National Health Service

National Programme for Information Technology


Early in our days with Unilever we were well trained by Bill Vale and, although we didn't know it at the time, we were well prepared for life under the soap pans in Apapa because we had read about the abject failure of grandiose schemes like The Groundnut Affair. And later as we crawled out of the Apapa quagmire we were fortunate in drinking with Pancho Jimenez and getting a second opinion on the desperate destructive violence associated with Allende and macho impositions from above embodied in The Cybersyn Project.

No wonder when we met Vernon Hockey at Warrington in 1984 we bought him a beer and talked about the gross stoopidity of top down grandiose schemes ...  

Top Down ProjectsNHS - National Programme for Information Technology   

Seven years of purgatory, a massively ambitious project drafted & costed by macho men but poorly understood; late, over budget, cumbersome, too complex to explain, justify and implement.

1. Commercial Appraisal of Profitable Projects  

Top-down projects fail. One size never fits all as innovations must start from the folk at the coal face who own the problems.
Top down projects destroy the fundamental building blocks of the decentralised system; NHS trusts & GP fund holders which build patient choice and local autonomy.
The 'motivation' for top-down projects tended to be 'political' not 'commercial' -

 public sector Political projects wasted tax payers money

 private sector vanity projects wasted resources earned elsewhere.

Objectives can be laudable even if motivation is questioned. But laudability and deliverability are different beasts.

A Capital Proposal required -

 Present Situation

 Proposed Solution

 Existing Experience

 Buying or Renting

 Alternatives Considered

 Environmental Impact

 Maintenance of Supply

 Asset Disposals

 Support Services

 Cost Estimates

2. Mutual Benefits for Buyers & Sellers; Providers & Patients

So called 'IT Projects' were not about technology looking for a problem to solve but about delivering an information flow that resulted in business benefits where value exceeded cost.

Failures resulted from misunderstanding the characteristics of Complex Adaptive Systems (CAS) where intended value and estimated costs are ephemeral and involve the foibles of folk.
CAS projects involve interactions with all stakeholders, starting with patients at the coal face.
From the start coalface doctors & patients were concerned about accessibility and reliability of garbage input and what exactly what was going to be delivered in the end.
Add to that the entrenched interests of the powerful clinicians, independent NHS trusts & PCUs all concerned about loss of control over their own existing systems which needed improving but not abandoning.
Many fiefdoms were inherently suspicious or downright hostile.

3. Without market prices bureaucratic deals are contentious   

Without due diligence & caveat emptor, speed & efficiency of procurement & contracting are compromised.
Trouble follows when specifications are changed and cost inflate.
Track records of prior successful buyer/seller deals can support contract specification & costs done on the hoof.

4. Blind contracting without trusted partners     

Drastic timescales, take-it-or-leave-it, aggressive legal remedies against service providers. Aggressive approachs to supplier management by macho managers are counter-productive and neglect the golden rule of long-term relationships generating trust.
A bankrupt supplier doesn't help production.

5. Competitive Multi-sourcing  

Trade off between management of healthy competition and putting all eggs in one basket.
Economies of scale v. local innovative autonomy.

6. Accountability   

Learning from failure. The 'function' of bankruptcy and the 'fatal conceit' of bureaucratic alternatives.
Losing face. Not invented here. The 'sunk cost' bias and the 'confirmation bias'.

Progress will follow from the localisation of NHS IT systems as local decision making will embrace innovative improvements, which can be copied elsewhere allowing Trusts to procure IT systems which meet their needs.
The opportunity for grass roots innovations also involve significant risks. The NHS does not have the necessary commercial skills to grow synergies with private sector customers.


(ETW watched this chaos unfold.

The start was Nye Bevan's nationalisation of clinical care in 1945. Health became a 'right' not a compassionate charity. Victory in war presented a hubristic opportunity to design the peace. Florence Nightingale would have been pleased with the grandiose scheme. The funding of the NHS moved from local charities & endowments and the Beveridge proposals for National Insurance to general taxation.

The old system was bought out as clinicians had their mouths stuffed with gold as they sold their successors down the river. Every dropped bed pan in Scunthorpe reverberated round the corridors of Westminster. Costs of waste & bureaucracy started their inexorable rise.

Health care improved following the discovery of penicillin in 1928 and the development of the pharmaceutical industry and progress of surgical & medical physics technology.

In 1990 costs and waste were cataclysmic. Independent Heath Trusts and GP Fund Holding localised & commercialised an 'internal market' in the NHS which attempted to introduce cost accounting and income generation.

In 2004 political pressure to 'do something' resulted in throwing money at the problem, 'Agenda for Change' put new funding straight into salaries and wages ... and grandiose projects like NHS NPfIT.

Meanwhile the funding R&D pharma was lost in a quagmire.)


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