We have to change the public sector's approach to IT

Monday, November 03, 2008

The criticism of the National Programme for IT is frustratingly ill-informed, according to Assist's John Leach. Here he asks for a better approach to public sector projects that involve IT, with IT thought of at the beginning, not the end

Several politicians have derided the "NHS super-computer". Inappropriate parallels have been drawn between healthcare and banking processes and systems. There has been much debate about the merits of particular technical IT architectures. This is not the real priority for service users and service providers. They want something to make their lives better, easier and more satisfying; they want practical help. Whenever people use a piece of equipment they need to know how to use it effectively, reliably and safely; they do not want to know how it works. Healthcare computing is no different.

ASSIST continues to support the vision that care professionals should be able to access up-to-date and complete information about their patients, where and when they need it. This has been the vision for at least 10 years since the publication of 'Information for Health'. Diverting energy towards another national health IT strategy will not get us any closer to the imperative of detailed care records available at the point of need.

There have been changes in the last 10 years. We are living longer and hence the country has an increasingly ageing population. People have become more mobile, the traditional concept of the family has changed and there is increasing diversity. Hospital trusts have merged, foundation trusts have been formed, primary care trusts and their predecessors have had turbulent existences, and the independent sector has become more prominent. We can expect this organisational maelstrom to continue. At the same time, people are receiving care from an increasing range of organisations, closer to their homes, benefiting from major advances in healthcare and mobile communications and other technologies.

This all reaffirms that we require patient-centric care records that are:
• independent of the organisations and particular type of care professional involved,
• securely accessible by appropriate staff.
• available across primary, community, secondary, specialist and social care
• accessible in NHS, independent and voluntary sector organisations.

There have been major health informatics successes nationally and locally. These include: primary care computing, electronic record transfer and prescribing; digital imaging (PACS); shared primary and secondary care access to test results and summary care information; digital patient monitoring systems; new funding flows (Payment by Results); electronic appointment booking and reminder systems; a massive expansions in information for regulation and accountability; and the secure NHS broadband network (N3).

ASSIST believes that now is the time to focus on a more information and IT standards-based approach, as distinct from previous emphases on systems and process standardisation. This offers the best opportunity to accelerate successful implementation of ICT solutions which are accepted and embraced, and it opens-up the market to new entrants and more rapid innovation.

In this respect the role of regulators is critically important to establish a framework within which all care providers — from large state-owned teaching hospitals running internationally recognised specialist services to small local social enterprises providing social care services—should be expected to meet a minimum set of information and IT standards in order to be permitted to operate.

The critical factors associated with the successful implementation of ICT in health and social care are more to do with the readiness of organisations to get the best that technology has to offer as part of structured change management programmes. IT-imposed solutions have always tended to fail, while IT-enabling solutions have been more successful. The practical experience of ASSIST members is that simple systems, which offer flexibility to be configured to meet local processes and circumstances, can achieve greater success than more sophisticated systems which bring rigidity. The "one-size fits all" approach does not work. The needs of a complex teaching hospital with multiple specialities, seeing patients from all over the UK, are different from the needs of a local general hospital. In the same way, the needs of a rural local authority will differ from those of a large city.

It is important to secure public confidence. Statements which seek to attribute blame on the adoption of a particular technology are unhelpful and corrosive: they undermine confidence in the use of technology by the state as a whole. ICT often provides a convenient scapegoat for more fundamental failures in policy or service planning.

There should be a debate about how to maximise the value of ICT in health and social care but such debates should not resort to arguments about technologies, or if they do, then they are based on evidence and facts, and not prejudice. "Super-computers" are not good or bad per se. Indeed many technological advances would be impossible without them. Similarly "distributed networks of local servers" are not good or bad, rather it is the appropriate or inappropriate use of technology which is important, and which itself is only one element which impacts on success. "Failures in IT" are rarely due to the technology per se.

The healthcare informatics profession is frustrated at continual ill-informed criticism of NHS, including short-sighted scaremongering, often focussed on a (non-existent) "supercomputer". The profession has risen to repeated challenges, from repeated restructurings of the NHS, to fundamental changes in the mechanisms for performance management and financial flows, ever-growing demands for data, and meeting the critical informatics implications of major new policies. This has happened with little change in the proportion of front-line NHS resources invested in informatics, despite the recommendations in the first review of the NHS by Sir Derek Wanless. Increases in informatics expenditure have mostly been concentrated in National Programme for IT.

Informatics is now fundamental to the delivery of national and local strategies and plans. Yet it often remains an afterthought in policy development and planning processes, at all levels. Last-minute, ad hoc information demands and system changes at best miss opportunities for innovation through ICT and can easily jeopardise delivery; as core systems become integral to front-line care this sort of approach will increasingly put patients at risk. Significant examples of informatics planning and impact assessment lagging behind policy implementation include the 18 weeks referral to treatment target, Payment by Results, and Vital Signs. Each of these has led to substantial, avoidable demands on limited informatics resources and capacity.

Improving public services generally depends increasingly on the effective use of information and information technology. Great strides have been made across government and more is not only possible but essential to meet legitimate public expectations. We must build the confidence of the public and public service staff in the use of ICT and ensure that informatics services operate to the highest levels of professional expertise and behaviour. Success depends on ICT being seen as integral to transformation and service improvement, not an end in itself or the narrow preserve of technocrats. This requires, among other things, assessing the informatics options and consequences of new policies at the earliest possible time; developing informatics skills in the general and specialist ICT workforces; transparency and openness about successes and failures; and more constructive and better informed public debate.