's going on in our personal lives and then be directed towards services that will best support us as individuals. As opposed to Rachel Hope, female from X part of the country, and I think that real shift, which is underlined in some of those ambitions, is a move towards personalised proactive, preventative healthcare, and I'm very supportive of it.

Sam: 18:46

So this would almost be talking to someone who's an expert on the health system as well as on health behaviours, who could pull all that stuff together and give you something very personalised.

Rachel: 18:54

Exactly, and actually you just mentioned the word behaviours. Now that is really key. We are still in a world where we are delivering mostly transactional digital services. Even in my portfolio, we will send out millions of invites every year to invite people to come and have their vaccine that they're eligible for, or come forward for their cancer screening, etc. But what we want to move towards, and we're already starting to build, is a much more personalized service, which means that once we start interacting with you, we know a lot more about you and you can tell us a lot more about yourself, such that we can give you much more tailored understanding of your risks and much more tailored access to services.

Rachel: 19:35

So, for example, through the new digital health check that we've just launched in three local authorities, people are telling us about whether they smoke, what their exercise habits are, their diet and other behavioural factors like that. We're also able to see what vaccinations they've had, what screening they're due and otherwise, and we're able to give them at-home tests at-home blood tests to test for cholesterol levels and off the back of that, we're able to give them a risk score about what their risk of cardiovascular disease is, for example, and then onwards from that, depending on what that risk score is, pass them through into appropriate services. At the moment that's on into the GP, but we're building out local directories of services. So, for example, if I know, sam, you live in Bristol and you have got a particular challenge where you need to exercise more or work on your diet, we can point you to local services, whether they're NHS or from the voluntary sector services, such that you can access them. So that's some of the big work we're developing at the moment.

Sam: 20:39

I was reading something that Malte Gerhold from the Health Foundation had written in Digital Health yesterday, and he was pointing out how lots of the functionality that's talked about in the plan and is being built into the app is about making it easier around existing processes and making it easier to book appointments or access results. What's less talked about is what does a technology enabled care pathway look like, and how do we redesign services and pathways with digital at the heart, rather than simply improving specific touch points, and I think that's what we're really talking about here.

Rachel: 21:15

I mean I'm so glad other people are talking about this and asking these questions, because they're absolutely right, good design is just as important as new technology like AI, and too many digital systems are not designed to meet the needs of clinicians or they potentially even reduce productivity or the needs of users. So I think there's some big ambitions in the 10-year plan that the NHS can just crack on with making vaccine records more available, which we're on with at the moment but there are other areas where we need to be much more humble and we need to set ourselves up to really test assumptions early. So we think about blending human and AI services and how that might like we talked about drive behavior change, but also, in doing that, we're not just creating these new digital systems that sit across existing workflows. We're getting under the skin and we're saying, right, well, how can this be done? How can this be rethought and done completely differently? And that's where we really need to learn as we go.

Rachel: 22:18

So we need to start by doing, we need to start small and we need to scale. You know it's easy to tell someone they're overweight or they should stop smoking or other things, but actually it's going to be quite a pathway redesign to make sure we're directing people into the right type of care. Particularly when you think about some of the new medicines that are coming online, like the new weight management drugs, we need to find the right pathways for people to fall into as they go through our services. One of the things that you'll hear and people talk about all the time in the NHS is we do these wonderfully fantastic, innovative solution well cyst services. Actually, can we stop? I hate the word solutions. I don't want to accidentally drop it in. I hate him in a passion.

Sam: 23:02

You know. It suddenly occurred to me that that word is responsible for so much that's wrong in the system. I couldn't agree more. People sell solutions. Technology is sold as a solution where it's a part of the solution. You know the fact that it's been sold as the solution, so the problem must be solved.

Rachel: 23:43

But language has so much impact If you use. What we need is for digital services attached to good design to be an evolving thing, because the problem will change, our understanding of the problem will change and what we do as a result needs to evolve. And solution implies and we do it too often in the NHS that there is a problem of which we can probably have a nice big IT procurement exercise, buy an off-the-shelf solution and that will be the end of the problem until five to seven years time or longer when we do another big exercise, whereas in reality, and particularly in this world where technology is changing so rapidly so we know that just the computing power alone means that we're doubling the power of AI every nine months. It'll be 10 times more powerful in two years. The idea that you're going to procure a solution that's relatively static for a long period of times means you're guaranteeing you're going to be out of date by the time you're coming to replace that.

