Leslie Willcocks, Professor of Technology Work and Globalisation, London School of Economics and Political Science.

and

John Hindle Knowledge Capital Partners

In our most recent research we have been tracking organisations over time to see how they grew their strategic use of RPA and cognitive automation. We have been looking across all the major vendors and their customers, and this has been providing rich insights. Last month we saw Uipath being deployed at Nielsen. This month we are taking an in-depth look at how East Suffolk and North Essex Foundation Trust (ESNEFT)—one of the largest NHS trusts in the United Kingdom—have deployed Blue Prism and Thoughtonomy technologies (recalling that Blue Prism acquired Thoughtonomy in July 2019).

In 2019 ESNEFT employed 10,000 staff to provide hospital and community health services to the population of Essex and Suffolk. Even before the pandemic of 2020, the NHS was under intense pressure to deliver high quality services with ever-diminishing budgets. Against this backdrop, ESNEFT embraced a philosophy of ‘Time Matters’, seeking to focus all use of employee time on improving patient outcomes. In alignment with this principle, the Trust’s intelligent automation strategy aimed to eliminate time spent on repetitive tasks, reduce costs, streamline processes and increase time spent on patient care.

The Institute of Public Policy Research (IPPR) has estimated that automation could save the NHS £12.5 billion per year. The ESNEFT automation program demonstrates that what is increasingly called ‘Intelligent Automation’— merging RPA and cognitive automation technologies—can deliver on this target and ensure hospitals can re-direct more investment in life-saving and critical patient care. The automation program has also supported and optimised ESNEFT’s obligations/operations around the Electronic Referral Service (eRS) and the government’s ‘Paper Switch off’ program. Our main contact for this case was Darren Atkins, then Deputy ICT Director ESNEFT.

Timeline of Activity

2018

• February: Proof of concept/business case
• April: Initial automation of invoicing process within finance department
• July: Roll-out of automation to streamline GP referral process
• October: Roll-out of automation to reduce rate of missed appointment/DNA
• November: Intranet to Active Directory automation

2019

• January: commenced project to introduce GP surgeries to ESNEFT’s centralised platform
• March: Cardio-Respiratory—creating diagnosis test requests from incoming referrals
• April: HR process automated within staff admin system (ESR)

Client Adoption

The first process automation was implemented within the ESNEFT finance department, using virtual workers to streamline invoicing processes. Whilst this automation was a success and released benefit to the organisation it was felt that the scope of that project was too limited and would fail to demonstrate the full direct impact of automation on patients and frontline staff.

Therefore, as project lead, Darren Atkins decided to re-direct the Thoughtonomy team to help tackle the GP e-referrals process, which deals with up to 2,000 incoming GP referrals every week. This was a high-volume process and very segmented process in terms of the different systems that ESNEFT’s medical secretaries and consultants need to access. It was also a slow and paper-based process, sucking up precious and scarce time and resource amongst consultants and medical secretaries.

As the success of the GP referrals project became evident, ESNEFT began exploring other processes within the Trust that would deliver the most significant and immediate benefits and expose more members of the workforce to automation and the positive results that it could deliver.

The team decided to set its sights on tackling one of the most costly and frustrating issues facing NHS Trusts to this day—namely that of missed patient appointments. Almost eight million hospital appointments were missed, or ‘Did Not Attend’ (DNA), in 2017–2018 alone, according to NHS England. That did not include appointments cancelled in advance by either the hospital or the patient. With each hospital outpatient appointment costing the NHS approximately £120, that equated to almost £1 billion worth of appointments missed in 12 months.

The Business Case And Objectives

The business case focused on releasing ‘time’ across the organisation. Repurposing this time towards patient facing activities was critical. In tandem, the ability for automation to shrink the time taken to act on patient care was a key target. Streamlined processes would also lead to savings by eliminating ancillary costs caused by manual processes.

