Table Of ContentTowards a Digital
Ecology
Towards a Digital
Ecology
NHS Digital Adoption through the
COVID-19 Looking Glass
Victoria Betton
First edition published 2022
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
© 2022 Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, LLC
Reasonable efforts have been made to publish reliable data and information, but the
author and publisher cannot assume responsibility for the validity of all materials or
the consequences of their use. The authors and publishers have attempted to trace
the copyright holders of all material reproduced in this publication and apologize
to copyright holders if permission to publish in this form has not been obtained. If
any copyright material has not been acknowledged please write and let us know so
we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be
reprinted, reproduced, transmitted, or utilized in any form by any electronic,
mechanical, or other means, now known or hereafter invented, including photo-
copying, microfilming, and recording, or in any information storage or retrieval
system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, access
www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222
Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not
available on CCC please contact [email protected]
Trademark notice: Product or corporate names may be trademarks or registered
trademarks and are used only for identification and explanation without intent to
infringe.
ISBN: 978-1-032-10866-7 (hbk)
ISBN: 978-1-032-10974-9 (pbk)
ISBN: 978-1-032-19879-8 (ebk)
DOI: 10.1201/9781032198798
Typeset in Garamond
by SPi Technologies India Pvt Ltd (Straive)
Contents
Preface .....................................................................................................................ix
Author ...................................................................................................................xiii
1 Introduction ..........................................................................................1
Where It All Started ....................................................................................3
What Even Is Digital Health? ......................................................................5
A Perfect Storm ...........................................................................................7
Backdrop to Broken ....................................................................................7
Necessity Is the Mother of Invention ...........................................................8
Relative Advantage ......................................................................................8
When People Drive Digital .........................................................................9
Context Is King .........................................................................................10
The Social Determinants of Digital ...........................................................10
The Jeopardy of Trust ................................................................................11
Bending the Curve on Digital Mental Health ............................................11
The Theatre of Tech – A Study in Solutionism ..........................................12
We Get the Market We Deserve ................................................................12
Momentum – Towards a Digital Ecology ..................................................13
2 Backdrop to Broken .............................................................................15
A Minor Inconvenience .............................................................................18
Ill-fated Plans ............................................................................................18
Central Ambitions.....................................................................................20
Changes You Can See from Outer Space ...................................................21
A Competent Workforce ...........................................................................24
X Is for Experience ....................................................................................27
Diktat and Determination.........................................................................29
Between Rhetoric and Reality ...................................................................31
3 Necessity Is the Mother of Invention ....................................................35
An Outbreak of Pragmatism ......................................................................37
Logging on .....................................................................................39
A Hospital in Your Home ...............................................................42
v
vi ◾ Contents
The Clinical Entrepreneur ...............................................................46
Data Quality Rules Ok! ..................................................................48
Attending Anywhere .......................................................................50
Fighting Fires of the Future .............................................................54
4 Relative Advantage ...............................................................................59
Relative Advantage ....................................................................................60
NHS Care Is a Relational Business ............................................................64
Saying Goodbye ........................................................................................65
Looking Forward .......................................................................................68
5 When People Drive Digital ..................................................................73
When People Drive Digital .......................................................................73
Command and Control .............................................................................78
First Responders ........................................................................................81
We Are Not Waiting..................................................................................84
A Software Ecology ...................................................................................86
6 Context Is King ....................................................................................91
In Celebration of Mess ..............................................................................91
Theorising Non-adoption ..........................................................................92
Context Is King .........................................................................................94
Thinking about Design .............................................................................96
What Happens in the Margins ................................................................101
Culture Eats Digital for Breakfast ............................................................102
Thinking Systems ....................................................................................105
Nurturing a Habitat ................................................................................109
Put a Dictator in Charge .........................................................................111
7 The Social Determinants of Digital ....................................................113
The Wellness Myth ..................................................................................113
Hello Inequality, Let Me Introduce You to COVID-19 ...........................115
The Drum of Progress .............................................................................117
One Condition. Two Tales ......................................................................118
Pay-as-You-Go ........................................................................................119
One Hundred Percent Digital .................................................................120
The Law of Inverse Care................................................................121
Designing for Everyone ...........................................................................123
Data Shadows .........................................................................................125
Who Leads Digital Health Matters ..........................................................128
