NHSmail barometer

According to the government, the 'transition' of the NHS from its old, inefficient, un-modernised state, to its new svelt, efficient, modernised state was accomplished on 1 April this year.  At least all of the key tasks of 'lifting and shifting' staff from closing organisations to opening organisations had been done and major change to IT systems had taken place.

I should know, I've read the closure report of the Informatics Transition Programme without falling asleep.

But what's this that a colleague has posted to my email account today?  It appears to be a catalogue of failure for local organisations to properly reconfigure NHSmail to reflect the new organisational structure.

The main points are:

• On 30 June, about 116,000 NHSmail accounts had not been transferred to new organisations (a third of those affected)
• 21,000 generic mailboxes had not been moved
• 76 closed organisations (i.e. those abolished on 31 March) were still creating new NHSmail accounts
• Local administrators had not been assigned to cover pharmacies, opticians and dentists in 7 out of 25 areas

Now there is a limit to the conclusions you can draw from this kind of information, but it does seem that, behind the scenes, it's taking very much longer than anticipated to set up the new, supposedly improved NHS.

The document was provided as background with a request to NHS England to provide assistance and pressure on local organisations to get their act together.  Precious hope there, given that NHS England is still struggling to set itself up, appoint people to key posts and develop its operating arrangements.

It's going to take 3-5 years for this round of changes to shake out and bed in.  And that's only if Andy Burnham doesn't set the whole sorry mess in motion again in 2015.

Plastic politics, plastic politicians

Yesterday I was rather piqued by an article by the BBC journalist Brian Wheeler on NHS privatisation.  The concept of the article was good in that it tried to ask a question too often mired in thoughtless and polarised debate.  Unfortunately it was compromised by only having one view from either side of the argument and very little analysis.

What really stood out though was that both individuals interviewed are part of what is becoming recognisable as a wider political class - a group that is largely white, largely male, largely privately and Oxbridge educated, largely metropolitan and largely unconnected with mainstream England.  Certainly those parts that lie outside the M25.

Part of the disillusionment with current politics is rooted in the sense that 'all politicians are the same' because in so ways they are.  Cameron and Milliband are both forty-something white men with little experience outside of the greater Westminster political  establishment.  Which includes a growing range of think tanks in addition to the party research departments that act as the sole incubators of supposed political talent.

Brian Wheeler's two interviewees are the next generation of this in the making.  Thomas Cawston, BA in history and politics from Exeter, MA in south Asian history from Oxford followed by 'research' (I use the term loosely) at Reform.  Oliver Huitson, more unusually with an OU degree (PPE) and postgrad from Birkbeck (politics and government) followed by some work experience in telesales, communications financial services, topped off with writing for OpenDemocracy and editing a pro-nationalised NHS website funded by the Wainwright Trust. All with a thoroughly metropolitan flavour.

Now I've never been one to dismiss academic study and think tank 'research' as 'fancy book learning' that has no value beside a degree from the University of Life.  But it is noticeable that the colonisation of the political classes by people with such narrow range of backgrounds and experience is having a profound effect on political discourse and debate.

The positions taken in Wheeler's debate is a good example. The pitch on both sides tend to be technocratic, theoretical and idealised.  Unleavened with any sense of real-world messiness and compromise.

Cawston's citing of examples from Europe of more mixed healthcare economies ignores the historical and cultural context of the NHS.  His assertion that competition can drive real improvement in care is not supported by hard evidence.  The example he cites is still in progress and whether it really delivers better care will only become clear some time in the future.

This kind of stuff is fine for scoring points in university political society debates, but this is the real world and real people we're talking about now.  The evidence we have from the compulsory competitive tendering of hospital cleaning services back in the late 80s points in the other direction: quality plummeted and ultimately this lead to MRSA and ridiculous spectacle of Gordon Brown ordering the 'deep clean' of hospitals. 

Two decades on from the purchaser provider split and we are still trying to get the results we want from market-based systems, whilst he overhead costs of maintaining that market in terms of contracting, legal bills and regulation proliferate.

It doesn't help that the person trying to make this argument looks about twelve (he's actually about 27).

Huitson makes a better fist of putting together a convincing argument (although I'll confess it fits with my own view), but it still has that desiccated feel of a final year essay rather than a real life issue affecting real people.  Ultimately, both arguments leave a lingering feeling of inauthenticity.

The net affect is to reinforce the perception that politicians are all dishonest and make politics feel remote and un-engaging to the majority of people.  This is the real reason that people feel no connection with national politics and the people that supposedly represent them in parliament.  If political parties really want to forge a better connections with the population at large, they should start by recruiting from a much wider pool of talent both socially and geographically and try to reintroduce some authenticity into the body politic.

Rebranding CFH: if not now, when?

