[email protected]: From local innovations to centralisation – 50 years of healthcare IT
From broom cupboards doubling as server rooms to teleprinters and green screens, as Computer Weekly prepares to celebrate its 50th birthday, we look back at NHS innovations, pitfalls and attempts to digitise over the past five decades
Over the past 50 years, the UK’s National Health Service (NHS) has experienced many useful localised innovations that have failed to catch on, as well as repeated attempts by the Department of Health (DH) to computerise the service from the centre out.
All have met with varying degrees of success.
In 1966 – the year Computer Weekly was born – NHS IT, if you could even call it that, was a far cry from what we know today.
Michael Thick, now chief medical officer and chief clinical information officer at healthcare software firm IMS Maxims, came across a clinician-focused computer system as a medical student in the Royal London Hospital, Whitechapel, in the late 1960s.
The Eliot 806 system was used for order communication and placement, with two green-screen terminals next to a ward sister’s desk, allowing users to order haematology and biochemistry tests.
“There was a little book which gave you a set of codes that corresponded to the tests you wanted to order,” he says, which alerted both the laboratory and the phlebotomist who took the blood samples.
The results were available 24 hours later through the computer, “although needless to say it had to be delivered on paper”. He adds: “It was very successful, but somehow it just didn’t catch on.”
An attempt at shared records
Roger Everitt, now managing director of outpatient clinic management supplier Savience, inadvertently became part of one of the first attempts at centralisation when he graduated from Exeter University in 1975.
As Computer Weekly moved into its first decade, Everitt joined around 70 to 80 staff using an ICL 1900 mainframe in purpose-built buildings at the Royal Devon and Exeter Hospital.
The project provided that site (the city’s eye infirmary and Princess Royal Orthopaedic Hospital), Exeter’s Mount Pleasant health centre and a location in Ottery St Mary (some 15 miles away), with a prototype integrated patient records system, using modems and teleprinters.
“This was pretty ground-breaking stuff, people having access to a shared record across primary and secondary care,” says Everitt.
The project was wound down in the early 1980s, as upgrading the system to ICL 2900 hardware would have cost millions of pounds.
However, it acquired a new purpose when then health minister Kenneth Clarke announced the computerisation of cervical screening, accelerated after the death of an Oxfordshire woman in 1984. Exeter’s system was chosen as the basis of the resulting NHS Family Health Services Computer Unit.
The government ordered each family practitioner committee to computerise (by 1988) its two-card indexes – one for patients and one for their registered practitioners – so all women within a range of ages could be called for screening.
The work started at 1 Empire Way, near Wembley Stadium, west London, with the records of five London boroughs. “It was two gigantic rooms, with millions of card-based indices in them,” says Everitt. Digital Equipment Corporation (DEC) provided PDP 11/44s, and Everitt ran the London support team.
“We had a team of five people, who would take these five huge manual registers, convert them into digital formats, install five large mainframe computer systems, deploy all the visual display units, convert the buildings and train the staff,” he says. “It was done inside a year.”
Over the following two years, Everitt and his colleagues computerised all the other family practitioner committees. “It was an enormous job, and because the timescale had been set by the minister there didn’t seem to be any flexibility to move that,” he says.
The National Call and Recall System for Cervical Cytology, followed by a similar service for breast screening, was “certainly the first national patient-facing system”, says Everitt. “It was hard work, but thoroughly enjoyable.”
Focus on administration
Meanwhile, Mark Venables, now chief executive of Highland Marketing, was selling 622MB System Industries disk drives for minicomputers, such as DEC PDPs and Vaxs. The memory capacity of a current £2 flash drive cost £25,000-£30,000 in the late 1980s, with half a dozen filling a large computer cabinet.
“It stacked up commercially pretty well against DEC’s own product at the time, and it was probably 30% cheaper,” Venables recalls, as well as being faster and smaller.
An East Anglian hospital told Venables it would have to get written permission from the US supplier of its CliniCom patient administration software (PAS), Shared Medical Systems, to install the disks.
After tests, Shared Medical Systems approved their use in all of its 30-odd NHS sites. “It demonstrated the close relationship suppliers had at the time with their customers,” he says.
Mark Venables, Highland Marketing
NHS computing and IT was at a much lower profile then than now. “While IT had a place back in the 1970s, 1980s and even the 1990s, it had nothing like the attention or the potential people are now realising,” says Venables. “It was almost just a background task.”
One reason was that IT was initially focused on administration, not patient care. Shane Tickell, now chief executive of IMS Maxims, worked for a women and children’s hospital in the late 1980s which employed a workflow system.
“Despite being able to successfully administer our patients, manage our stock control, procedures and billing, we were missing the detailed patient notes – which were on paper,” says Tickell.
“Even at this time, the effects of an ageing population were starting to show on the health service, with inaccessible paper-based patient information a major issue,” he says.
This remained the case in the 1990s. Musadiq Subar first worked for Homerton Hospital in 1995. “It was a very small team, looking after a handful of IT applications,” he recalls, including email, word processing and the PAS hosted off-site.
“Rapidly, over the years, more and more applications were required. It mainly started in the finance side; there were applications put in place to manage the hospital,” he says.
The need to build new systems resulted from Homerton splitting from Barts and losing access to its IT – something Subar claims contributed to Homerton becoming one of the first 10 foundation trusts in 2004. “Other organisations are still using the same systems, probably as old as I am,” he says.
