Joe’s view: of the new NHS IT arrangements

Take a look at the bin in my kitchen. I live with my wife, Fiona, and three children; Emily (21), Fin (18) and Jake (15). We all know that someone has to empty the bin but we don’t have a bin emptying rota or a designated bin emptier.

No-one is financially incentivised to empty the bin, so we merely rely on a collective sense of responsibility to get the job done.

Bin emptying responsibilities are distributed across the five of us and consequently everyone thinks someone else will attend to it. Plainly, this isn’t working.

So, farewell then NHS Connecting for Health

Colleagues who remain within the Department of Health Informatics Directorate officially learned last month what they have known unofficially for some time; that the directorate / NHS Connecting for Health will be no more from March.

Its functions and programmes will be spread between a new and improved Health and Social Care Information Centre, the NHS Commissioning Board, and the slimmed down Department of Health.

Potentially, this leaves NHS IT in a similar state to my kitchen bin; many people are responsible for it and therefore none are responsible.

While few will mourn the passing of CfH, the fragmentation of NHS IT is not without risks. CfH did support, for example, the development of our National Mental Health Informatics Network through funding my time as national clinical lead for IT, mental health.

We had begun to develop a professional infrastructure that connected system users to those who decide what data needs to be collected within the DH, through the Mental Health Information Board established by mental health ‘tsar’ Dr Hugh Griffiths.

All these hard won arrangements are now at risk. On a personal level, we have secured an interim future for the network within a lifeboat provided by the British Computer Society (although we still need a sponsor for our AGM in November – CfH used to fund this – apply within).

Men in sheds

I have been a keen student of the history of science and it strikes me there is a pattern. Initially, men pottering about with new ideas in their sheds bump into one another in the pub and discuss their new projects.

After a time, they realise other men – and indeed women – are doing similar things and they agree to meet up in the pub to compare notes. Eventually, they organise themselves into a club and elect a leader and a committee.

The committee realises other pubs also have clubs and begin to join forces. Constitutions are drawn up, subscriptions are paid and, if the new science has commercial potential, sponsorship is sought (did I mention our AGM in November?).

Eventually, a new profession is born. Founder members get to set exams for new members and charge fees that allow them to purchase a nice office in Central London, from which they can set the standards required to make the new science really fly. It currently feels like we are taking a step back towards the shed.

The People’s Front of Judea

Unfortunately, the nascent profession of ‘health informatician’ is not united. There is a wide range of players on the pitch who now have no clear sense of direction.

And there are many similar organisations and networks all trying to achieve the same thing by slightly different means. It’s like Monty Python’s Judean People’s Front versus the People’s Front of Judea. UKCHIP or BCS, RCPsych or RCP, Intellect or HIMSS, EHI or CLN? Who will take us forward?

Babies and bathwater

In our eagerness to remove the dead hand of CfH from the health IT market, we need to be mindful of the lessons of history.

There is a real risk that a new ‘silo’ structure is being born (once again), with the NHS having no idea what it will lose, and no obvious commitment to a clinically-led NHS in informatics. The ambition to get ad-hoc Informatics input from un-resourced ‘networks’ as and when needed seems risky and lacking in any ‘joined-up’ thinking.

For ‘connect-all’ to work, there have to be a few clinicians involved with an overview of what we can, and should, connect for meaningful results.

Internal CFH staff feedback points to an increasingly unhappy organisation, with leadership failings and the prolonged stagnation of ‘transition’ still impacting in every area.

So the ‘new’ HSCIS will get the delivery functions – but have we not learnt that all our programmes, projects and systems are evolving all the time? There is no ‘steady state’; IT to support health and social care has to adapt and improve all the time.

This is not just about adding a few new functions and behaviours. This is continued critical and reflective development – being dissatisfied with what we have and demanding improvement and innovation – the management of change where IT is a small component.

Watch out for the commissioners

In the middle of all this, commissioners and providers are recognising the potential for power and control through data. They are seeking to have a greater say over developments and investment.

This will not provide clinically led informatics priorities; these are increasingly about financial balance, command, control and reporting.

Less Clinical Informatics input at National level is a growing risk to front-line clinicians and to direct patient care – it cannot all be done at local level.

Lessons learned

In last month’s column, I reflected on the ‘Gaddafi-like’ management style practised at CfH at some periods of the organisation’s history, and the impact this had on those trying to deal with it.

In response, one correspondent called for a public enquiry into “the appalling yes men at CfH”; and while that might be seen as throwing good money after bad, I do think a ‘lessons learned’ exercise needs to be carried out.

Chief among those lessons needs to be the need for strong national clinical leadership for NHS informatics.

CfH failed because it was dominated by technical rather than clinical people. The new arrangements don’t do anything to address this fundamental issue. It is therefore likely that we will make nothing of all our painful experience, and hand over this market place to the United States of America.