Nigel Bell knew what he was getting himself into when, a year ago, he accepted the job of chief executive of the NHS Information Authority (NHSIA) - at least, he thought he did.
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On the eve of the authority's annual general meeting last week, Bell described his first year in office as "interesting" and, chuckling, recalled the old Chinese curse, "May you live in interesting times".
Bell is measured regarding the achievements of the last year. "A lot done, a lot more to do," he said.
It is a pretty fair assessment of a difficult year. Bell has been charged with delivering a coherent, national NHS IT strategy while welding together a group of disparate organisations, coping with layer upon layer of bureaucracy within the health service while responding to a fast-changing government agenda.
Early targets have been to rectify the problems with NHSnet, the health service's private network, and reorganising the NHSIA while trying to convince politicians and policy-makers that their bright ideas must be practical.
On taking up his post, Bell had to make a pretty hard decision on NHSnet. He immediately scrapped the target of getting every computerised GP practice on the network by December 1999, because it was unachievable.
Since then he has been trying to sort out the troubled project, which still raises the hackles of many GPs. Bell accepted criticism of NHSnet but said new service levels agreed with BT and Cable & Wireless in June are producing results. "Compared with what we were getting a few months ago, the network is far more stable and the service is far more stable," said Bell.
Progress required some banging together of heads. "When BT and Cable & Wireless wanted to talk to me about the future, the first thing I said was, 'Why on earth should I talk to you about future stuff if we can't get today sorted out?'"
Bell has also appointed regional co-ordinators, to monitor the information authority's performance and provide a more local contact to help sort out issues. "People should not be bounced between suppliers," he said.
The comprehensive NHSnet address book will be rolled out by the end of this year, which should rectify one long-standing complaint about the system.
These developments, said Bell, are part of his drive to get the NHS to build genuine partnerships with its IT suppliers. The negotiations with BT and Cable & Wireless, he said, were about, "Having the right conversations. Being realistic about how much you invest and what you expect to get for that, and long-term partnerships and short-term problems. On the one hand we can be demanding on suppliers, but on the other we can be a difficult customer because we're very fragmented.
"We've got to do our bit to say, 'we want these services, but we'll try to make it easier to do business with the NHS'. In my early days, I got the impression that some people thought suppliers should be honoured to be doing business with the NHS. But if I was a supplier, I'd wonder whether it was worthwhile."
The NHSIA has just published figures showing 66% of GPs' surgeries now have ISDN connections to NHSnet. However, influential GP leaders point out that there is a difference between having an ISDN box in the surgery and being able to use NHSnet (Computer Weekly, 21 September).
For Bell it is " a chicken and egg thing. The message we've been getting from the service is, 'Get the basics sorted out; get a reliable network; get everyone connected to it; give us Web browsers and e-mail. Get the basics working before you do anything too fancy'."
One thing Bell has set his mind on is the renegotiations of the NHSnet contract, which is due for renewal in 2003. "NHSnet is a massively complex wide area network and there are thousands of servers managed in different ways by different people," he said. "We'd like to make the net wider to include servers and try to get more consistency."
The NHSIA has created some controversy over its attitude to e-government and the interoperability standards being put forward by the Cabinet Office's IT Unit. IT is currently pressing ahead with the roll-out of a major pathology-messaging service based on 25-year old Edifact technology, rather than using the XML standards that from next month will be mandatory across the public sector.
Bell defended the decision. The NHSIA board had a lot of discussion about pathology-messaging and where its solution fitted with where the world was going, but "the case was very persuasively presented", he said.
However, Bell is determined to drag health service IT into line with government policy. "The NHS does not have blanket approval to opt out. We have to comply with the letter and spirit of e-government [policy]."
But he added, "This is a real challenge for us because we are not starting with a blank piece of paper." An update of the Information for Health document, the key NHS IT policy statement, will allow the authority to meet that challenge.
"I would like to see a stronger message about XML coming from the new document," said Bell. Debate on the issue, he thought, would be good for health service IT practitioners and would "give suppliers a message to start preparing solutions".
Another central government initiative that Bell wants the NHS to take on board is the Cabinet Office review of IT project failures, which was published in early summer. At the document's heart was the use of modular rather than Big Bang roll-outs; of shrink-wrapped rather than bespoke solutions; and of strong project management.
Bell wants the NHS to "fully exhaust market solutions before inventing things ourselves".
To emphasise the point, he said, "My background was in industry, taking out bespoke systems and putting in packaged systems."
When he spoke to Computer Weekly a year ago, Bell emphasised the need for a culture shift among IT professionals. That has not gone as far as he had hoped. He had hoped to facilitate the development of an informatics community in the NHS. "There are stacks of people in the NHS dealing with information and IT who are often not talking to each other. There is expertise out there."
Pooling that knowledge would allow a more evolutionary approach to NHS IT, and Bell hopes to get mechanisms and funding in place to allow it to happen. "We've got to avoid re-inventing wheels, and it doesn't have to be the centre deciding on what wheel is best," he said.
Year one: "A lot done, a lot more to do"