SARDisms 17 - Joe McDonald, CCIO

Transcript

Mariah [00:00:02]
Welcome to SARDisms, where we take great ideas and bring them together to have great conversations. In this episode, we're speaking with the recently retired Joe McDonald, who has been a child psychiatrist for more than 30 years and is regarded as one of the country's leading chief clinical information officers. Joe has always been a huge advocate of digital technology and despite retirement, is continuing to shape the future of NHS IT.

Mariah [00:00:26]
Welcome, Joe. Joe, can you just tell us a little bit about yourself and perhaps your origin story?

Joe [00:00:31]
OK, yeah, my origin story... I've never even thought about having an origin story. But, yeah, I'm, I'm a psychiatrist by background, have a longstanding interest in health I.T. and I was national clinical lead for IT brackets mental health back during the National Programme for IT and that went reasonably well from a mental health point of view. And for that reason, I was put into a very big health IT project called Lorenzo, which is part of the National Programme, as its Medical Director.

Kevin [00:01:05]
We are definitely going to discuss that.

Joe [00:01:07]
And subsequently having been career limitingly frank about that part of the project, I had to leave NHS Connecting for Health.

Joe [00:01:19]
And after that, I did some writing about health IT, and also helped to found the Chief Clinical Information Officers Network in England and the UK, which was six angry people in a pub when we set up, and there's about 6000 members now. Subsequently, I was founding director of a regional integrated care project called the Great North Care Record, which is used almost a quarter of a million times a month nowadays. That's about it, I think.

Kevin [00:01:51]
Can you tell us what the Great North Care Record is? Because I, I tried to sort of investigate it a couple of years ago, when, when I first sort of appeared on my radar screen, and I was like, was this thing? It was a little bit hard for somebody outside perhaps that world to understand how it differs from an EPR? Like an electronic patient record. What is it?

Joe [00:02:13]
There's lots of different EPRs in the north east of England, covering 3.6million citizens. We've got a mixed economy of GP systems, roughly 50-50 between EMUS and TPP the two big GP suppliers. And the idea of the game was to make patient care safer by making GP records sealable in the secondary care hospitals, which of course it wasn't. So every time a patient went into an acute hospital or a mental hospital for that matter, the doctors in the hospital were flying completely blind. They knew nothing about you. They couldn't see your GP record or anything else for that matter.

Joe [00:02:52]
And the first thing we did was make that GP record visible in secondary care, and then latterly we made secondary care records visible to the GP, and now all, pretty much all, you know, everybody wrote and said I don't want that to happen to me, has their record shared right across the North East. These people get, you know, safer care, basically. It's not an EPR per say, it's a means of sharing information at the point of care. So it's, in the ambulance they know that you're an epileptic, in A&E they know you're allergic to penicillin, et cetera.

Joe [00:03:27]
So it has very tangible benefits for direct clinical care. Great North Care Record also has the ambition to make the North East a really top-quality place to do research, by collecting patient preferences around research and your willingness to get involved around research. The idea behind that was from a conversation I had with Dave Whitlinger, who, at the time we started five years ago ran the New York e-health collaborative. So we have a little money to do something called Great North Care Record, we weren't exactly sure what it was at the time, so we thought we'd start small. But we have big aspirations.

Joe [00:04:07]
So I rang Dave Whitlinger in New York City as you do. He took my call, because that's an interesting, interesting thing about people who are into information sharing. They're really into it. So Dave, who had no idea who I was, but was aware that I was trying to do something for better information sharing improve patient care took my call. And I said, Dave, you're eight years record sharing journey in New York City, you've got eight million records shared, it's the biggest record sharing project in the world, what would you do differently if you were starting again? And he said, oh, I'd collect everybody's preferences about the willingness to be involved in research. And then I would have the biggest research facility in the world.

Joe [00:04:55]
And I thought ‘hello, that might be quite a good thing for an area of the country whose shipyards have all closed recently and mines are all closed, we're looking for something else to be excellent at since we invented mains electricity and the trains. It's been downhill a bit since then. But I thought what if we could be the most connected and consensus health economy in the world?’ So we thought we'd have a go at that. And it turns out it's really, really hard. If you get the right people and a small group of people, and you begin to show that the thing is possible between one general practice and one hospital, and another, and another, and another, and another, well 376 general practices later, 12 trusts and eight local authorities, and 3.6million citizens, you've got the Great North Care Record. Which has done OK.

Kevin [00:05:54]
Yeah. It's a massive achievement. It's why we ended up contacting you much like you did to this gentleman in New York, I think, we sort of contacted you just at the point of view of retirement didn't we? And and-.

Joe [00:06:10]
Yeah. The day after. The day after I retired. The plan was to slink quietly away.

Kevin [00:06:14]
Yeah you failed at that.

Joe [00:06:17]
But it got announced all over the place and then I got ambushed at a big online retirement party before you knew it, it was raining jobs! And retirement seemed slightly distant again. But there you go.

Kevin [00:06:32]
You don't want to retire.

Joe [00:06:33]
I retired a couple of years ago. It was boring.

Kevin [00:06:35]
It's lethal as well, right?

Joe [00:06:37]
Yeah. People die. They die of retirement.

Kevin [00:06:39]
I mean that literally.

Joe [00:06:40]
I think it's, you know if you've been working in a high pressure NHS environment for a long time, and you suddenly, suddenly stop. I think you can get the bends.

Kevin [00:06:48]
Yeah. So I, I feel like we saved your life, in that respect.

Joe [00:06:52]
That may well be true Kevin, may well be true.

Kevin [00:06:57]
No, it's been great because we've been working on a kind of open-source workforce project and yes, shall we talk a bit about that?

Mariah [00:07:06]
Yes, please.

Joe [00:07:07]
Yeah, definitely. I mean, you had me on the call at ‘open-source’ basically cos I've been trying to get the NHS to move into a more open-source direction for, I dunno, 10 or 15 years without any tremendous success, and when you called and said, "oh, we're going to do something open-source on the staff side, I thought, genius, I've been going full frontal assault trying to get Cerner and Epic’s tanks off the NHS lawn, you know, as a one man band, and that's plainly not going to work. But I think the door is open round the back of the NHS, but all the other myriad systems which are often terrible, that I have to use as an NHS doctor, maybe we can open-source things on the staff side, and when people see that that works, we could go from there?

Kevin [00:07:58]
Yeah, I mean, there's a few tanks parked on this side of the lawn as well. But it’s... I think it's underrated, actually, how much, how much scope there is and how much leverage there is to make changes in that side of things. Like the half of the NHS budget is workforce. And so, I think every consultant is a £250k on cost per year for that hospital, perhaps even higher? So if those resources are misallocated, then, the, well it has massive knock-on effects.

Joe [00:08:35]
Well yeah, I mean, the other thing that got me about your argument was that, you know, I've been banging on Twitter for a while about, can we please leave Matt Hancock's tech vision alone? We do not need to revisit that beautiful document, which is full of stuff that we all want. And yet we always seem to be on the verge of abandoning it or going into something new when we haven't actually had a go at implementing it. For all the best reasons, Covid and what have you clearly hijacked NHSX's agenda, at a time when they might have been looking to move on that, but I'm just worried now with all the chatter, that, you know, X disappears, the tech vision disappears, and the, you know, the wonderful open-source open platform vision that it provided will disappear with it.

Kevin [00:09:22]
Nope. Not going to happen.

Mariah [00:09:23]
No.

Kevin [00:09:23]
Not going to happen. And we know it's not going to happen because of that wonderful book you're reading, which I haven't read yet. But I should imagine it's something around the, the concept that people, people not organisations, right?

