By Tony Collins
National Audit Office reports are almost always clear and sharp but not this one.
Indeed, its preface expresses gratitude to the Department of Health & Social Care and the NHS for their help in confirming the factual accuracy of the report. By convention, the facts in NAO reports are agreed with the department in question but it is unusual for the NAO to express gratitude to the department it is reporting on – and prominently in the report.
The report is thorough, comprehensive and sums up the poor state of NHS IT. Digital Transformation in the NHS” laments the lack of interoperability, the mass of unlinked legacy systems, a lack of clarity on who is responsible for what, an NHS-wide IT skills shortage, huge technical challenges and the failure to change working practices before or alongside introducing new technology.
But it lacks any sharp criticisms of the billions being spent centrally on IT without proper scrutiny or a clear purpose.
And it doesn’t acknowledge the work of IT professionals on the front line in hospitals, often in old buildings, who keep legacy systems running in an idiosyncratic environment in which outages and failures can affect lives.
The report does, however, find that lessons might not have been learned from the largely-unsuccessful and centrally-run National Programme for IT [NPfIT] in the NHS which began in 2003 and was dismantled in 2011. Much of the £9.8bn spent on the NPIT was wasted though not all.
Those who followed the NPfIT from start to finish will know it was a dream turned to reality for a few multinational IT companies, consultants, international hotel groups, airlines and marketing people who helped produce DVDs, board games and coaching for the NHS on what language to use when speaking publicly about the NPfIT. The scheme was run by the Department of Health which kept its software and hardware problems secret – a closed reporting culture that remains intact today. IT-related problems in the NHS are rarely reported by the Department of Health, NHS England, any arm’s length body or by trusts in their board minutes.
But the NAO report fails to mention the NHS’s closed reporting culture or the waves of costly central initiatives that seem to mean little to patients, doctors or nurses.
At one point the report has to explain its repeated use of the jargon phrase “adaptive change” by bracketing an explanation after it: (changes in the way people work).
The title of the report is Whitehall jargon: “Digital Transformation in the NHS”. Nearly every Whitehall scheme that relies heavily on new technology is called a “Digital Transformation” project.
On what to do about the generally poor state of NHS IT ,the NAO report is unclear: its wordy and vague recommendations could have been written 20 or 30 years ago. Its windiness could be said to reflect decades of Whitehall thinking on NHS IT and may help to explain why central IT initiatives have a long history of failure.
The recommendations urge health officials to “collect more data to enable a better understanding of the full cost of delivering digital transformation and prioritise the work programme” … “maintain a comprehensive set of lessons for digital transformation” … “ensure that the expected technology plan for health and care includes an implementation plan with specific objectives and measurable actions that are required”…. “establish a resource to provide bespoke support to trusts in managing the adaptive change required for digital transformation… use digital maturity assessments of local organisations to gather additional information. ”
The NAO report has a crucial paragraph on page 43. It refers obliquely to the single biggest problem with NHS IT: that systems do not talk to each other.
The NAO says it was told by one technology supplier that “many of the benefits of interoperability could be achieved quickly by sharing the GP record, which it considered to be the most complete account of a patient’s history”.
But this powerful message the NAO appears to dismiss, citing the NHS as saying that the GP record does not include everything and the sharing of the GP record would “not be sufficient to deliver all of the benefits envisaged in the NHS Long-Term Plan”. But how many patients care about the NHS long-term plan? Wouldn’t they want their hospital doctors and nurses to view their GP records today?
Without interoperability, a patient can have a blood test in a local hospital but find that the full electronic results cannot be added to their GP record because the hospital and GP systems are incompatible.
Indeed, patients can be treated at different NHS clinics, hospitals or sites without clinical teams in each location seeing on their screens an up-to-date record of what the other is doing or not doing, full test results or x-rays. That is potentially dangerous.
The GP patient record doesn’t have everything in it but it may be the most comprehensive record available. If authorised users in hospitals and other NHS sites could view the GP record, they would have valuable access to the patient’s recent and past record. If many GPs object to their records being viewed by hospital clinicians, it would be possible, without vast expense, to make hospital records shareable by authorised users via secure internet links.
