For our latest interview we sat down for a chat with Ian Mackenzie, an NHS leader with over 35 years of experience in digital healthcare. Ian retired in 2021 but has been holding interim roles since then.
Ian’s background and experience in digital healthcare
Ian first started working in the health service in 1983 in what he called the “precursor to digital”. He explained: “I was working in medical records and I became involved in digital, as it has become known, in 1986, when we implemented a patient administration system at the hospital I was working in. It was the first time we’d had a computer of any sort in the hospital. I quickly became interested because it was so obvious how beneficial that system would be. We were literally writing appointment letters by hand and sending them on handwritten envelopes. When that was computerised the difference was phenomenal. Yes, it can add its own complications, but overall it really did make everything so much easier.”
From there Ian undertook various roles relating to his interest in this new way of working until around 1989, when he became an information manager in an acute hospital. He described how this role was effectively that of a CIO, though without the breadth of the CIO role as it is today.
Ian commented on the experience of implementing a proper network for the first time in 1990, when one was set up for a theatre system, leading to the trust’s first real use of email. Noting how times have changed but how attitudes to new approaches can often stay the same, he reflected: “I remember people saying: why would I want email? What would I do with it? They didn’t use it in their personal lives, so they didn’t see why they needed it at work. When you tried to explain the benefits, people would say that they didn’t need it because they could just walk down the corridor to relay a message to someone or send a memo. A perfectly understandable viewpoint; but colleagues quickly saw the benefit.”
A lot of things that are now seen as very basic were considered cutting edge at the time, Ian continued, but he emphasised the importance of paying due attention to these basic elements.
“I am very much an advocate for digital,” he said, “but if the basics don’t work, you can forget the rest. If a clinician can’t walk into their outpatient clinic and have access to a computer in good working order with two decent screens, a usable mouse and a stable internet connection, why would they want to hear about how a digital strategy that seems disconnected from their everyday experience? You can’t expect people to engage at a high level if it doesn’t work on an everyday level.”
Solving challenges
Looking back on the digital projects he is most proud of from his career, Ian noted that a trust he worked in for an extended period of time faced challenges with a key system through the national programme for IT. Over time they managed to tackle those challenges and get the system properly embedded.
Having worked in various organisations since retiring to help them out with digital transformation programmes, Ian added: “I see that in a lot of places – the technology will be seen as the problem, but often the system isn’t the problem, it’s often how it has been implemented.”
Ian noted that going live with a system is often seen as the conclusion of a digital project; but really is just the start. “I think the work I’m most proud of is where I have been able to help people understand this,” he said. “It’s hard, because it goes against what seems to be a commonly held belief.”
He continued: “Ultimately, in my career, it has come down to identifying problems and trying my best to fix them. That’s the other main source of pride for me; the number of projects I have been involved in where something has been going wrong and we have been able to help turn them round.”
The speed at which the healthcare system has been able to respond to what people need is something else that people should be proud of, Ian added.
“A lot of people say that things need to take a long time – I don’t agree with that. They often take a long time because people don’t fully understand the problem they are trying to solve; therefore, they don’t fully know what the solution should be. There is also reluctance to start a project, because people too often look for a perfect solution but that doesn’t exist and there is a degree of reluctance about starting something that could go wrong. If you’re happy to really push on those things, you can do things more quickly.
“If you wait for perfection, you will never do anything. You need to accept that there is no such thing as a perfect answer. There’s a good answer – you start with that, you get on with it, and then you will probably need to change it. If you recognise that this is part of leadership – knowing that you need to change and adapt all the time – then I believe you can do anything. But if you are always waiting for the right answer, you will struggle to do the right thing.”
Key learnings
Reflecting upon his key learnings, Ian said: “It’s all about people. It’s rarely about the technology; even if something goes wrong with technology, it will come down to people to fix it. It’s often about how people feel and their having confidence. If you’ve got people on board, then you’ve got a high chance of achieving your goal. If you don’t have hearts and minds, it isn’t going to work – it doesn’t matter how good your technology is. You need a compelling vision that people want to buy into, and you need to recognise that the reality of delivering that vision changes all the time. You must take people with you.”