The NHS is going through another seismic reorganisation and the future of the IT agency, NHS Connecting for Health (CFH), is under question.  Nobody seems to know where it will fit in the ‘future state’ or even whether it has any kind of role at all.  Setting aside the half-arsed way that the government has gone about this reorganisation and the woolly-minded thinking that underpins it (I know, that’s setting a lot aside), a question has arisen about the re-branding of the organisation in order to ditch what is perceived to have become a discredited brand.

This is not new.  Part of the legacy of Christine Connelly’s time as Department of Health CIO is that of brand confusion.  CC was keen to incorporate NHS CFH into what she termed the DH Informatics Directorate, but found that she couldn’t because the lion’s share of the organisation’s staff are NHS employees.  Although CFH is an ‘executive agency’ of the DH, in practice it operates as an NHS body and not as part of DH.  So when it came down to it, the Technology Office happily rebranded itself as DHID, but the rest of the organisation remained as CFH in the absence of a clear steer from above.

A large part of wanting to subsume CFH into DHID was connected to the perception that the CFH brand had become contaminated, and on this score, there is considerable ‘form’.  Historically, the Information Management Group (IMG) brand had been ditched for similar reasons and the NHS Information Authority (NHSIA) set up to replace some of its functions.  The bolt-gun was applied to the metaphorical head of the IA for similar reasons as what was then NPfIT (National Programme for IT) came into being.  Even CFH was cooked up in part because the NPfIT brand was starting to look rather tatty after only a couple of years in existence.

Now I want to make it very clear, I hate the name NHS Connecting for Health.  Part of that hatred stems from the supposed origin of the name in a competition run at the time which supposedly evaluated a number of options.  I don’t believe there was ever a real competition, and this was just a smoke-screen to make CFH employees feel they were all contributing to naming the new baby.  I think the name was actually concocted at the highest levels with the very political intention of 1) avoiding any overt reference to information or IT lest it turn off NHS managers and clinicians; 2) get over the idea that we’re working to connect the NHS and what a jolly good idea that is.  Frankly this is patronising tosh and anybody with half a brain in the wider service will see it for what it is, and very soon make the connection that CFH is about IT.
On top of that, it’s very true that the brand has become contaminated and that CFH has a very poor reputation across the NHS and with the national media – both specialist and generalist.

So why wouldn’t a rebranding help?  Well for a start, the organisation does not have any kind of plan to address its manifold shortcomings, although the even bigger challenge is to carve out a viable niche for itself in the new NHS.  So no idea what its role and purpose is, and no plan to tackle its shortcomings, which means no chance that this particular leopard will be changing its spots any time soon.  That being the case, a rebranding right now would only serve to generate more cynicism in the service about the IT agency and lead to another contaminated brand that will need ditching in a year or two’s time.  To bastardise Shakespeare: ‘a turd by any other name…’.

So what to do?  I think the example to follow has to be Skoda.  Not that long ago, this was a contaminated brand too – a national joke in this country and elsewhere, despite the firm’s enviable record in rallying and proud history of innovation and engineering skills from way back.  So would it have helped to rename the company Adoks back in 1988, or would comedians have just tweaked the punch line to their crap car jokes?  Probably the latter.

So instead, they set about changing the company: becoming part of the VW Group and rebuilding it around a couple of basic but well engineered products- the Fabia and Octavia – using VW technical platforms.  It’s taken a long time, but twenty years later, nobody is telling Skoda jokes anymore unless they want to look out of date.  And there are plenty of their cars on British and other European roads.  Czech-mate I’d say.
So CFH should follow their lead – concentrating on a focused set of reliable products and services which it can use to build a new image based on a track record of successful delivery.  Then in five years time, when perceptions of the organisation have been changed by actions rather than words, that is the time to consider changing the brand.

Informatics - not so very NICE

In the HSJ a couple of weeks ago, Alistair McLellan wrote a very good article in praise of the leadership of NICE, rightly attributing a large slice of that organisation's success to the combined efforts of Andrew Dillon and Michael Rawlins.

The article got me thinking because many of the issues that McLellan raised as contributing to their successful tenure at the head of NICE are exactly those that have been absent from leadership in informatics.  You could say the comparison is unfair because NICE was established on a very different footing to either the NHSIA or NHS CFH, but I tend to agree with McLellan that there are things we can learn from their approach.

Firstly, there has been continuity of leadership with both Dillon and Rawlins being in post for more than a decade. Not only that, but they appear to have a cast iron working relationship.  We have had three informatics leaders in less than ten years, but each has adopted a different job title and sought a different working relationship with the DH and NHS.  In all cases there has been a dislocation between informatics leadership (firmly on the DH side) and the delivery agency (less firmly, but in practice on the NHS side).  This is still the case with Katie Davis, now the MD for Informatics.

