Dr Mona Johnson says that working as a doctor has taught her that people – however much you may wish they would fit into neat algorithms – are always infuriatingly, delightfully messy.
Real people are “amorphous blobs of behaviours that blend and shape in all sorts of ways and, when you contain them with technology, they will colour outside the lines – because that’s how humans are."
Johnson, Deputy Clinical Director of Patient Safety at NHS Digital and a practicing GP, says: “I’ve spent ten years talking with patients. I know they don’t describe things in the way you would in a medical textbook. It would be easy to translate a textbook into an algorithm, but it would be useless because people just don’t behave that way.”
Dr Mona Johnson at Eyam Surgery in Hope Valley, Derbyshire
Johnson is one of a team of more than 80 clinicians working side-by-side with technologists on the design, deployment and management of NHS Digital’s products and services.
Dr Nam Nguyen, Clinical Lead for the NHS website and another GP, says his work is about ensuring that sound medical science, and an understanding of the complex reality of frontline clinical delivery, is part of the DNA of the products NHS Digital delivers.
I'm part of the leadership discussion in the same way that our head of tech is part of it. We're very much intertwined.
Clinicians at NHS Digital, he says, don’t act solely as an assurance, inspection or advisory function – merely checking on or signing off the work of technology teams. Instead, they are crucial and creative participants in the design process.
“The difference between many other government services and NHS Digital is that we have clinician input internally, not as an external adviser, but very much part and parcel of the day to day working of the team,” says Nguyen. “I'm part of the leadership discussion in the same way that our head of tech is part of it. We're very much intertwined.”
The result, says Nguyen, is more useful technology: “If you have a singular way of delivering, you’re going to lose out. If we had a tech first and tech-only mindset, there is a risk that it would fall down when it came to users, but if we’re entirely research-led, we may burden frontline services.”
Dr Nam Nguyen at Woodgrange Medical Practice, London
A new perspective
Akish Luintel is an Infectious Diseases and General Medicine Registrar in London. He took up a 1-year part-time position as the Faculty of Medical Leadership and Management Fellow at NHS Digital in 2020.
He is brutally honest about his technical knowledge before he arrived: “If you asked me what an API or user design or user experience was, I probably wouldn’t have known that at the start of last year. What I’ve learned is how a product is created and managed in terms of expectations and what you can deliver.”
Luintel’s clinical expertise, however, makes him a crucial member of the project team. “I am one of the people responsible for clinical safety – I look at whether the technology we’re creating for the NHS is safe for the patient, and where we are introducing risk for the patient, that risk is mitigated. So, the old adage of ‘first do no harm’ is very, very true here,” he says.
When I joined NHS Digital, I also saw the incredible amount of work that is done in the background.
Luintel recalls that the Shielded Patient List (SPL), a record and ruleset to identify vulnerable patients at high risk of complications from COVID-19, was one of his earliest experiences of NHS Digital’s work.
“I was one of the doctors [working on the front line] in the coronavirus pandemic and everyone was working really, really hard. But when I joined NHS Digital, I also saw the incredible amount of work that is done in the background. For example, the Shielded Patient List was stood up in 48 hours.”
Even once the SPL criteria were issued, clinicians were still needed to help identify patients that might have slipped through NHS Digital’s data analytics. For example, the NHS lacked data that identified patients with severe asthma, one of the conditions listed by the Chief Medical Officer for England in the SPL criteria. The challenge of identifying these people landed on the dining room table of Paul Brown, pharmacist and Clinical Lead at NHS Digital.
“We had to be smart with the medicines data we had. We looked at clinical guidelines and went back to the data to look for patients on certain combinations of inhalers, as we knew it was likely their asthma was severe. This is just one example of how I apply my clinical knowledge to digital issues as a clinical lead,” Brown says.
Leading the team
Clinical knowledge is critical in delivering NHS Pathways, the algorithm-based triage system used by NHS 111 and 999 which manages nearly 20 million calls per year. Any flaws in the design of this system, such as failing to probe symptoms with appropriate language, could have severely negative outcomes at such high levels of usage.
Unlike other NHS Digital programmes that may have 1 or 2 clinicians working within the team, NHS Pathways is a clinically-led programme. A team of 20 clinicians – a mixture of nurses, paramedics and medics who are all registered practitioners – work in multidisciplinary teams within the wider programme. They are led by Darren Worwood, one of the senior clinical leads and a registered nurse.
Worwood explains that NHS Pathways was built by NHS clinicians for the NHS: “It was developed from scratch by a team of clinicians. We don’t just do the clinical oversight and assurance; we actually write the clinical algorithms ourselves instead of passing them on to a developer or technical architect. We translate medicine into questions and algorithms for health advisors to use.”
The result is a suite of algorithms that are used by technical teams at NHS Digital for both the 111 telephone service and NHS 111 online. “We’ve just done a piece of work with the [NHS 111] online team, who are much more of a development team,” says Worwood. “They use Pathways content but digitise it so it can be used online by patients. Recently, we have jointly created the Streaming and Redirection tool used on an iPad in A&E by patients.”
Darren Worwood, who leads the NHS Pathways clinical team, working from home.
Bringing it back to patients
The mantra for the clinicians at NHS Digital is to remind teams that everyone is working in a clinical environment to ultimately improve lives. “There’s a danger that NHS Digital’s work is viewed as purely technical. But what we try and say is ‘the badge is the NHS’. Everything we do is around health and care,” says Brown. “Clinicians have a responsibility to work as an integrated part of NHS Digital, making sure that everything we do is clinically safe, appropriate and effective.”
Nguyen agrees. “When I leave Skipton House (NHS Digital’s London office) people would say ‘Oh, you've got your GP hat on now, or you've got the NHS Digital hat on now’, and I've always given the same reply, which is: ‘It’s the same hat!’ As a medical professional, my deep-seated responsibility is to the health and happiness of the people I serve, so whether that is the hand I’m holding in a consultation, or the person who will be going on to a website to work out what they can do for their health, it’s exactly the same principles and the same priorities; only the context is different.”
Nguyen talks to a colleague at the Woodgrange GP practice
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Last edited: 18 October 2021 1:37 pm