UKtech50 interview: Sarah Wilkinson, CEO, NHS Digital

Large-scale projects aplenty

Over the past year, several huge projects have been delivered at incredible speed. When the pandemic first hit and the country faced its first lockdown and wave of Covid-19 positive cases, NHS Digital quickly had to scale up its NHS 111 non-emergency helpline and online service. Another of the biggest pieces of work was the new risk stratification system, which enables the NHS to identify individuals who are clinically “extremely vulnerable to Covid”, namely the shielded patient list.

The organisation had to develop a clinical algorithm to identify those patients who were classed as high risk. The team had to pick out the right code sets to find patients with the conditions included on the list, then search through various datasets and pull all that data together.

The list has continued to evolve over the past year, and the work is continuous. In December 2020, NHS Digital included patients with Down’s Syndrome and with stage five chronic kidney disease. It has also done a lot of work to try to reduce the number of children and young people who might have been unnecessarily included on the list.

“The particular step forward that we’ve achieved in the past few weeks is we’ve included individuals who have been identified through a model that was developed by a team at Oxford University,” says Wilkinson.

She explains that the NHS chief medical officer (CMO) Chris Whitty’s team wanted to support a more sophisticated approach to identifying individuals who are vulnerable. The shielded patient list identifies individuals with a range of conditions on a list set by the CMO’s team in spring 2020, but the enhanced risk stratification system assesses an individual’s risk based on a combination of characteristics, such as age, sex, ethnicity, BMI and specific medical conditions.

“It looks at this much more sophisticated view of an individual and assesses their risk based on that,” she says, adding that the Department for Health and Social Care commissioned Oxford University to develop the underlying risk calculator, called the QCovid Model.

“NHS Digital has delivered the system to run that model and deliver all the scores. We’ve also produced a clinician-facing tool that allows clinicians to independently assess absolute and relative risk scores for each individual. So they can hold really tailored conversations with patients about their specific risk to Covid and what it emanates from,” she says.

The individuals who have been identified through this additional risk model are now going to be prioritised for vaccinations in cohort six, as well as being added to the shielded patient list.

NHS Digital is also responsible for delivering the infrastructure for the vaccination service.

“We’ve picked up the responsibility for delivering all the infrastructure for the vaccination service fairly late in the day, actually,” says Wilkinson.

One of the key services is the coronavirus vaccination booking service on the NHS.uk website. It allows people to book appointments at one of the big mass-vaccination centres that have been set up across the country, while bookings made into primary care and hospital hubs are managed directly by those providers.

“It includes a patient check-in system and appointment management system for staff, and it does a look-up of eligibility to ensure that only the people who are eligible get through the machinery,” says Wilkinson.

“We’ve also done a lot of work to support rapid adoption of the GP Connect appointment management functionality, which allows primary care staff to use their own clinical systems to book patients into appointments at the local vaccination site.”

NHS Digital has also had to deliver the point of care systems, the NHS and third-party systems that are being used to record the vaccination event.

“The complexity of that is really assuring the integrity and efficiency of data flows between the systems, because we pick up those vaccination records and do everything we can to get those written back to the patient record in primary care, to the GP systems and to the summary care record, as quickly as possible,” she says.

The project has also included communications infrastructure for the vaccinations. All of the vaccination centres require connectivity, so NHS Digital’s teams have had to hit the ground running, going out to make sure they are all properly set up.

There has also been “a massive amount of work on data, producing data flows and updates to different parts of the system, building dashboards, integrating vaccination data into existing dashboards”.

“We set up a data quality helpdesk for primary care staff, so that the clinicians who need to track vaccination records or see a problem in any way can get hold of us,” Wilkinson adds.

In the midst of all the work on Covid-19 systems and products, NHS Digital also completed a huge migration of NHSmail to the cloud. The migration included 2.1 million mailboxes, which were migrated to Microsoft’s Exchange Online platform.

