Weeknote, w/c 24 March 2025

This week felt like a return to normal service. People are still talking about the impending merger of NHS England into the Department for Health and Social Care, but there were no major events and teams were largely just getting on with their work.

Outside of my workplace, plenty of articles are still being published about the merger, with various pundits chipping in with their take on what the government should prioritise. An article by Mike Bracken published in Digital Health proposes that “digital must be a top priority for [the] NHS’ next leader”. This appears to be a write-up of Bracken’s talk at Digital Health Rewired, which took place a few weeks ago. There is a lot in this article I agree with, notably that “major digital systems that […] underpin the NHS should be seen as public interest technology”. Yes, exactly this.

The text then goes on to describe what would appear to be two fundamentally opposed futures as if they were one thing:

The NHS must shape a vendor market that delivers true value for public money by incentivising competition – driving down prices while improving quality.

This can be achieved through greater investment in national, NHS-owned platforms, actively supporting British, innovative, and bold solutions. We have a culture of technology for the public good, and the NHS should be its best version.

These two short paragraphs pull in opposite directions: shaping the market by outsourcing NHS technology to private companies vs. investing in nationally-owned platforms. Right now, we do a mix of both, but the balance could shift with the upcoming changes to NHS England. The key question here is how best to make and deliver digital services.

For a long time now, the public sector has been grappling with the question of how much of the national digital infrastructure is made and maintained by private companies. This question isn’t particular to the health system, it pervades every single area of the public sphere. On the one hand, you have private companies that offer their software and services for purchase, with a business model that typically relies on economies of scale. On the other, you have efforts to put in-house digital teams directly into the heart of government.

The UK’s Government Digital Service (of which Bracken was a founding member and executive director) has already proven that in-house teams can build digital platforms and services that are well tailored to the needs of the public sector – and can do so for less money, in less time, and at scale. If “digital” is central to the ambitions of the state, does it not stand to reason that the state should own the direction and implementation of these systems? Would it not be better for the state to take control of its destiny, utilise “internet-era ways of working”, and further develop its capacity to build and use the infrastructure?

There is a space for the private sector; it isn’t feasible for government to build everything itself. Local contexts are too varied for national solutions to handle every single scenario. Private investment makes it easier for industry to experiment with emergent technologies and the public sector can benefit from this. In my current team, we work with a lot of suppliers who find good answers to problems posed in healthcare delivery. The question is not all or nothing, but what the balance is and who does what.

This mixed economy is probably the only practical approach, but it tends to lead to a very specific problem: fractured services. In the NHS, it is rare for any single team to develop a “whole service” all by themself. Each piece of technology and each narrowly scoped digital transaction is typically just one small step along a path toward a patient getting the result they’re looking for. Someone needs to figure out how to make the whole puzzle fit together and then get everyone involved to make the necessary changes. Central teams responsible for joining up the individual pieces need strong (like, really strong) levers if they are going to be able to ensure that users can arrive at a positive outcome. My plea to whomever is going to shape future markets is: please design these in.

Moving forward, the government faces a choice about how to move from analogue to digital in the healthcare system. Building, maintaining, and improving digital public goods in healthcare, where delivery is a patchwork of public and private effort, requires an extremely high level of coordination. Without the right tools to stitch the quilt together we won’t be able create effective services that are coherent, trustworthy, and for everyone.

Elsewhere on the internet:

• Design values for public services. Earlier this week, ahead of giving evidence at a select committee, Rachel Coldicutt posted on Bluesky asking for input into “why public services should not be designed in the same way as private-sector ones”. The values listed include choice, simple vs complex needs, and justice. Video of the committee meeting, which also involved Richard Pope, Laura Gilbert, and Joe Hill is available on parliamentlive.tv.
• Performance review of digital spend: Enabling strategic investment and innovation. Absolutely vital work: a policy paper from the treasury looking at options for new approaches when it comes to financing digital projects.
• Local gov care case management – a perfect storm of cost, coordination and vendor lock-in. FF Studio on the difficulties of improving how services work in a space that has a stagnant vendor market with a very small number of entrenched players. They reference the work I did in Hackney too, which is nice – I’m glad it hasn’t been entirely forgotten!
• Visualising modern digital government. Helena Trippe and Tim Paul on work they did to support the Blueprint for modern digital government. I throw up a little every time someone says “bring it to life”, but there is value in being able to make concepts tangible through imagery and prototypes.
• Loyalty in a sea of change: Staying true to ourselves in the NHS. Can we distinguish our loyalty to an organisation’s mission from our loyalty to own values when we work for a mission driven organisation? Mike Chitty thinks we can (and should).
• Bleaknote – Hopes and fears on the road to an Adaptive State. Trilly Chatterjee on some things that need to be sorted out during the merger, and how they might go wrong.