Joe [00:09:37]
Yeah, absolutely. So organisations do churn. And that was one of the things that we learnt in Great North Care Record actually, is that trusts will merge. But your project doesn't have to die if you've got the right people, with the right attitude, and the right principles, you can keep going through organisational churn. So I share some of your optimism Kevin, but at the same time, you know that my ringtone is 'Don't Get Fooled Again', which is bitter and twisted, and a reflection of my time in the National Programme and all that.

Kevin [00:10:08]
Yeah, we've, we've met quite a few people who are kind of battle-weary from open-source in the past, we've got the two, the two grumpy, naughty boys Rob Dyke and Marcus Baw. Marcus, we've had on the podcast before. I feel like they kind of they remind me of the two old guys in the Muppets, you know, like every time something new comes through they're throwing things at it.

Kevin [00:10:34]
But I think with good intent, right? Like those guys, those guys want to see it change. And we're finding a lot of people, I've been speaking to, to people from all over the NHS open-source world and beyond local government, we had a good chat, didn't we, last Friday to Andy Sandford there and local government and... There's a lot of people that want this to happen.

Joe [00:10:55]
I agree. I mean, it's interesting you mentioned that Marcus and Rob, they're like the two old guys criticising everything in the Muppets, but I think of those two old guys as, they're Second World War veterans. You know, they're scarred. They are, they're traumatised, they've got, you know, health IT PTSD. They're so, they've seen so much pain, that they can't help but be a little embittered by it. You know there's a glimmer of hope that shines within them and they can't help but get drawn back to the open-source flame. But then they're very quickly discouraged by some of the behaviours that they see. But, yeah, you know, it's the only way out in the end.

Kevin [00:11:38]
Yeah, what you need is some fresh, completely green person to come in.

Joe [00:11:43]
Who hasn't had their spirit crushed yet Kevin, that's what I like about you. You don't know how pointless this is yet!

Kevin [00:11:49]
No, no! Honestly, I just, I always had like an optimistic nature anyway. I don't think it's because I'm particularly green. I've, when, when we started this business, there was a company which is now been sold, because they failed, but they, they won all of the Royal College contracts. And I remember Phil, when we co-founded it, he was like, 'oh, look at this'. I was like, 'don't worry about it. We're going for it'. And here we are, ten years later. And... We didn't need to worry about it. So...

Joe [00:12:21]
I'm a fellow believer, but trust me, towards the end there, my fire had started to go out a little bit, but I have to say meeting you guys has re-lit it, but not least because there's a new way into the problem, rather than going, you know, a full-frontal assault on massive EPR providers, both British and American. There's another way to show that the value of building an open platform with interoperable modules, it is the only logical thing to do and eventually logic will overcome some of the problems we've got here.

Kevin [00:12:53]
Yeah. I think we're approaching it a slightly different way as well. Because we've, we've been working collectively on this sort of execution essentials, which is to say, look, the vision is good, we want this to happen, but, you know, executing a vision is a harder thing to do that actually just have the vision. We all agree that the vision is a good idea, how do we actually make it happen and how do we make it come to life?

Kevin [00:13:18]
And I hope from all of the kind of research that we've been doing, and talking to you, and talking to everyone else who is battle-weary and has suffered all the scars, that we've learnt some of the lessons. One of the big ones being community and, and building up a sense of joy and purpose and fun about what you're doing, and bringing people along with a big vision.

Joe [00:13:44]
I agree absolutely. I think you've got a slide in your deck, which is like the periodic table, and all the different elements that you require to make, you know, a really big, really complex project work. And first time I've seen anybody really draw together the sheer complexity of those elements, and to include joy in that, in the periodic table I think, too often we've looked at this in a mechanistic and deterministic way. You know, we're going to build it. We're going to, you know, draw a big plan and we're going to spend a fortune and make it like it looks on bit of paper, and I'm afraid the world of health IT just doesn't work like that. As Margunn Aanestad says, it's much more like gardening than it is construction. And you've got to start somewhere. You’ve got to do something and you've got to replicate it, you've got to modularise it, you've got to make the interfaces all work together, and I love that gardening analogy because I've watched 15 years of that constructional approach, and, you know, in GNCR, Great North Care Record, we tried a modular - grow it, try it, water what works, cut back what doesn't, and it works. I know it works. And there is, there is a way to get this done but we have to have that understanding of the complexity.

Kevin [00:15:09]
Yeah, we love Professor Margunn Aanestad don't we?

Joe [00:15:12]
We do.

Kevin [00:15:13]
Which you introduce me to, to her. And another gem, the Abilene Paradox.

Joe [00:15:19]
Yeah. I mean, I love Margunn Aanestad so much that I travelled to Oslo to get a couple of hours with her in Starbucks, just to see if the legend was true, and it was. And, you know, I first saw her in a five minute video over my wife's shoulder, who was doing NHS Digital Academy stuff. And I thought, who's this brilliant woman? Who, you know, in a few words, says, actually, big architectural plan from why it won't work, never will work, never has worked, what you need to do this. And if you watch that little 15 minute YouTube video, there's a gem in every line.

Joe [00:15:58]
And then the other favourite is obviously Jerry Harvey, God rest his soul, organisational psychologist who coined the phrase Abeline Paradox and there's a wonderful, admittedly two hour, video on YouTube of Jerry Harvey talking about the Abeline Paradox, made short it is possible for a large group of people to all go and do a thing that none of them want to do. And that's kind of where we've been sat for some time in NHS IT. Everybody wants the tech vision. Nobody's doing it.

Kevin [00:16:29]
So how do you break that cycle? What's the actionable way to overcome the Abeline Paradox?

Joe [00:16:36]
Right well somebody has to point it out. You know, actually making jet fuel out of peanut oil probably won't work, and if you've been at it for a long time, it's not working, you might want to look at Plan B. Invest a little in Plan B. You know, years ago, Tony Shannon who is a big advocate of open-source, had a proposal that they just take one percent of the annual NHS IT spend, and put it in open-source, in a place, do an open-source thing, and see if you could grow an ecosystem and a community around that, and see if it would catch on, like Great North Care Record. The neighbours would see it was good, see it was reasonably priced, nothing's free, nobody wants something for nothing, but they can see it was reasonably priced, could see that they can improve it.

Joe [00:17:28]
And I was listening to a podcast by very senior GP IT people the other day, and they were describing 256 GP record systems which existed at the time, 30 years ago, and they were saying, you know, you could ring up the developer, you could ring up David Stables, he was the legend behind EMIS, and say, 'I don't like your medications page', and say 'oh right then, you change it, here's the code, you have a dabble mate!'. And that was how those systems got to be really user friendly, was by not being locked down and, 'you've had your three changes for the decade'. You know, 'if you want to move a full stop, it'll be more money'. Just doesn't work, and consequently, some of our stuff nowadays, looks old and tired, and not really up to it.

Kevin [00:18:24]
I'm glad you called me David Stables on speed. That was a compliment.

Joe [00:18:30]
I did call you David Stables on speed, because I think you have a similar enthusiasm, and a similar willingness actually, you know, to be the iconoclast. Somebody has to put their hand up and say ‘enough’. Somebody has to say, ‘you know what, I'm not sure this is working’. And I think you've done that and I think and with sufficient good grace, you know, not to rubbish what other people are doing, but good grace to say, can we have another go, can we try something a little bit different?

Kevin [00:19:01]
Yeah, yeah.

Joe [00:19:02]
And also, to spot, to spot with the Tech Vision, there's nothing wrong with the Tech Vision. Nothing wrong with it at all. Look, beautiful document full of great ideas. How do we deliver it?

