England's NHS IT system is at death's door

After nine years of trying and failing, the Public Accounts Committee of the Commons has at last come to the point of admitting that the flagship policy to produce an electronic records system for the English NHS is unworkable.

Pull plug on NHS e-records – MPs

The Public Accounts Committee said mounting problems with the electronic records system were making the £7bn project "unworkable". The group said the scheme – aimed at reducing the use of paper files – was beset by delays and uncertainty. If it was stopped, the remaining budget could then be spent on a better system, they said.

E-records are part of the overall £11.4bn IT programme. The scheme was launched in 2002 with the aim of revolutionising the way the health service uses technology. It includes developments such as digital X-rays and fast internet connections.

Under the e-records scheme, every patient was to get an electronic file that could be used when they were treated in the NHS. The MPs said it was a "worthwhile aim, but one that has proved beyond the capacity" of government to deliver.

BBC, 3 August 2011

It's sad, because if the project had been approached differently it could have not only have been successful, but done at a much, much lower cost. For an example of how to do it better, they need only look to Wales.

     

A year or so back, when another of the UK Government's computerization projects (the LIBRA system for Courts) was floundering, I came across this article by Michael Cross in the Guardian:

A Welsh cure for a nation's ills

Obama should look across the Atlantic for the huge task of computerising the US health records – but not as far as England

... For a lesson in how to manage the programme, Obama might do well to look across the Atlantic. Not to the NHS in England, where a £13bn programme is this year reeling from its latest parliamentary battering, but to Wales.

Earlier this month, Edwina Hart, the Welsh assembly's health minister, approved a plan to extend a system called the Individual Health Record (IHR) across the country. The decision comes seven years after the equivalent announcement in England, but no one need apologise for the delay. The Welsh IT team says that, by eschewing political deadlines and working with the NHS rather than trying to impose technology, it has created an electronic medical record that is not only more useful than its English equivalent but will cost a fraction of the price.

The secret, says Gwyn Thomas, chief executive of the agency Informing Healthcare, is to listen to users.

The contrast with the gung-ho English programme, now enervated by contractual rows and political grandstanding, is graphic. In the latest report, the chairman of the Commons public accounts committee, Edward Leigh MP, said: "Essential systems are late, or, when deployed, do not meet expectations of clinical staff; estimates of local costs are still unreliable; and many NHS staff remain unenthusiastic."

Wales and England started off with the same goal – to make computerised medical records available where they are needed. However, the two countries went about it in wildly different ways.

In England, the NHS took it for granted that the right technology was available and that staff were enthusiastic about adopting it. The central challenge was seen to be procuring the technology on the best terms, and implementing it to timetable. This involved a series of billion-pound contracts to provide central services and to rip and replace hospital systems across five regions created solely for the IT programme. Tellingly, one of the programme's explicit aims was to double the proportion of the NHS budget spent on IT. In Wales, by contrast, there were no big procurements and virtually no new money. When Thomas took up his role in 2005, he decided to work with existing technology to make information available where doctors needed it. Everything would move incrementally, with the consent of all concerned.

This involved several radical departures. In England, a central "spine" is designed to carry a summary record of every patient. The Welsh IHR draws data directly from GP records, with sensitive data such as terminations removed. Patients are asked for consent every time their record is viewed – unlike in England, which initially assumed patients to have given consent unless they explicitly opted out.

The Guardian, 29 January 2009

Now I certainly don't want to give the impression that the Welsh system has been trouble free. It hasn't. Mistakes have been made, companies providing services have gone bust. But because the Welsh approach has been fundamenatally different from that of the UK government in Westminster, these difficulties did not derail the whole programme. For those who are interested, there is a series of progress reports here:

     Health Insider, 8 January 2009
     Health Insider, 21 January 2010
     The Guardian, 19 October 2010
     Health Insider, 20 December 2010

To me, as a "health outsider", the picture seems to be one of steady progress; each step being taken after consultation and with consent, and with feedback informing the next step. Though I'd welcome any comments from people who know the system better than I do.

     

The IT records programme for the English NHS was described by one MP as "one of the worst scandals in terms of wasting public money", and another said, "Trying to create a one-size-fits-all system in the NHS was a massive risk and has proven to be unworkable."

It's timely illustration of the central conclusion of the research done by Adam Price and Ben Levinger as published in the Flotilla Effect. A reminder that being part of a large, over-centralized country brings inherent problems, and that smaller countries can more easily adapt to technological change by virtue of being smaller and more socially cohesive. We can tailor solutions to fit our own needs, rather than accept a one-size-fits-all solution from others.

Of course being able to make decisions for ourselves is no guarantee that we will make the right decisions. But if we compare our decisions about electronic NHS records in Wales with the unmitigated disaster of the decisions made by the UK government on behalf of England, it should give us all the confidence we need to press for more decision making responsibility in more areas to be transferred to Wales.

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7 comments:

Siônnyn said...

Syniadau - I don't know this system, but I am a system professional with experience of designing and implementing large 'mission critical' systems in international businesses. I was also involved in the disastrous Torus project (representing a user - a bank - not the ISE).