Rachel: 24:43

But more broadly, it separates out the functions, which I think is what I have the biggest problem of. It thinks about digital being a technology solution that is led by a function and dropped into whatever situation. It will be a workflow or some part of a person's journey, whereas in reality, what we need to be doing is constantly evolving the operational rules, the pathway design. Maybe it's the policy or the legislation that needs to be redesigned, and the digital service needs to evolve and adapt to get the best outcome. So it should never be thought of as a solution. It can be thought of as just a really great service that we're going to keep improving over time.

Sam: 25:23

It's part of the solution, but it's not the solution. You know, related people often think that transformation is just about technology, but actually it's about people. And as it becomes increasingly possible to do anything we want with technology, how do we make sure that we put people and their needs at the heart of change?

Rachel: 25:42

I think that's where human-centered design, which I know we've spoken about in the past, really comes into that. So we've got to make sure that we have teams that have the skill sets to get under the skin of the problem, that can do really, really great design and think about what people need. Like I say, have a bias to action and experimentation, get products out there, see how they're working, iterate and change them in response to feedback, and what all of that is doing is it's building trust. It's building trust for those who are using those digital services, because they can see how the services meet their need and where it's not. It's changing, therefore, to meet the needs of that person, and it's also giving that person the ability to make change themselves, because they can suddenly say well, we can do the way we do. This thing can be different, and I can make sure the digital services change to enable that.

Rachel: 26:45

So I think that's people are at the center of everything, and they think this also touches on points that you'll hear a lot of people talk about across the NHS, which is we do fantastic innovation in pockets, but we really struggle to spread that innovation around the system or scale, and I think that problem is eminently solvable.

Rachel: 27:08

I think we've already shown that can happen through some of the services we deliver, where we start small and then scale rapidly, like our new recorder vaccine service. We started small and it's now in every maternity unit in the country, but what we need to do is, as leaders, create the conditions to enable services to be scaled, and that really does mean for any service. That doesn't mean creating big products that are always delivered by national bodies. That means designing a digital centre that supports and equips a decentralised system. So we have a sort of from anywhere to everywhere type policy, and that means it can be a digital service that's created nationally and iterated and developed as it gets rolled out, or it can be digital products that are created locally but then supported to go nationally, and at the moment we're just missing the leadership that bridges the gap between these different types of organisations within the NHS system.

Sam: 28:14

We did some work with NHS Gloucestershire just after COVID, when there were huge waiting lists for mental health support. The idea was initially to create a mental health dashboard where people could monitor how long it might be until they could see a clinician. But once we got out and spoke to people young people, mental health professionals co-design revealed that there were lots of other useful services that people could access. So actually it was much more about signposting and triaging and what was needed was a support finder rather than a dashboard. I mention this because it's a good example of where discovery research has got to the root of a problem and changed the direction of a project. Have you seen similar examples of this type of pivot in your own work?

Rachel: 28:58

Yeah, many times, both before the NHS and my time within it, I guess even most recently. If we think about appointment types, it's quite easy, if you're thinking about building a book of vaccine service or a screening appointment service, to think, right, well, we'll work out the amount of time that's needed for a screening appointment or vaccine appointment and we'll build it around that. But actually through co-design, you're able to think about the nuances that those who administer the vaccine face day to day. So, for example, particularly with our elderly cohort, they actually quite like to come as couples that go at the same time and they'd like the ability to book an appointment for two people so a joint booking. And so we need to create the ability to book an appointment for two people so a joint booking and so we need to create the ability for that to happen. We also know that many people are eligible for more than one vaccine. So when working with them they say well, actually we need a certain appointment type if we're going to administer a COVID and a flu vaccine at the same time. And it's all through research that you're able to look at what's really needed and therefore create a service that's just intuitive to what those on the ground need and what people want to book, and that ultimately supports take up. So you see, those things happen all the time.

Rachel: 30:09

I think one of the ones that sticks with me, from which really changed the direction of a piece of work was in the Department for Education, where people kept talking about well, we really need a new identifier for teachers. We really need to understand cradle to grave. What's happened to these people? Where have they trained, how long do they stay, what do they earn? Why do they leave?

Rachel: 30:30

And we got under the skin of this sort of let's go create a new identifier and realized it was actually there's a real problem with just how people were able to find out what their teacher reference numbers were, how we were able to stop them becoming quite messy, for example, when someone changed their name, for example, if they got married and things like that.