Mariah [00:19:14]
Exactly.

Kevin [00:19:14]
Yeah. It's a great document. I think, hmm, how do we phrase this? Matt Hancock... treading carefully here, you know, people love him or hate him like Marmite, but one thing is clear, he's come from a tech background and I think he understands the revolutionary power of technology to, to change things. And I know there is, there's a reluctance, particularly in the clinical community, to sort of go, ‘well, tech doesn't solve all our problems, right?’ You know, we've had this coronavirus pandemic, it wasn't really technology that solved it, it was feet on the ground doing the work that needed to be done. And, and I get that scepticism too. But, but for someone like me who comes from a health tech background, having someone in that position who, who gets it, is a great opportunity. And I don't want to waste it.

Joe [00:20:12]
Look, I'm, I'm a card carrying, literally card-carrying member of the Labour Party, always have been, always will be. But we've seen Secretaries of State come and go. I think I must be on my, I dunno, 13th, 14th in my career? Average length of stay about two years to be honest. And when you get one who turns up who's tech savvy, believes in tech, writes a decent tech vision, or got somebody writing a decent tech vision, I don't care if it's a Tory, if the vision's a good enough one, we should go after it.

Joe [00:20:48]
And if we don't get after the vision, if we don't open platforms and stuff, when Matt Hancock is in charge, it's not going to happen any time soon. So I think there's an opportunity here, love him or hate him, whether you're a Tory or whether you're a communist, the right thing to do is take that Tech Vision and just get on and do it.

Kevin [00:21:10]
Yes, we can. To quote a big man. My follower on Twitter. Barack Obama.

Joe [00:21:17]
Barack Obama follows you on Twitter?

Mariah [00:21:18]
Oh God this again!

Joe [00:21:19]
We did this, we did this in the last podcast. Yes, he does. Yeah. And we've never known why.

Mariah [00:21:25]
Well, we figured out that he probably doesn't know who Kevin-.

Kevin [00:21:28]
There's another Kevin Monk that works for Dave Chappell, but anyway.

Joe [00:21:32]
OK, cool. Yeah.

Kevin [00:21:34]
Covered, covered in our previous podcast.

Joe [00:21:36]
But that means you can DM him though, doesn't it?

Kevin [00:21:38]
It does! I could? I don't follow him though. Maybe I should. I should do.

Joe [00:21:45]
Yes you definitely should!

Mariah [00:21:46]
A wasted opportunity!

Kevin [00:21:47]
I know. I know. I will ask him. I will just slide into his DMs. It's actually interesting, the American health tech industry. I've been spending some time on Clubhouse, which is like this new social media app thing, and there's various health tech rooms on there. And so much of the debate revolves around the financial and insurance set up that they've got there. Every discussion about EPRs is around how you get paid and who gets paid by what. I'm not, I'm not saying that the people care in there, don't, don't, are money obsessed, it's just that the EPR systems have to manage that thing and it becomes, it becomes this huge part of what shapes those systems.

Kevin [00:22:35]
And it really points at something that we've been discussing and been discussing with NHSX and other people who are trying to make this Tech Vision happen. Is that the, the culture, the sort of external pressures in a sort of Darwin, Darwinian sense, what's the environment around it? How does it shape the products you end up creating? Is a, is a really big part in the technology that emerges from that. So, like a big push for what we're trying to do at the moment is to try and change that culture so that it, so that technology companies that care about interoperability can do what David did, and respond to your requests to change the software so those sorts of companies start to emerge more. Sorry I’m on my soapbox here.

Joe [00:23:25]
No that's fine. I'll join you on the soapbox there Kev, because-.

Kevin [00:23:29]
Yeah come on I’ll move over.

Joe [00:23:30]
One of my hobbyhorses is that we've actually conflated electronic patient records and performance management. So, we've got clinicians recording stuff because of the, you know, we went down the market route saying that people have to compete for patients and you get paid for what you do and all the rest of it. Now, the clinicians now have record a lot of performance management. So that isn't patient records. It isn't, Mrs. Higgin’s has a temperature of 39 and a nasty cough, It’s Mrs. Higgins arrived at this time, and we did this, this and this, and consequently, we have to send a bill for this, that and the other. Some of that is coming to an end now, in the next round of NHS reforms.

Joe [00:24:16]
I mean, it's mad isn't it. The Tories are going to do away with the internal market. Who saw, nobody saw that coming.

Kevin [00:24:24]
I know.

Joe [00:24:25]
You're all going to have to work together, health and social care, you'll all have to work together in an integrated care system. What? The Tories? Are you kidding me?

Kevin [00:24:34]
Become a strange couple of years, hasn’t it?

Joe [00:24:37]
It is, the world's turned upside down, but it might give us an opportunity to free clinicians up from the of recording poor performance management stats, which has become the bane of our lives. Conditions in the NHS and 25 percent of their time with patients, and 75 percent doing something else. A large chunk of something else is recording the stuff and systems that aren't very good at recording stuff. There's the prize.

Kevin [00:25:03]
Yeah. How do we get from just some bits of paper and recording stuff in some notes, to where we are now? It feels like, if we could just simplify somehow the, sometimes I'm playing around with word and things are jumping around all over the place, and I think who the bloody hell complicated this thing, like at one point, at one point it was a typewriter, and now we've got this thing old Clippy popping up, trying to, to write my letters for me or whatever. It, it got complicated and I always wish there was a slider that I could go from somewhere between typewriter and it would just make a bell sound when I got to the end of a line, and what we've got now, and I could just change the slider. Presumably at a point there was a medical record system, there was bits of paper in a folder. And can't we have that? But electronic?

Joe [00:26:03]
You could do, but we get, I mean to be fair you can still have that in some hospitals in the UK where it's bits of paper in a folder. That hasn't gone away, that is still there. I think part of the problem was that we did look to go beyond that and make the data useful, you know, and be able to get some intelligence out of the system.

Kevin [00:26:26]
But that's what I mean, did we overstretch, is that what happened? Because to me, hospital that had essentially a Microsoft Word document on, I'm banging on about Microsoft Word here, but had a freeform text document that was encrypted and stored online, and you could give that and you could pass that around...

Joe [00:26:46]
There are elements of that. Obviously, I'm a psychiatrist so in mental health, we record a great deal of free text in our electronic patient records. We record people's life stories as told to us. And largely in quite a wordy format. Now I got involved in electronic patient records 15 years ago, because, because I hate what schizophrenia does to 16 year old kids. If you can imagine getting dementia at 16, then living with it for the next 60 years, that's what it does. Or it's what it does to some of them. I mean, in my time the treatments have improved greatly, so now sometimes people are better in a few weeks rather than in an institution for a lifetime, in my own lifetime, but when people ring me up, as the only child and adolescent psychiatrist they know and say, ‘Hi Joe, I know I haven't seen you since university 40 years ago, but my son has just developed first episode psychosis, what's the best treatment? and I have to say, I don't know, there's a dozen treatments, but I'm pretty sure which treatment will work for your son is recorded somewhere on their genome. But we're unable to access the data because it's all in the long, handwritten form over the last thirty years. So, there is some value in collecting coded data, so if I can look back through 30 years of notes, and see actually which treatment works for, you know, the blonde, blue eyed children of Nordic people, or maybe even if their genome was in there, I could actually isolate a few genes. So, there's value encoded data and the value in getting that down.

Kevin [00:28:22]
Are you saying there's a trade-off then between having to codify the stuff so that we can learn as a society from it, yeah, but then to that patient, the immediate... I had an MRI, you know, I've known people to go into hospitals and say, 'I had an MRI last week or whatever', and the doctor that they're consulting with that week says, 'Oh, I didn't know, what was that for then?' And, you know... There's confusion about what, what was even happened, or your history. So, for the patient, it can be really disorientating because, because it's, it's not just a clear history of what happened to them. So, for them, they don't want it codified. I wouldn't want it codified.

