Tech debt hangover: a tsunami of point solutions and interoperability

6 min readFeb 9, 2021


Tech debt hangover: a tsunami of point solutions and interoperability challenges #Interoperability

Over the years there have been a few subjects I have soapboxed on and interoperability is definitely right up there in my top three.

I left the NHS three years ago now. Even then we were talking about Fast Healthcare Interoperability Resources (FHIR) standards and the challenge around Interoperability. It was one of the programmes of work that Paperless 2020 was set to address.

But, let’s face it, it isn’t in suppliers interests to open up their systems and get things connected. Licence fees and big old lock-ins have been the motivation of many suppliers for a long time.

There has been some headway, the NHS has opened up the GP Connect framework to allow more suppliers in. The ongoing challenge to this is that they still haven’t solved the Digital Tariff challenge. The UK is one of the few that haven’t put a digital tariff in place for the provision of services. But, watch this space as it is being lobbied heavily and maybe incoming later this year!

When it comes to the NHS, it’s not easy to get stuff done because it is not just one organisation. It is thousands. It was described to me early in my time at the NHS as ‘a shoal of fish rather than a whale’. However, the public see it as one organisation regardless of experiences such as my own recent one. I’ve not long come off of the phone to Test and Trace and shared my information to the same agent three times over. They can’t write the information down (GDPR, which I get) so keying into three different systems. This is far from ideal when I am chasing a COVID test from 6 days ago……anyway, I digress.

Interoperability, it’s not a sexy subject. It doesn’t float the boat in things to sort as it’s below the radar but it is something that was a massive challenge at the start of 2020….. even before COVID19 landed.

Since then, an absolute tsunami of point solutions have been knocked up across the health landscape in response to the COVID19 challenge. Now, we have all played our part in helping the NHS build these solutions. I’m not saying that wasn’t the right thing to do but at some point, a handbrake will need to go on. We will need to stop building. We’ll need to look at technical debt, consolidate and or sort out interoperability or we will continue to build with no clear view of the outcome and no ability to read data across the landscape.

I posed this question about Interoperability to Matt Hancock during 2020, have a watch from this YouTube link?

I didn’t find his answer quite as reassuring as Jens Spanz, have another watch via YouTube?

I’m absolutely heartened to see public and private working together, and the ‘royal we’ will need a proper program of work to look at this. It should aim to reduce spend, headcount, manage tech debt, and better customer experience to citizens and patients. How do we make this happen? Taking a leaf out of the playbook across Government would be a great start. Have a read about the work James Findlay led at Multi Agency Industry Transfer to achieve similar outcomes to the challenge we are facing.

Emergency Services responder sitting at a desk in front of three screens

Image: Emergency Services responder sitting at a desk in front of three screens

What about Tech?

There is a lot of talk about using trendy technologies, such as AI, within the NHS. Providing patients with omnichannel digital experiences. However, this is the equivalent of applying a new render to a house that is about to fall down. The underlying technology platform and services, data models and APIs don’t really exist as standard. There is no guiding technology vision, principles, or standards to drive real change.

Organisations that have thrived? Amazon and Salesforce. For example, they have all built technology ‘platforms’, which although can be a misused term in IT, has specific significance in relation to the NHS. The reason why? They have a really well designed core system that is services based. They use open web standards therefore simple to integrate with and build upon, supporting multiple parties working at scale as part of a consistent approach.

The point here is that the thinking to design a better NHS technology provision has already been done. There are multiple examples within both Government and Private Sectors. There are approaches and technologies, such as microservices oriented architecture, Open API specs, data platforms and extensive cloud offerings from Microsoft, Google and Amazon including serverless capabilities. All this makes these goals easier to achieve.

Rich Picture of the NHSBSA, ‘a shoal of fish rather than a whale’

Image: Rich Picture of the NHSBSA, ‘a shoal of fish rather than a whale’

Through the adoption of an internal open source community across the NHS, it would be possible to look at reusing code, libraries and utilities to provide efficiency gains. This also could avoid duplication of effort that must be rife across such a large complex organisation. It is critical that the NHS adopts a technology strategy where a core platform is developed, which includes common services to handle essential use cases. This would need a dedicated team to design, build and manage with support from specialist partners.

The technical debt

Technical debt is rife across the NHS. Studies have shown that when issues are not resolved as they are found, i.e. within sprint boundaries, the negative impact spreads. The same principle applies to the ecosystem as a whole. This is why the NHS needs to strive for an evolutionary architecture based on microservices. Those microservices can be easily iterated and reduces the chance of repeatedly having to do major rewrites.

The harder things are the organisational changes needed, consolidation of departments, new operating models, governance and things like service design and user experience. Internal teams will also need to be taken on a journey and buy into any new technology approaches. For instance, it would need mandating for it to work and people would need to be upskilled at scale. It was this mandate that proved so successful for Government Digital Services back in the day.

Partner selection criteria would also need to change to encourage innovative agile consulting and engineering businesses that can not only deliver with precision but at pace. It would also help the NHS set standards, upskill staff, and fight for their best interests. Big firms often aim to lock in clients through legacy technologies, closed standards, proprietary systems, and IP ownership. Large consulting firms are typically unable to be agile because their operating models are predicated on landing huge numbers of people to cover overheads and make money. More often than not, holding onto IP and legacy systems as a means to retain business. This way of working is completely at odds with the drastic changes needed.

So, how do we move forward?

I’ve debated how to close this off many times and what the call to action should be but I keep coming back to things much bigger than tech.

This is about challenging the NHS to adopt a standard through HM Government Open Standards Board (via the Open Standards Hub). For someone senior in the Department of Health and Social Care to really lead the charge and become a Challenge Owner to champion the effort to make it an official UK Gov standard. This absolutely must be led from inside the system and mandated to those of us outside who want to come in and help improve services across the ecosystem.

Want more?
Check out Rachel as she discusses interoperability with GIANT Health using this link.

Originally published at on February 9, 2021.




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