Put cross here

Last month, E-Health Insider and Doctors.net.uk decided to run a poll on the future of electronic health records in England. The aim was to test support for the Conservative Party’s plans for a shake-up of the National Programme for IT in the NHS and its reported interest in letting patients store records with Microsoft and Google.

More than four in ten of the EHI readers who took part also added free text comments. These not only shed more light on the headline findings, but suggest that all is not harmony in healthcare IT. Lyn Whitfield reports.

The world of NHS IT is a fractious and unhappy one. That, at least, is the impression given by the 400 free text comments added by E-Health Insider readers to the EHI / Doctors.net.uk survey of doctors, IT professionals and suppliers on the future of electronic health records in England.

At first sight, the survey delivered a surprising vote of confidence to the National Programme for IT in the NHS, with 60% of Doctors.net.uk readers saying it should not be ended and 77% of EHI readers saying the same.

Yet the comments suggest this support is not born of any great enthusiasm for the programme, which was set up in 2002 to deliver a new broadband network to the NHS, place big contracts for detailed electronic patient records, and run national projects such as the Summary Care Record and Choose and Book.

Instead, they suggest it is born out of fundamental disagreements about why the programme has run into problems, a grim determination to keep going now so much time and money has been spent, and a belief that the widely touted alternatives are no more likely to succeed; with occasional flashes of optimism that something good is about to happen.

Flawed and badly implemented

So, one strand of argument that comes across strongly from the comments is that the thinking behind the national programme was flawed and it should never have been tried.

“In 2002-3, the NHS started the ERDIP electronic record implementation programme. This was the future,” said one respondent. “Scrapping all the legacy systems and contracting the likes of Accenture and BT to procure/write new ones was never going to work. Unconnecting for Health has been a complete disaster; as IT professionals like myself predicted.”

But others felt the national programme had the right approach; it had just been hampered by other problems. “NPfIT is a GOOD idea BADLY implemented not a BAD idea,” another respondent wrote. While another argued it was a “good concept, badly managed” that had “showed a lack of understanding of the complexities of healthcare and the work required to either develop new systems or adapt existing (foreign) ones.”

Putting the programme to one side, the survey showed deep divisions on why progress on implementing better IT systems in the NHS has been so slow. Doctors were adamant that “lack of clinical involvement in designing systems” was the main reason, with 46% of Doctors.net.uk readers but only 29% of EHI readers picking this.

Doctors also felt there was too much political interference (25% to 16%) while EHI readers blamed centralised policies (24% to 13%). Respondents who left comments also identified changing political requirements as problems, along with unrealistic budgets and timescales and US contractors.

“If the politicians didn’t keep changing their requirements during deployment it might work a lot better,” wrote one respondent. “For example, 18 week waits didn’t work with Cerner Millennium [the ‘strategic’ solution for London and, until last May, the South of England]. US software, never heard of waiting lists, wrong choice.”

But a lot of respondents were also inclined to heap blame put on colleagues. So although doctors felt one reason for slow progress on IT was lack of engagement with them, a number of respondents commented that IT should be run by IT professionals – and clinicians could be difficult to engage, at best.

“Clinical staff and doctors in particular are always moaning about clinical engagement. But when you try to involve them and get them to participate they are too busy to attend meetings, demos, etc,” wrote a respondent who said they had18 years’ experience as a radiographer. “I can understand their position, but if they want engagement they have to make time to participate.”

Another respondent wrote tartly: “Every doctor has a different idea about what is needed, so simply saying that more consultation with doctors is the answer somewhat misses the point.”

The comments also reveal intense frustration with the NHS’ general managers. “IT in healthcare is great. It is when you involve the NHS that the problems begin,” one wrote.

“No ONE person in the NHS at hospital level has enough authority to make the informed decisions that are being asked of them. The main concern of managers in the NHS is not to exceed their budget for the year PERIOD. There is no long term vision because budgets are annual and managerial posts don’t last much longer.”

Conservative home

The survey was launched shortly after the Conservative Party published the independent review of health and social care IT that it had commissioned from Dr Glyn Hayes, and published its response to it.

Although the party said it would not scrap NPfIT, it also said it would dismantle much of its centralised approach, renegotiate its multi-billion pound contracts, and give trusts more control over their IT by letting them by systems that met standards for interoperability.

This approach has been widely recommended, and is welcomed in the survey. Some 60% of Doctors.net.uk readers felt the programme should not be ended and 77% of EHI readers felt the same.

But more than 80% of both groups felt it should be reformed, with two thirds of EHI readers feeling that centrally purchased common systems were not the way to deliver electronic health records and 86% saying that interoperable systems were.

“Private providers being allowed to innovate TO A ROBUST INTEROPERABLE STANDARD is the key to success, not the strict, cumbersome contracts that we currently have with the LSPs, which have quite frankly hindered progress and added to implementation costs in many different ways,” wrote one respondent.

However, not all participants agreed. “There should be more centralised procurement and management of NHS systems. There are too many small, inefficient, local IT teams,” said one respondent

Another found the idea of every trust doing its own thing odd. “Much is made of local choice in systems, but I think this is a red herring,” they wrote. “Why should there be a deviation from the norm? McDonald’s doesn’t have 250 different systems throughout its stores.”

Lack of confidence in NHS management – and scepticism about how well it had done with NHS IT before 2000 – was one reason. “The history of IT in the NHS pre-national programme is hardly encouraging” noted one respondent. “It’s not enough to kill NPfIT without having something else to drive standards and adoption.”

“If fully implemented, the Conservative Review would drive local ownership too far,” argued another. “It would most likely end in a five year period of stagnation in which very little would actually be implemented. It would also change the supplier landscape to the detriment of all, with major suppliers seeing the NHS market as too difficult and expensive and niche suppliers seeing the cost of standards adoption too high.”

Another was a lack of confidence in the systems that might be retained as a result. “The current fad for ‘interoperability’ fails to recognise the fragile and outdated state of many of the local systems,” said one comment.

“The national programme has totally failed to understand the over-riding need to urgently replace very old and very likely soon un-maintainable PAS, Pathology, RIS and associated administration systems before they fail catastrophically – as they surely will in the near future.”

Better keep going now

Given all this, it is perhaps not surprising that many respondents to the survey seem to feel that it will be better to push on with the national programme than give in now.

“I think the overambitious nature of the national programme caused issues initially,” said one. “However, benefits are now being seen and rather than scrap it we should build on the work that has been undertaken by a lot of staff.”

“It would be a mistake to abandon the work done so far. An age old problem with the NHS is that things get reinvented all the time, as if they had never been thought of before. And expecting total reform in the lifetime of a Parliament is unrealistic,” said another.

And puncturing the generally gloomy and tetchy mood, some respondents felt that whatever its past problems, NPfIT was on the verge of delivering something worthwhile. “Lorenzo is agonisingly close to actually delivering what acute trusts have waited ten years for,” wrote one respondent. “It would be tragic if it was snatched away for political or (in the South) commercial reasons.”

“IT is coming on so well for patients and clinicians it would be a shame to hinder progress. We need to implement the best means of delivering safe, auditable patient care, which is basically underpinned by clever clinical and administrative IT systems,” concluded another.