Rachel: 30:51

And what we were able to do is we were able to build a digital service which was as simple as enabling teachers to look up what their reference number was as simple as enabling teachers to look up what their reference number was and that enabled teachers to identify where they had duplicate numbers. It also enabled them to access it for lots of other reasons, which was a key pain point, and once we'd got this service in place, it was able to raise the quality of the teacher reference numbers. We were then able to reliably use that teacher reference number to look at the data we already hold about these people and do the really interesting policy research around who stays, who leaves, are there any patterns we can identify where we can do more to retain some of our best quality teachers? But what was originally envisaged as, quite frankly, a big procurement of a data store turned into a interactive digital service for teachers to access their reference number, which was really interesting and saved the government a lot of money.

Sam: 31:48

Research carried out by Lloyds last year estimates that 1.6 million people in the UK currently are living offline and around a quarter of the UK population have the lowest levels of digital literacy or digital capability, which means they struggle to use online services. When you're planning radical change at a population level that is driven by technology, how do we make sure that that change works for everyone?

Rachel: 32:15

I think right from the start, it's about framing what we do not just as creating a digital service. It's about creating a service for people to access a vaccine or otherwise and in doing that, we need to think about the digital journey. How do we make that digital journey as accessible as possible? We have really high accessibility standards. We have an accessibility lab in AHS England where we can go and test out our services. We want to ensure that there is support on the ground for people to access those digital services as well. We have NHS app champions who go into libraries and help people with libraries as an example, help people access it. But then, alongside that, we have to ensure there are non-digital routes for people to access these services at the same time, and that has to be given as much thought as the digital service. And in fact, I saw a really great example the other day that was actually outside the world of healthcare, where this team had done a beautiful design where they were able to show people coming in and out of the digital journey.

Rachel: 33:23

Because I think too often we think about it as binary Someone's either in a digital journey or they're not able to access a digital journey, whereas in reality for quite a lot of our population who may struggle with some of the digital aspects it's not all of them, it's just at key parts. And how do you enable people to go back into the journey where possible? And actually, and it probably comes as no surprise, but when you look at users of the NHS app, the over 60s are some of the biggest users of the NHS app. They have the greater health needs, but they are really big users of the NHS app. So what we've got to do in we have to design for everyone face-to-face and paper and non-digital routes as well as digital. But at the same time, I think I have to make the case continually around the number of people who cannot access digital services, so we don't walk into the situation with a number of pre-built assumptions which turn out not to be correct.

Sam: 34:12

One thing I've learned is that human-centred ways of working are as much about mindsets as they are about process and tools. So the mindset of someone who's been through medical school can be very different from the mindset of someone who's been working in design and research, and I don't think there's a right or wrong. It's just different routes you take through your career. Clinicians seek certainty and clarity, where designers and researchers, on the other hand, are more comfortable working without ambiguity and exploring multiple perspectives and iterating towards solutions. In your role, you're working with people with skills at both ends of that of that spectrum. What have you learned about ways we can bridge these different mindsets to build a shared understanding and collaboration around service transformation?

Rachel: 34:56

Yeah, it's a really interesting question and I hadn't quite appreciated the true difference in mindsets until I entered the NHS, and one certainly lends itself to some of the models of delivering digital services which we've been trying to move away from doing rigorous, potentially year-long requirements gathering, where you try and really interrogate everything up front, think about every possible avenue that could happen, create your digital system and then have a big launch which can be really staged, managed and tested and what we know from the past. But what we've been also able to show some of our colleagues who are from more of a background which seeks that certainty and clarity that you asked about up front, is that actually that carries more risk. It carries much more risk to introduce a system nationally in one big go. Most of us know that who do these digital services? But it isn't a given if you're coming to that fresh. So we've been going through a journey where we've been moving from these much bigger releases of technology to trying to get to a world where we're daily deploying new bits of code into the software product, making changes daily, and actually what we've been able to do over the course of that journey not for everyone but for most is to show actually how that reduces risk.

Rachel: 36:20

That enables us to make changes where we see problems and quickly correct things as well, and I think that journey has been possible by building a shared understanding of what we're supposed to do, but also making sure.