Joe [00:29:05]
So there's a trade-off between codification and they're inversely proportional, how much coded data you put in versus how useful it is, and if it's just stories, you know, in a word document, then that's really easy for everybody to understand include the patients. The GPs, to some extent, because they've been putting in coded data for years, they kind of speak this Klingon of recodes, and they can understand these codes, but they don't mean anything to anybody else.

Joe [00:29:33]
So in the end, they, have you heard of SNOMED Kev?

Kevin [00:29:37]
Of course. Yeah we, we have to do it, like job planning and stuff.

Joe [00:29:40]
Well there you go. So, SNOMED, 400 terms, that's more than some languages, 400,000 terms, sorry, that's more than some languages have got. And consequently, most clinicians, when you talk to them about SNOMED other than the dweebs like me, and those that hang out in the CCIO network, snow what? And they've no, no idea what it is.

Kevin [00:30:05]
It's a really funny system, isn't it? Because you can basically code, code up any kind of ailment that someone has, they'll be like, they had a bee sting in their, in their left arm and it was this type of bee, I don't think it quite goes into that...

Joe [00:30:22]
I think it does!

Kevin [00:30:22]
Does it?

Joe [00:30:22]
It's like we've had to invent a new language to talk to the computer. If only we'd just left the whole damn thing in Latin two or three hundred years ago, we'd have been fine. If we all spoke fluent Latin in the health service, we'd all be speaking the same language, but we're not. So, we have to invent a new language called SNOMED, which might be replaced by artificial intelligence, before we’ve ever coded enough into SNOMED to get an answer out of it because it's 40 years old, and hasn't exactly delivered anything yet...oh that’s a bit harsh, I'm harsh there.

Kevin [00:30:55]
Has it not, because this is one of the things that Margunn Aanestad says about the importance of these projects, is immediate benefit.

Joe [00:31:04]
Yes, because we're all psychopaths. We're not all psychopaths, but we do like a bit of instant gratification, many of us can defer gratification for ooh nearly an hour, before we want to see some return on our work.

Kevin [00:31:18]
But her argument is that, you know, you should, you should attack problems where you do see an immediate benefit of it, because it gives you immediate feedback that you're, you are tackling a real problem.

Joe [00:31:30]
Exactly so. So, if you're not getting benefit really quite quickly, if there's no wow, or there's no ooh that's better than yesterday, which is probably all the people expect in the NHS to be honest, is that if you come into work, and better than yesterday, they love you. Because it's painful to use what they've got now, so just make it a little bit better. You get that instant reward. You also draw a crowd back the next meeting about improving whatever it is. And if they begin to see all sorts of less pain, then, then you can build a movement. And that's what you have to do. You have to build a bit of a social movement around this stuff, and an ecosystem around NHS IT.

Kevin [00:32:15]
I can't remember what else I was going to say. I'm crap at this podcasting.

Mariah [00:32:19]
No you're not, you're very good.

Kevin [00:32:21]
I find it really hard to think what... I don't know, it's tough. We'll edit that bit out.

Joe [00:32:31]
Well sometimes, sometimes Kev, it doesn't take all that long to say what it is that needs to be said. And sometimes you can go on and on and on asking questions when, you know, it really is as simple as, we've got a great tech vision, we don't quite know how we're going to deliver it, but here's a plan of what we made. We'd like to press on with. It will take a little money, like everything, to get it going. But just what if, what if the NHS in the UK became the place that created the open platform, open-source system, that lit the blue touch paper. In the same way that the Internet took off. A few, you know, believers coming together to make it go.

Kevin [00:33:14]
I do feel we're in a unique position to do so as well, because you know something I have also learnt from being on Clubhouse and talking to kind of US health tech groups, is that there is something about the UK and its ability to deliver on the public sector that's special, you know, the GDS team, the Government Digital Service team that does all of the, you know, your DVLA licensing and things like that, that tech is good, and that's been rolled out, and that, that team, that team there is a special team and something to be proud of. And I'd love to see that replicated more in the NHS.

Joe [00:33:50]
Kev, the other thing about the NHS is, you know, we've slightly rubbished the National Programme for IT there but it did give us the NHS number. And that means that every citizen in the country has a unique identifier. In the United States of America. I took this story to Harvard, they would kill to have a unique identifier for every citizen and be able to link up health data for across geographies, and across time. We've got 30 years’ worth of electronic data sitting in the GP records. It's the biggest successful electronic patient record system in the world without question, in General Practice IT, and there is a ton of valuable data in there. The world is clamoring to get their hands on that data. And, you know, we could use it for the good of the NHS, you know, with the right permissions and make it all above board.

Joe [00:34:44]
You know, in America, they're trying to strike a deal with Facebook to figure out who's dead! The ultimate health outcome, ok? So, we at least have a register of who's died, we have a unique identifier in the GP record, in the NHS number, and we can link up stuff and do incredible research, if we get the government's piece right. In America, they're asking Facebook who's dead.

Mariah [00:35:09]
Not good.

Kevin [00:35:10]
I mean, we're kind of the perfect size nation with the perfect kind of background in this. I do think it can be a real beacon of open, open-source technology. Often, we are downstream of the USA on open-source technology. The things that we build our systems in, one's Ruby on rails, well actually the guy who created it is Danish, but he lives in America now. It's backed by a kind of American company. The React JavaScript framework comes from Facebook. There's lots of open-source technology that is downstream of American business. And I kind of feel like because of their, because of some of the cultural issues there around health tech, that we don't get any of that downstream benefit. And so, it has to come from us.

Joe [00:35:57]
But I think the actual environment that we've got in terms of, you know, patents already there and our ability to link it across systems, with the right permissions, I'm not sure that happens anywhere else in the world, to be honest. And not with 30 years’ worth of electronic data.

Kevin [00:36:17]
Gary McAllister, do you know Gary McAllister, who wrote a-.

Joe [00:36:21]
The Liverpool footballer?

Kevin [00:36:22]
No! I think, I’m going to get it wrong, he’s either CIO or CTO of GSTT, although I think he left a few months back, wrote a book called An Introduction to Digital Health Care in the NHS. I could be getting it wrong because, actually I'd love to get him on a podcast, we'll tag him in this, maybe he'll have a listen. But I think he kind of makes the argument, and I could have this wrong, that a National Programme for IT was just ahead of its time. There was, it was too early.

Joe [00:36:52]
Well, you could make that argument.

Kevin [00:36:55]
Where did it go wrong? Shall we, should we talk about the war? Let's talk about our battle scars and the war wounds.

Joe [00:36:59]
Well for me it was upside down, in terms of where the money was. What we got right about GP IT and consequently had the most advanced GP systems in the world, is we gave the money to the GPs and said, go off and buy or build IT systems. And they did. And because they'd have to use them every day, they were spending effectively their own money on themselves. Or the money they'd been given. When we did the National Programme for IT, we kept all the money central and thought ahh, you know, those dodgy hospital doctor types, they'll go up and spend it on, you know, ludicrously expensive stuff, so we'll control it all from the centre, with a few central contracts.

Joe [00:37:47]
And that way we'll get best value. But what they got was, as Milton Freeman would say, that's spending somebody else's money on somebody else. That's never a good way to spend money. But it was unfortunately underlined where we spent money in the National Programme, and consequently there was little clinical consultation, and so when things got bought, they didn't really do what people expected to do, and they didn't use them. So consequently, I mean, I'm a big fan of the three U's test, if software is any good it's useful, usable and therefore used. And you know you've failed 1 and 2 if nobody's using it. And then it's just a question, was it 1 or was it 2? So, you've got to, you've got to make stuff that people want to use.

