“The National Programme for IT: it’s time to acknowledge the elephant in the room”
Professor Trisha Greenhalgh OBE is Director of the Healthcare Innovation and Policy Unit at Barts and the London School of Medicine and Dentistry, Queen Mary University of London. She led the independent evaluation of the Summary Care Record Programme.
“In this latter story, it is now a simple matter of installing some extra software and tripping the switch. Where does the truth lie?
The Summary Care Record exists – but how much will he technology be used?
“The entity whose existence is contested is the Summary Care Record as a technology-in-use.
“This is despite generous resourcing at the centre and what have been, by and large, well-planned efforts by competent local implementation teams to get the technology up and running.
“The well-known delays and disappointments with other centrally-driven innovations (such as local detailed records, electronic transfer of prescriptions, GP2GP and Choose and Book) suggest that the significant gap between proof-of-concept and technology-in-use is a systemic problem across the entire National Programme for IT.
“The difference between a technology and a technology-in-use is the complex and often dimly-understood configuration of policies, resources, people, priorities, permissions, upstream tasks, buy-in and bits of infrastructure needed for a particular technology to ‘work’ in a particular setting at a particular time. And if it does not actually ‘work’, the technology might as well not exist for that particular use case.
“Complex policy interventions inevitably slow to a crawl. Westminster’s stirring mission statements attenuate by the time they reach the provinces. Even in volunteer pilot sites, initial enthusiasm dwindles and real life must go on, despite the succession of away days, briefing breakfasts and promotional mouse mats. Steel and silicon obstinately refuse to appear on time or work as expected.
The elephant in the room
“But it would be a serious mistake for those leading the newly-announced government review of the Summary Care Record programme to slap a could-do-better diagnosis on the current implementation strategy and ask everyone to push harder.
“It is a mathematical axiom that as a system gets more complex, it becomes less predictable because fixed inputs cease to produce fixed outputs. Different parts of the system adapt locally, insofar as they are able, to local influences and available information, leading to organic rather than linear change.
“As predicted by complexity theory, high workload, unforeseen costs and continuing emergence of things that need ‘fixing’ have been consistent findings from empirical research studies on the National Programme for IT. These problems will be ongoing.
“The anticipated steady state at which all pieces of the jigsaw fall into place and maintain themselves with minimum or no maintenance effort is a dangerous illusion.
“Much progress has been made. Civil servants have embraced the concept, inasmuch as they understand it, and begun to use the rhetoric. The National Programme for IT is described in the corridors of Whitehall as comprising “10% technology, 90% business change”.
“These significant gains notwithstanding, the National Programme for IT is still largely predicated on the kind of assumptions and business processes that built the Model T Ford rather than the ones that allowed New Zealand to produce a technically robust national electronic patient record system which is being delivered within budget and simultaneously deemed acceptable by the professions, civil liberties campaigners, government, service users and the commercial IT sector.
“The NHS is not a homogeneous entity with a single point of contact for negotiators. Every strategic health authority, every primary care trust and every GP surgery up and down the country has its own (implicit or explicit) policy on the different technologies in the National Programme for IT and – crucially – its own Caldicott Guardian on whose job description the protection of patient confidentiality in that organisation lies.
“The first generation of Connecting for Health top brass perhaps failed to appreciate that progress in developing a national electronic record system depends above all else on an ongoing process of sensemaking – that is, on the buzzing, blooming cacophony within the NHS and beyond it on whether a particular technology is, on balance, a “good thing”; on whether it should be implemented right now in its current form and through standard operating procedures, or at some other time in some other form and in idiosyncratic ways; and on whether to rip-and-replace wholescale or retain (in some form or other) a particular devil-we-know legacy system.
NHS Connecting for Health’s enduring legacy
“Their successors have a far more nuanced and appreciative understanding of how negotiation, co-design and interpretive flexibility by local teams embeds and strengthens technologies-in-use. But their ability to apply this understanding is severely constrained by what some of them have described as Connecting for Health’s enduring legacy: a non-adaptive, reductive, anti-dialogue Gantt chart culture.
“For the past 13 years, the NHS has led the world in a pioneering natural experiment to test the hypothesis that large, densely interconnected and centrally managed information systems would greatly increase accessibility of data (and thereby quality, efficiency, transparency and trust) as well as bringing economies of scale.