How do you smooth the path to a digital NHS?
Late last October, the Department of Health announced that Dr Bob Wachter, author of the Digital Doctor, had been asked to lead a review for the NHS on the ‘lessons we need to learn to ensure a smooth move towards a digital future.’ Dr Wachter will appoint his review team soon, and incredibly, I’m not in it.
The NHS is difficult. Somebody who worked in it for thirty years once explained it to me: ‘Don’t think of the NHS as a whale. It’s more like a shoal of fish. The only way to get them swimming in one direction is a large and scary external threat. The swimming often ends up being round and round in circles.’
What’s annoying is that this trait is often exploited by people who create false predators; the scythe-toothed sharks of political nightmares. These conceal the real predators, that look far more more like mosquitos. Unassuming, near invisible and deadly.
All sides of the political spectrum do this, as do too many senior officials and top-level reviews of the type Dr Wachter has been asked to lead. They reach for easy, headline-grabbing answers about reorganisations and funding, rather the doing the hard, prosaic things that will make a real difference.
Dr Wachter has a difficult job. I’ve written him a letter.
Dear Bob,
I enjoyed your book. I liked the clear-eyed assessment that digital transformation is as much a humans problem as a technology problem. I liked your dismissal of breathless tech hyperbole that infects parts of the healthcare system. I really liked your clear message that digital health is about transforming the whole idea of healthcare, not ‘replacing doctor’s scrawl with Helvetica 12'.
The month before you were appointed, you’ll probably know that the NHS trust running Addenbrooke’s Hospital in Cambridge was put in to special measures by Monitor, the health regulator. Patients had been ‘put at risk’, said the Care Quality Commission. The CEO and CFO resigned.
Addenbrooke’s had recently implemented EPIC, an IT system you will be familiar with from the US. It creates electronic health records for patients. It cost the trust £40m. And while it was far from culpable for all of the trust’s problems, EPIC crops up all over the CQC’s report, like the unassuming murderess in an episode of Poirot. It is mentioned 115 times. For the purposes of comparison, ‘surgery’ — a pretty core part of the hospital’s work you’d think— is mentioned 120 times.
A lot of people over here just shrugged. Another classic IT cock-up they said (we’ve had a few of those). It’s not so much they are indifferent, more that many have become too fatigued by this kind of NHS story to pick through the bones of what went wrong. EPIC at Addenbrooke’s became another story spun by everyone on all parts of the political spectrum with an axe to grind about the NHS. This weak analysis is a shame, because people were put at risk of real harm, a lot of money was spent and we’re none the wiser about why.
I hope that you can find some answers.
I was nine when I first went to Addenbrooke’s. We’ve both grown a fair bit since. The hospital now sprawls over a site the size of a large village. Turn right at the main reception and you’re greeted with a view that would not look out of place in any international airport; a food court, WH Smiths, weary loiterers sprawled on plastic chairs. It employs over 8,000 people and looks after a thousand beds. Probably not that impressive on the scale of some American institutions you’ve worked in, but big nonetheless.
A few weeks ago, I went to the hospital for a few informal meetings as part of some training. I had the opportunity to speak to a few people who were closely involved in the EPIC roll-out. There was no agenda, no minutes, nothing on the record.
The first and most obvious learning was that EPIC was not introduced by misguided people. That the good and the smart put in the wrong culture can get things wrong is not said often enough. The other basic thing I learned was that neither EPIC nor the idea of electronic patient records is intrinsically wrong. The system — flawed as it is — will undoubtedly save lives and cut out errors.
There were two symptoms of the Addenbrooke’s experience that, if repeated, will make building the path to a digital NHS hard.
The first is that EPIC was launched as a big bang. A switch was flicked, and the entire system was live for everyone. Every doctor, every nurse. No going back. There were two reasons given for doing this. One, it got all the pain out the way in one go. Two, the hospital was an indivisible unit, making it hard to implement EPIC in a more agile, iterative way.
Personally, I don’t think these arguments hold up. But they’re important because they reveal much about NHS culture. They reveal that change without pain is seen as an unimaginable dream, based on decades of agonising reorganisations and initiatives. And they also reveal an organisational mindset that is rooted in 1948. We don’t want to think of clinicians or patients as service users, like Amazon or Uber would. And we don’t want to think about healthcare in different components, different team shapes.
Addenbrooke’s second struggle was that EPIC is proprietary software. EPIC owns the code. The hospital has a degree of flexibility; it can set its own care pathways and the like. But if it wants to make substantive changes to the code base, it has to submit a request to EPIC and hope that other hospitals using the system vote for it.
If I ran an NHS hospital, I would be terrified — lie awake at night terrified — that the core working layer of my business is out of my hands. That I put my ability to change strategic direction and meet clinical and patient needs in the hands of a Eurovision Song Contest style voting system.
(Postscript: After publishing this post, it was pointed out by well-placed people that it’s worth clarifying that an estimated 1% of the changes requested by Addenbrooke’s could not be made quickly because the hospital would need the system provider to carry them out as part of a major software upgrade. Even that number would worry me, but that’s obviously a point of interpretation.)
Addenbrooke’s is not unusual. There’s nothing to suggest these issues won’t arise elsewhere.
One last thing. In the UK, decision makers have a instinctive bias towards splitting apart the what and the how; the policy and the delivery. It’s how things have always been done. Policy makers will come up with a smart idea — electronic health records, say — and then throw it over the wall for others to figure out how to make it work, without having engaged them with the idea in the first place. You’ll probably see the effects of this a lot in your review. It drives clinicians crazy. We should stop it.
Iterative development based on what users need. Pushing for commoditised, open source software. Breaking the division between policy and delivery. The sort of thing the excellent NHS.UK team is fighting to do.
These suggestions won’t win friends or headlines. But the NHS has enough of those. Now it needs some answers.
Best of luck.
(I’ve amended the figure originally cited as the cost of the EPIC system — it is £40m taken from a wider programme totalling £200m — this wasn’t clear. I’m very grateful to those who pointed out the error.)