In the NHS, he continued, there can be a tendency to view digital as “something that somebody else does. But that’s not the case, and digital isn’t just a job that falls under somebody’s else remit. You don’t consider that you’re ‘doing digital’ when you buy something online or booking a holiday, for example. It’s part of our lives, it belongs to all of us.”
On a related note, Ian continued, digital leaders need to “walk the floor – literally and metaphorically. If you want to be credible, and deliver credible projects, you need to be on the shop floor. You need to be able to connect with people in person.”
Control is another key aspect, he said. “It sounds obvious, but I have seen so many projects where people will say something can’t happen because someone has said this or that. And I say: we are in charge. We are the leaders of this project and we have to work to get what we need. If you want something to happen, it’s down to us to make it happen.”
Another of Ian’s key lessons, particularly when it comes to large-scale projects such as EPR implementations, is that there can be a tendency for people to think that the go-live is the end of the project; that the objective has been achieved and it is time to move on. “Your business case needs to include the total cost of ownership for the whole life cycle of that programme. That isn’t just buying a system and going live with it, it includes everything that happens after that. Following a go-live, for at least two or three years afterwards, there needs to be relentless focus on adding functionality, optimisation and fixing issues – because there will always be issues.” The board needs to really understand this point, he added. “Things will almost certainly get worse before they get better and risk-management and business cases need to be more open and much stronger in these areas.”
A lesson that Ian believes is particularly needed within the NHS is recognising that change has to happen. “You mustn’t simply put new software on top of processes that have developed over the years. An EPR, for example, should be seen as an opportunity to standardise how you do things like booking and waiting list management. It’s the best opportunity you can have, but people are often reluctant because they are fearful of making big changes and implementing organisational standardisation.”
What should the digital priorities be for the NHS?
Ian noted that he was about 38 years into his career when he started to work in an ICB for the first time, which gave him insight into the limitations of some organisations in “seeing beyond their own walls”. It is easy to understand why, he added, acknowledging that he himself was in the same position during roles in an individual trust. “There are so many things to do – you’re not worrying about what’s happening across the system when you are so busy worrying about your own areas of responsibility.”
But reality does not reflect this way of working, he continued; patients don’t think in terms of trusts, but in terms of the touchpoints they have contact with across the NHS.
“I think the first thing the NHS needs to do is break down the boundaries between different organisations. Digital is a really good way to do that, but at the moment I believe it is having the opposite effect and forming a barrier, rather than removing them. Information governance is part of the issue here, but it’s also because IT departments can be very parochial in how they function.” ICBs, he added, should be leading the change to take on system-wide working.
Ian then shared what he said is “probably a very unpopular view”, stating: “We need more central control and standards. I don’t think individual NHS organisations should be allowed so much autonomy. It doesn’t help patients, it doesn’t help colleagues, and it wastes a lot of money and time.”
We need to be confident that the tools that we give people are the right tools, he continued. “As a person – a patient, a consumer – the NHS is probably the organisation I deal with that offers me the fewest digital tools to help me deal with it and navigate it. For example, the NHS App is a great tool but what is on it varies across the country, it needs to be standardised across the NHS.”
Ian also raised an observation from across his career, which is “how little the NHS wants to share. People often ask if a colleague from another trust will share learnings with them, and everyone agrees that they will, that it’s a good thing to do; but how often do they actually follow through? Publicly, there’s a show of willingness, but I think privately there’s still a tendency to hold onto information. We see the same problems repeated across the NHS, because people are not open enough with each other. It’s understandable to an extent, because people are worried about sharing where things went wrong; and I also think the NHS culture can be unforgiving. But we need to talk and share with each other if we are going to learn.”
Fixing a challenge
If Ian could fix one challenge in the NHS, what would it be?
“For me, it comes back to my earlier point – the NHS needs to be much more open to change. There is too much protectiveness of the way things have always been. Change will mean new ways of doing things, but if that is for the good of the patient, you need to be part of that. You need to recognise when it’s time to do what is right.”
Many thanks to Ian for taking the time to share his views.