Staff pressures take their toll

While the list of successful projects gets longer and longer, the incredible amount of work involved has put staff at NHS Digital under huge pressure.

Wilkinson says that while the work itself has been challenging, the biggest challenge has been “knowing that we put such intense pressure on our staff this year”.

“The most painful times have been when the impact of that pressure on individual people and their families has been laid bare in front of me. I think one of the hardest things is being part of a larger system that’s under so much pressure,” she says.

She adds that it has been important over the past year to talk about all the value that has been delivered, but that is partly because she can see what clinical colleagues on the front line are going through, and there’s a sense that “anything we’re going through kind of pales in comparison and we want to remain humble”.

However, Wilkinson says there have been many occasions over the past year when she has been on a video call to someone in tears. “I’ve had more of those conversations in one year than the whole of the rest of my career,” she says. “I think people have pushed themselves so hard on programmes, often on top of looking after kids, home schooling, looking after someone, or dealing with grief. Or, in some cases, just dealing with the unbearable loneliness of living alone over the course of the past year.

“Sometimes, the crazy thing is you beg people to take time off, and they really don’t want to because they’re driven, above all else, by wanting to be part of the solution and not wanting to fail anyone.”

Lockdown after lockdown, combined with huge amounts of work, has exhausted people, she says. “They need some recovery time. They need to get their mojo back to be able to attack the next project with some energy. We’ve got to be really thoughtful and mindful about that.”

Despite the tough times, the pandemic has also made staff shine. Wilkinson says that winning the UKtech50 award is a huge recognition of the amazing work everyone across NHS Digital has done in the last year.

“We’ve got so many staff who’ve worked so intensely hard, and in such challenging circumstances, and again and again we’ve taken on major programmes of work, often with timeframes for delivery that just seem pretty unmanageable, and in every case, we’ve come good,” she says.

“We have brilliant staff. And actually, I believe all organisations have lots of brilliant staff within them, it’s just that sometimes the leadership don’t know who they are. In a hugely pressured situation like this, one of the deep joys is that you find your superstars much more easily than you would in normal times.

“You get that real buzz when you realise there’s a vein of untapped talent, and it’s right there in front of you. So many times, I’ve reached out directly to people to ask them to do something that was completely above and beyond, and they’ve just kind of gulped and said yes. So we’ve had all that going for us.”

Lessons learned from Covid-19

The experience of going through a pandemic has also led to new ways of thinking and leadership, particularly when it comes to risk.

“We’ve had to take risks that we simply wouldn’t take in the normal course of things. Particularly in terms of going live with systems that haven’t gone through anything like the usual quality assurance processes,” says Wilkinson.

“When the option is to put a new service through more quality assurance and, in doing so, delay access to Covid testing in the middle of a pandemic, or put the system live and deal with issues on the fly, you have no option but the latter”

“When the option is to put a new service through more quality assurance and, in doing so, delay access to Covid testing in the middle of a pandemic, or put the system live and deal with issues on the fly, you have no option but the latter.”

She adds one of the key things that struck her about the impact of working at pace is that as long as you take risk in a deliberate and controlled way, it can have a hugely positive impact on talent and culture.

“That’s a realisation that will stay with me. Heavyweight processes and a risk-averse culture lead to a capability and confidence deficit in an organisation. It’s been a key reflection point for me this year. And that’s so much harder to fix than design flaws or higher incident rates. The reality is, if you give talented engineers the confidence and the ability to move fast, they actually often perform much better at speed.”

Despite this, she adds that there have been times when going live with a new product that she “honestly felt sick”.

“It’s not a good feeling when you put stuff into the live environment and it’s going to be used by millions of people, and you haven’t really got a sense of how it’s going to scale,” she says. 

“When you look back on it, it’s not a bad set of learnings. We had no option at the time, but in hindsight, I think we’ve really got to think about the balances we make, the judgements we make, and the cost and impact of those judgements. I think we’ll do projects quite differently going forward.”