Thoughtonomy’s SaaS based platform provided a robust, flexible foundation through which the Trust could afford to access sophisticated AI and RPA technology and train a pool of ‘virtual workers’ to assist its human workforce across the Trust.

The automation program focused on two major process automations within the Trust, each with its own specific challenges and objectives. There was also a wider, organisational workforce objective within the Trust.

The program had three specific objectives:

1. To streamline GP referral processes within ESNEFT to free up time amongst medical secretaries to focus more on patient care, and to reduce costs and allow patients to be seen sooner by clinical staff. Every week the Trust receives up to 2,000 requests for consultations with clinicians through the National GP e-referrals process. Disparate documents and patient data were downloaded manually from several systems before being recompiled into a new file, uploaded and sent to a consultant for review.

2. To reduce the rate of missed appointments (DNA—Did not Attend) at Colchester Hospital (part of ESNEFT) thus reducing the time and financial costs of missed appointments, and ensuring more patients can be seen by clinical staff and improve patient care altogether.

The DNA rate at Colchester Hospital was marginally over the NHS 5 percent key performance indicator (KPI) standard; the Trust needed to address this as a matter of urgency. One challenge was that members of staff were inaccurately recording some DNAs, even when a patient had made every attempt to cancel their appointment. Many patients were struggling to notify the hospital of their intention not to attend, being unable to get through to speak to a member of staff on the telephone and with no other alternative available to them.

3. At a broader level, the Trust wanted to prove the benefits of Intelligent Automation for the Trust itself, for staff and for patients, and to establish a positive culture of automation across the workforce, to smooth the path to further automation in the future that would meet key commercial and patient-focused objectives. It was essential to demonstrate the way in which automation supported ESNEFT’s guiding philosophy of Time Matters—freeing up time for all staff to focus on utilising their skills and capacity to deliver first-rate patient care.

This meant ensuring that ESNEFT staff were able to see past the scare stories around ‘robots taking jobs’ and be comfortable with the introduction of automation. ESNEFT needed to equip its staff with the understanding and skills to work effectively and harmoniously alongside virtual workers, having recognised the benefits that automation would deliver to the Trust and to them personally.

Success Factors

The success of the programme hinged on a number of different factors, all of which combined to deliver game-changing results for the Trust, and its staff and patients.

The first factor was partnership: building the Trust’s virtual workforce with close collaboration and teamwork. Thoughtonomy’s solution team worked alongside the Trust’s team to ensure the program would deliver high impact. Online and in-person training ensured the Trust’s team were equipped with the skills to build automations, deploy them into the organisation, and manage the workloads and performance of their virtual workforce.

Separately, Thoughtonomy’s solutions team ran workshops with the Trust to identify which processes were ideal for automation and map the impact that these would have on the organisation. Experienced automation designers from Thoughtonomy then built and tested virtual workers working closely with the in-house team.

Outside of the automation team itself, ESNEFT ensured strong engagement with frontline staff, helping them to understand how automation would benefit them from a personal perspective, easing the burden of administrative tasks and freeing them up to focus on what they are best at—namely, delivering excellent patient care. This meant that frontline staff were eager to embrace change and have been vociferous supporters of the automation program.

The second factor was best practice and governance supporting continuous improvement enabled by virtual workers. The Trust’s internal team became able to manage the virtual workforce on a daily basis via their online Connect portal. Whether on a laptop or phone, they became able to monitor utilisation of the virtual workers. Exceptions were highlighted, allowing the team to quickly investigate and initiate a ‘learning process’ to teach the virtual workers how to deal with a similar situation in the future.

Utilisation levels are monitored and the team can influence virtual worker workloads in line with hospital priorities and volumes. Automation eliminated errors that inevitably creep into manual processes, especially when staff are under pressure.

