ASSIST says NHS one-size-fits-all doesn't work

Assist, an association of 1,800 IT professionals in the NHS, has produced an excellent paper which summarises the best and worst in health service informatics.

Assist is the Association for Informatics Professionals in Health and Social Care. It says in a paper that a “one-size-fits-all” approach does not work. And it calls for “simple systems” which can be configured locally – not more sophisticated systems which it says bring rigidity.

The Association says “We observe that IT-imposed solutions have always tended to failure…”

It recommends a “focus on the basics before trying the ambitious” and adds that the emphasis should be on getting “clinical systems working in hospitals working”.

It also says there should be focus on standards, not the standardisation of systems – which was one of the original aims of the NHS’s National Programme for IT [NPfIT].

Assist has submitted its comments to an Independent Review Group, set up by the Tory Shadow Health Minister Stephen O’Brien MP. The group’s aim is to inform the Conservative’s policy for the use of IT in the NHS, health and social care in England. 

The Association’s members are particularly concerned about the bad publicity over NHS IT. They say there have been “stunning” IT-related successes over the past 10 years. They praise the standards of IT in use in GP practices and say that the UK leads the world in the development of health information and IT standards. Thanks to the NPfIT, there is a “robust, secure IT network”.

Assist says that although informatics is now fundamental to the delivery of national and local strategies it often remains an “afterthought in policy development and planning processes, at all levels”. This lack of planning leads to “last-minute, ad hoc information demands and system changes at best miss opportunities for innovation through ICT and can only jeopardise delivery”.

As core systems become integral to front-line care, an ad-hoc 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 and Payment by Results, and Vital Signs.

The association calls for greater openness and transparency over learning from what has gone wrong.

“From an Assist perspective, no informatics professional would knowingly implement ICT [information and communications technologies] that could jeopardise patient safety or their organisations. To do so would be totally unprofessional; as well as being at odds with the fundamental ethos of the healthcare professionals to “do no harm”, an ethos that we as healthcare informaticians fully identify.

“We would therefore call for greater openness and transparency in learning from what has gone wrong. To do otherwise is not just a matter of seeking to avoid criticism; patients’ lives may be at risk if we do not heed them.”

Some points from the Assist paper:

Technical standards not standardized systems

“The implementation of the National Programme for IT has previously focused on the
standardisation of systems solutions. We believe that the current shift in emphasis towards the adoption and implementation of standards rather than systems standardisation is the right one.”

One-size-fits-all doesn’t work

“We observe that IT-imposed solutions have always tended to failure, while IT-enabling
solutions have tended to be more successful. The experience of the members of the
group suggests that simple systems, which offer flexibility to be configured to meet local
processes and circumstances, can achieve greater success that 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 to the needs of a local general hospital.”

Tensions over Foundation Trusts having IT autonomy?

[Tension is] exacerbated by the apparent inconsistencies in national policy. As an
example, the tension caused by the increasing autonomy offered to Foundation Trusts to
direct their own development appears to contrast with the expectation that they will adopt
a nationally procured solution to meet their needs.

Don’t scapegoat IT

“As we have alluded to already, the factors impacting on successful adopting of ICT are more complex than just the technology alone. ICT often provides a convenient scapegoat for more fundamental failures in policy or service planning.”

The NPfIT shift from many to few suppliers has gone too far

“As a consequence of the National Programme there has been a significant (radical) change in the marketplace for ICT systems and services. There has been a shift from a very wide range of small to medium sized suppliers, to one where there are a few very large suppliers with relatively constrained supply chains.

“While the past practice of placing systems from small suppliers at the heart of operational processes of large complex businesses has been all but wiped out, with considerable merit, the balance has swung perhaps too far the other way. We observe that this has reduced the speed of innovation, responsiveness and flexibility. This is in contrast to the rate of innovation in other areas of medical technology. For example, the development of home diagnostic and assistive technologies has continued apace.

“Unless the core ICT systems which have been contracted for are capable of adapting to cope with the interaction with such technologies, we will see a fracture in the vision of comprehensive records. We believe that the successful exploitation of IT to improve health and social care relies on an innovative, robust and competitive supplier market.”

