So we need to spend billions on the F35 fighter because...?

The news from the BBC is that 'Defence' minister Phil Hammond has just jetted off to Texas to see one of the new F35 fighter planes we've ordered be taken for a test drive.  At 100M each, they're certainly not cheap, although as always, it's not clear what is included in this cost.  Does it, for example, just cover the initial purchase of the aircraft, or are there additional costs rolled in, like the training of test pilots and maintenance personnel and support for their introduction into operational use.

For a bit of context, the RAF's Tornado aircraft cost around 15-17M each when introduced almost exactly thirty years ago.

Most interesting though were Hammond's words paraphrased by the BBC's Jonathan Beale: 'He said it would give the RAF and Royal Navy "a world class fighting capability" with the ability to "project power" off the two new aircraft carriers now under construction, anywhere in the world.'

In doing this, Mr Hammond is articulating our de facto defence doctrine, which, like the US is based on a degree of global power projection.  Obviously, this isn't in the same league as the US with it's numerous carrier battle groups, thousands of combat aircraft and asprirations to 'full spectrum dominance', but it is effectively a US-lite policy, albeit very, very lite in comparison.

All this raised some questions in my mind because, to my knowledge, defence policy hardly ever gets any real discussion in the media and certainly very little public debate, apart from the pros and cons of being in the nuclear club.  Although that's important for all sorts of reason, it is but one specific issue in what should be a wider debate about how our defence needs are met.

Perhaps more importantly, there is a debate to be had about where our actual defence needs start and finish and where the needs of our political masters to enhance their own importance and give themselves international political leverage start and finish, and whether the costs of maintaining the latter can be justified.  And I mean justified at all in a modern, post colonial world, and not only justified in the current financial climate - although does exert additional pressure.

Now I'm no defence expert, but my view as a citizen is that our defence needs should be based on a systematic assessment of the following:

1. Any known threats we face and any future threats we have evidence for;
2. The defence needs for mainland UK and overseas territorial posessions we have a duty to provide for the defence of
3. The economic benefits to UK Plc of defence spending in terms of supporting employment, hi-tec industry and maintaining strategic industrial capacity

Now I'd be very surprised if a genuine review of that came out in favour of buying into the next generation of US nuclear weapons systems, but it might just about support the purchase of F35s. Although it might equally support the development of less elaborate, indiginously produced military technology. 

But if nothing else, we ought to have some debate about whether, decades after the end of the British Empire, we really want or need to spend vast amounts of money on global power projection to prop up ministerial egos.

Ever decreasing circles

In its infinite wisdom, the DH has published what it calls an 'infographic' which purports to depict the new structure of the NHS. It's available at https://www.wp.dh.gov.uk/healthandcare/files/2012/06/system-graphic.pdf.

For some reason, policy people love this sort of thing because they think it encapsulates the important high-level concepts at work in the re-disorganisation of the NHS.  It's also loaded with some fairly obvious symbolism: patients are placed right in the middle of seven concentric circles (ie patients are 'at the heart' of the reforms), whilst the DH and Lansley form a crust on the outside, perhaps holding everything together (I migth be reading too much into that).

But what does it really show? In practice, it illustrates the vast array of disjointed organisations - and entire solar system of quangos and layers of management than now surround patients and the 'real NHS' (ie the bit that the public actually use) and form an enormous buffer between the public and the secretary of state.

And whe all know what that huge layer of flab is really there for don't we?  Yes, to insulate Mr Lansley's ears from the sound
of falling bedpans.

What's wrong with a relatiionships and accountabilities model

A document hit my inbox recently that has emerged from the informatics transition programme and has the rather wordy title of the Accountabilities and Relationships Model.  Essentially, it’s an attempt to codify the relationships between different elements of the healthcare system (Department of Health, NHS Commissioning Board, Clinical Commissioning Groups, public health etc) and their responsibilities and accountabilities for informatics activity.

I dread to think how long it took to create this, how many hours of meetings and conversations, how many hours of head scratching, writing, revising and reviewing that went into the creation of the final document, because in essence it’s bollocks.

I’m not saying that it’s completely without value, because it does contain some useful information about what some of the organisations are expected to be responsible for and how they should related to each other.  The problem is that any value is drowned in a vast tide of detail and complexity.  It’s not just unhelpful in that it obscures some of the higher level information that people need to understand, but because there is no way at this stage in the development of the organisations that the detail is likely to be accurate.

Unfortunately, this kind of problem is quite common in government where very intelligent people (sometimes but not always management consultants) are given a task to try to clarify and explain something that is quite complex and obscure.  The frequent response is for those leading the work to try to model the detail very accurately, attempting to capture everything that is known about the problem and build it into some kind of coherent whole. 

This can be disastrous for those needing to understand what’s going on and for those trying to communicate this, because what emerges is something frighteningly complicated and difficult to understand.  In this case, my will to live started to evaporate before I’d got through the definition of terms and the initial paragraphs claiming that this was a ‘plain English language’ explanation of the relationships and accountabilities.

Paa and phoey.  It’s nothing of the sort.  In many cases these pieces of work are carried out by very intelligent people, so people for whom complexity is no barrier to comprehension.  Indeed, it might even be something that is appreciated, because these are people that enjoy getting their head around complex problems and ideas.  They are also likely to be the sort of people that have succeeded both academically and in work by demonstrating just how much complexity they can handle.

So we’re left with something that purports to illuminate us to the relationships and accountabilities that underpin the informatics functions in the new NHS but which has all of the simplicity and elegance of the average PhD thesis.  So the problem is, who is actually going to read it?  Who is it going to help and why did anybody spend a whole lot of time and energy in putting together something so patently useless?

Answers on a postcard please.

Accepting criticism gracefully

I've recently come across the writings of the self-styled 'Patient From Hell', the journalist Richard Sarson, or Dick Vinegar as he prefers to call himself on Guardian Healthcare Network.  I'm certainly not going to slag him off here, because he does raise some very important issues with the NHS from the perspective of an older patient, even if I don't agree with many of his solutions to the problems he identifies.

Unfortunately, criticism is one of the issues most of us that work in the NHS struggle with.  I've always thought that the NHS is a bit like our dear old mum in this regard.  Those of us inside the service are allowed to criticise all we like because we do it from the point of view of knowledge, affection and respect.  People outside the service are not coming from that position, so our response is to be defensive instead.

The problem is that there is some legitimacy to insider views on this, after all, those of us working in the NHS day in, day out do know the system better than anyone else and quite often have a clearer idea of its shortcomings.  Generally, patients have a very limited perspective which it's difficult to generalise from, and as anyone familiar with evidence-based medicine will tell you, anecdotes do not constitute good 'evidence'.

But that still does not render the perspective of the individual patient irrelevant - far from it.  If nothing else, these views should be seen as the symptoms that they are - something that we must listen to and understand in order to diagnose the problems in the service that they spring from.

So online platforms like Patient Opinion or NHS choices would be very valuable if they could aggregate patient feedback into something greater than individual anecdotes, and these could be used by the service in a systematic way to address some of the problems with the service.

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.