Kevin [00:38:32]
Professor Margunn Aanestad says about that second project, so should probably explain that she investigated, I'm sure she's done other projects and other academic papers, but the one that springs to mind and the one that she talks about in the video that we'll link to, is that there's these two projects in Denmark, one is to change the PR system on a, on a national level so it's very centrally organised, and the second project is emergent and comes from the ground up.

Kevin [00:39:03]
It was a small number of actors. It was a patient extraction tool, and it was two hospitals that needed to share patient record data between them. And, and so they had a problem, and again, this comes to that kind of, get the immediate benefits. They had a problem and so they sort of created their own system, and it came out of that. And then once they started using it, this is your ‘U’, you know, ‘Used’, they, they did not want to give it up. And they, you couldn't wrestle it away from them. And then that best practice started to spread. And now, as I understand it Sunhed, probably pronounced it wrong, Sundhed.dk is now the national standard. So, it came from the other way round.

Joe [00:39:46]
Yeah, it's a classic description. I mean she describes in her book, working with the install dates, she describes a number of these projects which are grown from seed, as it were, from end users working with technical people. ‘I've got this very specific problem which I'd like you to help me solve’, and then solve it and go, ‘ooh well that works for that, will it work for anything else?’ And before you know it, it's gone through a country. I don't think it took very long at all actually, to go through the whole of Denmark, in the same way we put in a very simple solution for the North East of England, and it went to 12 trusts in really short order. 3.76, 3.6 million citizens etc.

Joe [00:40:23]
If you get it right, it flies off the shelf. You don't even have to advertise it. You don't even have to tell anybody. The doctors go to the pub and go to the other doctors, ‘Oh I can see the GP record for my A&E system.’ ‘Really? Why can't I?’ Goes in on Monday morning, complains to the IT department. Says ‘Bryan can see GP records from A&E, why can't I?’ Well, he rings up the other trust, and they go, ‘well, you just have to put this in.’ ‘Really? That cheap? Honestly? Really?’

Joe [00:40:49]
Yeah, success is generally cheaper than massive, massive, architected failure, which is one of the great lessons.

Kevin [00:40:56]
But they do have a problem, don't they, that if, if things emerging from the bottom up and sort of fandom in the lower levels, the grassroots sort of emergence is the way to run these projects, how can a central body orchestrate that? Because the two obviously don't go hand in hand. How can you centrally orchestrate emergent bottom-up systems? Well, we think we've got an answer to that, don't we? This is a concept behind our plan.

Joe [00:41:27]
I think that's right. My favourite story about how you, how you build something really great at a distance, without having much control, is there's a massive fortified castle on the island if Nisyros, and it was, it was built by a guy who never went there, never saw it, never touched it, and the guy was called Mausolus, from which we get the word mausoleum and he was the king of Lyceus, and he had a federated structure, such that the general from the island of Nisyros would have to go to Halicarnassus, where also the first mausoleum seventh wonders of the world was built, so he's building all the biggest engineering projects in the world, including massive castle on Nisyros, and all he said is, more or less secure Nisyros, make sure there's a massive castle there that will last for two thousand years. ‘Here's the budget. If I visit you, and it's not built, you'll be gutted and flayed.’

Joe [00:42:25]
Now, obviously, we don't want to be an organisation that's gutting and flaying people, but we do want to distribute the budget to trusted lieutenants and people who could be trusted and have got the right principles, not enforced by gutting and flaying, but who we know to be on board delivering the project. Now I daresay, he probably hired people who delivered actual things before. I suspect he didn't go to somebody who'd never done it, or to an academic who's written a paper about it. I suspect he went to builders, to build his castle.

Kevin [00:43:00]
Well, ‘skin in the game’ is what Nassim Taleb calls it, right? If you're going to be gutted in flayed, then you're gonna go to someone who actually knows what they're doing.

Joe [00:43:09]
It was, much of it was done before written language, so his reputation may have been somewhat embellished down the ages, but-.

Kevin [00:43:16]
Don't let the truth get in the way of a good story!

Joe [00:43:20]
Yeah! But delegation of a budget, to people who can do things is key. And given that he had no internet, he didn't even have any post, didn't even have any handwriting, all he had was a chance to tell somebody here's the message, here's the money, go build it. And when you look at it today, it's brand new! It's two and a half thousand years old, it looks brand new.

Kevin [00:43:43]
I was reading, we discussed this a little bit the other day, but they were talking about Penn Station in New York. There was an article about Penn Station in New York and saying how it'd really become, it was decaying, there was this grand, grand station built at a time of the American railways. You know, this fantastic thing eventually got taken over by Amtrak and things like that. But the central argument of this, this article was that we've moved into a time in history where people are scared to give power to people, because historically it's been rich old white guys, you know, and they've not always, they've not always used that power for good, good purposes.

Kevin [00:44:31]
That said, if you never give anyone any power to do anything, and you're scared to hand over power, then you end up with something like Penn, Penn Station in New York, where nobody is trusted to act benevolently on that thing. And we're stuck, aren’t we, we're paralysed...

Joe [00:44:51]
Yeah.

Kevin [00:44:52]
I think I’ve gone like woah, in our Execution Essentials, we talk about Autonomy, Mastery and Purpose. And I think the Autonomy thing, transparent autonomy, is another thing. To say, ‘yes, we trust you to go and do this thing, but as long as you do so in a way that everyone can see what, what you're up to, so if you start doing things wrong, we'll pull the plug.’

Joe [00:45:13]
I mean, I mean, absolutely. I mean interesting, the US reference in Penn State chimes with Mausolus and with ancient Greece, because the Lyceum federation that Mausolus was king of, delegation was the whole point of that, and it worked reasonably well for several hundred years, but in fact, Thomas Jefferson built the US Constitution around the Lyceum Federation history.

Kevin [00:45:37]
There you go.

Joe [00:45:38]
You, you delegate, you delegate to trusted people, because the geography was too big to control, you know, and you have to have a federation of people who you trust, you know, in order to make it work. But the other thing about Penn State, that example you gave I think is, it reminds me of a, because I'm trained as a family therapist, systems can get into an unhealthy equilibrium, and they can stay that way for years and years and years.

Joe [00:46:07]
Sometimes Salvador Minuchin, he was the founding father of family therapy from a structural point of view, he said, that sometimes you have to go into a system and you have to just disrupt it anyhow, and he called that the creation of an unbalancing manoeuvre. You know, and he'd go into a family therapy session, and he'd just turned a table over, and go and sit in a corner and sob, and see what the family did. And everybody then shifted out of their position, their unhealthy, stable equilibrium, and then have to reform into another system.

Joe [00:46:41]
So you unbalance the system, gives you chance to put things down in the right place. The NHS IT market has been in an unhealthy equilibrium for some time, and requires an unbalancing manoeuvre I think, in terms of, you know, back to open platforms.

Kevin [00:47:01]
I feel like we come, we come to the same conclusions from different places, because in tech world there's this sort of idea of finding local optima, you know, if you're trying to climb a hill and you're trying to get to the highest point in the hill, that you don't know that there's another bigger hill further away. And actually, you have to, you have to go exploring, you have to go, you have to get outside of your local optima, out of your local maximum-.

Joe [00:47:31]
Yeah, yeah.

Kevin [00:47:32]
In order to discover there's a start of a bigger hill over here.

