Thrive by Design Leeds & York Partnership NHS FT

Inclusive Digital Transformation

Briefly describe the initiative/ project/service; please include your aims and objectives

COVID-19 led to a rapid digital transformation of health and care services. This was crucial for the continuity of safe service delivery though the pandemic and has helped further highlight the incredible potential of digital to help us deliver high quality and effective health services and to help create the conditions where people feel empowered with a wide choice of information, services and tools. But an estimated 14.9 million people (16%) are unable to use the internet or their device(s) by themselves and 4% of households don’t have access to the internet at all. People not able to access and use digital technology are more likely to be older, living with disabilities, living on low incomes, engaged in the criminal justice system, homeless or claiming benefits. Evidence shows that these groups of people are also more likely to have poor physical and mental health and more likely to need health and care support and services.

The unintended consequence of rapid digital transformation is then threefold; the problem of COVID-19 compounding digital exclusion and pre existing health inequalities; widening the divide between people who are online and those excluded from digital and digitalised services. Our team felt that we had reached a fork in the road, a choice between a two-tiered or inclusive digitally transformed health and care service, and we chose the latter. The NHS Constitution holds the operating principles of the NHS and it’s contract with society. The first principle is ‘The NHS provides a comprehensive service, available to all’ and we think that this is what we should be aiming for with inclusive digital transformation, a (digitally-enabled) comprehensive service, available to all. With this in mind, we set up a national social change programme which we called Inclusive Digital Transformation aimed at exploring how to co-design inclusion into the digital transformation of health and care so that it works for everyone. Co-designing Inclusive Digital Transformation is about working in partnership with people who would be excluded and as far upstream as possible. People-centred co-design methods blended with social change and systems thinking provides a useful and inclusive approach to tackling this complex, multifaceted, system-wide challenge.
As part of the initial discovery phase we carried out a mapping exercise for NHSX looking at the current picture at an Integrated Care System (ICS) / Strategic Transformation Partnership (STP) level. Early evidence showed that most systems recognise the importance of Inclusive Digital Transformation but that there was a patchy approach to understanding the needs and very little co-design activity. There is a need for more funding, leadership and direction setting at all levels and capacity building across the workforce.

Through our existing networks our team started to reach out to like minded partners and we developed a framework for Inclusive Digital Transformation. The purpose of the Inclusive Digital Transformation Framework is to provide a process, set of principles and useful tools to support systems, localities and organisations to co-design inclusion into digital transformation as far upstream as possible and ensure we use digital innovation which reduces rather than compounds inequality. The Framework emerged from a discovery stage testing out different parts of the jigsaw in various different systems, places and organisations. It uses a blend of tools and methodologies from service design, quality improvement and social change approaches. The discovery phase involved a number of projects including with the Yorkshire and Humber ICS’s where we developed a digital and data poverty blueprint, Remote Monitoring Programme with the AHSNs and NHSE in North East and Yorkshire and Humber, Remote Consultation Discovery in Leeds and York Partnership Foundation Trust and a co-design project with Oxford University to explore what inclusive Remote Video Consultation looks like.

What are the key achievements?

Over the last twelve months we have continued to spread Inclusive Digital Transformation across healthcare in England leading national, system and place based projects, all the while sharing our research, methods and learning. Our innovative projects using Inclusive Digital Transformation include: Norfolk and Waveney Integrated care Systems: We collated local and national evidence and worked across sectors to provide tools that bring together a toolkit for inclusive digital transformation. Colleagues across the system can use our interactive map to:
-Use local and national data sets to predict digital exclusion in LSOA areas and by filtering through different indicators of exclusion (such as age, deprivation etc)
-Find a the nearest place that is offering digital inclusion support for people (training, devices, data etc)
-See where the gaps are in regional support offers
Use our assessment tool to:
-Help identify digitally excluded individuals during your appointments and give them information on where they can get the specific support that they require

Use our impact and benefits tools to:
-Show the impact of digital inclusion activity in terms of money saved for public services and also for individuals
-Use the evaluation framework to collect quantitative and qualitative data to show the human impact of your work.

These allow the ICS to project the impact digital inclusion activities will have along with the potential savings. This set of tools support inclusive digital transformation and are something that we are now rolling out with two further ICS’s. Leeds and York Partnership NHS Foundation Trust: We have been working with our own host Trust to explore how to co-design Inclusive Digital Transformation within a mental health and learning disability service context which includes:
-A rapid review of digital exclusion in this context
-A decision making tool for clinicians
-Three co-design processes focusing on specific services
-A series of events designed to engage all staff in the process.
Connected Nottinghamshire: We have been working on a new multi-purpose digital exclusion mapping tool which maps out need and current activity, provides a cost benefit analysis and an evaluation framework for the delivery of digital inclusion activities. Oxford University: We have been working with the team to co-design what inclusive video remote consultation looks like. Digital Skills for the Mental Health Workforce (with the NHS Confederation): We worked with the NHS Confederations Mental Health Network to develop a co-designed guide for individuals and teams working within the mental health care setting to understand their current digital capabilities and build their digital skills and confidence in order to deliver and promote digital services confidently to service users. The guide is available nationally and free of charge recognising that workforce skills need to keep pace with digital developments and the expectations of the public of healthcare services. Inclusive Digital Transformation in Mental Health (with NHS England and Improvement): We have delivered NHS England and Improvements digital mental health teams national ‘mental health and digital inclusion’ discovery programme: we co-designed and delivered a research and learning programme and are developing a guide for local systems and providers which will be launched and available nationally. The programme was designed to help a cohort of NHS participants working at system or Trust level to embed inclusion into live or future digital transformation projects within mental health.

