HTN Now: The transformative power of agile in healthcare with practical implementations

Starting out by offering a brief introduction, Harry talked about being a doctor by background, and training as a surgeon before “getting excited by health tech and jumping ship, about ten years ago”. Since then, he described having “a variety of roles”, joining Aire Logic three years ago as the director of health and innovation, and also working as the business and commercial lead for the NHS Clinical Entrepreneur Programme, “where I support over a thousand NHS staff who want to build innovations to help the NHS”.

Over that time, Harry went on, he has regularly used agile techniques to build software products and to lead digital transformation projects across the NHS. “I’m really passionate about agile, having seen how good it can be, and I think there can be massive benefits around its wider application in the NHS,” he shared.

Victoria also told us how her background involved “20+ years in project delivery in various settings such as higher education and utilities, always in a delivery role, and delivering different products and services in a number of different areas”. Having started out working on PRINCE2 delivery, she told us how she had “quickly realised it wasn’t really fit for purpose”, and “jumped across into the agile space”, where she quickly saw the benefits. She has now been with Aire Logic for the last two years as a senior delivery manager and agile coach.

Harry also shared a brief introduction to Aire Logic, “a health technology consultancy formed in 2007 by two founders who’d worked on the national programme for IT, and thought there’s got to be a better way to deliver tech services to the NHS”. Since setting up Aire Logic as an “agile-focused, ethically-driven” consultancy, the company has been involved in “pretty much every major national NHS IT project, including the vaccination service and SPINE”, he told us, “growing to around 250 people full-time and about 150 associates”.

Aire Logic’s values include “tech for good’, meaning it will “only take on a project it feels has a societal benefit”, Harry continued, as well as focusing on what is good for staff in terms of making the company a great place to work, and then looking at what might be “good for the company”. Aire Logic is also employee-owned, he shared, and delivers about 15 pro bono or at-cost projects per year.

In terms of what services the company offers, Harry talked about three “arms” of the business: technical consultancy – architecture, strategy, tech strategy; DevOps – design, build and maintain; and Aire Innovate – rapid development, low code platform with ready-to-use forms.

The agile approach

Victoria took us through some of the basics to an agile approach, as well as some of the common misconceptions, including that it’s “just for software development”. Presenting a slide covering the 4 Agile Manifesto values: individuals and interactions, working software, customer collaboration, and responding to change, she said: “It basically emphasises iterative development, collaboration, and flexibility, and adapting to changing requirements. It’s based on the belief that the people are the most important asset in any organisation.”

Other focuses of the manifesto include adaptive planning, early delivery, continuous improvement, and rapid response to change, Victoria continued. “That was introduced in 2001, so it’s old now,” she said, “so although people often think it’s a new thing, it isn’t, and there are a lot of organisations across different sectors that are adopting this way of working.” She also highlighted key principles including new relationships where business people and developers are working together regularly, building things around “motivated people” and giving people the support that they need, valuing face-to-face communication, and having a team which reflects on how it can become more effective and “adjusts its behaviour accordingly”.

Moving on to discuss some statistics around agile, Victoria shared that “around 97 percent of organisations report using agile development methods to some extent – that figure has climbed steadily, which indicates that these methods are becoming the norm, rather than the exception”. She also pointed to success rates, where “projects managed with agile methodologies report a success rate of 75 percent, which contrasts sharply with the success rates of traditional project management methods, which hovers around 56 percent”. Scrum and Kanban remain the most popular frameworks, she went on, “with 63 percent of agile practitioners using Scrum, and 50 percent using Kanban”.

Victoria highlighted some statistics demonstrating the benefits of agile, which showed “increased collaboration mentioned by 59 percent of people, because you’ve got those people talking”, as well as “better alignment to business needs, which is mentioned by 57 percent”. This helps avoid the challenge of delivering a project to a customer that is no longer what the business needs, she considered.

Applying agile in healthcare

“How can we use these techniques in healthcare, and how can we use them to improve patient care?” Harry asked. “The pressure on the NHS means the ability to respond and to deliver projects effectively is really important. Not only is demand going up; it’s happening in an environment where the speed of technological advancement is enormous; we need tools, frameworks, and methods to be able to rapidly adopt that technology, to make sure that it’s fit for purpose, and to make sure that’s led by clinicians and patients.”