Rachel: 36:33

This comes back to my slightly boring point of multidisciplinary teams but embedding people from different backgrounds, with different mindsets in the single team, so everyone feels that they have an ability to make change happen, as opposed to being a gatekeeper for the change, and that's their one and only moment to make sure something is going to be delivered. And I think that point around focusing on outcomes and iterative delivery can't be overstated. The only sad thing I find yet is I've yet to be able to bottle it up and give it to people as a cold drink. What I'm mainly able to do is when people have lived it, they become complete advocates for it. So how do we enable that change to happen when actually the way I'm enabling it is actually getting people to do it themselves, because we have to go on quite a journey for that to happen at a large scale.

Sam: 37:24

Do you do lots of encouraging people to observe research?

Rachel: 37:27

Yes, we certainly do that and get out there, certainly now the pandemic has ended. It's been brilliant. We've been trying to send quite a lot of people to the face-to-face services and observe some of the non-face-to-face services as well, so people can see what's really happening, because that brings it home. You have less of a theoretical argument when you're faced with what someone's doing in real life.

Sam: 37:48

The ethos that you're talking about very much aligns with what the government digital service was set up to do 10, 15 years ago now, particularly that funding the team so that you can keep on making change and iteration and so on. I mean GDS radically changed the way government approached digital. What do you think we can learn from their success and how realistic is that kind of approach in the health system?

Rachel: 38:10

So I think there's an incredible amount we can learn from the government digital service about how change is delivered, but also how do you get a federated system to respond. If you think about what the Government Digital Service did, it was quite transformational across a number of government departments and wider public sector bodies. It wasn't one single organisation, it was many, with many different leaders, many different political leaders. Even so, that resonates with what we're faced with in the NHS and I actually think some of the core principles that underpinned GDS could apply to a sort of digital era Department for Health and Social Care. So if we think about some of the core principles principles that GDS held where I think the application in the NHS would be fantastic and probably needed right now to realise the ambitions and the 10-year plan so that's one having a really clear digital centre for healthcare which thinks about the strategy for the whole system and so there is that whole system leadership but also has outcomes-based teams that can be embedded into areas that own outcomes. So, for example, in GDS they had their exemplars where they sent in really fantastic digital experts into, for example, the Ministry of Justice and they were deeply aligned with the Ministry of Justice outcomes, whether that's sending digital outcome teams into areas like prevention or the neighbourhood health programme or out to areas of the system and help work on problems together. So that's that whole system change that can happen.

Rachel: 39:47

I also think what GDS did really was get a strong backing from those who could make change happen.

Rachel: 39:55

So GDS had very strong backing from political leaders like Francis Maud, and I think that was really important for when it's hard to keep everyone happy, you're going to need that advocacy to drive forward change and I think that if we can get a really strong digital center with really strong leadership backed by the politicians of today, that could be really important for having some really tough questions, particularly with our software market, about what standards we expect, how data needs to be intraoperable and what we expect in terms of integrations with national products and services.

Rachel: 40:32

So I think that backing that GDS had we can learn a lot from. I also think there's a whole part around how we approach change. I think potentially we've moved on slightly since when GDS set it up, but the GDS mantra of discovery alpha beta onwards was really important for people to have a shared understanding and framework to deliver change that was ultimately user-centered. And while I think we can probably move quite rapidly through the discovery alpha phases now. We've got some really innovative ways we can do rapid prototyping. I think the principle still stands of this sort of test, learn and grow approach, which we can certainly learn from GDS.

Sam: 41:13

How important do you think their cons were to their success? They were very good with slogans and posters important, do you think their cons were to their, their success.

Rachel: 41:19

They were very good with slogans and posters, yeah, and I think um, underpinning all of that um is a value I hold quite deeply, which is working in the open. So it's really important that people can see what you're doing and understand why. So show, not tell uh your work. Show the digital services as they're being developed. We publish public design histories of the reasons why we've made decisions about our digital products. We have various other external communications and all that's important to show what we're doing. And then I think what GDS did really well was had a series of blogs and other communication channels to explain the why and, like we say, give people that shared language. So all of a sudden, people across government were starting to talk in the same way about working in the open and being bold, for example.

Sam: 42:05

A lot of what you're talking about is enabled through collaboration and deep collaboration, and that kind of radical change that you're trying to make happen, I think, is only possible through that deep collaboration between departments and organizations. How are you building collaboration into your ways of working now, and what does this look like in practice?