The third factor was commitment to experiment and innovate with Software-as-a-Service (SaaS) that gave access to evolving cognitive capabilities. Success came down to a real determination to do things differently, to test new ideas and to adopt an innovative mindset. ESNEFT has been the first UK Trust to embrace the use of virtual workers within the organisation. Combining cognitive and RPA technology in a single platform has allowed the Trust to target its virtual workers at bottlenecks in a wide range of processes that impact people’s time. It was the first Trust to deploy digital labour on a SaaS basis, reducing the need for costly investments in maintaining IT infrastructure dedicated to automation and so maximising the value it reaped from its budget over the long term. As new cognitive capabilities were added to the platform ESNEFT could increase the range of tasks automated further at no great additional cost.

Business Value Delivered

The automation programme delivered almost immediate results to the Trust, both from a financial perspective, but also in terms of operational efficiency and cultural improvements.

Within the first three months of the GP referrals automation programme, the Trust saw cost savings of £220,000, whilst within the first eight weeks of the DNA automation programme; Colchester hospital had saved £216,960 from being wasted through missed appointments. When you consider that the estimated cost of an outpatient appointment in Colchester Hospital is £160, ESNEFT expected to avoid wasting more than £1.5 million in the first year.

Beyond the financial benefits, the GP referrals automation programme resulted in more than 500 hours of medical secretaries’ time being redirected to direct patient contact. Referrals were now processed immediately, 24 hours a day, seven days a week, meaning that processing time was cut from 25 minutes to five minutes. There was a very marked improvement in job satisfaction and levels of morale amongst the medical secretaries, who were now able to devote more of their time to helping patients, rather than on repetitive administrative tasks.

Similarly, the DNA automation programme prevented 1,356 appointments from being missed in its first eight weeks. This freed up vital outpatient capacity for the booking team to actively manage so patients were now being seen more quickly by clinical staff, meaning better patient care, an instant improvement in clinical utilisation and reduced waiting times. The service will have a significant impact on the ESNEFT Patient Tracking list (PTL) performance and the Trust’s DNA rate.

Overall, ESNEFT saved over 6,000 hours of staff time through automation since July 2018 (to October 2019), which was given back to patient care. And the rate of time saved increased rapidly each month as the Trust ramped up its use of the automation platform. In April 2019 alone, more than 2,000 hours of staff time was moved away from administrative tasks back to patient care.

At a wider organisational level, these successes led to the emergence of a strong culture of automation across the workforce, where employees have a clear understanding of the benefits of automation to their own role and daily activities at work, to the wider Trust and to improving patient care and outcomes. Many staff were now proactively looking for processes which could and should be automated in order to free up their time from repetitive and mundane activities to focus on patients. This resulted in a long list of future automations, which the automation team was set to work on throughout 2019–2020.

What could have been done better? According to ESFNET, they should have spent more time creating a structured programme of automation opportunities at the outset, prior to the start of the initiative. This would have meant the benefits were realised faster and given the automation team and the Trust’s leadership a more holistic view of the programme, alongside a clear timeline. Secondly, they could have done more to engage with staff at a ‘grass roots’ level at the outset. The automation team came to realise that working more closely with staff who actually did the work released richer and deeper opportunities that deliver bigger benefits, and ensure an easier implementation.

Cognitive Automation

By 2020 The Trust was deploying more cognitive automation, incorporating machine learning, algorithms, natural language processing and virtual assistants. For instance, in the cardio-respiratory processes they began analysing unstructured data to determine which diagnostic requests could be automated. They also worked on plans to create a cognitive engine for clinical coding.

There have been challenges on this automation journey. It took some time to get to grips with the full range of tools available on the Thoughtonomy Intelligent Automation platform and to apply them correctly to the automation processes to drive maximum returns. Another challenge has been the sheer scale of ambition amongst the team. It set out to deliver at pace from the outset, with a target of delivering automations within a four week window. The team, because of its level of commitment and excitement about the possibilities of automation, delivered on this goal, but it meant a lot of hard work and long hours. The potential according to Darren Atkins, was immense, and only limited by their own capacity.