There are two ways of approaching systems design - the monolithic approach where 'the system' is perfect, and does everything. This is the one favoured by the large consultancies (fujitsu, EDL, Capita etc) - but of course, there are far too many dependencies and points of failure in a huge monolithic system, which is why their projects hardly ever work properly. This is the approach adopted by the English NHS - it either all works perfectly , or it doesn't work at all.

This approach brings with it a 'Daddy knows best' attitude towards users - in other words, the needs system has primacy over the needs of the business. The consults trample over the users. I have seen it many times, ( not least in a large Government agency in Swansea).

The other approach, that which appears to have been adopted by the Welsh NHS is to study the business (in this respect, the NHS is a business) - find out what the practitioners and operatives of that business actually need to do their job better. Find out what they have, and see if there is away of using this in the solution. It is a collaboration, not a dictatorial relationship. A very large system is made up of lots of small, semi-autonomous systems, or modules, which interact with each other only to the degree that is minimally necessary. This design has an in built resilience. If one of these systems fails, the rest of the system continues to function. Existing systems, through specified, standardised interfaces can be easily adapted to fit in.

Well done Edwina Hart for choosing this route. Well done, Syniadau, for trumpeting this success.

It strikes me that this is a very good metaphor for governance. The centralist, unionist model, where power is drawn to and exercised from the centre has inherent weaknesses, and will never work properly. A devolved system is resilient, and delivers better service to its people.

Cai said...

"It strikes me that this is a very good metaphor for governance. The centralist, unionist model, where power is drawn to and exercised from the centre has inherent weaknesses, and will never work properly. A devolved system is resilient, and delivers better service to its people"
And of course a small Independent country of about 3 million people could have done even better!
Another example of where small and co-operative works better than big and hierarchical.

Neilyn said...

Indeed! The difficulty, it seems to me, lies in getting this and other examples demonstrating how small Wales can, and more importantly IS NOW doing things better than big England across to Joe Public in Wales. Will there be reports on the London BBC/ITV/Channel 4 news bulletins trumpeting the relative success of the Welsh model compared to the English fiasco? Perhaps an interview with the relevant Welsh Minister? Maybe, but I'm not holding my breath. Hells bells, £7bn - that's a huge chunk of our annual subsidy and the "perceived wisdom" is that Wales is the drain on resources! I doubt whether the televised news bulletins in Wales will bother either. It's a real shame we don't (yet) have more Welsh newspapers. Nevertheless, this is ammunition for the inevitable full blown debate on devolution max/independence. Bring it on.

Siônnyn said...

The "Big is Beautiful" model is badly damaged - Adam's timely and magisterial report has seen to that - and now we need to hammer in our advantage by making sure that stories like this get maximum attention in Wales, do that the damage becomes fatal.

Welsh Ramblings said...

Syniadau ably demonstrates the adaptability that Adam Price mentioned being put into practice...by a Labour Minister.

Now, i'd never have heard about this from a Labour source.

The question Labour Assembly Members need to ask is whether they want us to innovate in more areas of public policy, or whether they are content with being quiet about their own success, and being limited by their own timidity on constitutional issues.

Anonymous said...

OT

http://www.guardian.co.uk/commentisfree/poll/2011/aug/03/independence-wales

MH said...

Thanks for the comments, and sorry it's taken me a while to respond. Some good points, Siônnyn. I also read your comment in the Guardian and noticed it hadn't been picked up by anyone. It would appear that the most English readers simply don't what to learn how to do it better. They only want to complain at how bad things are.

Perhaps that's another metaphor. That the people who made these decisions don't actually much care about how to deliver a better system, they thought that they just had to pay companies to do it for them. Is it part of the "market forces" mentality, the "Anglo-Saxon" economic model?

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Ramblings makes a good point that it was a Labour minister that introduced this in Wales. That highlights the fact that thisis not a party political difference of left and right. The only party political element is that the Tories are now in power at Westminster and will therefore have no compunction about pulling the plug ... so long as they can blame it all on Labour. Labour would have probably persevered for another few years until the full budget had been spent rather than pull the plug now.

The real question is why Labour in Wales made a different decision from Labour in England. It almost reflects the U-turn that Welsh Labour made over the NHS internal market. First breaking up the health boards into 22 smaller units in order to provide enough scope for competition between them. Then having to go back to more or less what was there before because the competion inherent in an internal market was wasteful and counterproductive. Interesting that the change back and the start of IHRs both happened as part of One Wales, though.

So it must be a matter of the difference between Wales and England rather than the political ideology of left-right party politics. More socialist values can work in Wales in a way that simply can't work in England. England is so big that change has to be imposed from the centre, there are simply too many divergent groups and factors to bring them together in a model of cooperation. The fact that we are a smaller country gives us more social cohesion and therefore a greater sense of common purpose.

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Thanks for the link to the Guardian's CiF piece, Anon. The comments were so predicable, but one or two were good. One in particular might form the basis of a post.

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