An annual tradition, this year’s Joe McDonald Christmas column looks at Christmas past, present and future with regards to digital health and NHS IT and the issues and pressures facing the NHS.
Christmas 1986, the snow fell silently in the ambulance reception area of the Ingham Infirmary, South Shields. I was half an hour in from the end of my day shift when the Ambulance Service hotline rang and we were told to expect a road traffic accident (RTA).
Standing in the snow in my white coat, my breath freezing in the yellow sodium light, my stethoscope around my neck I knew immediately from the expression on the ambulance driver’s face that the patient was a B.I.D. [brought in dead]. Christmas Eve.
I was six months into my stint as an Accident and Emergency senior house officer. Twelve-hour shifts, no set meal breaks, a week on nights, a week on days, constant stream of patients.
Sometimes up to 120 hours a week if anyone went sick. It would be another 10 years before the European working time directive would arrive and protect juniors from the worst excesses of their own loyalty to the NHS. The good old days?
It was shattering and dehumanising, after a number of months of chronic sleep deprivation, I’m seeing things no 24-year-old should ever see. I was a burned-out husk of my former self. I’d come to regard the public as the enemy. People became acronyms. On the small white cards which served as the record of a visit to A&E I’d record the history:
P.F.O. (Pissed and Fell over).
And the outcome of my assessment:
N.B.I. (No Bony Injury).
And my management plan:
T.T.F.O. (Told To F~#K off).
We kept the card and a carbon paper copy (younger readers ask grandad) went to the GP, and we gave a copy to the patient.
I put my stethoscope to the patient’s chest in the back of the ambulance, I looked into the fixed dilated pupils that appeared when I opened his eyelids. I certified him dead and looked at my watch. Twenty-five minutes of my shift to go and I have a hot date in the Westoe Arms at 9:00 PM exactly. I wrote on the card, history R.T.A., outcome B.I.D. The entire encounter summed up in six hand-written letters.
The family arrive in A&E and are shown to the “crying room”. It’s my job to tell the family that Daddy won’t be home for Christmas.
They know from my demeanour what I’m gonna tell them. I tell them and they dissolve in tears, “no it can’t be true” they say, like they always do. “I’m so sorry, there was nothing we could do, he didn’t suffer”. I look at my watch, 8.55pm. How long is this going to take, I’m late for my hot date.
I finally get to the pub and my hot date is still there, Reet Petite by Jackie Wilson is playing on the juke box. She asks how my day was, she’s a student nurse. I apologise for being held up by the B.I.D. “How do you feel?” she asks.
It dawns on me that I feel nothing, because some time in the previous 6 months I have died inside. The hours, the work, emotional trauma, years of tory underfunding of the NHS have left me burnt out. I can’t tell her that, can I?
Anyway, I tell her and watch as she reacts with a mixture of horror and sympathy. I resolve there and then to quit medicine or at least try something more humane, say, psychiatry, maybe. Maybe regain my humanity. Burnt out.
Now this Christmas, I know thousands of NHS staff are feeling burnt out. Record numbers are leaving. 12 years of Tory government has left the NHS where they generally leave it, where it was for me in ‘86.
I understand how hard it is for NHS staff this Christmas. We have 3 kids and 2 of them are junior doctors on the front line. Their workloads are overwhelming, and I can see them developing the character-armour and detachment from people required to survive.
Their pay isn’t enough for them to get on the housing ladder. Australia beckons. Their nursing colleagues are going to food banks and worse still is the user experience they have of NHS IT. They can only dream of recording a clinical encounter in 6 handwritten letters with pen and paper. I can’t help but feel I have failed them.
Poor UX of Electronic Patient Records is often cited as a major cause of burn out in the USA but not something we often talk about here, and yet last year’ s national usability survey commissioned by NHSX (R.I.P.) revealed the NHS to have some of the worst IT UX in the civilised world and it is causing burn out.
It’s not just the EPR though, it’s everything. Someone famously tweeted that the NHS Online Learning Management System alone was reason enough to quit the NHS. We are getting ready to spend £1.7 billion pounds on a replacement for the Electronic Staff Record and £360 million, which we don’t have, on an ethically and practically dubious Federated Data Platform which will very likely benefit the American economy more than ours. Why?
Football fans often say “It’s the hope that kills you in the end” and so it is with digital health. And yet…. And yet…… As I write, I see the great lava lamp of NHS organisational churn begin to glow with a faint hope once more.
The proponents of the great oversimplification of the problem which was “managed convergence” on EPIC is put to flight by the Trussonomics black hole in our finances. We will have to build on our installed base after all.
Just as my psychiatric career was born out of the toughest time in my life, my football club have come from seemingly hopeless despair to be the richest club in the world sitting 3rd in the premier league this Christmas. Just as my emotional life seemed washed up on Christmas Eve 1986, the darkest hour was just before the dawn. I’ve been married to my hot date for 32 years.