Secondly, there has been little clarity of purpose, with even the initial four pillars of NPfIT being augmented with additional responsibilities and deliverables. As long as I've been involved there have been problems with basic portfolio management, with senior leadership failing to exert much authority over the organisation's business.  The almost constant rounds of questionnaires and forms that programmes have been asked to complete documenting basic details like deliverables and costs seem to indicate not only a senior leadership with no handle on current activity, but also one with no organisational memory.

We have been through a couple of attempts to assert some basic ground rules with the DH, based on the (in my view) flawed assumption that the DH represents the 'head office' of the NHS and therefore the top of the business.  It has also been assumed (again incorrectly) that DH officials understand that they need to formally commission the Informatics Directorate to deliver work and to back this up with business cases and funding streams.

I believe that a lot of the woolliness around the fundamental relationships with both the DH and NHS arise from the lack of direct NHS knowledge in the senior leadership team. It's no surprise that at NICE both Andrew Dillon and Michael Rawlins are both long-term NHS people.  Informatics on the other hand has had the dubious benefit of 'expertise' from the private sector where the relationship between corporate head office and wider organisation is far more straightforward.

One of the keys to NICE's success and acceptance has been that its guidance is not mandatory, thus avoiding direct conflict with NHS organisation's own decision making processes and autonomy.  Contrast that with the heavy-handed and ill informed imposition of IT systems on an NHS with widely varying levels of enthusiasm and commitment. 

Finally, there is something to be said for the personal style of the individuals involved.  Neither Dillon or Rawlins at NICE are bigger than the organisation itself.  They never became the story.  Yet both are highly competent media performers striking a calm, measured and precise note in interviews.  Again, constrast this with Richard Granger's pugilistic style and infantile management speak, or even Christine Connelly's tortured Scottish accent and excessive control freakery.  Katie Davis apprears upbeat, but it remains to be seen whether she can project a more clear-headed and rational voice than her predesessors.

So the bottom line is, yes, informatics could learn a hell of a lot from an organisation like NICE.  Unfortunately, there's no indication that those in authority in the DH have recognised this.

Primacy of the patient - not the right approach

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.

The smartest man in the room is not always right

There has been a minor debate on the internal NHS CFH bulleting board about the role of choice and competition in the NHS.  Specifically, the discussion has centred on what the evidence is to support the government's oft-repeated notion that it will drive up quality. 

The reality is that such evidence is pretty thin on the ground.  The theoretical underpinnings to the potential role of choice and competition in the NHS come largely from the work of Julian Le Grand, professor of social policy at LSE and one-time senior adivsor to Tony Blair.  In spite of the lack of hard evidence, competition and choice have become articles of faith for the current administration.  In particular, they are drawn to nudge theory as a means of manipulationg choice to bring about better outcomes.

However, the reality is that re-engineering the entire NHS in order to promote choice and competition between 'any qualified provider' is a massive experiment, based on a largely untested theory and driven forward by an ideologic faith in market mechanisms as the best way of distributing all goods and services.
The problem as I see it, is that even where the introduction of competition and choice are thought to have delivered benefits for 'consumers' the results are pretty equivocal.  Also, the introduction of market mechanisms into complex sectors and natural monopolies tends to lead to both a plethora of unintended consequences and a consequent creation of a large and complex regulatory mechanism to try to manage those consequences.

To take some examples.  The privatisation of public utilities in the UK was undertaken in the 1980s on the basis that it would lead to more efficient services and keep prices down for consumers.  The reality is that, although it can be argued that prices have been kept down, the net result is also included the rise of 'confusion marketing' and complex tariff structures to inhibit the workings of the market.  And that's in spite of the significant amount of interia in the system(s) which have seen only a small proportion of consumers switching suppliers.

On top of this, there have been significant strategic problems.  Firstly, the privatisation of energy supply helped to create the 'dash for gas' and has made the UK dependent on Russia for its energy.  Secondly, the privatised power companies have prioritised profits over investment with the net result that the energy infrastructure of the UK has been run down and is now likely to require government intervention and public investment to ensure it is fit for purpose for the future.

It might be argued that in the case of the railways, the problem was that privatisation was the goal, rather than the creation of mechanisms to promote choice and competition to drive benefits for the paying customer.  But there is a real lesson in there about seeking to introduce market based reform into something that is a complex, multi-facetted organisation where quality and safety depend on collaboration rather than competition.

So in sum, the omens for further market based reforms to the NHS are not good.  Like many people, I believe that the market based reorganisation of the NHS will at the very least lead to a host of unintended consequences that will probably have a detrimental effect on the quality of patient care and the integration of different parts of the service.

In spite of the academic credentials of Professor Le Grand and the authors of Nudge, I remain to be convinced by hard evidence.  To quote US politician Richard Holbrooke: 'The smartest man in the room is not always right.'