Rachel: 42:25

Yeah, there's lots of different angles to the collaboration, but I mean, it's the core of how we deliver. So, whether it's like what we spoke about the collaboration with other disciplines, so whether it's like what we spoke about the collaboration with other disciplines, so whether we are working alongside or as single teams with our policy colleagues or operational colleagues, that's hugely important. The other important part of the collaboration is obviously with people who are delivering frontline services. So how we try to deliver our digital services is work with a wide range of different organizations to test and learn. So we start by this is all stuff that quite a lot of us know and love in our toolkits, but we start with prototypes and we test and get views on those. We then start to deliver.

Rachel: 43:13

We try to start to deliver as early as possible because that's the best way we can learn. We'll deliver with a few different parts of the system, we'll learn, we'll then expand, we'll then learn, we'll then expand, etc. And I think it's those collaborations which drive the good products. And once we've got the good products, then adoption becomes relatively easy. It's that hockey stick curve relatively slow at the beginning, where you get the product and the design uh underlying design right and then you see it really take off. Um, I think we we scaled our recorder vaccine service within, in the end at less than six months, because we got that we've done the hard work up front to make it a really valuable service to people out there and that's quite often invisible.

Rachel: 43:55

That work too yes, and it's the hard bit as a leader actually at the start, to buy your team's time to get it right, because there's always a pressure and is rightly applied to say, actually we're investing this money, when are we going to see the return on investment, when are the outcomes or the cash release and savings going to be realized? And as a leader, you have to hold the space for the team to be able to test and learn and get it right before you do the rapid scaling and that those tweaks and changes become a little bit harder. And holding the space what do I mean by that? I mean by telling the story of what you're trying to achieve, building confidence in your area that you do achieve these things and you can achieve it on this particular product or service, and by showing the constant development so people can see there's progress, even if it's not going from 10 to 50 different hospitals or community pharmacies overnight. And then actually, once you've done that, by the time you're scaling, it's just a given that everything's working well.

Sam: 45:00

I've heard the term discovery fatigue used a bit. I think it's a shame.

Rachel: 45:04

I agree and I think the problem is or at least the problem I've observed in some parts of the NHS is discovery not done very well. Discovery which has been too long, very well. Discovery which has been too long, perhaps a little bit navel-gazy, perhaps produced some very beautiful artifacts but hasn't enabled that part of the system to go on and make change. And I think people become quite allergic to lots of slideware coming out of discoveries, whereas actually what a great discovery is and you this is it's relatively time boxed, it's relatively clear on its focus and it comes out with a set of learnings that enables the next phase.

Rachel: 45:48

I think what people often underestimate the power of discovery is is also building that team, building a team which is just working well, has got a shared understanding of the problem, that can then grow and grow to deliver the ultimate product and service. That discovery time is not just about the artifacts that come out at the end of the discovery, it's about the creation of a group of people that are going to lead really significant change. And I think sadly, actually the way our procurement works sometimes when we bring in third party organisations to support us and otherwise, it means we don't have that. It's a group come in, they leave a set of recommendations and they've gone, and that richness that comes with someone working on a problem day in, day out walks out the door and the slideware doesn't quite gain the traction it's needed. So I'm really a huge fan of bringing in teams that don't just do the discovery but go through and do the full build and implementation.

Sam: 46:45

Yeah, I think the separate procurement of discovery alpha beta is not necessarily the best way of running projects.

Rachel: 46:50

Certainly not. I mean, you might, you do need different skills at different phases, but they are additional to teams and it's not about re-procuring and bringing different, different organizations in there's a language thing as well.

Sam: 47:03

So discovery I think I was talking to someone I think it was in nhs cluster show who was just saying you've got to stop talking about discovery, because every company tries to sell us a discovery and what they might mean by discovery isn't necessarily what you mean by the gDS discovery. I think there's a fatigue around that language as well.

Rachel: 47:19

Yeah, I mean, we see it quite often, don't we? That once something's got a bit of fraction, it then becomes used as a sales tactic, and that's what we've got to guard against, which is partly why we need digital expertise within the NHS workforce and I'm a huge fan of rainbow teams, as we call them, but blended teams between permanent members of staff and any third party digital experts we need to bring in to deliver a product or service, because that enables that continuity, it enables the knowledge to be brought through and it also enables a bit of a sense check that we're doing the right things at the right time and a poor organisation hasn't been sold something that won't really get them an outcome.

