Joe’s view of Lorenzo

Someone kindly suggested on Twitter that I should write a book about my time in the National Programme for IT in the NHS.

And since I’m writing this column esconced in a beautiful, secluded villa high above the Aegean Sea I thought I’d give it a go. So here, at least, is the first thousand words.

The years go by

Joe slipped off his clothes and looked at his reflection in the full length mirror. In his head he was still 25 and had the athletic body of the keen amateur footballer, father of three beautiful children and husband to the implausibly gorgeous Fiona.

Reality was somewhat different. Everything was going south; too many hotel breakfasts and late nights with Lorenzo. A half decent amateur middleweight with a good right hand in his youth he was now definitely a heavyweight with a waist measurement approaching his reach.

Five years earlier, Joe had been riding high. Already a consultant psychiatrist, at 30 he rose rapidly through the medical management hierarchy to become one of the NHS’s youngest medical directors. What had gone wrong?

Accepting the hand grenade

The secluded villa had seemed the perfect holiday solution when he’d seen it on the internet; somewhere to relax, reflect on his career and on having been “let go” by the Department of Health.

But stepping into the shower, having hauled the case of beer up the hill from the nearest shop, he thought: “I need to solve the getting beer up the hill in 40 degrees C problem.”

The thought of 40 degrees C and the steady warm rain of the shower took Joe back to June 2010 and to Chennai, India. At the time it seemed unreal to him; it seemed even more unreal now.

After two good years with NPfIT, things had been going pretty well. Joe was getting the (undeserved but welcome) credit for the successful deployment of electronic patient record systems in mental health trusts.

His perceived success made him the obvious choice to go and help with the delivery of a system called Lorenzo Regional Care, the problem child of the national programme.

Joe knew it was a hand grenade with the pin out, but he’d always struggled to resist being drawn to a dramatic crisis. He was an adolescent psychiatrist for Chrissake!

How much are we paying for this?

Relaxing in the business class lounge of Emirates Airways, awaiting his flight to Chennai, Joe sipped complimentary champagne and recalled his first encounter with Lorenzo.

It had come in 2008 at Winnick Leisure Centre. Fifteen mental health clinicians were talking about the required clinical content for the forms that were to be built in Lorenzo.

Suddenly, it hit him like an uppercut: “My God we’re trying to computerise something we haven’t standardised on paper!”

It got worse. At subsequent meetings about the content of the forms, the faces frequently changed and new faces had to be brought up to speed with the project.

Prototype forms designed by clinicians were then sent to Chennai via the main contractor for the North, Midlands and East, CSC. Then they were sent back for checking.

Somehow key factors would be lost in the process and the clinicians would say: “That’s not what we asked for.”

The problems would be noted and sent back to Chennai. Then they would be re-checked by the clinicians; but the forms would then be unsatisfactory in new ways or in ways new clinicians didn’t like. Plainly, a visit to Chennai was required.

Joe had never flown business class. He tried not to fiddle too much with the buttons that made the seat into a bed or made it vibrate and tried to affect the air of seasoned business traveller. The beautiful air hostess smiled: “Is it Joe or Dr McDonald?”

“My God. She knows my name,” he thought, suddenly remembering he was a tax payer.

Chennai daze

Arriving in India was an assault on the senses – the colours, the noise, the smell. Getting into a tuk-tuk, the driver offered Joe a joint and five minutes into the terrifying journey to the Marriott he wished he’d taken up the offer.

The next six days involved 12 hour shifts working with the delightful Indian software developers, but Joe felt increasingly uneasy. He knew what working clinical software looked like and it was simple, easy to use, and designed close to the coalface.

This wasn’t simple. In fact, a secretary described it as looking like ‘Sky Sports 1, the screen was so busy. By the end of the week, Joe knew that the deadlines being set back in London were unachievable.

Maybe the whole damned project was unachievable. Maybe the project was trying to build a Rolls Royce when a scooter would do the job, and do it better.

The flight back was a blur, punctuated only by changing planes in Dubai. Joe turned on his iPhone in the business lounge and immediately received a text message from his controller in London. “Well?” it said.

Joe replied with what may well have been career shortening frankness: “It’s a dead duck.”

40 degrees in the shade

Stepping out of the shower Joe reflected on his refreshingly simple problem of how to move beer up hill in a hot climate. What was required was a cheap, easy solution.

A quick phone call offered two solutions. One, an air conditioned Mercedes 4X4 for 1,550 Euros per week. Two, a Vespa for a tenth of the cost. Reflecting on the last four years, he opted for the Vespa.

To be continued?

OK. I won’t give up the day job.

New contract with CSC

To be serious for a moment, I see there is much anger about the new deal with CSC for the NME, but I see this as a victory for common sense.

Trusts in the region are free to choose the systems they want; one of the basics we, in the National Mental Health Informatics Network have been pressing for over three years.

Lorenzo (which has some sound ideas at its heart) can develop at a sane pace close to the coalface, and we can stop putting software that isn’t yet ready into life threatening situations.

It has to be remembered that Lorenzo was a political, not a clinical, project and the new contract reflects that there was fault on both sides. We shouldn’t have asked for the earth, moon and stars and CSC shouldn’t have said we could have them.

I am reminded of the legendary NPfIT story about one local service provider chair who was asked how he felt about winning the NPfIT contract. He replied: “Like a dog chasing a car who actually caught the car. What do we do now?”

Neither CSC nor NHS Connecting for Health set out to fail, but Lorenzo was an attempt to leap a tall building in a single bound compounded by a contract where incentives were given for hitting clinically irrelevant targets.

It would be nice if there were clear heroes and villains to point at in this story, but life isn’t like that. Nonetheless, I will end with my customary call for some sort of lessons learned exercise to be carried out. As William Edwards Deming said: “Learning is not compulsory – but then, neither is survival.”

The money spent on Lorenzo can only be regarded as wasted if the knowledge gleaned in the process is allowed to dissipate. Maybe Shane Tickell’s idea of a permanent NHS Health IT Centre should get some DH help? Check it out here.

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