A year at NHSE 

I’m the Head of Product for Personalised Prevention Services in NHS England (NHSE). I am responsible for a growing portfolio of products that help people understand their health risks and take preventative action to address them.

I’ve been in this role for a year now and this blog post covers my reflections on the past year (and what a year it has been!).

Motivation

Prior to NHSE I was leading two of the ‘crown jewel’ products of GDS – GOV.UK Notify and GOV.UK Forms. And for most parts, I loved it – the products, the teams, the culture. It felt comfortable. So naturally for me, I had to change. 

I needed to get out of my comfort zone and feel stretched. I also wanted to be closer to actual public service delivery, supporting a cause close to my heart – helping people to stay healthy and avoid preventable diseases. The good news is – I got what I wanted!

Learning to swim

When I first started at NHSE exactly one year ago, I knew very little about my new role, how it fitted with the rest of the organisation and the wider prevention space. I was in for a shock – I was put on a single project that was delivered by two organisations (NHSE and the Department of Health and Social Care), with the product delivery completely outsourced to a supplier. I was responsible for the product delivery but not the product strategy. And I didn’t have any contractual levers to support the delivery. 

Top that up with a huge organisation to navigate, no structured (and very little unstructured) onboarding process, and a new, and overwhelmingly large domain. I felt like I’d gone from coming first in a primary school swimming gala to being thrown in the middle of the ocean during a storm and told I have to swim to shore. I felt like I was drowning. Fast. 

Spoiler alert – I didn’t drown, I’m still here. But I also haven’t found land. 

It’s difficult to sum up my last year working in this space. To avoid it being a long list of not very coherent ramblings, I’ve tried to structure my thoughts through the lenses of the structure, organisation and people, starting from the macro level and zooming in. If you want a snappier set of observations about working in this space, Frankie Roberto compiled a list of his one year observations and it’s spot on. 

The healthcare system 

First and foremost, working in healthcare is working with huge complexity. As Ralph Hawkins aptly summed it up in his first weeknote, ‘the learning curve for health is basically a wall’. 

My biggest takeaways so far are:

1. The healthcare system consists of myriad organisations and structures – national and international, central and local, public and private – that deliver, govern, fund and administer a variety of healthcare services. Although NHS England sits at the centre, it doesn’t mean it has a monopoly or even awareness of everything that happens. It’s not surprising that things often feel fragmented (like a series of interactions rather than end-to-end services), duplicative and siloed. It’s been a running joke for our work in Personalised Prevention that every week we uncover at least one service seeking to operate in the same problem or opportunity space as us. (What’s our product – market fit is a topic for another blog post)
2. To a newbie, it’s also strange that what an outsider would assume as foundational capabilities – things like writing into the GP record, having one source of the truth between records, interoperability between primary, secondary, urgent and emergency care – are mostly not there. And the options to get there seem convoluted, dependent on multiple external parties and their contractual obligations, complex information governance and legal wrangling, and mostly, buy-in from the medical profession. As usual, the problem is not one of technology. 
3. Clinical processes and assurance are intense and difficult to navigate but essential. Building in clinical assurance from the start of product development, and seeing clinicians as an essential part of the multidisciplinary product team rather than an SME to be consulted with or for approval, is a lesson I learned the hard way. There’s also the big spectre of Software as a Medical Device and the work required to document and ensure regulatory compliance. It’s a process that works for a physical product, developed largely in a waterfall, clinical trials and evaluation method. Fitting that into the agile, rapid ‘test and learn’ product development cycles is like seeing my preschooler write her letters. It’s hard going, best endeavours and difficult to figure out at first.
4. My work is not only about health outcomes but also about reducing health inequalities. In public healthcare, it’s not enough to deliver brilliant services if they only serve people with high health and digital literacy and access. Sarah Fisher has summed this up excellently in her latest blog post. And reaching those hard-to-reach and often disengaged people takes a lot more than just well-designed accessible digital interventions. It’s about behavioural change and long-term impact. Measuring effectively how well your product is meeting those long-term outcomes is a challenge in itself, so often we have to rely on early signals that we’re shifting the dial in the right direction. 