Digital Health Inequality Pioneers: We are providing support to 10 Integrated Care System (ICS) projects to prepare them for tackling digital health inequalities. The ICSs have presented ideas for how they will make their chosen clinical pathway more accessible to those who are currently excluded; their projects will be one of the stepping stones to an inclusive tomorrow and we’re thrilled to be on that journey with them. We will help nurture, test and evolve these ideas and provide tailored coaching to improve the skills of the ICSs on a range of topics, including but not limited to: co-design, data collection & analysis, digital inclusion and strategy. To kick off the project, we’ve designed a Self Assessment for each ICS to complete as a way of reflecting on their current capacity and capability to deliver inclusive digital transformation. We’ll be using the information and evidence each ICS provide as part of their Self Assessment to design a tailored learning programme that we’ll deliver over the next five months. The learning programme will be a combination of group sessions and individual coaching. There are plans for the commissioner of this project, NHSX and NHS England and Improvement to role this programme out to all 42 ICSs in England.

How innovative is your initiative?

In the summer of 2020 we launched a social change programme we called ‘Inclusive Digital Transformation’. This work is innovative as it is the first time that anyone has taken a systematic approach to tackling digital exclusion in the health and care context. We carried out a mapping of what was already happening to tackle digital exclusion in health and care in 2020 and we discovered that whilst the issue was widely acknowledged, action was generally limited to short term siloed digital inclusion projects. Even national programmes such as NHS Widening Digital Participation were only focusing on activities to change individuals capacity not changing exclusive systems.
It was this realisation that led our team to put together and launch a challenge inviting others to join us in a discovery to understand how to co-design the Inclusive Digital

Transformation of health and care.
We have used a creative blend of social change, design, community development and quality improvement methods and tools to engage the system, to carry out research and to develop a brand new framework to enable health and care systems to self assess and develop a whole systems approach to tackling digital exclusion.
We have campaigned for change from the inside of the health and care system in our mission to ensure we do not compound pre-existing inequalities with the digital transformation of health and care services pushing boundaries and influencing at a national and local level across the country. We have shone a light on the issue, created the space for a community of people to collectively tackle this issue and made sense of the findings of our discovery in a way that is useful and impactful. We have worked directly with 15 different integrated health and care systems from Liverpool to Norfolk and from the Humber to Devon helping them to move from digital inclusion activities to implementing Inclusive Digital Transformation.

What are the key learning points?

We purposefully set out to have a wide reaching impact on how we tackle digital exclusion in health and care across the country. We have used social change and management theories, methodology and tools to enable spread and adoption including Sheila Mckechnie Foundation’s Social Power project, Everest Rogers’ Diffusion of Innovation theory and Myron’s maxims. Our approach has been to act as ‘Trojan Mice’, enabling the testing of a new approach in a safe, under the radar environment before spreading across a system. The Digital Inequality Pioneers programme is an excellent example of this. We developed our evidence base and narrative through primary and secondary research and through co-design activities using both facts and figures and stories to influence and engage people across the system from frontline clinicians to senior decision makers.

We have purposefully taken an open source approach and are clear that we share everything we learn and produce from research about mental health and digital inclusion to the development of our self assessment tool. We think this has built trust and credibility and in itself has been a key engagement tool. We also recognise the power of community and have created a workspace and repository on the Future NHS Platform for learning and sharing across like minded people – currently there are around 250 members. In the last three months alone we have delivered our learning programmes and events to over 340 people from across many different roles and geographies within the NHS with the aim of building capacity and capability to understand and implement inclusive digital transformation across systems.
We have also spoken at many different events at a local, regional and national level including at British Medical Journal, Health Service Journal, NHS Confederation, Healthcare Excellence Through Technology, and the East of England Accord events.

Since we started we have seen the language used by the system changing, for example a recent presentation at the National CAMHS (Children and Adolescent Mental Health Services) Taskforce group used ‘Inclusive Digital Transformation’ as a concept; we have seen a change in funding programmes, where we influenced a national digital health funding programme(NHSX) to include a question on how local systems were going to ensure they don’t compound inequalities and national initiatives such as the Digital Inequalities Pioneers programme which we are delivering.

This initiative is adaptable and scalable. We would encourage everyone working in healthcare settings and the wider public sector on digital transformation projects to step back and consider who is most excluded and follow our principles to co-design services with them so that health and wider stretching inequalities are not compounded by digital transformation. Our tips to get this going would be to start small and where the energy is; find like minded partners and friends who care about the same things as you, and share and collaborate with them; identify those excluded from your work and find trusted touchpoints that can help connect you with them and understand their life context; and to be prepared to share power and look beyond your own walls.

Additional Comments

The problem we are trying to solve is both complex and solvable. We have used every trick in the book to co-design an innovative and systemic approach – the secret of which is that it is about building relationships of shared trust, respect, understanding and purpose. It is about using a ‘new power’ approach which enables local systems to customise and tailor the framework to their own contexts and also creating the pipework and process for every new activity and person to share learning.