A reflection from Kath Kaboutian, Bristol NHS Group Deputy Chief Digital Information Officer following the HETT Leaders' Summit session 'People or Productivity: NHS Transformation in a Constrained System'.

At HETT last week, several anonymous questions were submitted that we didn’t have time to answer.  

They weren’t really about the tech - AVT / documentation standards, or consultancy spend in isolation. 

They were about something much deeper. 

They were about whether the NHS can genuinely transform within the fiscal, political and workforce constraints we are currently operating in. 

From my perspective operating within a large acute Group serving a significant population 1.25 million people and exploring merger across two organisations employing circa 26,000 staff with an average turnover of £2.2 billion— the questions fall into five themes. 

1. Talent: We cannot transform without people 

Several questions centred on technical talent:

  • How do we retain staff when consultancy pays more?
  • Why don’t we constrain digital consultancy like clinical agency spend?
  • How can government compete for tech talent given red tape and salary limits?

We’re a publicly funded organisation and sometimes we can’t compete with the salaries of private organisations. The honest answer is: we cannot win a salary arms race.

But we also cannot afford long-term dependency on consultancy. It is more expensive, erodes institutional memory, and reduces internal capability over time.

Digital roles must become professions in the NHS in the same way medicine and nursing are:

  • Clear career pathways
  • Recognised standards and accreditation
  • National frameworks
  • Leadership routes into executive space

If digital colleagues feel they are building a profession not just occupying a pay band, retention improves. 

We also need greater honesty nationally. Agenda for Change was not designed for many of the specialist digital roles that now underpin modern healthcare. 

Until workforce frameworks evolve to reflect this reality, organisations will face persistent recruitment challenges, increased reliance on consultancy and uneven capability across the system - all of which slow transformation and increase cost. 

But culture matters too. Purpose, visibility, growth and belonging are powerful retention levers. When technical teams see that their work directly protects theatres, improves cancer pathways or strengthens cyber resilience, the impact is tangible. 

Retention improves when colleagues are involved in shaping the ambition - not just delivering someone else’s plan. When technical teams are invited into strategy conversations, when they can influence architecture decisions, when they see their fingerprints on the future direction of the organisation, something shifts. 

If people buy into the vision, they want to help deliver it. 

Transformation is not about tools. It is about people who know how to build and run them. 

There is another factor we must acknowledge: change fatigue. 

Digital teams are not operating in isolation. They are delivering transformation while the wider NHS workforce is managing operational pressure, financial constraint and constant structural change. When every initiative is framed as urgent and critical, even the most committed teams begin to feel stretched. 

Productivity cannot be delivered on the back of exhaustion. 

In a constrained system, the risk is that we layer transformation onto already full roles, expecting discretionary effort to bridge structural gaps. That approach is not sustainable. Change delivered without capacity leads to burnout, slower adoption and, ultimately, poorer outcomes. 

If we want people to stay, to innovate and to lead, we must be realistic about pace. Not every improvement can happen simultaneously. Prioritisation is not a sign of reduced ambition - it is a sign of mature leadership. 

In a system already fatigued, sequencing matters as much as strategy. Sustainable productivity depends on protecting the energy of the people delivering it. 

2. Standardisation versus local autonomy 

Another question asked:

Sainsbury’s staff may feel stressed with a tech change, but it is a national tool. Why do we allow GP practices and hospitals to have unique processes?

It is a fair challenge.

Healthcare is not retail and we have learned hard lessons from over-centralised approaches. If we are to deploy national platforms at scale, we need shared standards that make them safe, interoperable and usable - without repeating the mistakes of over-centralisation.

As we form a Single Digital Enterprise Team across Bristol NHS Group, we are simplifying how digital services are organised and governed. That structural alignment creates the conditions for consistency - but it does not automatically standardise clinical practice.

Standardisation of clinical and nursing processes is a different and more complex conversation. Productivity cannot be imposed on clinicians; it must be designed with them.

It is not about removing professional judgement. It is about identifying where unwarranted variation in process introduces risk, duplication or inefficiency particularly when technology is involved.

A single digital team can enable:

  • Shared configuration approaches
  • Consistent data definitions
  • Common documentation standards
  • Clear integration principles
  • Documentation standards
  • Data definitions
  • Integration expectations
  • Adoption support

But decisions about clinical pathways and workflow design must remain clinically led.

The risk is assuming that joining the bringing together of digital functions across multiple organistaions, whether in group or merger equals harmonised practice. It does not. It simply creates the platform from which harmonisation becomes possible — if there is clinical appetite and leadership to pursue it.

And this matters beyond organisational neatness.

The NHS 10 Year Plan sets out a clear ambition around neighbourhood care, integration and collaboration across system partners. That vision depends on our ability to share information safely, consistently and meaningfully across organisational boundaries.

If every organisation defines data differently, documents care differently or configures pathways in isolation, neighbourhood working becomes harder not easier.

Consistency is not about control. It is about enabling collaboration.

If we are serious about greater consistency across the NHS, then mandating platforms alone is not enough.

Mandating tools without mandating:

…simply shifts burden onto frontline staff.

Without documentation standards, implementing more technology risks increasing cognitive load rather than reducing it.

Standardisation must be paired with investment in adoption and workflow redesign. Otherwise it becomes a compliance exercise rather than transformation.

 

3. Learning must be shared — not rediscovered 

One question struck a particular chord:

Why can’t we mandate and share centrally lessons learned and outcomes from investment?

I agree. We ask every Trust to write business cases, benefits frameworks and evaluation reports and then we leave them in local folders.

If public money funds digital transformation, the learning should be public too.