Complexity of care is also increasing, Harry stated, “and we’ve got people with complex multi-morbidities who need input from a wide range of services, which again means we need a more dynamic way of delivering projects”. The push to community will also bring with it “a whole range of challenges that we need to manage effectively”, he shared, “and I think agile could have an important role to play there”.

Looking at the benefits of agile through a healthcare lens, Harry told us how it could help solve these challenges, including by offering improved collaboration and self-organising MDTs, and faster and more effective communication “giving us the ability to respond to change and to the insights we’re now able to draw from data”. In some settings agile is being used “to some extent” he went on, “and there are areas where it’s not being used at all – by looking more broadly, there’s an enormous potential for benefit”.

It’s now mandated that a lot of Aire Logic’s work with the NHS is completed using agile practices, Harry shared, “and when we look at digital transformation projects like rolling out an EPR, it’s thinking about how we apply it in a clinical pathway, and what work we could do in supply chain – I know there are some areas it’s been adopted in pharmacy, and I think we could go further and faster on that”. Looking at how services are designed and delivered around users is “the interesting bit”, he went on, “and ultimately in frontline care, which is where I think agile is probably used the least”.

Harry then presented a case study from Brigham and Women’s Hospital, “who were looking at completely revamping their heart failure services, and who adopted agile as a methodology to help them manage that transformation”. This involved multiple MDTs, according to Harry, “working in a series of sprints and running improvements in things like medication management and patient education”. The key bit, he continued, “was being able to get the feedback from the end users, the staff and the patients, and then incorporate that rapidly into what they were doing with technology, but also process changes”.

Results, Harry shared, included “statistically significant reductions in hospital readmissions, improved clinical outcomes, increased patient and staff satisfaction, and staff retention”. Lessons learned were that using a culture of open communication and having teams “who take on shared ownership of problems and seeing them through to delivery, with a laser focus on end users, ultimately enabled better patient care and outcomes,” he stated.

Elsewhere, Monash Health did a “complete redesign” of mental health services, covering technology, but also how their services were running, “including how their doctors were interacting with patients, and even a purpose-built building that was more conducive to an agile patient management methodology”. This resulted in high staff satisfaction and retention, as well as a 37 percent decrease in A&E visits across admissions and readmissions, Harry reported, “and the before and after clinical outcomes are night and day”.

At St Helens and Knowsley NHS Trust, adopting scrum techniques during the COVID-19 pandemic, upskilling surgical teams in airway management and assisting with the pandemic response, helped the trust cope with 30 percent of its staff missing; and a combination of agile and lean techniques implemented at Royal Hospital Oman to run CI projects during COVID-19 led to “significant improvements in interdepartmental collaboration and workflow efficiencies, improving patient outcomes despite the pandemic”.

Highlighting the potential for agile in the NHS

Uptake of agile within the NHS is ‘limited”, Harry considered, “and it is mainly used for software development, with sporadic use in other settings, but when it comes to project management, traditional approaches remain the norm”. Likening not using agile methodology to performing a surgery “which was outdated and had an almost 50 percent failure rate, when there’s a new surgery available with only a 25 percent failure rate”, Harry said, “if I kept doing it the old way, I think I’d be drawn up in front of the GMC and probably be sent on my way – why are we tolerating approaches we know are less successful?”.

After asking our live audience for their insight around the problems they’re faced with when looking to use agile, Harry responded to a comment about patient safety, and the risks associated with “putting in place early versions of products/processes which might cause errors in patient records, or gaps with patient safety”. Referring to this as “one of the common misconceptions with agile”, Harry told us how agile’s systematic and rigorous nature allows teams to “really prioritise clinical safety”, adding: “When we’re approached to take on mission critical platinum services, they actually mandate that we use agile best practices, because you get early feedback on problems and errors, and you respond to them quickly.”