On opposing the current NHS reorganisation

In this week's HSJ, former Labour advisor and all-round competition evangelist Paul Corrigan hits out at opponents of the government's market-based reforms to the NHS accusing them of defending their own vested interests.  It might be just me, but I think I detect a hint of tetchiness about his comments and the potential for the modifications to the Health and Social Care Bill driven by the NHS Future Forum to undermine the holy grail of competition.  To true believers in the 'Gospel according to St Julian (LeGrand)' like Paul, this is heresy.

Unfortunately, looking at other examples of privatisation and market-based reforms over the last 30 years, there's ample evidence for scepticism about the supposed benefits, and some clear alarm bells about the potential negative consequences of these reforms.  To get a full appreciation of the issues here, you need to consider the two parallel processes that have operated in many of the privatisations that the UK government has undertaken.  On the one hand, you have the transfer of ownership of publically run companies, either through stock market floatation or contract letting processes.  Secondly, there is the creation of complex artificial markets and regulatory frameworks within which these newly privatised firms operate.

The NHS reforms tick both of these boxes to a greater or lesser extent.  Certainly there has been an increasing willingness to contract out more and more NHS services so they are 'delivered' by the private sector under NHS branding.  The coalition government's interest in encouraging NHS organisations to become mutuals, is and arguably more palatable version of the same thing. 

But even before this, the last Labour government were heading down the road of creating an artificial market in which individual NHS organisations competed for business, the idea being that this would tap the supposed benefits of competition and markets (driving down costs, stimulating innovation, driving difficult decisions by reduction to a financial bottom line), with regulation offering protection against the negative elements.

The problem for me is that government has a poor track record in devising these artificial markets, particularly in more complex industries where the twin pitfalls of perverse incentives and unintended consequences beckon.  You only have to look at the debacle of rail privatisation in detail to see the
potential for disaster.  On top of that, government's track record on managing the healthcare sector generally is pretty poor. Part of the attraction of marketisation is the frustration felt by governments in trying to exercise control over a large, complex and unweildy beast like the NHS.  The discipline of the market is a seductive model with its promise to automate some of the messy business of managing the beast whilst also insulating politicians from the consequences of change.

However, in attempting to redesign the systems they need to be mindful of Marios Papadopoulos' analysis of surgical patients using chaos and complexity theory, which if nothing else helps to illustrate the difficulty in predicting the outcomes of specific inputs.  Papadopoulos' characterisation of the NHS as a 'complex system on the edge of chaos' rings so true to many of us with a reasonable amount of NHS experience.

So my response to Paul is that far from being concerned with defending our cosy little fiefdoms, those of us speaking out against the reforms are doing so from the following viewpoint:

1. We are not convinced that the reorganisation of the service will deliver the promised benefits
2. We believe the reorganisation will waste time, money, goodwill and undermine patient care
3. We believe the reorganisation of the service will have significant negative unintended consequence
4. These unintended consequences are likely to include increased (if better hidden) management costs and bureacracy and an undermining of integration and cooperation
5. We believe that the reorganisation will lead to reduced terms and conditions for staff and the fragmentation of the NHS as an employing organisation and
6. that this will have a detrimental effect on service delivery in the longer term.
7. We are not convinced that the reorganisation will allow ministers to distance themselves from their responsibilities for the NHS
8. We believe the reorganisation will lead to an increase in costs and an overall decline in value for money for the public as an more money is siphoned out of the system for private profit

Track record

David Cameron has just announced that the government will revise their plans for shaking up the NHS: a little tweak here, and little tweak there. Unfortunately Mr Cameron's party has form in this area.  JacquesO's livre du jour is Christian Wolmar's book on rail privatisation and although there are huge differences, there are things that chime with the current debate in healthcare (I know I'm not the first to make this comparison).

The first issue is the unquestioned assumption that competition of any sort is an unalloyed good and any opportunity to introduce it should be taken.  This overrides any rational or systematic assessment of whether competition actually makes sense in the context in which it is introduced.

The second is the presumption on the part of ministers and civil servants that they can contrive a highly regulated, pseudo market in a complex domain of which they have little real knowledge that actually works, and delivers the stated benefits without too many disbenefits or perverse incentives. Certainly the rail comparison indicates that the challenges of such a task is beyond even civil service high flyers.

The third is the unseemly haste with which poorly thought through policy ideas have been developed and converted into similarly poorly drafted legislation, the controversial nature of which results in much chopping and changing for the sake of political expediency.

The fourth is the impression (correct in the case of railways) that the government is making things up as it goes along.

Given this context it's hard to have any confidence in Mr Cameron's statements on the NHS, however well intentioned.  As for the actual results on the ground of Mr Lansley's botched reorganisation, it's anyone's guess.