Feature / Digital people

04 September 2023 Debbie Paterson

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The NHS long-term workforce plan is all about people, right? Well, not quite. Because underpinning the plan is a reliance on digital systems and IT. In some areas, digital systems will reduce the need for the increases in staff that would otherwise be required – through the use of remote monitoring and self-service tools. But it will also mean staff working in different ways and having the skills to be able to make the most of the digital revolution.


James Freed is deputy director of the Digital Academy for Health and Care, which supports digital learning and development in the NHS and social care. He anticipates the need for a major upskilling of staff to make the most of digital opportunities.

But to understand why digital is important, he says we must start with the concept of value. And the quadruple aim (see box) – which is internationally recognised as a definition of value – is a good place to start:

  • Improving the health of the population – encompasses prevention and having longer, healthy lives
  • Enhancing the experience of care for the patient –better outcomes and an improved patient experience
  • Reducing the cost of healthcare – value for the taxpayer. Increasing demand means the absolute cost of healthcare provision is unlikely to reduce, but it is about keeping the rate of cost increase below the increased rate of demand
  • Improving staff experience of providing care – encompassing work/life balance, staff wellbeing and ensuring that staff feel safe at work.

Mr Freed, former chief digital and information officer for Health Education England, says NHS bodies should always be looking to increase value and maximise the rate of increase of value. He believes one of the most important ways to do this in the modern health service is working digitally.

Digital systems can help improve population health – for example, with data analysis helping to target specific solutions on specific population groups. They can enhance patient experience through virtual monitoring, faster diagnosis, better booking and improved communication. They can improve efficiency by performing routine or standard tasks and facilitating care in the community instead of inpatient admissions. And they can support staff, taking on some of the administrative burden and giving them more time to focus on their patients.

People often cite Moore’s law when considering the growth of technology – it suggests the power and the opportunity that digital offers the world will double every two years. This appears to hold true for the NHS, where digital opportunities and solutions are being proposed in almost all frontline and back-office areas.

digital_James Freed

Mr Freed (right) offers anecdotal evidence of the digital takeover – in NHS England’s clinical entrepreneurship programme in 2021, of the 64 innovations proposed 63 were digital.

So, digital is a toolset that is exponentially increasing and gives NHS bodies the opportunity to increase operational productivity. There is always a ‘but’ and, in this case, Mr Freed says it comes in the form of a high failure rate for digital innovations.

This must be understood and accepted, requiring a different mindset than when investing in other programmes. But it can be addressed by education and training. Three fifths of the reasons for failure are cultural or skills-based, he says.

To achieve their digital potential, NHS bodies must be digitally willing and able – and this applies to NHS staff too.

Digitally willing and able NHS bodies will make changes quickly. Changes that are delayed or deferred simply mean getting the value from that change is deferred or simply not realised, he argues. Organisations, such as Amazon and Booking.com, change their model hundreds or even thousands of times a day. Small changes are made to their websites to test hypotheses about what will improve the end-users’ experience and increase sales. They analyse what those changes mean in real time so they can be adopted or reversed, which means value is achieved very quickly. To do this, the organisation’s senior leadership has to support this level and pace of change.

Mr Freed recognises this approach cannot be adopted wholesale in the NHS because patient safety is of the utmost importance. But mechanisms that reduce the risk of harm can also prevent other changes being introduced at pace and, therefore, delay increasing value.

‘Not all digital projects are patient-facing and sometimes not making the change could also cause harm,’ he says. An example would be delaying small changes to electronic patient record systems as part of a full rollout.

For the finance community, Mr Freed has a simple message. ‘Money enables change to happen, so finance professionals have to support digital changes and at pace,’ he says.

To do this, he suggests a change in approach to business cases – they should be considered a bet, not a promise. His logic is simple. ‘A good business case is an assessment of options, including their cost, that enables a decision to be made as to the best option. As no one can see the future, that selection is always a best guess based on the available information. So there is always a risk the business case will fail.’

Simply altering the perspective means this risk is acknowledged and the expected benefits are a best guess of the outturn based on the information available at the time.

Assessing options

Mr Freed is not suggesting business cases are not required. But he wants them to focus on testing the options and proposals. It may mean revising the approach to developing business cases, investing more money in the discovery phase to really understand the problem and test the assumptions in the options appraisal.

But this should mean the best possible assessment of the benefits is included in the business case and weaker proposals do not get past this stage.

‘The business case should be based on what is known,’ he says. ‘There is no point in writing lots of information to “de-risk” spend if the case is based on guesswork.’

An iterative approach to investments can be more effective and quicker. ‘Make the case for an incremental spend. See if you are right. And then continue or stop.’

The outcome, he suggests, is that scarce resources can be invested in proposals with the best possible chance of success – though this is still only a chance of success; it may still fail. This should be accompanied by a recognition that failure is not necessarily anyone’s fault.

It could require changes to an organisation’s governance processes – to facilitate good decision-making at pace, rather than being a process for decision-making. This is difficult as it means a change in culture.

Changes in culture will often be driven by the boards, so the Digital Academy has invested in its digital board offering with NHS Providers. This development programme is designed to support boards as they lead the digital transformation agenda.

Upskilling staff

Currently, not all staff working in the NHS are digitally willing and able. One way of assessing this is to use the Department for Education’s Essential digital skills framework for life and work. A recent report, UK essential digital skills for work, published by FutureDotNow identified that only slightly more than a third of staff in the medical industry can perform all of the essential digital work tasks, while 15% cannot undertake at least one task in each work skill category.

Mr Freed says the NHS ambition must be to support an escalation of the skills of all staff to be able to use digital, so they can contribute to teams that increase value.

Some of the changes simply enable staff to do their job more efficiently. A survey of nurses recently concluded that, to do their jobs well, they needed a smartphone or tablet-style device, connectivity wherever they are and the ability to read and write to an electronic patient record. In addition, NHS bodies must stop writing policies that prevent this. Part of digitally enabling staff is asking them what they need and working out how to provide that. It is giving them permission to change the way that they work and the tools to make that change.

Digital systems are part of the answer to delivering a sustainable health service that meets demand in the optimum way. But the systems will only be as good as the people using and operating them. And the work to equip the NHS workforce with the appropriate skills is just as important as accessing the new digital devices and infrastructure. And, according to Mr Freed, it has to start now.


Debbie Paterson is the HFMA’s senior technical manager


Triple aim and fourth dimension

The Health and Care Act 2022 introduced the triple aim for all NHS bodies in England, which means they have to have regard to the likely effect of decisions in relation to:

  • The health and wellbeing of the people of England
  • The quality of services provided to individuals
  • Efficiency and sustainability in relation to use of resources.

Although a fourth aim around staff experience is not explicitly included in this requirement, it could be argued that it is necessary to ensure that quality services are provided to individuals.

In Wales, the quadruple aim was used to develop A healthier Wales: our plan for health and social care

Useful links and resources 


There is a digital skills development network in every NHS region. Finance staff can also get support from their HFMA branch and from finance and procurement skills development networks.

As part of the Delivering value with digital technologies programme, the HFMA offers three bitesize online courses free to NHS staff:

  • Introduction to digital transformation
  • Making the case for investment in digital transformation
  • Change management for digital: making it happen
  • To join the HFMA’s digital network, please complete this form: hfma.to/sep236

One NHS Finance celebrates digital innovations as part of its innovations programme.

Supporting documents
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