Joe’s view: of NHS IT leadership

I didn’t have a great deal to do with Katie Davis during the short time we coincided at the Department of Health Informatics Directorate.

Since I was “let go” during her tenure, I might be forgiven for feeling some bitterness towards a regime that is nearly over – it has been announced that Davis will leave by 1 September.

I don’t, but I see from the EHI newsfeed that some have been quick to criticise her contribution and point out that her legacy is NHS informatics hopelessly split up across three organisations.

In the future, the Department of Health is meant to do IT policy, the NHS Commissioning Board is meant to commission systems and standards, and the Health and Care Information Centre is supposed to manage and monitor them.

It’s also the case that some fundamental problems – like what will happen to CSC’s contract and so to Lorenzo in the North, Midlands and East – remain stubbornly unresolved.

Perhaps it’s not surprising that some have pointed out that “spending more time with the children” – which is what Davis is going to do – is a Whitehall euphemism for “fired” – even though there is no evidence that this has happened in Davis’ case.

To get a proper understanding of her contribution, though, I think you really need to look at those who went before.

Not my mate Marmite

When I became national clinical lead for IT our Leader was still Richard Granger. I never met the director general for NHS IT, as he was styled.

But he appeared, from my observation of NHS Connecting for Health, to have had a Marmite-like quality – people either loved him or hated him.

The organisation I joined seemed to be in a state of grieving for his loss and in mourning for the dilution of the philosophy of “ruthless standardisation” through big, national contracts for “strategic” systems.

On the other hand, there was a dawning acknowledgement that it might be a good idea if clinicians had more input – hence the hiring of people like me.

There followed, in short order, Matthew Swindells and Gordon Hextall in brief caretaker roles that didn’t give them the time or opportunity to provide a replacement for Granger’s clarity of purpose.

By the time he left – and I arrived – the programme had already fallen over. I didn’t know it at the time, but the NHS was pointing at it and laughing.

One more heave

In this atmosphere, the programme turned to Christine Connelly, who arrived from the private sector, where she had helped to turn around Cadbury Schweppes.

A fierce project management approach prevailed. Hard bitten project managers and ex-military types would be working 20 hour days and travelling the world in the belief that if we just kept pushing it would come right.

Our favourite drink was the tequila slammer, lunch was for wimps, greed was good, and a cultured evening out meant Karaoke. Fortunes were paid to contractors who could, given enough money, put a man on the moon and return him safely to earth.

The problem was that the project was fatally flawed from the outset. The development of successful electronic patient records is the outcome of ongoing relationships between end users and system suppliers.

And this was something that the contracts placed by the National Programme for IT in the NHS rendered extremely difficult. Where we succeeded, it was despite the contracting process, not because of it.

Good Lieutenant Syndrome

Leadership styles played their part in prolonging the agony, however. Examine if you will this picture of Colonel Gaddafi.

If I attempted to leave the house dressed like this, I’d like to think my wife might point out – kindly – that my outfit was perhaps a little over the top.

In the street, a crowd of small boys would inevitably gather to ask: “Oi mister, where’s the fancy dress party?” And on arriving at work there would be mirth unconfined.

However, if I have a very scary leadership style – to the point where grown men quake in fear in my presence – when I ask my lieutenants how I look they will reply in unison: “But of course Colonel, you look magnificent!”

And so it was at times within the programme. The only acceptable news to be fed up the chain of command was good news. Good news kept the show on the road and the longer we could keep the show on the road the greater our chance of success.

Messengers with bad news were routinely shot pour encourager les autres. We all had to become “good lieutenants” to survive and keep paying the mortgage. Doubly true if you were on a short term contract.

A change of government

I fully expected that the end of the programme would come quickly when Gordon Brown’s government fell at the general election.

But, in fact, we continued to drift, while investing a huge amount of effort in writing an information strategy for our masters, who hadn’t really set us a coherent exam question.

The situation in the mental health sector was becoming critical. Half the country had no electronic patient record and we were getting ready to take mental health onto Payment by Results without systems to transact our business.

What Katie did

With a sense of rising desperation, the National Mental Health Informatics Network wrote directly to Katie Davis shortly after her appointment to invite her to speak about our growing discontent. To our great surprise she agreed immediately.

She asked for a briefing paper, and when she came to the event to confront what was a potentially hostile crowd she was coolness personified.

The contractual issues meant she couldn’t really take our pain away or make any promises but she stayed longer than we’d asked and took difficult questions head on.

The atmosphere in the room changed as she spoke. Here was someone who was prepared to hear bad news, who was interested in what users felt about systems, and who was in a position to influence things. Maybe things could change.

Leadership for the future

Clearly, NHS IT isn’t all sorted out. The Power of Information strategy might be a bit woolly and CSC/Lorenzo remains unresolved.

But on that afternoon last November it looked like the madness would stop at some point, and for that I remain grateful to Katie Davis. I hope she enjoys her time with her children. I, for one, consider her a loss to NHS informatics.

What we need now is more information about who will lead in the future; and on who will take up the key jobs at the three organisations now involved with NHS IT.

Interestingly, at a time when the Power of Information suggests every NHS organisation needs a clinician with responsibility for IT, the NHS Commissioning Board still lacks a chief clinical information officer.

About the author: Joe McDonald is a practising NHS consultant psychiatrist. Over the past five years he has been an NHS trust medical director and national clinical lead for IT at NHS Connecting for Health – a stint that included 18 months as medical director of the Lorenzo delivery team!

His experiences in the National Programme for IT in the NHS have left him with a passion for usability and "end user knowledge networks.” He is the founding chairman of the National Mental Health Informatics Network. Motto: we don’t get fooled again. Follow him on twitter @CompareSoftware