Recognise success

“The healthcare informatics profession is frustrated at continual ill-informed criticism of NHS “IT”, including short-sighted scare mongering, often focussed on a (non-existent) “NHS supercomputer”. The profession has risen to repeated challenges, from repeated restructurings of the management of the NHS, to fundamental changes in mechanism for performance management and financial flows, to meeting ever-growing demands for data, and to meeting the critical informatics implications of major new policies.

“This has happened with relatively little increase in the proportion of NHS resources invested in informatics, despite the recommendations in the first review of the NHS by Sir Derek Wanless…

–  We have primary care computing that is – by any definition – “world class”.

–  We have a robust secure IT network

–  We lead the world in the development of health information and IT standards.

–  We have new modern primary and community systems which share records swiftly and securely between professionals – systems which can underpin rapid service improvements – whether through optimisation of existing service delivery models or by acting as an enabler for the development and deployment of new service models.

– We have implemented clinical systems – notably PACS systems – on a large scale
and at an unprecedented pace, with demonstrable benefits.

– We have worked hard on the introduction of a security and information governance
regime which recognises the critical importance of managing personal data safely.

“Some of the work leading to these achievements predates the National Programme, whilst others can be clearly associated as a result of adopting a more national approach.”

Lack of planning could put patients at risk

“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 only 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 and Payment by Results, and Vital Signs. Each of these has led to substantial, avoidable demands on limited informatics resources and  capacity.”

Learn from mistakes – or patients may be at risk.

“The corollary to building on our past successes is to learn more from our failures. It is generally accepted that deployment of ICT in acute hospitals through the National Programme has not gone well for a variety of reasons. However even pre-dating the National Programme there were mixed experiences, with some notable successes but also some spectacular failures.

“We also return to our earlier point about avoiding unnecessary media point scoring and scapegoating. Most importantly, we must not forget the lessons of the Bristol Heart Deaths Inquiry, Harold Shipman and Victoria Climbié. These tragic events all highlighted fundamental issues about access to and the use of information. While progress has made in some areas, we are still some way from being able to be confident that such calamities could not recur.

“From an ASSIST perspective, no informatics professional would knowingly implement ICT that could jeopardise patient safety or their organisations. To do so would be totally unprofessional; as well as being at odds with the fundamental ethos of the healthcare professionals to “do no harm”, an ethos that we as healthcare informaticians fully identify.

“We would therefore call for greater openness and transparency in learning from what has gone wrong. To do otherwise is not just a matter of seeking to avoid criticism; patients’ lives may be at risk if we do not heed them.”

Some of Assist’s recommendations:

Focus on the basics before trying the ambitious

“Focus on standards not standardisation. A key theme of the 2002 NPfIT implementation vision was “ruthless standardisation”. This emerged from an attempt to see the health services as analogous to a big business, where efficiencies and control was exercised through the deployment of common systems.

“We reject the notion that the NHS is analogous to a bank (especially in the current ‘credit crunch’), a global telecommunications company or an airline, and thus believe that focussing on their ICT models for a healthcare environment was fundamentally flawed. By all means study and learn from such environments but avoid blinkered extrapolation. The guiding principle should now be “ruthless standards”.

Avoid structural change

“This drains resources, diverts management attention, incurs cost, creates substantial disruption, and delays implementation of the consistent vision. It is better to improve the ship than move the deckchairs. The achievement of truly person-based records and information – independent of care setting and the nature of the care professional and based on our unifying concept of the encounter – is future-poof against structural ad other change; what we have now is a barrier.

Avoid stand-alone data demands

“Information should be derived as the product of operational systems – a principle enunciated by Dame Edith Körner some 30 years ago and never truer than now. Ad hoc demands, often requiring inefficient and staff-intensive solutions, are wasteful, produce poor quality data and
continually divert resources and attention from addressing the underlying information and systems gaps.”

Links:

Assist paper in full – dated September 2008

BCS response to NAO launching its (first) investigation into the NPfIT – January 2005

Hospital has long-term NPfIT problems, warns paper – New Technology blog, October 2008

NHS Scotland enters patient data via tablet PCs – Nurse2Nurse, September 2008

Newcastle abandons NPfIT – The NHS Blog, September 2008

NPfIT go-live at Barnet and Chase Farrm – the facts – August 2008     

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