Joe [00:47:35]
Well, from a Cognitive Behavioural Therapy point of view Kevin, we would say, if you always do what you've always done, you'll always get what you always got. You know, so you have to change something, from a therapy point of view, if you're depressed today and all you did was lie around the floor watching the telly, for God's sake do something tomorrow. Anything. You know, even if it's just five yards walk to the front gate, it's a step up from what you did yesterday. But you've got to change something.

Kevin [00:48:01]
I was going to ask you actually, just, I know we're talking about NHS tech, but lessons learnt and just general mental health from a year, from, from a career in psychiatry. What are the big take aways? Were they too acute? I mean, sorry am I equating, sort of...just general kind of good mental health in, in a, in a lucky section of the population compared to, you're probably dealing with some really acute cases? I know that's the case of Oxleas.

Joe [00:48:37]
Yeah. I ended very highly specialised, as people with very severe mental illnesses for a very long time, but from a Covid point of view, top tips, have a getting up time, have a bedtime, go out during the day. You know, for the rest of us that's probably about it, you know, the maintenance of routines, wearing a tie during the week etc. That's your normal workwear I'm guessing. This is mine.

Kevin [00:49:06]
I'm routinely badly dressed.

Joe [00:49:08]
But building, building in some routines, and the importance of getting some daylight on the back of your eye, because your optic nerve actually acts like a fibre optic cable, the amount of light that goes down that cable to the inner gubbins of your brain, as we doctors call it, is really important in keeping your mood right and keeping your appetite set and, you know, keeping your internal clock working.

Kevin [00:49:35]
Yeah.

Joe [00:49:36]
So that's my top tips for, for lockdown.

Kevin [00:49:38]
For good mental health. Generally. I know, I know we talk about tech because that's our shared passion, but I couldn't, I couldn't resist asking you.

Joe [00:49:52]
That'll be 250 guineas.

Kevin [00:49:55]
Yeah!

Mariah [00:49:55]
Good on you!

Joe [00:49:55]
For my advice!

Kevin [00:49:55]
Yeah, no one wants medical advice from Kevin, Kevin off the internet. I asked, I was asking Marcus Baw when we had him on about vitamin D and Covid. Yeah. We shouldn't be giving out any medical advice in our podcast.

Joe [00:50:15]
No. No, I suspect not.

Kevin [00:50:19]
Actually could we ask about Apperta as well at some point, our two grumpy lads up in the balcony-

Mariah [00:50:27]
I can't wait for that tweet.

Kevin [00:50:28]
They've got it in for Apperta, haven't they, Rob Dyke, he's not a fan. And if I don't ask you, what was the issue there? And we'll tread lightly because I think there are good, there are good people, right, in this and sometimes...

Joe [00:50:42]
Well, I think to be honest, to be honest Kev, sometimes, and I'll say this out loud, sometimes the open-source crowd can be a little bit Judean People's Front/People’s Front of Judea/

Kevin [00:50:57]
Yeah.

Joe [00:50:58]
In terms of they passionately believe in the same thing. In fact, they all want rid of the Romans, but sometimes they passionately differ on how to get rid of the Romans. And sometimes that can overtake the fact that it's the Romans that are the problem, and they can end up in a fight. And you think, sometimes I look at factions within the open-source crowd and go, come on guys, you're all on the same side, really. And yet you're gonna fall out over a bit of history like Apperta.

Joe [00:51:30]
Apperta was an earlier attempt sponsored by the NHS to try and stand up an open-source ecosystem.

Kevin [00:51:38]
Is it still going as a?

Joe [00:51:39]
No, I don't know. I was, I was, I was on the board when it was first founded, but to be honest, we didn't go at it the right way and there are some important lessons to be learnt here. The board of directors, myself included, all amateurs, all with no time in their day jobs to do it, and so there was a great expectation I think that we would be able to achieve things, which actually, we were all busy clinicians, for the most part, on the board, and I got why they brought clinicians in. I think there was inadequate funding going forward in order to fund any proper support for that. So, I don't think there was enough money put in, what was put in may not have been, you know, the best news.

Joe [00:52:28]
Intentions were good. There was also a hint that we were busy renegotiating contracts with some very, very big IT suppliers and may be some people felt it was just a smokescreen. If you don't take the price of this down, we might go off down an open-source route. Some people have a theory.

Kevin [00:52:48]
Used as a bargaining tool.

Joe [00:52:51]
Yeah like it was a bargaining tool, and then the executives not long after major deals were done. It left, I think, a number of people with a bad taste in their mouth. I suspect that there’s the Community Interest Company that's still on the books but has withered for want or lack of intention I would suspect.

Joe [00:53:10]
But it's important because it was an attempt, or a seeming attempt by the NHS to stand up for an open-source entity, which in the end didn't pan out.

Kevin [00:53:21]
Which is, which has similarities to what we, as in you and I and the rest of SARD, but also lots of other, what we've loosely called the Rebel Alliance.

Joe [00:53:31]
Yes. But I think, I think the key, the key difference with this is, is that you're looking to stand up something that's already there, in terms of staff side software and having a thing for an ecosystem to build up around. And I think that, that will be key. But the other thing is you're asking for a bit more money and I think that's very wise. People will have to make this their day jobs.

Kevin [00:53:55]
Yeah, you need, you need good people, but good people have mortgages, and they need paying, and they...

Joe [00:54:03]
Yeah.

Kevin [00:54:04]
It can't be a hobby anymore.

Joe [00:54:06]
No it can't.

Kevin [00:54:06]
I think our interest in it at SARD is actually we've got a commercial interest in seeing this success, in seeing this be a success, because an environment in which this exists is a good environment for us to do business. And so, I always see that as a feature, not a bug.

Joe [00:54:27]
And I agree with you, and if a project isn't going to make enough money to both sustain itself and improve itself, it will die. You know, what we would like to see is a really healthy ecosystem around health IT where people can make money, and we can have a really healthy marketplace in vibrant health software, which, if it works here, it won't just work here, you know there's potential exports, rather than get your developers to look at me and say, well, how will we sell it to the NHS? And I said oh don't try and sell it to the NHS, too bloody difficult, why don't you go to the, I dunno, the Middle East, sell it there, prove it there, where people have got money to burn and they can make decisions and then you can bring it back to the NHS and sell it to us, once you've taken us on a jolly to see it in Bahrain. We can see that it works. But we're a hard market. That's got to change, if we're going to get a really healthy software market around health care in the UK with our unique advantages, we need to create that opportunity to make some money, you know, not obscene buy-a-jet money, but a nice little sailboat would be nice.

Kevin [00:55:35]
You could buy a Greek house?

Joe [00:55:38]
Well, yes, you used to be able to do that once upon a time. Let's not go there!

Kevin [00:55:43]
You were on ‘A Place in the Sun’ weren't you?

Joe [00:55:45]
I was, yeah, I was.

Kevin [00:55:47]
So Fiona's also a clinical informatics nerd.

Joe [00:55:54]
Yes, yeah I'm sure she'd be alright with that. But, you know, I'm a doctor, she's a nurse, we're a cliche. And we've both been working in health IT for a very long time. Fiona was part of the team that successfully developed the electronic prescription service.

Kevin [00:56:14]
Fiona's your wife, I should point out to listeners.

Joe [00:56:15]
Yes, or I'm her husband, as she would say.

Joe [00:56:21]
But yeah. So we, we live and breathe health IT in our house, in dinner conversations, the children are bored with acronym soup, that goes on over dinner. And they describe us as the Posh and Becks of Health IT.