Maybe NHS IT’s darkest hour is the turning point. It maybe it isn’t too late to build an open NHS IT ecosystem, more like the app store than a 30 year-old monoliths we’ve converged on but it will require leadership who understand the need to put NHS staff ahead of dogma and AI pie in the sky. Maybe NHS IT can save the NHS?
Merry Christmas and a Hopeful New Year.
NHS Psychiatrist (retired), peripatetic medical director at Sleepstation, SARD JV, Ethical Healthcare and Parsek Health
23 December 2022 @ 09:36
I’ve only met Dr Joe recently, so I’m still newly dazzled by his superb, Dickensian writing style. Biting satire, but with incredible warmth and deep experience…and I’m 100% on board with his mission to improve NHS IT usability and interoperability, starting with collaborative suppliers, up-to-date tech, and the will to make change. Thanks for the ongoing inspiration, Joe, to see potential glimpses of glorious summer in this understandably discontented NHS winter 😊
22 December 2022 @ 21:59
Like many in the NHS, there is a feeling here that technology will solve all – interoperability, AI, EPR and so on. I have 50+ years in IT and hundreds of visits to NHS clinics and hospitals and my conclusion is that the Clinical PROCESSES are badly deigned ad hoc or non-existent. The surgeon above spelled out his needs. This is what is needed but those needs need to be stated in clinical flow diagrams with data sources and sinks included – no technology, just a diagram which shows how his part of the world wants to operate. This is then translated into an IT architecture to map on to the processes and then that architecture is translated into products or technology in IT terms. I have diagrams to illustrate this principle, free if you send a note to me at firstname.lastname@example.org The message in a nutshell is Process design (by clinicians) first, then architecture, then technology. The fact that NHS efforts seem to start with technology tells me they will never get it right, however hard they try and whatever ‘shiny’ new technology they employ. Trust me, I have been around a long, long time and know this from experience.
Ex NHS Techie
4 January 2023 @ 09:53
Last year I joined an NHS digitisation project mid-project and, as part of my induction and familiarisation, I asked to see the current and future state clinical process maps. There weren’t any “because we use SOPs here”.
The Trusts involved had gone into great detail over technical functional requirements but there was no clinical context to provide a framework for change management – just reams of Word documents describing Standard Operational Procedures.
22 December 2022 @ 11:09
Hi Joe – many thanks for writing this, as usual an authentic and clear-eyed view of the world in which we live and work. My career to spans carbon paper to failed IT and I too have seen great tragedy and more often than not miraculous miracles brought about by the skill and teamwork that typifies the NHS at its best. I hope that technology begins to deliver the benefits it promises sooner rather than later. Merry Christmas and thanks again
9 January 2023 @ 17:47
What did I say above? Thanks for the supporting comment. I have had a couple of takers for my offer of process templates (layman style to show the principles not real life health processes.
21 December 2022 @ 16:09
Joe, you are right, we need to build open digital systems that are fit for purpose for our colleagues on the shop floor. We need to move bejond old monolithic systems running on out of date platforms, mainly on Citrix so as not to “disturb” the dependencies! We need change! I know we have been saying this for years, but I hope we can now make said change happen! I put my money on the FCI making this happen!
21 December 2022 @ 10:56
10 years ago I thought we might achieve this, but I don’t think we’re any closer to seamless integration between different clinical systems.
I’m a surgeon. I need a single workflow. For example I need my clinical noting, theatre booking, ordercomms, EPMA and MDT solutions to work in harmony IN THE BACKGROUND, not have me duplicating work across different areas. Just because I have a single log in doesn’t mean I have a single system. Even if it’s been sold as a single system.
And to Frank Hester, I would absolutely love to see S1 providing this capability. But there’s a reason Epic and Cerner have university sized campus, that’s the resource needed to develop complex software for large hospitals.
There’s a reason the NHS invested in Microsoft office. It works. Even if you’re not an excel whizz, & you only scratch the surface of pivot tables, someone who is can send you their work, and you can open it, and embed it in Word, forward it via Outlook and discuss over Teams.
I wish it wasn’t so, but I think it’s hard to argue against the reality of where we are with integrated software vs interoperable systems.
So for the NHS to succeed, and I agree it could do this, we would need massive investment in health informatics similar in scale to that seen in the US private sector.
20 December 2022 @ 16:36
The ghosts of Chrismas Past and Christmas Present converge so depressingly here.
A newspaper today advised people to phone a taxi instead of 999 as if that were unusual. A paramedic friend gave me the same advice before Covid and the situation has worsened since then.
There are some positives in contrast to 1986; my recent blood results from the DGH were available on screen to my GP and not held up by the postal strike, my CT scan appointment at the cancer centre was confirmed by text and again the results will be on my care record in near real time.
It could be worse, I could be an NHS Equality and Diversity manager appointed to ensure compliance with equal pay, gender pay gap, social mobility and ethnic diversity targets invented by central government who awoke this week to find cabinet ministers using me as a right-wing meme for what is wrong with the NHS ignoring the fact that my role is a symptom of their over-regulation of the NHS after 12 years of their control.