Just as Vital as a Food Parcel ....................................................................130
Beyond the Stats......................................................................................133
8 The Jeopardy of Trust .........................................................................139
The Boundaries of Health Data ...............................................................140
Contents ◾ vii
The Data That Didn’t Care ......................................................................142
A Cautionary Tale ...................................................................................143
WannaCry ...............................................................................................145
Amazonian Challenges ............................................................................147
The Internet of Health ............................................................................148
One London ...........................................................................................149
The Controversies Continue ....................................................................154
A Social Contract ....................................................................................157
9 Bending the Curve on Digital Mental Health ....................................163
Introduction............................................................................................163
A Mental Health Pandemic .....................................................................164
A Salutary Lesson ....................................................................................165
Cinderella Services ........................................................................167
The Fruit That Hangs the Lowest ............................................................168
The Detractors ........................................................................................170
A Faster Horse .........................................................................................170
In Search of the Gold Standard ...............................................................173
A Digital Mental Health Pandemic .........................................................175
Bending the Curve on Digital Mental Health ..........................................177
To Save the NHS Click Here ..................................................................178
An Open Future ......................................................................................180
10 The Theatre of Tech – A Study in Solutionism ....................................185
There’s an App for That ...........................................................................187
Silicon Valley Style Hubris ......................................................................189
Do Something. Do Anything ..................................................................190
We Don’t Have an App for That ..............................................................191
Checks and Balances ...............................................................................192
In Love with Ada .....................................................................................193
A Masterclass in Mismanagement............................................................197
The Beat of the Drum .............................................................................199
A Footnote ..............................................................................................201
11 We Get the Market We Deserve ..........................................................205
How the Money Flows ............................................................................205
A Founder’s Story – Fixing a Simple Problem ..........................................207
The Scissors of Doom ..............................................................................209
The Elusive Return on Investment ................................................212
Who Buys? ..............................................................................................214
But Does It Even Work? ..........................................................................215
The Dark Art of Procurement..................................................................216
Who Holds the Purse Strings? .......................................................220
viii ◾ Contents
The Imperative Gap ................................................................................220
A Static Market .......................................................................................221
An Open Future ......................................................................................224
You Don't Win by Designing for Health Outcomes ................................225
What Business Models Actually Work? ....................................................229
Lessons Learned ......................................................................................232
12 Momentum – towards a Digital Ecology ............................................235
Towards the North Star ...........................................................................238
Entrepreneurs of the Future ....................................................................240
The Characteristics of a Digital Ecology ..................................................242
Creating Curiosity ...................................................................................243
Index ...........................................................................................................247
Preface
At first, it didn’t seem like such a big deal. I had passively absorbed the coronavirus
news from China, but only insofar as it formed part of my daily intake of Radio 4
news, as I got ready for work. Even when cases reached the UK, it still seemed quite
remote with no particular personal salience. When my boyfriend and I went away
for a seaside weekend mid- March break, we happily stood at the bar next to fellow
customers and walked along the bay bustling with people taking in the chilly spring
sun. Government ministers were still debating whether to permit large gatherings,
and the official position determined that closing schools or sporting events could do
more harm than good.1
As I started writing this book less than a month later, a BBC News alert popped
up on my mobile telling me that the UK’s daily death toll of 980 has surpassed that
of Italy and Spain. The newsreader announces that gatherings of not more than two
were banned. Shit got real. But just as it took a while for the penny to drop in our
personal lives, so did the enormity of the implications for the digital health sector
and the National Health Service take some time to sink in. As I began to write this
preface, the pandemic was in full force and its implications beyond the immediate
days and weeks, still very much unknown. As I concluded the final chapter, one long
year later, the impact of the pandemic on technology adoption in England’s NHS
has been the subject of much debate, both within the sector and in any number of
policy and research papers.
Having worked in and around the NHS for most of my working life, I am end-
lessly fascinated by its culture, organisation and idiosyncrasies. I have always been
drawn to knotty problems, and it is probably for this reason I have found myself
working in digital health. Digital in the NHS is still immature and emergent (we’ll
come back to that as a core theme in this book) but with the NHS engulfed by the
biggest public health challenge of its 70 years, it appeared to come into its own.
After personal protective equipment (PPE), a term most of us had never heard of
before, digital appeared to be front and centre of rapidly shifting practices over the
course of the first pandemic wave.
However, this is not a book about the pandemic. The starring role for this tale
is our National Health Service, a flawed hero whose imperfections we the audience
are endlessly frustrated by, but ultimately forgiving of. COVID-19 is the villain of
the piece, wreaking a path of destruction which forces an inflection point whereby
our hero has no option but to address their deficits and imperfections. This story
may not give us the happy ending we desire, but it does conclude with a note of
ix