Sam: 48:06

I want to move on and talk a bit about the results that you're looking for in the vision for the future. So let's imagine you are immensely successful. You managed to put digital right at the heart of the way we deliver health and care in the UK. You create radical change. What does this look like in three or five years time and how does it feel for the public and people working in the NHS?

Rachel: 48:28

I hope we create a service through the NHS that is so intuitive that you don't even notice how great it is, unless you remember how bad it was before. And by that I mean you're able to access what you need when you need it and we don't tie clinicians' time up dealing with lots of systems that don't really support them to deliver clinical care face to face. They get caught doing admin tasks. What I think success looks like and what I'd like success to be for, when I think about what people will experience, is a way to enrich my own personal understanding about what my health risks are be able to have information and access to services that will help me stay healthy, whether it's joining my local couch to 5k club, or whether it's accessing a vaccine at the end of my road in my community pharmacy rather than having to wait for access via my gp surgery, or whether it's having a more targeted approach to when I'm brought in for screening based on my own personal genomic makeup or otherwise. So it's about an intuitive service which feels like it's there to support me to stay well and then ultimately catches me when I'm not very well and makes that as easy as possible.

Rachel: 49:54

I think we've all had experiences of the NHS. I think we've all had experiences of the NHS, and more recently I had a child, so I went through the maternity services, where it was really hard to stitch together the services that were offered by my general practice, my midwife team and then the hospital support services. They'd all talk in different language with different letters, which didn't necessarily explain why things were being offered. I think that's already changing and what we'll probably be seeing is a much more intuitive system where people are not only easier easy to achieve the basic things, but it's explained why. So people feel much more in control of their own healthcare.

Sam: 50:33

The fact that there's even the role of a care navigator feels like a sticking plaster, rather than the way the system should work.

Rachel: 50:40

Yeah, absolutely. I mean, I just mentioned maternity services there. So since I had my son two and a half years ago, we've already introduced the ability for pregnant women to self-refer into midwife services. Whereas when I was pregnant with my son, I had to contact the GP, wait to speak to my GP, my GP then referred me to the midwife services, whereas when I was pregnant with my son I had to contact the GP, wait to speak to my GP, my GP then referred me to the midwife team.

Rachel: 51:06

And all of that now doesn't need to happen. I can do a self-referral into the midwife team of my choice. That midwife team then automatically notifies my GP so that they can record it on their books and be ready to support as needed. So I think that some of that change is already coming, where we're becoming much more efficient but also much more logical for people. But there's so much more to do in the NHS. I think our Secretary of State, wes Streeton, described it the other day as it should be as simple as ordering a takeaway. Now, I'm not sure that's quite the prevention narrative to talk about.

Sam: 51:36

A healthy takeaway.

Rachel: 51:37

A healthy takeaway. We all understand what he's trying to say. We all have experienced the move to online banking. We've experienced the access to taxis or takeaways or whatever, and actually that's where we need to get to with healthcare. We need to not necessarily all be rooted by the GP every time. We need to be able to access the care we need as closely as possible to home or in the home, with home testing, such that we can more quickly get the care we need.

Sam: 52:04

You've been working in transformations for some time now. I wondered if you had any advice you'd give to someone starting out in transformation and trying to lead change at scale.

Rachel: 52:13

That's a really good one, I mean, I think drive and determination will always be needed. That's a really good one, I mean. I think drive and determination will always be needed. So come prepared for whatever you do, it will always have some hard moments that you'll need to dig deep. My advice would be find your allies who are going to help guide you through I think that would be really important and then, as you go through, grow those allies. And you'll grow those allies by doing about some of the things that we talked about Show, not tell. Get some wins in early and talk about them so people can understand what you're doing, why you're doing it, Trust that that works and then be relatively willing to be tactical as well as strategic. Always have an eye on the strategic plan, but be aware we're in a world that's constantly changing and you're going to need to grab some tactical wins along the way to get to that overall outcome.

Sam: 53:04

And similarly, what advice would you give to people working on the ground inside a big organisation who want to create change? What can people do to influence change upwards?

Rachel: 53:13

I think I have that challenge as well.

Rachel: 53:15

How do I influence upwards as well as elsewhere?

