Carruthers becomes the fifth SRO for NHS IT programme

1

A clever plan ...

19 Apr 06 15:43

You've got to admire the DH - when it eventually becomes clear to everyone that its NPfIT / CfH programme has completely missed the mark - only 20% of the blame will be attributable to any one "responsible" individual!

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2

Financial Drains and the Old Friends Networks

19 Apr 06 16:36

Just a month ago I ended almost three years working in the NHS, having experienced Primary Care, PCTs, Hospitals and the SHA in various guises, but all focussed on processes and IT systems. It is my strong belief that the NHS provides some remarkable and first-class healthcare for it's patients. Unfortunately, the efficient operation of the Health Service is largely being undermined by the culture that exists amongst many holders of purse-strings at Trust and Strategic Health Authority levels. (I have no direct experience of the DH, therefore can only conjecture as to the extent this is true at the "top"). There are many specifics to address but here I am concentrating on two:- 1. The lack of accountability, either demanded of or taken by senior people in the management chain and, 2. The inefficiencies of constant change at all levels, including the basic "business" of service provision.

Reading of a fifth SRO in post in the three years since the inception of the national IT programme seems an all too familiar story. Similar to my experience of Chief Executives, Finance Directors, Directors and Heads of Departments at Trust level, this seems to be yet another example of paying a series of people huge amounts of money to do a job that they are not qualified or experienced for. What is more, by keeping in with the old boys and girls networks, it is too easy for these people to "hide" and to avoid accountability for their poor performance. The money they are being paid (to fail) is public money - tax - paid out of the earnings of largely honest, hardworking individuals.

Whatever governments and civil service departments may come and go, there are a set of fundamental business principles that apply in any service-providing organisation. These involve communication, IT systems, business and office administration, contracts and other legal basics and project support offices etc. At a defined, fundamental level, a set of principles should and could be set in stone and applied nationally - like the armed services have been doing for decades. Autonomy and reaction to local healthcare needs comes at a level above this and allows for regional authorities and project-based work but in a standardised business environment.

These two issues are strongly linked - the Old Friends network works best where information systems are "fuzzy" enough to provide hiding places. One can feel untouchable and safe as an incompetent Director if no-one can really know what you are doing. And if it gets a little "hot", a friend will find another place for you, where you can build another empire and convince your friends to allocate you money for your project.

Richard Granger must succeed in "Connecting" the NHS for it's own health, the health of the population and for the good of our bank balances.

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3

Localised administration, and standards

paper.records@ntlworld.com

20 Apr 06 07:26

This note is further to the previous comment, by far one of the most thoughtful I have read here.

To summarise: the writer is saying that the NHS needs standardised administrative, or back-office, functions. Without that standardisation it is not possible to compare the performance of NHS managers. There is also the claim that bad NHS managers know this and so resist standardisation.

I'd like to compare the NHS with Social Security - I have, btw, worked in the NHS, in local Social Security offices and in both 'sides' of DHSS/DH.

When the Welfare State was set up Social Security and Health were handled differently in two ways. Social Security, as the National Assistance Board and Ministry of Pensions and National Insurance, took over the responsibilities of their predecessors but they did not take over what we would now call their systems. The new 'systems' that were set up were set up as centralised Government Departments with Local Offices. In contrast, the NHS changed what we would now call its governance arrangements but did not become local arms of the Ministry of Health nor did the (parts of) the NHS have to change their administrative systems.

Readers will see from my email address that I am interested in records. NPfIT is the latest in a long line of attempts to computerise, inter alia, the medical record. The NHS does not have a standard paper medical record.

In 1965 The 'Standing Medical Advisory Committee' of the Ministry of Health published a report on the 'Standardisation of the Hospital Medical Record', the "Tunbridge report" - for the specialist that is the origin of the HMR forms found in some present medical records. Here are quotes from that report:

Para 108, "The standardisation of medical records is an essential preliminary to the efficient utilisation of mechanisation."

Para 110: "There remain many technical difficulties still to be overcome but the equipment or, in the jargon of the technique, the hardware, exists which would allow medical histories to be stored either regionally or nationally and to be capable of recall either as a printed document or on a screen in different parts of the hospital."

Para 112: "The implementation of our recommendations cannot be other than voluntary by hospital authorities. ... We hope therefore that hospital authorities will carefully consider the advantages of standardisation and will keep the awkward interim before effective standardisation as short as possible."

To remind, this was all said in 1965.

As others have said on this site, we have put the mechanisation cart before the standardisation horse. But how to achieve the standardisation of complete administrative processes, "voluntarily"?

Should we, should CfH, be having a debate about where we have and have not achieved mechanisation over these last 40 years. A good place to start would be with PAS. To what extent is standardisation driven by the need to submit 'central returns' to the Ministry of Health as if parts of the NHS were the local offices of a central government department?

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4

Time for a fresh start?