For example, with Ambient Voice Technology (AVT), many organisations are independently developing:

  • Business cases
  • Clinical safety artefacts
  • DPIAs
  • Evaluation frameworks

A central, curated repository of artefacts and lessons learned would accelerate safe adoption and reduce duplication.

As a Group exploring merger, we are acutely aware that duplication is a cost we can no longer afford even within one city. The NHS does not lack innovation. It lacks systematic knowledge transfer.

There is already infrastructure we could use more effectively. NHS Futures exists as a national collaboration and document repository platform, yet it is used inconsistently across programmes and regions. Rather than building new platforms, we could make more disciplined and mandated use of NHS Futures as a curated repository for business cases, evaluation reports, clinical safety artefacts and lessons learned. If publication of implementation learning became a routine requirement of investment approval, NHS Futures could move from being a passive repository to an active knowledge engine for the system. The opportunity is not necessarily to create something new but to use what we already have with greater intent and consistency.

 

4. Resourcing transformation properly 

Another recurring theme:

Transformation is too often an add-on to existing roles.

This is one of the most honest questions submitted.

We cannot deliver enterprise-level change through goodwill alone.

Planning, delivering and adopting transformation requires:

  • Programme infrastructure
  • Change and adoption capability
  • Clinical informatics
  • Dedicated technical capacity
  • Faster change
  • Lower cost
  • Higher safety
  • Greater resilience

But there is another important shift required.

Digital is an enabler - it is not the transformation itself.

Too often, digital teams are expected to “deliver transformation,” when in reality transformation must be owned by the organisation. Business cases should be organisational business cases, not digital business cases. Change should be operationally led. Benefits should be owned, tracked and realised by those who run the service not assumed to materialise once technology goes live.

If benefits realisation is not actively managed post-implementation, productivity gains remain theoretical.

In a budget-constrained system, digital is sometimes framed primarily as a savings lever. But under-resourcing transformation leads to slower delivery, lower adoption and poorer outcomes which ultimately costs more.

There is also a tension here with public expectation.

Can the NHS transform within current fiscal and political constraints? Perhaps but only if we are clear about priorities and pace.

We cannot promise:

…without trade-offs somewhere.

Sustainable transformation requires investment in capability, clarity of ownership and disciplined benefits management. Without that, we risk deploying technology rather than delivering change.

 

5. Inclusion and the teams we build 

One question asked about supporting neurodivergent colleagues, including those with ADHD.

Digital teams often attract neurodivergent talent. That is a strength, not a weakness.

But it requires leadership maturity:

  • Clear prioritisation
  • Structured communication
  • Flexibility in working patterns
  • Psychological safety
  • Strength-based management
  • Compete for global tech talent
  • Implement AI safely
  • Standardise documentation
  • Share learning nationally
  • Reduce consultancy
  • Improve productivity
  • Maintain morale

In Bristol, as we build our Single Digital Enterprise model, we are consciously thinking about team design not just org charts.

Transformation requires cognitive diversity. But diversity only thrives in environments that are intentionally inclusive.

Other Thoughts:

Disciplined technology choices

There is another discipline required in a constrained system.

We cannot transform by continuously buying more systems.

Every additional platform introduces cost, integration complexity, documentation burden and cognitive load. In Bristol, as we design a single digital enterprise, consolidation and optimisation are as important as innovation. The question is not “What else can we buy?” but “How do we use what we already have better?”

In a financially constrained NHS, maturity means resisting sales pitches, avoiding fragmented pilots and being disciplined about architecture. Not every free pilot is free. The downstream cost of integration, adoption and support is rarely zero.

Transformation requires focus not proliferation.

Universities, research and knowledge building

As a city with strong university and research partnerships, we also have an opportunity to think differently about capability building. Digital talent does not only come from recruitment — it can be grown through academic collaboration, research partnerships and joint appointments. If we want sustainable capability, we should be investing in pipelines, placements and shared learning between the NHS and our academic partners.

Building knowledge locally is as important as procuring solutions nationally.

Strengthen the Executive / Board ownership theme

None of this works without executive sponsorship.

Digital cannot sit as a technical sidebar. Boards must understand, champion and own digital ambition not just approve business cases. When digital is understood at Board level as infrastructure, workforce strategy and clinical safety enabler, the conversation changes.

Transformation accelerates when executive leadership sees digital as core business not discretionary spend.

The bigger question

Underlying all of these themes is one fundamental issue:

Are we trying to transform the NHS within structures that were never designed for digital-era healthcare?

We are asking organisations to:

…while operating under constrained pay frameworks and fiscal pressure.

That is not a complaint. It is a reality check.

At Bristol NHS Group, forming a Group and exploring merger has forced us to confront these challenges head-on. Scale gives us opportunity but also responsibility.

Digital is not the engine room alone. People are the power.

If we professionalise digital careers, mandate knowledge sharing, resource transformation properly, support diverse teams and standardise intelligently then yes, transformation is possible.

But it will require structural change, not just technological ambition.

And perhaps, as leaders, it requires us to be more honest about the trade-offs involved.

And finally,

There is so much opportunity in front of us in Bristol and Weston - Group formation, potential merger, the chance to truly design digital once and design it well.

But increasingly, digital risks being positioned primarily as a vehicle for CIP rather than an investment in long-term transformation.

We are asked to describe readiness with confidence, while knowing the financial reality means we cannot yet fully fund the foundations that readiness depends on - infrastructure, capability, adoption support, professionalisation.

That tension is frustrating.

It is the tension between ambition and affordability. Between political narrative and operational reality.

And it sits underneath many of the questions raised at HETT.

When transformation is framed primarily as cost reduction, we narrow the conversation. When it is framed as capability building, safety improvement and workforce sustainability, the conversation changes.

Digital can deliver productivity - but only if we invest in the foundations that make productivity sustainable.

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