Kevin [00:56:42]
I like it. Yeah, there's a lot of people who do feel really passionately about this. Once, once you’ve accidentally, in our case, accidentally found ourselves in this market, I kind of can't leave it alone. Because it's really annoying me, and I want it sorted. I kind of feel like I could go off and work in FinTech or I used to work in the Ministry of Defence, I used to work in the defence industry.

Joe [00:57:09]
What you made bombs?

Kevin [00:57:10]
I didn't make bombs! I did do lots of, I can't really talk about this without-.

Mariah [00:57:18]
No, you're not supposed to talk about it!

Joe [00:57:18]
Oh, then you'd have to kill us? I see.

Mariah [00:57:18]
Exactly! I don't want to die!

Kevin [00:57:20]
I think, I think I'm allowed to say, put it this way, I can't go to Cuba without someone putting on a pair of rubber gloves.

Joe [00:57:32]
There you go! I'll get the pictures Kev, sorry.

Kevin [00:57:33]
Yeah, but if you, if you want to see massive public sector wastage on a huge scale, healthcare's got nothing on defence. So that might make us feel better!

Joe [00:57:47]
But healthcare IT is addictive because you know, you know what's at stake. You know, you know how important it is. And, you know, if you shave a few seconds off the millions of interactions we do every day, or you make your one in a million type accidents slight less rare, you make a massive difference.

Joe [00:58:09]
You know, the NHS does a million interactions a day with the patients, so a million to one short accidents happens every day, and if you make software a little bit easier, a little bit of better for clinicians, a little bit safer, you'd make a massive difference on a massive scale. I got involved in this because I got tired of saving patients one soul at a time. We need to save, we need to save them in droves, we need to make it easier for them to save themselves with tech.

Kevin [00:58:36]
I know. It's funny how when we, we work on, like, appraisal stuff, and you're a SARD user, or you were a SARD user when you were working at NTW, hopefully you've got nice things to say about it?

Joe [00:58:48]
Well I wouldn't have spoken to you, if I didn't like your software would I?

Mariah [00:58:50]
There you go, it's a good point.

Joe [00:58:50]
People ring me up and say, ‘ohh can you have a look at this?’ or ‘I want to talk to you about that?’ and I thought ‘Oh, he has decent software. He has software actually where somebody pops up and what I think is a human, not a bot’.

Kevin [00:59:03]
It is a human.

Joe [00:59:05]
It asks if I can help, so it's not just about the software, it's about the service that goes around it. I mean, you guys have been delivering for me, a serviceable appraisal system, which was easy to use, and the service alongside it meant that if I was having a problem, there was a human who would help me with it. And that's not very common.

Kevin [00:59:26]
Right. Just capture that. Nice soundbite.

Joe [00:59:30]
Another 250 guineas for that one, Kev.

Kevin [00:59:33]
I did not pay him to say this! He comes on here of his own free will. But no, that is, that is nice to hear. But actually, I think that's probably why we...this, this approach, of we Rebel Alliance, I think it's got a shot, because I think we're coming at it - I'm a techie, but I also come from a creative background and an arts background, I know Mariah, Mariah and I have been on stage together.

Mariah [01:00:00]
We have, yeah.

Kevin [01:00:00]
Yeah. singing. Singing and dancing. I come from not just a tech perspective but a, a community perspective, a customer service perspective, the full business stack, the marketing, the sales, you know, and I think that's where sometimes these things have gone wrong in the past. It's gone, 'oh, it's a technical problem'. No, no, it's, it's bigger than that.

Joe [01:00:28]
Well it's like the NHS Covid tracing app, I've recently did a bit of Tweeting about that and it’s like everything else, the delivery of the app is the start of the project. Not the end. You know, everything comes after that. It's improvements, embedding it, training, staff, support, all of that stuff. You know, we've often, I think, thought the end point was the delivery of software, and it's not. Generally a mistake.

Kevin [01:00:55]
I feel that the, the joy and purpose part of our execution essentials is my favourite part, because I think it is where, where everything else comes from. Everything else hinges on that idea, that people have bought into the purpose of what we're doing. And people, people work hard on tech, we've got a guy Alex Rudall has been working on our open-source ESR Wrapper project, and I hope he won't mind me saying, he's been volunteering his time on that, even though we paid him for, for contracting work, he's come along and said, 'no, I believe in this project' and started working on it, even though we don't pay him. Which is not sustainable long term.

Joe [01:01:37]
It's not. But the power of joy, the power of a shared idea. I mean, I’ve been working as a volunteer vaccinator over the last, I dunno, two months or however long it's been since we've had the vaccine. And it is awesome. The power of this army of people. And it's just a joyous, joyous place to be. Not least because when I get into the vaccination centre, it's full of just retired consultants who I was at medical school with. We're having a ball. We're suddenly useful again. We're having a great time. We're delivering vaccinations faster than they can deliver vaccine, and, you know, every patient we see is delighted to be shown the light at the end of the tunnel. You stick them with a needle, and they thank you and smile.

Mariah [01:02:27]
That's amazing.

Joe [01:02:29]
That's the power of a social movement. So, it's delivered 15 million vaccines. I see people on Twitter say, ‘ooh couldn't be right, can't be 15 million’. I'm telling you, it is. From the local numbers that I’ve seen, it's absolutely right. And most of that is being delivered on goodwill and local knowledge. Sound local knowledge.

Kevin [01:02:48]
Yeah, I hope you don't mind me saying you said that you came back from the centre, and like welling up emotionally from-.

Joe [01:02:55]
I cry at Pottery Throwdown, man. It's, it's whenever I see these things or beautiful work, or beautiful teamwork actually makes me cry. When a team, a team are doing really good, and the machine that's delivering vaccines, here in Newcastle, did make me cry. Although it's not difficult. Lassie, come home. Every time.

Mariah [01:03:16]
Yes.

Kevin [01:03:18]
Yeah. And you're a Newcastle United fan as well.

Joe [01:03:22]
Well I cry every week at that. Don't mention Chelsea last night, but there you go.

Kevin [01:03:28]
My dad'll be listening. He's a Chelsea fan. Season ticket holder.

Joe [01:03:33]
He'll have enjoyed that then. To be fair, even, even the attendance at Newcastle United, 52 thousand there, every week. We haven't won anything in my lifetime. But there's still, faith, joy, a sense of togetherness, and hope above all else, that things might be different. Things might not always be like they've been for the last 50 years, and that's my hope about what you're doing Kevin, and what we might do, you know, platforms in the NHS.

Kevin [01:04:06]
If there's hope for Newcastle, there's hope for us!

Mariah [01:04:10]
Oh dear.

Joe [01:04:13]
Yes, maybe that hasn't worked out at some points. You too could be Newcastle United!

Kevin [01:04:21]
If the elements... I really admire Jurgen Klopp, there's, there's a man who seems to symbolise, I know he might get, by the time this goes out, he might be fired or something, but he seems to embody leadership to me. In terms of how he treats his players, even when things are going, you know, not, not that great. And we've had three, three bad hits on the run.

Joe [01:04:50]
He's got, he's got a kind of leadership. He's got one, you know, he's got that charismatic sort of authority that, that goes with having a really big personality, and that, that'll get you so far, probably get you all the way in football. In health IT you need different kinds of leadership and different kinds of authority. Sometimes I could vote for England on the nature of authority, but you need the Financial Authority, 'he who pays, says'. If you've got the budget, you get to call it.

Joe [01:05:18]
You need the Structural Authority, ‘I'm the boss, I’m the NHS England, so I get to tell you what it looks like’. Or better still, I get to tell you that you can go and do it, and you can tell me what it looks like. And then there's Sapiens Authority, the authority that comes from special wisdom, like the doctors have got. Sapiens meaning 'wisdom' in Latin. And they need to make all those parts of leadership and authority line up in a big IT project. And often they don't. If you get one out of whack, you might have a brilliant, charismatic leader? No money. Falls over. Or you might have a brilliant, charismatic leader, money, but the connections aren't brought in, so you've got not sapiential authority, so it falls over.

