The NHS is many organisations posing as one. It’s complex. Process beats outcomes.
NHS England (NHSE) is one of the many organisations in the NHS. Within NHSE there are seams – we’re still NHS Digital, we just happen to be inside NHSE.
The seams and organisational complexity mean that even if we attempt to build the right thing, the organisation can still treat it as foreign. Putting work into the hands of users is two jobs. Building the service and stopping the organisation from rejecting it.
This complexity rewards those who can navigate it. I suspect that leads to more complexity. Some process is necessary and good when working in health. It’s the machinery for getting work into users’ hands. Politics is how we get through the process – know who to speak to, get a board to approve, or avoid the board in the first place.
In our team we’ve been referring to the alpha being about data and politics. Essentially all early work in NHSE is about data and politics. The data question is – can we connect fragmented systems to make something valuable for users? There are many politics questions. Can we ship with a scope tight enough not to tread on toes, but not so big that others want in or feel threatened by it? The boundaries and how we cross them shape the work.
We’re all trying to do good, but in the absence of clarity it’s hard to know if we’re moving in the same direction. As underwhelming as it is, the 10‑year plan at least gives us something to coalesce around. Something to point at and agree on.
Navigating the organisation takes more effort and is harder to get right than designing the service that gets to users. It feels like working in a bucket of crabs. Everyone is trying to climb out. The thing to remember is that we’re a crab too. Inside the bucket we can only fix from our perspective. Every local fix creates new process or boundary. We climb a little higher and pull the other crabs down.
We’re not stuck in traffic, we are traffic. I don’t want to pull the other crabs down. But from in here, all I can see is claws and legs – and when people push back on our work, I can’t tell if they’re pulling us down or building a crab ladder.