National Health Service

National Programme for Information Technology


NHS KlugeEarly in our days with Unilever we were well trained by the most affable maverick known to man, W R F Vale, respectfully know as 'Bill'.

As the management team of cloned bureaucrats, the 'men with the plans', a cast of thousands plagued with analysis paralysis, were urged to 'get a grip' and deliver 'polished presentations' ... Bill Vale came from overseas, got a hammer and smashed the obsolete technology & bureaucratic kluge at the Port Sunlight factory to make space for new productivity ... the ancient practices were endless ... coal fires in the 'balcony offices', graded eating separated from top to bottom, Vim canister making, water cooled Bowsprit, framed wire cut Hard Soap, Sail Makers, Engravers, Boiler Makers & Heavy Gangs ... proliferating 'Miscellaneous Products' ... the list went on & on, a bottomless pit of expense ... force majeure, they said?! 

Although we didn't know it at the time, but because we had seen Bill's action at the coal face, we were well prepared for life under the soap pans in Apapa  ... and we had also read about the abject failure of grandiose Unilever schemes The Groundnut Affair.

Later as we crawled out of the Apapa quagmire we were fortunate to drink wine with Pancho Jimenez, Technical Director, Chile who waxed lyrical and went into print with his 'second opinion' about the desperate destructive violence & hatred associated with Allende and the 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 computer schemes ... and Vernon concurred and mused ... 'think bottom up modules, it's simple, a pump is either on/off/or knackered' ! 

In 2004 we mulled over with Ed, a hands on Medical Physicist, with a cunning capacity to poke fun & spin laughter about NHS incompetence ... if you didn't laugh you'd cry ... and there was real work to be done at the coalface!

Top Down ProjectsNHS - National Programme for Information Technology   

The National Health Service National Programme for Information Technology, even the name was a fiasco.

£12bn worth of electronic patient records which wasted taxpayer’s money by imposing a top-down grandiose scheme rather than an innovative modular systems driven by local decision-making. Seven years of purgatory, a massively ambitious project drafted & costed by macho men but poorly understood; late, over budget, cumbersome, far too complex to explain, justify and implement.

Evolutionary change demands diversity ... and it was the only game in town.

Top-down projects fail ... there were more ways if being dead than alive.

One size never fits all as innovations always start from the sparks of the folk at the coal face who own the problems.

1. Commercial Appraisal of Profitable Projects  

Top down projects destroy the fundamental building blocks of the decentralised complex adaptive system ... the independent 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.

Of course objectives can be laudable even if motivation is questioned. But laudability and deliverability were different beasts.

Unilever Capital Proposals were 'post hoc ergo propter hoc' fallacies they required -

 Present Situation

 Proposed Solution

 Existing Experience

 Alternatives Considered

 Buying or Renting

 Environmental Impact

 Maintenance of Supply

 Asset Disposals

 Support Services

 Cost Estimates

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

So called 'IT Projects' should not be about whizz technology looking for a problem to solve but rather about delivering an information flow that were required for 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 easily confused 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 & GP fund holders, 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 are needed to 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 ... all aggressive approaches 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.
Local innovative autonomy first Economies of scale follows.

6. Accountability   

Learning from failure is confusing the 'function' of bankruptcy and the 'fatal conceit' of bureaucratic alternatives.
Losing face, not invented here, 'sunk cost' bias and the 'confirmation bias' are all pertinent.

Progress will follow from the localisation of NHS IT systems as local decision making at the coalface 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 involve significant risks. The NHS does not have the necessary commercial skills to grow synergies with private sector customers.

Our son-in-law watched first hand the chaos unfold ... 

The start was the nationalisation of clinical care in 1945. Health care became a 'right', an 'entitlement', replacing insurance & compassionate charities ... health care seemed to have little to do with technology and know how in R&D pharma and medical physics commerce. Victory in war had presented a hubristic opportunity to design the peace. Florence Nightingale would have been pleased with the ambitious intentions.

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.

Immediately National Insurance and 'insurance' principles were supplanted by general taxation.

The reality was that health care progress and improvement followed the discovery of new know how and technology ... penicillin in 1928 and the blossoming of the pharmaceutical industry and the progress of surgical & medical physics technology.

By 1990 costs & waste were cataclysmic. Independent Heath Trusts and GP Fund Holding attempted to localise & commercialise an 'Internal Market' in the NHS and hopes for cost accounting and income generation ... but commercial discipline was anathema for the political circus.

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

Meanwhile the funding of R&D pharma & medical physics was lost in a quagmire ... Florence Nightingale would have been distraught ... 


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