Organisational sludge

At GDS I referred to a part of our work on Notify as the ‘war on sludge’. If only I’d known what real sludge is. 

Coming from central government, and having worked with multiple parts of the wider public sector, I know these problems are not unique to NHSE. However, here everything – from large-scale procurements to day-to-day ways of working – seems much more difficult to fix or approve quickly because the system is so large. 

So far I’ve been heavily involved in two procurements as well as supporting a lot of business case development. The lead times and up-front requirement definition for these have been so disproportionately large, and the process to get approvals has felt complex and ever-changing. It’s encouraging to see the Blueprint for modern digital government focus clearly on transforming these processes and funding for outcomes and innovation.

There are many examples of OTT sludge for even the simplest processes – from having to add seven different entries to the main HR-system for a two week holiday over Christmas (because bank holidays and weekends are added separately, duh!), to using two different accounts for different software (the hacks are real). All these are symptoms of the wider problem – even simple processes are not optimised for success and efficiency, let alone ‘user satisfaction’. 

Finally, this won’t be a section about the organisational challenges at NHSE without THE organisational challenge to rule ‘em all – NHSE’s abolition. 

From my first day at the NHSE I was surprised how much emotional energy had gone into and was still going in the transition following the merger of NHS Digital, Health Education England (HEE) and NHS England in 2023. Then, early this year, just as the dust was finally settling, the NHSE restructuring process was announced. This came with a flurry of executive resignations, bringing more uncertainty and speculation. 

And last month, in a surreal irony during our strategic yearly planning event, came the PM’s announcement for the plans to abolish “the world’s largest quango”. 

Trying to stay on top of what’s happening without too much speculation, whilst remaining motivated, whilst being one of the two permies in my area has felt at times quite soul destroying. 

People and culture 

In the end, it’s all about the people. It’s difficult for the culture and people not to be impacted by the wider changes and general inefficiencies. 

But all the people I’ve met working in or with the NHS genuinely care and are extremely committed to making a difference to other people’s lives. 

My microcosm of Digital Prevention Services Portfolio (DPSP), part of Products and Platforms (the digital transformation and products side of NHSE), feels protected and stable. The culture is focused on the right values – being considerate, inclusive, open, and bold. There is an incredible amount of talent and leadership that’s effective and inspiring. This makes it infectious (lol!) to get out of your comfort zone and try to be your best at what you do every day.  

The past year has also allowed me to reflect on my personal values and ways of working as a leader. For me these are kindness, pragmatism and giving the space for people to be themselves. These can happily coexist with the wider DPSP values too. I realised that for me these are non-negotiable. They should be protected, even when the pressures of delivery and the stress of the day-to-day are overwhelming. 

On a personal level, I’ve also found work fun and even coming into the office has been really enjoyable, which as a parent juggling two different drop-offs can feel like effort. Last week I was gutted to miss a brilliant pun-filled Easter egg hunt. But at least there’s the karaoke to look forward to. Not to mention the proper collaboration and friendships I’ve formed with many.  

Swimming

So, 12 months in, I’ve definitely found my flow. To use the swimming analogy, I’m starting to see how reaching the other shore is possible, even though I can’t yet see a land on the horizon. Together with my DD Emily Houghton and the rest of PPS SLT we’ve grown our portfolio area to an exciting set of products and a compelling proposition, right at the centre of the three government shifts.

I am confident the products my teams and I are working on have the potential ambition to completely reinvent the way healthcare is delivered, allowing people, in particular those who are not be able to access it privately, to understand their health risks and act on them. 

A note on writing

Recently, I’ve had trouble finding my voice and confidence (not least because I’ve focused on not drowning, to continue the analogy). I finally feel ready to write. A special recognition to the people who’ve inspired me with their writing – particularly, Georgina Watts, Ralph Hawkins, Frankie Roberto and the late Vicky Teinaki whose legacy remains alive. 

I’m committing to document more often, probably fortnightly or monthly notes will be the frequency that works for me.