Beginning to join up
As the 1990s ended, some hospitals were joining up. Shaun Smale, a solutions consultant at BridgeHead Software, worked on sending head scans from the Luton and Dunstable Hospital to the Royal Free in Hampstead, where consultants made recommendations on treatment.
This used video capture and a pair of dial-up modems working at 2,400 bits per second, and “it used to take about 20 minutes to send a single head slice, but it was a life-saving tool as the decision could be made whether to put the person in the ambulance or treat them locally,” he says.
The new millennium saw local innovation falling away. The devolved governments in Scotland and Wales took control of health services in 1999 and introduced central programmes, but England went much further.
This started with the formation of the NHS Information Authority (NHSIA), also in 1999, taking over Exeter’s Family Health Services unit.
Judy Aldred moved to NHSIA from the oil industry: “There’s a lot more discussion and meetings in the NHS than in the private sector [where] there’s more ‘get on and do it’. In the public sector, you’ve got to keep all the stakeholders happy.”
As programme manager for NHS.uk, her team created a single online directory of more than 2,000 health service providers, which she recalls as “horrendous”, adding that “everybody just wanted their own website”. NHSIA had to persuade organisations to comply through a series of meetings around the country.
The pitfalls of NPfIT
Centralisation intensified with the National Programme for IT (NPfIT) in the NHS, announced by prime minister Tony Blair in 2002 after a meeting with Bill Gates. It was initially run by NHSIA, but in 2005 the government transferred responsibility to a new body, NHS Connecting for Health (CfH).
NHSIA had been led by Gwyn Thomas, who Aldred describes as “a really good leader” who allowed people to get on with their jobs. He moved to Wales to run its Informing Healthcare programme, eventually becoming the Welsh government’s chief information officer.
Aldred worked on e-prescribing systems for CfH in its Leeds office, but the atmosphere had changed: “My project stagnated, because there was somebody in the DH who didn’t like the way it was specified,” she says. “That was really frustrating, when I had a big budget but I couldn’t do any work.”
Gary Birks, Dell UK
The NPfIT affected every part of the English NHS. Gary Birks, now director of healthcare and life sciences for Dell UK, but then head of IT at Enfield Primary Care Trust, says this worked well in some areas: “The introduction of systems such as RiO within community health has been a great addition.”
However, GP surgeries were largely ahead of the rest of the NHS in computerisation. “It certainly helped move those GPs who were dragging their heels with technology to the same level as those who had been using it for some time,” says Birks.
But the programme refused to let GPs use Emis, the market-leading software package developed by NHS doctors. “I sensed that those who used Emis were more than happy with it, and said to the National Programme ‘we’re not moving’,” says Birks. CfH eventually changed its mind.
Broom cupboards and portacabins
And then there were the hospitals. Shaun Smale worked for the programme’s London local service provider BT as its delivery manager for picture archive and communication systems (Pacs). “The server rooms were quite often a broom cupboard,” he says. “Somebody even suggested a wooden shelf on the roof of the hospital.”
There were culture clashes: “A lot of the BT people came from places such as GCHQ, where security was absolutely paramount. Where hospitals were saying ‘we’ve got this broom cupboard, can we put it in there?’, BT was pushing back.”
Barking, Havering and Redbridge University Hospitals NHS Trust put its systems in a portacabin – which CfH and BT surrounded with wire fences. “We used to joke it had a lookout with a gunman in it,” says Smale.
By this time, Musadiq Subar had joined North Middlesex University Hospital NHS trust, where he is now IT programme manager. By choice, the trust was the last in London to accept the programme’s Pacs, having been stung as the first adopter of its Choose and Book system. “You go through a lot more of the pain,” says Subar.
The end of NPfIT
Michael Thick spent four years sitting next to CfH’s director general Richard Granger, where he worked on the still-in-use GP2GP transfer system, which Granger called “polishing the turds”.
Granger became known for his aggressive approach, but Thick defended him, arguing he was “actually a very nice man, badly misunderstood”.
Granger had received political backing while setting up London’s congestion charge, “but when it came to things going wrong with the National Programme, he turned around for the political support and it wasn’t there”, says Thick.
Following its failure to get systems into hospitals, the programme was abolished by the coalition government in 2011. Thick points out that it succeeded in setting up several nationwide systems, but “what didn’t work well was the clinical engagement piece”.
“There was no choice over the systems, and it was going to be these enormously monolithic things that did not reflect the clinical practice in the organisations to which they were put,” he says.
The health service seems to have learned that lesson. Vijay Magon, managing director of document management provider CCube Solutions, says his firm used to deal only with IT staff, but now its engagement is largely with the user – the clinician. “IT people became enablers, rather than providers, and it’s the users who make decisions about the functionality of the software, the look and feel,” he says.
Years and years of usage
But NHS IT retains its sense of history – not least by using software applications for decades longer than most industries would tolerate.
Shared Medical Systems, which authorised Mark Venables’ 622MB disk drives in the 1980s, was bought by Torex, which was bought by iSoft, which was bought by CSC, which in 2015 told several NHS trusts still using CliniCom that it was stopping active development of the system.
National systems developed by CfH in the 2000s, including Choose and Book and the Spine, both which have been redeveloped by the HSCIC, are still in use and not compliant with current browsers.
“I’m putting legacy web browsers on up-to-date PCs,” says Subar. “I always joke that we fight for funding for IT in the NHS, but by the time we get it, it’s outdated.”