Rachel: 53:19

And I think the biggest thing that we've been able to do is not just deliver the change but be able to quantify what that change means, whether it's time safe of clinicians, lives saved, hospital emissions avoided, efficiencies delivered, productivity gained and I think that can be really powerful. If you're earlier on in your journey and you're just trying to make the case for something to change, I think the showing people what's really happening, whatever way that might be. Record something that's not working very well, or get some statistics about the number of people who are not attending, or whatever problem you're trying to solve. Get that information together and try and put it in front of as many people as possible, because you will find someone who says you know what? Go, put your money where your mouth is. I'm going to back you to bring about this change and throughout my career, that's always been when I've managed to break into. A new problem is when I've talked to enough people that someone gets tired enough to tell me to go away and solve the problem.

Sam: 54:26

Determination.

Rachel: 54:27

Certainly.

Sam: 54:29

If you could wave a magic wand and change one thing about the way we do healthcare right now, what would you change?

Rachel: 54:35

I think I would bring about really strong digital leadership. I think we're in need of an overarching strategic direction for what digital is for the whole system, and I think we need someone who is a bit of a superstar to come in and show us the direction, but someone who really knows what good looks like. In terms of the how, we've got plenty of what We've all seen brilliant technology deliver really amazing things, but we've never cracked the how, and we've talked about this on this podcast like, how do you truly enable transformation? And I think you need a leader to come in and say actually, this is what we're going to do as a whole system, marching in unison. This is what we're going to do where there's going to be national services and products, like I said, from anywhere to everywhere doesn't need to be developed nationally, but they need to be national products. This is where we're going to have some guided choice and this is how we're really going to open the innovation bucket and let that go for it.

Rachel: 55:38

I was really struck the other day. I was talking to someone who was a CIO for an international organization and he said to me Rachel, I look after technology in 24 different countries. I do not let them to have their own choice in every single one of those countries. It is absolutely vital that we have a degree of consistency to enable the data to flow, to enable there to be a parity of service. And then I need to give them a space for innovation so they can meet their local needs.

Rachel: 56:10

And he was reflecting on what we have in the NHS, which is almost the reverse, where we start with the sort of local bespoke nature of things and then try and aggregate that out into something which can be a little bit more efficient across multiple areas.

Rachel: 56:24

And I truly believe that face-to-face services need to meet the needs of their population. But what we often miss in digital is the fact that digital doesn't have a geographic footprint. It doesn't need to have that. So what I think if I had a magic wand would be some really inspirational digital leadership for the whole system, and then I would quite like to move to a world where everyone has a shared understanding of what digital is. If I could just do a magic wand, that'd be brilliant. So we move away from anyone thinking about it being the IT team who does some IT procurement of some solutions that drops in to someone's pathway, and start to see digital as a skill set that's integrated into other teams to deliver big transformation. I think that would revolutionise how we deliver services in the NHS, how we deliver services in the NHS.

Sam: 57:17

Good answer. The question I'd like to end on is there something you know to be true but that others might not agree with? So this doesn't have to be related to health and care. Previous guests have talked about everything from non-human intelligence in hearings in the US Congress to ways to build better culture in big organisations. Is there something that's pertinent to you?

Rachel: 57:37

I mean I'm laughing because I was thinking I would say Branston pickle sandwiches are certainly the best sandwich in the world. I know that to be true, but I'm not sure everyone would agree with me.

Sam: 57:47

That's a very good answer.

Rachel: 57:49

I think a more serious answer or what I definitely know to be true, but I've yet to win the case with everyone is something we've talked about, which is that policy and digital can exist in single teams and single leaders, and I think we need to get to a place where we are equipping our leaders to lead change as a whole and not necessarily lead in their function of policy digital communications operations. So I think we've proven that out. We were really successful in having single teams of policy and digital specialists in Department for Education in the part I led around teacher services. I think we're doing it already a little bit in the NHS, but I think we can go a lot further. So, yes, that's a work answer, but I do believe that policy and digital can coexist in single teams under single leaders.

Sam: 58:38

Especially if powered by Branston pickle sandwiches.

Rachel: 58:41

Exactly.

Sam: 58:43

Fantastic, Rachel. Thank you so much for taking the time to come to speak to me here in Bristol today. It's been a pleasure talking to you.

Rachel: 58:50

Very much enjoyed it. Thank you very much.

Sam: 59:02

Problems Worth Solving is brought to you by Healthia, the collaborative service design consultancy for transformation in health care and public services. Find out more about how we can help you deliver user-centred change at healthia.services.