Article by Robin Guenier (25 Jul 2002)

From Nhs It Info

Article published in Computer Weekly on 25 July 2002

There’s no more pressing priority for the Government than improving the NHS. If possible, dramatically — and comfortably before the next election. It has less than three years. The money is available; although increased pay may absorb more than had been expected. How best to spend what is left? Surely to improve the lot of the patient?

Apparently not. The Government has chosen a course that is likely to make it worse: sweeping and massively expensive changes to NHS computing systems. We are told it is “the IT challenge of the decade” and “a Herculean task”.

Why don’t people learn? Why are big IT projects seen as a badge of virility — a sign that we really mean business? They nearly always cause trouble: the bigger the change the bigger the trouble, especially in the public sector. Difficulties with this Government’s earlier IT plans for the NHS (this is the third) demonstrate that the risk is especially great for such a uniquely complex organisation — employing 1.3 million people with over 50 million potential patients. Ambitious IT changes rarely deliver what is promised and commonly cause serious inconvenience for those they are intended to benefit: in this case, the patients. Surely anyone who wishes the NHS well would be striving to introduce the minimum necessary IT change, the smallest possible challenge?

This is not a Luddite rant. Computing systems are an essential part of healthcare delivery. There is undoubtedly a case for extension, innovation and improvement and extra funding is plainly needed. But, particularly for the NHS, plans for change, however desirable, must be balanced against risk — and, where there is serious uncertainty, doing the minimum necessary must be the best course.

In contrast, the recently published Department of Health plan, Delivering 21st Century IT Support for the NHS, sets out a massive programme involving massive risk. Yet the case for that programme is not, to use current medical jargon, evidence-based.

It starts with a “vision”. Vision, with integration and centralisation, is one of the most dangerous words in computing. Central control and “ruthless standardisation” will bring about a wonderful new world where health professionals and managers will have instant and simple access to a wealth of information (case histories, test results, research data, resource services, etc.) designed to support the patient “quickly, conveniently and seamlessly.”

This dream requires a major new NHS-wide IT infrastructure, a new procurement strategy and centrally defined data and system standards, focusing initially on national health records, booking systems and prescriptions. It sounds splendid. But such plans always do, particularly when technically naive senior civil servants, in alliance with enthusiastic industry representatives, are painting an idealised picture for ministers. That’s before the dull practicality of the real world intervenes. Four examples:

1. Ruthless standardisation means that perfectly good but non-standard local systems — often introduced after much trial and agony — that are at last working and serving staff and patients, will have to go. There are many such systems. Is dismantling them really a good idea? Is it desirable to pile new problems and “challenges” on health professionals and management — let alone the patient?

2. IT is constantly changing: it’s salutary to recall that Bill Gates recognised the importance of the Internet only about seven years ago. A standardised system defined today with, as is proposed, a “limited portfolio” of “compliant” equipment could be wholly obsolete in just a few years. Yet the plan’s full implementation will take eight years. In other words, the NHS could be setting out on a course of pain and disruption for a period going way beyond the foreseeable future, only to be left with a hugely expensive museum piece.

3. The NHS’ IT skills are inadequate. Delivering 21st Century IT Support recognises this and, after considering various options for implementing the plan, opts for one that involves outsourcing many of its major components. But is it acceptable to put effective responsibility for much of our healthcare delivery into the hands of big computing and telecommunications businesses? What happens when, as seems likely, this proposal runs into opposition?

4. Electronic Patient Records (EPRs) are a critical component of the programme. The concept involves huge problems: health information is far more complex in nature and detail than, for example, financial information. The Government has already experienced difficulties: although 35% of NHS Trusts were supposed to have implemented EPRs this year, so far only a handful have done so and the target of 100% by 2005 looks increasingly difficult. And concerns about data privacy and human rights are a growing worry, particularly sensitive regarding such a personal matter as health. Recent ID card worries suggest that a centralised system for health records would exacerbate these concerns.

So an exciting vision risks damage and disruption for an already vulnerable healthcare service. The Government even recognises this: Delivering 21st Century IT Support notes that “significant risk will be involved”. And a senior Department of Health official recently described it all as “incredibly ambitious … we’re betting the farm on this”. Why? Where is the evidence that such risk is justified?

What is envisioned would clearly be desirable. But, to justify a huge gamble with the nation’s healthcare, the potential outcome must be more than desirable — there must be plain evidence of major and achievable benefit. No other test will do. Delivering 21st Century IT Support provides no such evidence. Perhaps that was not its function: it is a plan for action. For the strategy we must go elsewhere.

The Wanless report, commissioned by the Treasury to examine healthcare funding, gave prominence to the need for much greater investment in IT. Delivering 21st Century IT Support is the response to that. Key Wanless recommendations are that IT spending should be doubled (and protected to ensure it was not diverted elsewhere), that national standards for data and IT should be set centrally “and vigorously applied” and that investment should be aimed at “better integrated and more flexible” IT.

So far as funding is concerned, the principal justification is that spending per employee is lower than in other sectors of the economy and is less than is spent in overseas healthcare services. Doubtless true — but not of itself an argument for spending more. Clear evidence demonstrating the likelihood of major benefits coming from greater funding and supporting the centralise and integrate theory is needed. There is no such evidence.

Instead there is assertion: “The benefits of ICT [i.e. IT] will not come through significantly until the necessary infrastructure is built…” That is despite a statement towards the end of the Report that “decisions to invest in ICT need to be accompanied by firm evidence of the costs and benefits.” Exactly.

Unfortunately, although it notes the “clear risk given the scale of such an undertaking”, the Wanless Report fails to provide that firm evidence. The closest it gets is its comment that evidence (coming from Kaiser Permanente, a Californian healthcare provider and currently controversial Government favourite) “suggests that significant benefits are achievable…”

In the light of the potentially damaging outcome of what is now planned, a mere suggestion is quite inadequate, confirming my fear that the Government is gambling with the future of the nation’s healthcare. That would be unwise in any circumstances. To do so when the chances of success are low is irresponsible. To do so when the costs of even a successful outcome are high and its value uncertain must be foolish. We seem to be embarking on a course that is both irresponsible and foolish.

Wanless may be right about the inadequacy of NHS investment in IT. Probably greater expenditure is needed. If so, where would it be most beneficial in a reasonable timescale? My experience is that it is usually best to start from the bottom and work up — the antithesis of what is proposed. Identify the best local examples of effective IT-enabled healthcare delivery in the NHS (not in California) and build carefully on those. I’m no expert on NHS IT but there are many who are, including some clinicians — they should be heard. There may be some who believe that additional IT expenditure is not the best way of delivering a better service to the patient. They also should be heard. In other words, we need a debate.

Some months ago, the Chancellor spoke of his wish for a great debate about the future of healthcare in Britain. It hasn’t happened yet. But, as the programme defined in Delivering 21st Century IT Support does not get fully started until April 2003, there is time for a widely based and informed debate about whether these proposals are a risk too far and, if so, what is the better course. Not consultation, debate. I believe it would be widely welcomed by NHS staff, healthcare professionals and the public.

© Robin Guenier
July 2002

NOTE: Guenier is Chairman of iX Group plc a business that
uses the Internet to provide services to the medical
professional and pharmaceutical industry. In 1996, he was
Chief Executive of the Central Computing and
Telecommunications Agency, reporting to the Cabinet
Office, and was subsequently appointed by the DTI as
Executive Director of Taskforce 2000.
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