Joe [01:06:00]
And it's the lining up of these different kinds of leadership and authority, which I think is important. And Klopp maybe gets his rights, I’m pretty sure he's got control of transfer budgets. I'm pretty sure he gets to decide who comes and goes. I'm pretty sure he knows more about football than anybody else, so he's got the sapiential piece covered. But you've got to line it all up. Not always in the same person, but you've got to line up the different kinds of authority.

Kevin [01:06:24]
Yeah, I thought it was probably a bit of a push to get you to praise Jurgen Klopp.

Joe [01:06:31]
I refer the honourable gentleman to my earlier answer.

Mariah [01:06:36]
Do you guys want to talk a little bit about NHSE?

Kevin [01:06:38]
Oh yeah, what's going on with NHSX? Yesterday we heard they were getting merged into NHSE, I was speaking to someone from NHSX who was very senior yesterday, who was sort of aware of it...

Joe [01:06:50]
I don't know. I don't know. But it's not unusual for what we're seeing, NHS Alphabet, to have a bit of a churn. The NHS runs on the lava lamp principle, you apply heat to the bottom of a blob of wax, in a sea of oil, and they break up into smaller blobs, go up to the top, and down to the bottom, and then they're called Regional Health Authorities or ICSs. The same is true within the centre. So over time we've had NHS Connecting for Health, which became the Information Centre, which became the NHS Information Centre, before all of that was the NHS Information Authority, and since then we've had NHS Digital and we've had NHSE and NHSX.

Joe [01:07:33]
Now I thought Matt Hancock's creation of NHSX was the right idea at the time, because I thought he wanted to disrupt what had been going on, and I think he was looking to put in a new agency to disrupt the way things have been, kind of stuck in that unhelpful equilibrium that I talked about earlier. Required an unbalancing manoeuvre, and I think X was to be that unbalancing manoeuvre.

Joe [01:07:57]
Timing couldn't have been worse at X. Covid hit, you know, eight to ten months into their existence and suddenly they've got to produce apps that are gonna contact people and trace this, that and the other, you know, the Earth's moved under their feet, miracles have been achieved in terms of NHS connectivity, they've done good things about freeing up budgets, you get video calling and Microsoft Teams across the piece, which has made national co-operation much easier than it was before, but their mission, their Tech Vision, has got lost.

Joe [01:08:33]
And because of that, I think they're now under pressure from, you know, other silos, you know, other islands, within the centre, and it is merciless, the rate it churns, sometimes at that level within the organisation. And it's difficult for people. The only thing to hang on to, I think, is that that it is a perfectly good Tech Vision. Please, God, let's not write another one, because we've got, you know, ‘NHST’ coming down the track or whatever. Please stick with Plan A, only fund it, and try it out in a few places. You don't have to do the whole thing big bang across the NHS, let's do a few projects that demonstrate the worth of open platforms, with a decent amount of money, and see if we can make improvements- We do, we always make progress, but the constant organisational churn can be quite distracting.

Kevin [01:09:22]
I know that they were getting it the neck a little bit from the Public Accounts Committee for having the Vision, but not executing it. It's sort of-.

Joe [01:09:30]
To be fair they can't go back to the Public Accounts Committee and say, 'excuse me, have you noticed what's going on?'.

Kevin [01:09:38]
Well the PAC, erm, report was in November. So, it was during Covid that was, that they met and discussed it so-

Joe [01:09:46]
I mean I get it; the PAC are doing their job, their job is to hold these people to account, but at the same time, have a heart man. You know, there's quite a bit going on.

Kevin [01:09:57]
But the call is there to implement it.

Joe [01:10:01]
Yeah.

Kevin [01:10:02]
Hopefully I think we've got a way to do that. That's my belief.

Joe [01:10:07]
While they've had their mind on other things, you've been writing a delivery plan and coming up with a way to have a look at it. Hopefully they'll see the value in that.

Kevin [01:10:16]
Yeah, let's hope so. If not, I'm gonna do it anyway.

Joe [01:10:20]
There's a lot to be said for that. There really is a lot to be said for that. If, if the government can't create this eco system and community, well you have to create it yourself.

Kevin [01:10:31]
Do with a little bit of a jet engine. But, yeah.

Joe [01:10:33]
Would help, yeah. But you never know. There's more than one way to get things done usually.

Mariah [01:10:38]
Joe - I have one last question for you, and that is, if there's one thing our listeners should know, what would that be? No pressure.

Joe [01:10:48]
One thing you should know... One thing you should know, is you should have watched the 15 minute video by Margunn Aanestad, that will explain to you, why you can't architect this all massively from the centre, and how you have to grow it. Cultivation is better than construction in larger, in very large multi-organisational IT projects. Go and see Margunn Aanestad's little video. It's 15 minutes of your life, 15 minutes that changed my life. Have a look at that.

Mariah [01:11:17]
Perfect, I will definitely be putting that out there.

Kevin [01:11:19]
I love that video. I'm so glad you introduced it to me. I've been a big, I've been really interested in sort of Darwinian processes and Cultural Revolution and having that approach. And when you showed it to me, I was like, 'oh, of course'. Yeah. Of course. It was, it was-.

Joe [01:11:36]
It was like that for me. It was a, it was a revolutionary moment, because you like to think that everybody isn't a psychopath who needs a reward every 10 minutes, and most people aren't thankfully, 99% of people aren't psychopaths. But most organisations, they do need a reward every 10 minutes. They really struggle to defer gratification because they've got a report at the end of every week and they've got to report that things are better than they were, otherwise, you may have no value for the organisation. And organisations do spit people out. There's a psychopathic tendency for most organisations, and you've got to deliver more quickly than you think.

Kevin [01:12:11]
Well, listen, whatever happens of this project, one of the things I've really enjoyed is getting to know you, because I feel like we've spent quite a bit of time discussing these things, and I feel very fortunate that we've got to know you and others on this journey.

Joe [01:12:28]
Well it's been entirely mutual Kevin, and I've said this before, but you've re, re-lit my open-source fire. So, play out with...who sang Relight My Fire?

Kevin [01:12:39]
Dunno. But that one. That song. Better than Xanadu.

Joe [01:12:44]
Is it Take That? We never even mentioned dancing guy. That's a shame but never mind.

Kevin [01:12:50]
Dancing man on a hill. That's for another day. It's Simon Sinek, isn't it? The Dancing Man on a Hill. About how you start a movement. And I feel like, you need to embrace the people who come along and join in to the start of that movement. And I don't know who did start this. Probably you or someone or Marcus or Rob Dyke or, who knows, there's lots of people who've been doing this stuff, but whatever it is, I think we're all starting to dance together now. And we want.... So, if that sounds fun, come and join us. We're all dancing on a hill side. It's going to be good.

Mariah [01:13:26]
Great. Well, thank you very much for joining us.

Joe [01:13:29]
That was great fun.

Kevin [01:13:29]
Yeah, it was good fun.

Mariah [01:13:30]
Thank you to all our listeners who tuned in to today's episode of SARDisms. We hope you've enjoyed hearing about Joe McDonald's digital legacy. And if you're looking to join a community of users who want to help shape and develop an open-source future, then get in touch. You can find out more about SARD by visiting SARDJV.CO.UK, or send us a tweet on Twitter @SARDJV and use #Sardisms. Until next time, have a great week.