Wisdom and insight into the problems of NHS IT and what needs to happen can be gleaned from some reader reactions to The Register’s summary of the NAO’s findings.
One reader’s comments are a reminder that hospital IT people in general do a “miracle” job although the NHS tends to have a one-size-fits-all low pay structure. This is not reflected in the NAO report.
Other reader comments criticise those who suggest, start and run major schemes centrally. Says the reader, “Has any large-scale [NHS] IT project ever learnt any lessons from previous failures, other than the lesson that folks who plan out these repeated failures are none-the-less handsomely rewarded?”
Another apt comment,
“You can’t ‘digitise’ business processes until those processes are fit for purpose, and clearly understood, documented, and accepted by all.”
“There is an experience asymmetry between the buyer (public sector) and the seller which I have seen play out countless times in a neighbouring industry:
“The lead buyer often runs their first procurement of this magnitude and complexity, as each organisation only procures one of these types of projects every few years or so, often accompanied by advisors (e.g. procurement advisors on process, external domain experts, internal stakeholders). On the other side of the table you have sellers who are engaged regularly in these kinds of procurements and consequently have experience – often lots of it – on how to maximise the opportunity for them.
“The outcome is varied and while there may be a postmortem after the procurement and implementation, lessons learned are forgotten (by the organisation), because the next procurement is a few years away, the lead buyer has changed through promotion or retirement and a new lead is in place, possibly with new advisors and stakeholders.”
Another reader says,
“You need to ask front line staff what they do. How they do it. What is making it harder for them to do it; and could it be done better? You do not want to ask the senior managers this.”
The nuclear physicist Richard Feynman was famous for explaining complex things simply. He explained the Space Shuttle Challenger disaster with a glass of ice water and a little rubber “O” ring.
It’s usually a strength of NAO reports that its investigators extract simple and punchy messages from their complex inquiries, but not this time.
The NAO could have seen problems from the perspective of patients and clinical users of the systems. Instead it seems to take the Department’s line on the problems with NHS IT,
Perhaps the best way to tackle poor NHS IT is to avoid what the consultants and centrally-based officials say.
Big companies, consultants, Whitehall officials and even the NAO in this case revel in the complexities of the NHS IT. But as Feynman said: “You can recognize truth by its beauty and simplicity.”
The simplest way to start tacking poor NHS IT is to recognise that there is no overall solution: the NHS has spent the last 20 to 30 years working on big solutions and the message, untold billions of pounds later, is that they don’t work.
What no Whitehall NHS report in the past 30 years has recommended is compromise. Whitehall has never accepted that the NHS has too many systems, too many autonomous hospitals, too many different ways of working at innumerable sites and too many pressures on time and money in a safety-related environment to adapt to national standards and a national way of thinking.
One strength of giving autonomy to hospital IT chiefs working alongside their clinical directors is that they can be extraordinarily innovative and provide useful systems of benefit to patients. Some trusts are, when left to their own devices, bringing shared patient records to entire regions.
That’s not to suggest that centralised thinking is best avoided altogether. A reliable Covid test and trace app is the current top priority but when or if the virus is under control, a top priority would be to sweep away a mass of vague central initiatives and consult health IT SMEs on finding the simplest way to use existing systems to talk to each other.
It’s possible – but unglamorous – for hospitals with different systems to make their records available using secure links to hospitals in other regions. The trouble is it doesn’t involve large numbers of consultants, big companies and Whitehall officials . It’s too simple for Whitehall to implement. What’s worse, it’s cheap. It’s a compromise.
Whitehall officials and advisors would instead prefer to spend their time and public money working on initiatives that will look good in ministerial and departmental press releases. Such as AI to analyse X-rays, CT and MRI scans without a doctor in sight.
The NAO ought not to be writing reports on NHS IT that could have been written 30 years ago.
Centralised thinking needs to change. You don’t need every hospital using the same standards with the same working practices. It will never happen. Just concentrate on interoperability – not of new systems but existing ones.
Here’s a genuinely innovative approach for NHS IT: compromise.
Thank you to FOI campaigner David Orr for alerting me to the National Audit Office NHS report
Digital Transformation in the NHS – National Audit Office report