20 Apr 06 08:13

I'm not sure I entirely agree with the previous comment. In my experience, the "remarkable and first class" service that the NHS often provides requires the efforts of its talented and dedicated professional managers in Trusts etc (including CEOs, finance and other directors) as well as the skills and commitment of front line staff. Their efforts, however, often appear to be hampered by a contrasting lack of managerial expertise from DH's civil servants, seemingly obsessed by trying to performance manage the Service through the imposition of unhelpful targets developed as a result of "policy" (whatever that means).

In my opinion, the Department's CfH programme is a shining example of an inappropriate centralist approach aligned to unachievable targets. There is little that is new in the objectives of the national programme: shared multidisciplinary electronic records, patient empowerment, better information for patients and practitioners etc, have been the direction of travel for over 10 years. But they have not been achieved to date, and there is not much evidence so far to suggest that CfH's efforts will bear fruit. The barriers to success are more fundamental and are in part to do with the heterogeneous nature of "the NHS".

The Austro-American economist Schumpeter wrote about the "gales of creative destruction" that lead to innovation and change. Until the winds of change blow through the DH's approach to IT implementation - recognising the diversity of the NHS and empowering local managers (though within agreed standards) - I'd be surprised if we see much real progress. Perhaps the new SRO will rise to this challenge?

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5

Incompetent or burned-out

20 Apr 06 11:39

Interesting thread, but I don't agree with the Financial Drains comment.

Many of the local NHS Managers I have seen come and go have worked extremely hard, are always seen as the kicking horse from above and below, asked to do ridiculous things to impossible timetables by the Centre, without any resources to do it, and never have enough time to do any of it well.

Yes, there are some who are unable to cope with what is demanded of them. Few attract the salaries of senior GPs or Consultants and that is why it is difficult to recruit and retain good people.

Remember that CfH is just one imposed programme alongside a whole slew of contradictory mandates from HM Government. Chaos theory has lots to say about unexpected outcomes from tinkering with complex systems.

And it does not sit well with an agenda of otherwise devolved responsibility and funding, and direct competition from the independent sector, who have not been saddled with NPfIT solutions.

And I can't see the NPfIT programme being a shining example of good value for money for the taxpayer on any level.

(Post edited by E-Health Insider)

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6

Priorities for the new SRO

20 Apr 06 15:19

I largely agree with 'Incompetent or burned out' above. StHA's and PCTs often act as 'middleware' between the DH and local NHS organisations. There are a lot of people trying to make sense of woolly policy documents and to deal with the army of policy bods that write them. But CFH is in a similar position in trying to reconcile the latest incoherent ramblings from the DH with its own plans and the requirements of the wider NHS.

Reforming the woefully inept way that the DH produces and implements policy is probably a bit of a tall order for the new SRO, but clarifying the way that the DH and CFH interact would be a start.

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7

Conflicting Policies

simon.mortimore@royalsurrey.nhs.uk

21 Apr 06 12:13

As somebody who is new to the NHS and one of the “incompetent & hiding Heads of Department" the thing I find most interesting is conflicting policies. For example a market based service with all the entities competing against each other and cost saving by standardisation. Can't be done. The nature of a market is that the organisations will adapt and operate in different ways given the local environment and the resources available. Even if the objectives are the same it is impossible to deliver them in a standard way.

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8

Moths circling the flame....

21 Apr 06 12:35

The increased cycling of CROs is akin to the fatal circling of moths around a flame; it's an index of the whole dysfunctional edifice that is the NHS, of which CfH is but a small, albeit, significant part. The economic model that the NHS uses is that of the old "command economy", and it is no comfort that North Korea has chosen to adopt the same model. The NHS will fail just like the former USSR & Eastern Block, and I detect that at the core of the DH there is a schism between those who recognise this and want to modernise and transform to a market type insurance based model, and those diehards wedded to the concept of the NHS of 50 years ago. This split is compounding the problems of the ailing NHS as it creates a sense of lack of leadership and lack of direction.

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9

Giffiths

jlgh_consult@dsl.pipex.com

21 Apr 06 14:46

Some interesting comments here. My view is that whilst there are no simple answers, part of the blame for management problems in the NHS lies with whoever chose the grocer. In 1983, someone asked Sir Roy Griffiths to make recommendations on how the NHS should be run. Unsurprisingly, Sir Roy (the chairman and MD of Sainsbury's) and his colleagues (luminaries from BT, United Biscuits and a Television company) concluded that the best way to run the NHS was like a grocery. The result of implementing his ideas has been tribal conflict. A few years later, Professor Checkland (of “Soft Systems” fame) commented that by the standards of classical management science “...the role of the [NHS] manager is technically impossible”(Soft Systems Methodology in Action, Wiley, 1990). In a 2002 editorial, BJHC editor Michael Fairey wrote “There is... one issue ... at the heart of difficulties in the introduction of medical information systems... It is the relationship of clinicians to managers.” (http://www.bjhc.co.uk/issues/v19-8/v19-8editorial.html). Widespread (if not universal) antipathy between these two groups is fairly clear to anyone who has had much to do with the NHS. It would be unfair to blame Sir Roy Griffiths. He was no doubt doing his best. The government of the day should perhaps have given the job to a general or perhaps to an airline executive (pilots are in general more highly selected and better trained than many running the airline as a business. They also have – quite rightly – a lot of autonomy: if something goes bang in mid-Atlantic, the captain can choose unilaterally to go to Reykjavik instead of New York. The parallels in medicine are obvious). I wish Sir Ian well. It is however perhaps indicative of the changes introduced by Griffiths that he is neither an IT professional nor medically qualified.

