The tangled undergrowth of complexity

Adventurers beware!

Photo by John Barkiple on Unsplash

I am two months into a new job which is incredibly interesting, but also has the potential to be the most intensely frustrating of my life. This of course, can only be working in the NHS. In my case, it’s NHS England (NHSE), transforming the software that underpins the National Breast Screening Programme.

Even in this relatively short period of time working on the programme, you can see the interplay between what the service can currently manage and the evolution of the programme over time. But like many legacy services and long-running programmes, the result of that decades long evolution has meant that the complexity of the system has grown in a way that can seem almost impossible to unpick.¹

Developing a new service on its own is hard enough, but when there’s layers of systems, integrations, and wider organisational and government priorities - it can seem overwhelming.

I know most people hate complexity, but I have learned to navigate my way through it. In my experience, finding the edges of the problem is a good place to start. It allows you to uncover issues faster, but also the flexibility to adapt and change as you hack away at the undergrowth of complexity. Whereas if you think you know everything at the start, any unknowns that emerge can become very demotivating.

What does this complexity look like

Complexity in NHSE is both familiar and completely foreign. The scale of it is also just so vast - on par with the build of GOV.UK (which was four years of my life as part of the Government Digital Service). I completely understand why early GDS leaders just went ‘NOPE’ when faced with it.

The familiar part is the rhythm of a big organisations - people, finance, business cases, information governance, technology assurance. All familiar touchstones for anyone working across a big programme or department.²

There is also the familiar, but massive complexity of integration. It’s now just incredibly vast and spread across so many layers and geographies:

• internal NHSE assurance for your own stuff (technical, information governance, all that fun stuff)

• integration with other NHSE products (for example, NHS Notify or other services)

• integration with third parties, such as the GP IT systems or NHS Trust infrastructure (which can either be run by the Trust or by third parties as well)

And of course, to do anything that isn’t in NHSE (and even within depending on circumstance), you also have to go through the different layers of governance!

For example, in order to replace the National Breast Screening Service, we’ll have to talk to 75 NHS Trusts (those with a Breast Screening Office) and integrate our new service with them. This is because all the diagnostic images for breast screening are on Trust infrastructure.³

What is more opaque is the policy making. Usually this is straightforward in government but the NHS has a complex overlapping landscape of people in NHSE, clinical advisors, national advisory groups, the UK National Health Security Agency, and even the Royal College of Radiography.⁴

I think (so far) that the reason for this is down to advising on clinical risk. It’s not as straightforward as looking at capacity or delivery or even law. Instead, you’re looking at emerging evidence and trying to understand the balance of improving outcomes vs what can the NHS has capacity to do.⁵ It’s also that the Breast Screening Programme is the oldest screening programme in the UK, so there’s a lot of history there in general.

In many cases with other government services the risks of getting things wrong doesn’t have a huge impact - something arriving late or applying for the wrong thing. But the risks of getting it wrong in screening programmes is people could get a cancer diagnoses much later and have worse health outcomes as a result.

Where to start

So how do you even start finding your way through such complexity?

My motto of recent weeks has been ‘the only way is through’. We just have to start tackling some of the hardest things first. And that thing for me is going to be the governance. It’s going to be a very long road but we’ve already had some really good advice from other teams (inside and outside NHSE) who have successfully navigated their way through these complex governance processes.

We know enough at this stage to understand what we’re going to need to deploy and the integrations we’ll need. So we can start working on things like data protection and information governance, which in turn will help Trusts understand the work we’ll ask them to do.

Most importantly, I’m approaching working with Trusts like I would approach the user needs of building a new product. I need to understand their constraints so that when I do an official ‘ask’ (for them to do some work for me) it’s in a way that they will recognise, be able to action, and on a timeline that is reasonable for them to deliver.⁶

We already know they’ve got a lot on their plate, so understanding what our delivery timeline looks like is going to involve understanding their constraints.

Let’s do this

I’m only two months in, but I’ve spent a lot of time talking to a lot of people, from senior clinicians to members of the product teams building the new service.

The areas of concern, of what needs to be addressed, become obvious, very quickly. And these are things that block (or scare) multiple product teams. Or things that will cause delays or impede delivery and roll-out of a new service if left too late.

Starting is the most important thing you can do, and having enough information and understanding to start, is better than waiting for 100% clarity. It’s more likely that the details will change but the overall approach to tackling a problem will remain the same.

Despite the incredible complexity that lies ahead, I’m still very excited to be involved in this programme. I also have overall fuzzy feminist feelings about helping to transform the service, given the importance for women’s health outcomes.

This week I’ve been chatting to our other users (breast screening offices) about their constraints, finding even more complexity. Hopefully my optimism will remain even when I’m deep in the weeds of trying to improve and change things!

1. This definitely feels like the kind of programme where finding reasons for things will not result in rational answers but rather a historical view of the programme and the compromises that were made due to a legacy system.

2. Of course there is also the massive complexity of smooshing NHSE into DHSC.

3. A little insight into the next year of my life.

4. My specific role is ‘pathway lead’ which I describe as trying to get us from now to a future where a new service is deployed. So there’s a lot of governance, understanding the old service, understanding the policy and a wide array of other things to untangle. So finding out the levers of policy making are important.

5. Capacity in the sense of their enough radiographers, enough mammogram machines or MRI machines (if you are on the Very High Risk pathway, you might get an MRI rather than a mammogram).

6. My main insight about delivery is that this is not the norm. I’ve already made lots of friends by actually planning ahead? Yes, this freaks me out too.