There has been something of a spirited discussion on the internal NHS CFH bulletin board on who should be considered to be the 'customer' as far as any national shared informatics function is concerned. This takes me back to the demise of the old NHS Information Authority in 2002-ish when I started writing an article that explored this very issue.
My point at the time was that the IA had in effect determined that 'the patient' was the ultimate customer and the needs of the patient ought to drive all decisions – although I'm not sure how explicit the process was that lead to this conclusion.
There is obviously some logic to this – the patient after all is the ultimate user of NHS services and since all tax payers are entitled to use NHS services free of charge, there is a very strong overlap between tax payers and patients. It's a fairly easy step from this proposition to saying that the ministers in the Department of Health, and DH officials more widely in effect have a popular mandate to articulate what 'the patient' and 'the tax payer' want.
Both the IA and the philosophy underpinning the National Programme for IT / NHS Connecting for Health were largely based on this fundamental principle. The problem is that in both cases, this does non seem to have worked terribly well in practice, and the reasons for this need some consideration.
The key problem as I see it is that the concept of 'primacy of the patient' is used by the centre as a pretext for foisting things on NHS organisations that they don't want or feel they don't need. Effectively, it's just a mechanism that ministers and DH use to give legitimacy to any kind of heavy handed, top-down scheme that they think the NHS ought to have.
More charitably and more importantly,it has also been used to try to impose change that makes sense at a larger geographical scale than the individual NHS organisation, but that has little benefit within those organisations. In effect, you're asking NHS organisations to implement some new system that does not actually benefit them, because it works better for the overall system, whilst simultaneously telling them to become semi-independent organisations with more autonomy. The two things just don't stack up.
So, in practice, not only has this irritated local NHS staff (both clinical and non-clinical) who have not felt sufficiently consulted in the decision making processes, it has also provided local NHS leaders with a stick to beat ministers and DH with by allowing them to use non-cooperation and foot dragging on national schemes as a potent weapon.
So what changes are required in order to avoid repeating the mistakes of the past? Well the prescription is broadly the same as it was ten years ago. Any central IT function should be seen for what it is: a producer service; an entity that largely exists to satisfy the needs of NHS organisations as its customers. It's primary purpose is to provide products and services that help those organisations to do their job. If it can't do that, then it has no business being in business.
More problematic, is the other dimension: the central IT function must also be able to satisfy the legitimate needs of the centre for change that benefits the system as a whole and for functionality that it needs to do its job in terms of management and oversight.
Perhaps the most important challenge for the new information strategy being developed through this Autumn will be resolving these two potentially conflicting needs – and that does it in a way that resolves opposing pressure whilst delivering a coherent programme of evolutionary development for NHS IT.
Quite a tall order, but the key decision is abandoning this concept of the primacy of the patient.
