In spite of the huge amount spent on NHS Connecting for Health (CfH), the largest public sector IT project ever, the response to it can hardly have been heartening for its developers. Politicians equivocate, the press has been damning, patients are sceptical and clinicians – for whom the system is intended – have given a collective shrug of the shoulders.
Should we even be pursuing this expensive and controversial development in the way that the NHS operates? For the staff of the NHS, the answer must be yes. It will allow us, be we doctor, nurse, paramedic or social worker, to be better clinicians to our patients.
View from the inside
This is the best argument, but it is possible to make the case for an NHS-wide electronic system on economic, academic and even ethical grounds. I have spent part of this, my second foundation year, as a clinical advisor to CfH prior to leaving the NHS for the Royal Navy – and an expected deployment to Afghanistan with the Royal Marines. As a relatively junior doctor within CfH I feel I have a unique viewpoint from which to provide insight into the machinery of healthcare IT in the NHS and the challenges it faces.
The great advantage of a well-designed, well-used computerised system is its ability to provide clinicians with a quality, breadth and accessibility of data that has never been possible before. Data processing is currently arduous, full of bias and error, and more subjective than it should be. With good design of software applications and good teaching of how to use them, the processing of raw data will be done for us in the way we want it to be done, on a huge scale.
From myopia to 20:20 vision
In addition, approaches to disease processes will be greatly augmented with improved, better processed information, as our ability to see the effects of our actions moves from myopic vision to 20:20. Then there are other benefits; improved patient safety – especially through medication control – and improved transparency of information at critical points such as hospital admission, handover and discharge.
All of this is self-evidently a good thing. So why has support for the system not been whole-hearted? First, there is the suspicion that ‘coding’, or the assignation of medical information to categories in databases for efficient retrieval, is principally for the benefit of the bean-counters – building pictures of cost, estate management and patient processing rather than epidemiology, clinical management and disease processes. And this could happen, if clinicians do not insist on good IT support to enable better healthcare performance. The ideal system will deliver managerial information as a spin-off, not vice-versa.
Engaging clinicians in systems design
Another concern among clinicians is that rather than help them in their principal role – caring for patients – IT has become burdensome, requiring training on diverse ill-maintained systems. Software failures lead to data errors, with potentially serious consequences. Perhaps a bigger problem still is the manner in which clinicians are engaged in the design of systems. Doctors are expected to fit in the extra work on IT around their current jobs, without a productivity bonus or similar reward.
But the consensus that computer power is needed in medicine for the management of information, means clinicians have a duty to engage more in harnessing its potential. The NHS needs to cater for improved training and IT resources, but also needs to establish incentives, and a mechanism, for clinical engagement that will encourage responsiveness.
Even where the usefulness of IT is acknowledged, it is sometimes asked whether we need a universal system for the whole NHS. Perhaps it would be better if individual hospitals and trusts were freed to develop the solutions to their own needs?
The limitations of local
Having been involved in a number of these local projects, however, my experience is that they are typified by lack of practical assistance from other busy clinicians, are generally hampered by tight hospital budgets which are not agile enough to respond to such needs, and get little support of recognition from hospital management staff. Software then functions in a sub-optimal way, and use decreases as frustrations grow.
Moreover, local IT projects may meet a local need in the short term, but they often repeat mistakes made elsewhere, increase the variety of applications making training and transfer of information harder, and are squeezed out of under-resourced IT departments and exhausted clinicians.
The piecemeal nature of current developments complicates the picture still further. Clinicians and managers are not waiting for the National Programme for IT (NPfIT) to be delivered by CfH, but purchasing or developing stand-alone systems. This is exacerbating the problems driving the NPfIT in the first place, but also making it harder for the NPfIT to deliver. Private vendors are producing software which is in some cases streets ahead of anything that the NPfIT has to offer. Smaller vendors who are agile enough to respond to new technologies and ideas are producing applications that clinicians will be reluctant to drop in favour of something less advanced. The politics between private business, trusts and the NPfIT have become so confused with opposing agendas that when solutions are found, they benefit no one.
Collaboration basis for success
But it is possible to find a way through. At Charing Cross Hospital in London they are sourcing a bed management system, a handover system for on-call doctors, an application to allow nurses to input observations electronically, and a common nursing database of daily notes for shift handover. Clinicians have mediated between CfH, private vendors and the NHS trust to generate a business plan for a pilot scheme, with potential for full-hospital roll-out.
The collaborative approach combines the strengths of each actor to achieve a stronger overall result, combining the different projects into one. As a result the overall benefit to clinicians is greater, there are reduced maintenance requirements, and the system produced uses the standards which form the blueprint for future NHS applications, helping to ensure compatibility with future software.
The collaboration is not free of problems, which range from difficulties quantifying the financial benefit to a reliance on unpaid outside-hours contributions by doctors. But it has been done with the involvement and consent of clinicians who will be affected, so that they do not feel alienated by such a process. As an added benefit CfH gets to test its guidance for standardisation in a real environment. The trust meanwhile can spread the burden of work amongst the other partners, and the private vendors not only enter a new market but can improve their understanding of processes surrounding their current product to enhance it further.
Recognising realities of local IT
Such projects provide valuable lessons for the whole NHS. There needs to be more joined-up thinking between the reality of IT at a local level, and the ideology of healthcare IT at a regional and national level. This could be enabled by clinicians if given the time and resources to do so, with official recognition to ensure that it is not viewed as time wasted in personal and professional development. This year I have been working with the Northwest Thames Foundation School, Imperial College and Connecting for Health to explore formalising junior doctor and medical student engagement in clinical IT projects.
Criticism over the cost of the project should be considered in the context of chronic under-funding of IT in the NHS, and that implementing clinical software isn’t as easy in healthcare as it is in many other industries. An overall strategic view may outline more important issues to address with NHS resources, but this is a programme that in its unique complexities could provide unique benefits to the future of health care.