Another comment Harry picked up on was that NHS organisations struggle with a lot of documentation. “If agile is done really well, whilst there should be some documentation and some artefacts which are maintained appropriately; actually the focus should be on people rather than on extensive documentation, compared with something like PRINCE2,” he considered.

“There is a common misconception that agile doesn’t require documentation,” Vicky agreed. “There is documentation, but that is needed documentation.” Using the analogy of a minimalist home, she said: “You wouldn’t live in a minimalist home with no furniture. You would still have a bed, a sofa – you still have these items but there might not be many of them. Agile prioritises working software over processes or comprehensive documentation, but it doesn’t eliminate it – the focus is on keeping documentation that is relevant and useful, and not wasting time writing what isn’t needed.”

Touching upon the point around clinical safety, Victoria also spoke from her experience working on critical NHS projects using agile techniques. “You refer to your clinical safety experts, and you bring them in. You start with a small piece, and ask what the clinical safety is around that, build in the regulatory aspects, the quality aspects, and the safety aspects; it’s not an afterthought, it’s built into the process.”

And sharing some of the common objections to implementing agile, Victoria talked about a tendency within the NHS to “like our old ways of working, because they’re kind of currently working”, and about the abundance of regulation, the focus on rigour, compliance, and the rigid structure. “You address that in your planning, and rather than being overwhelmed, you pick up a small piece at a time,” she considered, “discuss them and bring them into your priority in the right order, but not all in one go – build it in intuitive cycles.” When it comes to encouraging buy-in for agile working, Victoria recommends “starting small – starting with a small area, a small team, a small project, and using the benefits from that to showcase to people, then scale from there”.

“That’s something I come up against quite a lot in my work on the Clinical Entrepreneur Programme,” Harry shared, “and I guess that’s the difference compared to a waterfall approach, where you go into a dark room for 18 months, build something, and only then realise the benefits; with agile, the advantage is being able to break the project up and find somewhere you can deliver value early, so people can really see the value being added early on.” Continuous improvement means listening to people’s feedback and then working that in, he continued, “so people are having their voices heard”.

Where to start when approaching agile

“All of this can feel a bit intimidating,’ Harry considered, “so it’s important to look at where to start when we’re introducing agile. We’ve got lots of demand and limited resources, and we know technology can be part of the answer to that – where would you start if you were going into a team and helping them to take their first steps in implementing agile methodologies?”

Victoria noted the importance of recognising that “it’s a culture change and a gradual process”, adding: “The first thing I would do is assess the current state of readiness for change. If the people are not ready for change, it isn’t going to work, and getting the team fired up to make those changes, building their awareness, isn’t going to be quick. It’s important to have buy-in from the leadership, as well.”

Next would be looking at the current processes, the problem statements, and understanding “why now?” Victoria added. “And then you need to consider which bits of agile are right for the project, because there are so many different tools, techniques, and change implementation models, so there’s some research that needs to be done there first.” Learning from successful approaches elsewhere is valuable, too, she noted, “seeing whether there’s anything that we could learn from or use with a few modifications”.

The concern about having constant iterations on a project is “when is it done?”, said Harry. “I think it’s important to be very clear about that from the start to avoid creeping scope, and making sure the end users are prepared for the handover, to take that piece of software or whatever it is, and run it themselves.” And another thing to consider when talking about the team is their capacity for the project, he went on, “because yes there are competing demands, but you focus your sprints on what is going to deliver the most value, and keep that at the centre of your work”.

Having a clear delivery roadmap in place is one way to tackle this from the outset, Victoria stated, “or a product development roadmap with features – listing now, next, later, and some clear priorities, which you could then link up to the organisation’s strategy – there should be a golden thread right though from strategy to an individual task that someone has in a backlog”.

Things can still go wrong when using agile, and it isn’t the “perfect” approach, Victoria said: “Often organisations simulate being agile without actually having that deeper understanding of what it is and the values and principles that it relies on. They go through the motions, but they’re not getting the mindset and the culture. That’s really bad agile, and if you’re working at an organisation that’s doing that, please call that out.”

We’d like to thank Victoria and Harry for sharing their insight with us.