Darren Atkins saw the biggest factor in the success of the programme as the motivation, skills and vision of the team. Beyond this, the partnership with Thoughtonomy was key because of their dynamic and flexible approach and deep understanding of the healthcare sector. The Thoughtonomy (now Blue Prism) platform provided tools which have been constantly upgraded and optimised, and offered full resilience and a cloud-based model which enabled the Trust to scale its use of virtual workers according to changing organisational requirements.

Into 2020, ESNEFT explored opportunities to deploy the automation platform in other areas of the organisation, including HR Processes, Clinical Coding and Service Desks. In addition, at a wider level, the Trust looked to share its experiences (and its automation objects and processes) with other healthcare organisations and to collaborate with other Trusts across the NHS.

The Trust participated in establishing a free NHS marketplace that allows healthcare organisations to collaborate and repurpose the work already done. This would speed up the time of delivery for Trusts and reduce the overall deployment costs—key targets throughout 2020.

During 2020, ESNEFT continued to look for new and innovative ways to improve operational efficiencies and drive better patient outcomes in the face of ongoing budgetary pressures and increasing demand for services. A major focus has been the consolidation and digitisation of patient services, and this move towards deeper and more strategic use of technology continued as the UK government looked to implement its 10 Year Plan to transform the NHS to meet the needs of future generations.

Our Analysis

The United Kingdom public sector has seen rising use of RPA, but especially amongst local councils and the National Health Services. This reflects the budgetary pressures, demands for higher quality service, increasing workloads, and skills challenges faced by these organisations. Within an NHS trust like ESNEFT automation is required to eliminate time spent on repetitive tasks, reduce costs, and streamline processes. The objective then is to re-direct more investment into life-saving and critical patient care. An immediate insight is that this clarity of goals, and the urgency required—the ‘burning platform’ idea—explains both why RPA is adopted, and also why it is likely to be successful in value terms, as has been the case at ESNEFT.

At ESNEFT there were obvious pain points that RPA could help reduce. However, ESNEFT did not have the experience and in-depth capability to deploy RPA as fast as the Trust required. Therefore the partnering with Thoughtonomy was definitely a way of accelerating automation, as we found RPA leaders doing. Interesting here is, firstly, the choice of a vendor that already had a set of connected RPA/cognitive technologies indicating a more long term view of where automation was likely to lead.

But even more interesting is the more radical decision to go for a robust flexible SaaS platform—as Darren Atkins points out, the first such deployment in the NHS. ESNEFT embarked on innovation from the outset—with Darren pointing to a major success factor: “a real determination to do things differently, to test new ideas and to adopt an innovative mindset.” This translated into developing a dynamic approach, identifying that the real payoffs would come from using the platform, adding technologies, in order to innovate and continuously improve.

As in every ‘leader’ case we have looked at, ESNEFT built a strong, relatively centralised team backed by strong governance, able to build best practices supported by close monitoring, but also built a high level of engagement amongst user staff which gradually grew into a supportive culture for further automation. One should also point out that in all our ‘leader’ cases the very positive relatively quick results—such as the ones ESNEFT report—lubricated further adoption.

In summary, the organisations we study tend to spend a lot of time on dealing with the challenges of old technologies and their legacy systems, while looking also to move into emerging technologies that can also actually solve some of the inherited problems. RPA and cognitive tools and platforms sit in between these two worlds. On the whole up to very recently, most organisations have seen RPA in particular as tactical, for example patching over legacy inefficiencies, getting business value quickly using technology available outside the IT priority queue, or providing cheaper, quick alternatives to the problems created with more traditional technologies. A more advanced user like ESFNET had already seen RPA and cognitive as part of a more strategic evolution into emerging technologies of which they form an increasingly integrated component.

Note: This case has been updated from our research for Willcocks, L., Hindle, J. and Lacity, M. (2019), Becoming Strategic With Robotic Process Automation, SB Publishing, Stratford-upon-Avon, UK. The book is available to purchase directly from www.sbpublishing.org. International shipping available.