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10

Mothballs

21 Apr 06 15:07

Repeating the mantra of the 'failing NHS' a la Daily Mail might give heart to those salivating at the prospects of an market / insurance based health service and the money to be made therein. It might help to undermine public confidence too, but fortunately, it doesn't make it any more true. Flawed though it is, the NHS is a long, long way from failing.

The current situation vis-à-vis the CFH SRO is a reflection of all sorts of things: the scale of the task, the money involved, the vested interests being challenged, and a large slice of organisational politics in the DH. But implying that the rapid turnover of SROs is an indication of the imminent collapse of the last great socialist edifice is taking things a bit far.

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11

Building local bridges ...

21 Apr 06 15:19

Technical specilists (whether they are clinicians or IT professionals) often don't make good general managers - though they do like to dabble. The Bristol Royal Infirmary Inquiry report highlighted some of the potential problems in this. Fortunately for us all, most professional managers don't try their hand at the technical specialisms!

Whilst it is undoubtedly true that there is often a "culture clash" between specialists and managers in the NHS, this does not inevitably preclude introduction of effective information systems (Wirral is a good example of a success story). It does - however - seem to need a local implementation focus with strong local leadership to manage the cultural divide. This is something that just doesn't appear to have been factored into the CfH approach.

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12

The Wirral and medical records

21 Apr 06 17:32

For the record...

The last comment, 'building local bridges' speaks of the success of the Wirral computer system. When working for the Department (of Health), I saw a demonstration of that system.

A few years later, I had occasion to visit the Medical Records Department at the Wirral. That Department was not noticeably different from Medical Records at other Hospitals, eg:

- trolleys loaded up with multi-volume records, some needing repair from constant use

- scanning of notes (to disc) to reduce the need for storage

- a team photocopying patient notes, mainly for the clients of solicitors.

In sum, the paper record was still the master record and included printouts, from the 'Wirral system', for the record; not least because not as many clinicians were converts as the demonstration led you to believe.

One wonders how many of those who make policy and investment decisions for the computerisation of clinical data administration have any practical experience of the variety and vagaries of the current arrangements.

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13

Building local bridges

jlgh_consult@dsl.pipex.com

22 Apr 06 09:47

Agreed absolutely on the ...does not preclude...

Apologies for lack of clarity in my "Griffiths" post. The point that I was attempting to make is that in some environments (grocery stores?) the whole concept of general managers without specialist domain knowledge works, and in others (military?) it does not. The NHS is in my view in the latter category.

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14

Even American Moths have a safety net

24 Apr 06 09:09

Those who think that the current leaning towards market forces (GP Fundholding x10) is a schism only ignored by diehards, ought to look at even America where Medicaid/Medicare covers those without insurance.

Europe is a patchwork. The medical encounter stays about the same, it is always the 'how do we pay for it' that is different, and we seem to be circling each other. Everyone looks with envy at the UK NHS, at the social model in Sweden, at the rugged health of the mediterranean population. The truth is that none is perfect, costs worldwide are escalating, and healthcare systems for all countries are in a state of 'productive tension'. The real problem for England is that too many elements are being changed at once. The outcome could be expensive, and the NPfIT experiment is one of the initiatives with highest risk of low gain or failure.

Everyone wants to see how we do, all want to learn from it, and few to follow.

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15

More on building bridges ....

24 Apr 06 19:27

(1) Wirral - I also saw the system in action and the fact that it ran alongside paper records didn't - to my mind - mean that it wasn't a success. Does anybody seriously believe that the deliverables from CfH will *replace* the paper record in the NHS?

(2) NHS like the military? That's a view that one might imagine is popular with some of the die-hard NHS professionals. Actually, though, it's a *service* that is increasingly required by the public to be user-focussed, responsive and efficient. In my opinion, there is still a lot more that the NHS could learn from the retail sector.

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16

Military

jlgh_consult@dsl.pipex.com

25 Apr 06 10:20

Apologies again for the lack of clarity: I did not say and do not believe the the NHS is LIKE the military - just that the NHS shares with the military (as one example amongst many), the characteristic that it does not respond well to a non-specialised general management model