It has been a year since I stopped working for NHSX. A few weeks ago, someone reached out to me inquiring about a job there. They wanted to know what they needed to know before joining. As well as the normal moaning about the quality of vending machine coffee, I told them about three things which caught me off-guard when I joined.

So, here for your edification, are three things I wish I'd known about NHS technology before I joined...

The NHS Doesn't Exist

I often tell people that the NHS is a figment of their imagination. When I say this, I don't mean "the NHS doesn't exist". I mean "the NHS doesn't exist".

Health is a (mostly) devolved competency - which means there is no single NHS for the UK. Within England, you have local responsibilities, Clinical Commissioning Groups (CCGs), and a whole host of other organisation. Then there are national bits of the NHS like NHS Digital, or NHS Blood and Transplant. But it is a mish-mash of (brilliant) organisations.

Here's an explainer video which I found pretty useful:

The NHS is a federation of different groups, with their own priorities and budgets. If you were to design a healthcare system from scratch, you probably wouldn't end up here. But, understandably, it would be impractical to restart the entire infrastructure from scratch.

The NHS has a lot of private organisations serving it

I'm not making political commentary here; I'm stating a fact. There is no big NHS-owned factory which produces bandages and scalpels. Hospitals buy equipment from private suppliers. A GP's surgery is a private organisation (usually) owned by the doctors. You may have feelings about whether this is sensible. But, again, it is where we are at the moment.

Similarly, the NHS doesn't manufacture computer hardware - it buys it. The same is mostly true with software. There are some things that only the NHS needs, and so it designs and builds the software itself. But most software programs - be they payroll systems or the canteen menu printer - are bought from the market.

Should the entire NHS use a single piece of software to do XYZ? Or should each hospital be free to buy anything it likes to do XYZ?

The above two points are both a feature and a bug. Is it annoying and confusing to have to do things multiple times? Yes. Does it prevent breaking changes from causing lasting damage to the system? Also yes. Monocultures are efficiently dangerous.

The NHS Can't Move Fast And Break People

The NHS is a risk averse organisation. When introducing a new technology, you need to be prepared to answer the question "how many people will this kill?"

When Facebook updates its UI, that's annoying. When the clinically critical system a doctor uses every day to keep people alive changes the order of its buttons - that's an unacceptable risk. That's why lots of health systems don't receive an update once deployed. Training people costs time and money - and introducing change introduces confusion. Tired and stressed healthcare workers don't want to fart around with a new UI every five minutes.

Similarly, back end changes need to be justified in terms of risk. The existing system may not be perfect, but people know how to manage its risks.

Rolling out technology changes have to take into account all three of these points. It isn't enough to say "this tech is good enough YOLO!" You have to get buy in from multiple stakeholders, some internal, some external, some with contradictory needs. You need to ensure safety and value for money, for both the short- and long-term.

What else?

There are many other things I wish I'd known (buy me a drink in a pub some day!) but those were the three which stood out for me.

Things are changing. Sometimes they change more slowly than technologists would like and far too quickly for patients and healthcare workers. The NHS is a wonderful organisation - and they're hiring! - but it is a complex beast with equally complex needs.