2 August 2014 07:32


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Joe’s view: of NHS IT leadership

As Katie Davis gets ready to leave NHS Informatics, Joe McDonald reflects on previous NHS IT leaders and their legacy.
25 July 2012

I didn’t have a great deal to do with Katie Davis during the short time we coincided at the Department of Health Informatics Directorate.

Since I was “let go” during her tenure, I might be forgiven for feeling some bitterness towards a regime that is nearly over - it has been announced that Davis will leave by 1 September.

I don’t, but I see from the EHI newsfeed that some have been quick to criticise her contribution and point out that her legacy is NHS informatics hopelessly split up across three organisations.

In the future, the Department of Health is meant to do IT policy, the NHS Commissioning Board is meant to commission systems and standards, and the Health and Care Information Centre is supposed to manage and monitor them.

It’s also the case that some fundamental problems - like what will happen to CSC’s contract and so to Lorenzo in the North, Midlands and East - remain stubbornly unresolved.

Perhaps it’s not surprising that some have pointed out that “spending more time with the children” – which is what Davis is going to do – is a Whitehall euphemism for “fired” – even though there is no evidence that this has happened in Davis’ case.

To get a proper understanding of her contribution, though, I think you really need to look at those who went before.

Not my mate Marmite

When I became national clinical lead for IT our Leader was still Richard Granger. I never met the director general for NHS IT, as he was styled.

But he appeared, from my observation of NHS Connecting for Health, to have had a Marmite-like quality - people either loved him or hated him.

The organisation I joined seemed to be in a state of grieving for his loss and in mourning for the dilution of the philosophy of “ruthless standardisation” through big, national contracts for “strategic” systems.

On the other hand, there was a dawning acknowledgement that it might be a good idea if clinicians had more input - hence the hiring of people like me.

There followed, in short order, Matthew Swindells and Gordon Hextall in brief caretaker roles that didn’t give them the time or opportunity to provide a replacement for Granger’s clarity of purpose.

By the time he left - and I arrived - the programme had already fallen over. I didn’t know it at the time, but the NHS was pointing at it and laughing.

One more heave

In this atmosphere, the programme turned to Christine Connelly, who arrived from the private sector, where she had helped to turn around Cadbury Schweppes.

A fierce project management approach prevailed. Hard bitten project managers and ex-military types would be working 20 hour days and travelling the world in the belief that if we just kept pushing it would come right.

Our favourite drink was the tequila slammer, lunch was for wimps, greed was good, and a cultured evening out meant Karaoke. Fortunes were paid to contractors who could, given enough money, put a man on the moon and return him safely to earth.

The problem was that the project was fatally flawed from the outset. The development of successful electronic patient records is the outcome of ongoing relationships between end users and system suppliers.

And this was something that the contracts placed by the National Programme for IT in the NHS rendered extremely difficult. Where we succeeded, it was despite the contracting process, not because of it.

Good Lieutenant Syndrome

Leadership styles played their part in prolonging the agony, however. Examine if you will this picture of Colonel Gaddafi.

If I attempted to leave the house dressed like this, I’d like to think my wife might point out - kindly - that my outfit was perhaps a little over the top.

In the street, a crowd of small boys would inevitably gather to ask: “Oi mister, where’s the fancy dress party?” And on arriving at work there would be mirth unconfined.

However, if I have a very scary leadership style - to the point where grown men quake in fear in my presence - when I ask my lieutenants how I look they will reply in unison: “But of course Colonel, you look magnificent!”

And so it was at times within the programme. The only acceptable news to be fed up the chain of command was good news. Good news kept the show on the road and the longer we could keep the show on the road the greater our chance of success.

Messengers with bad news were routinely shot pour encourager les autres. We all had to become “good lieutenants” to survive and keep paying the mortgage. Doubly true if you were on a short term contract.

A change of government

I fully expected that the end of the programme would come quickly when Gordon Brown’s government fell at the general election.

But, in fact, we continued to drift, while investing a huge amount of effort in writing an information strategy for our masters, who hadn’t really set us a coherent exam question.

The situation in the mental health sector was becoming critical. Half the country had no electronic patient record and we were getting ready to take mental health onto Payment by Results without systems to transact our business.

What Katie did

With a sense of rising desperation, the National Mental Health Informatics Network wrote directly to Katie Davis shortly after her appointment to invite her to speak about our growing discontent. To our great surprise she agreed immediately.

She asked for a briefing paper, and when she came to the event to confront what was a potentially hostile crowd she was coolness personified.

The contractual issues meant she couldn’t really take our pain away or make any promises but she stayed longer than we’d asked and took difficult questions head on.

The atmosphere in the room changed as she spoke. Here was someone who was prepared to hear bad news, who was interested in what users felt about systems, and who was in a position to influence things. Maybe things could change.

Leadership for the future

Clearly, NHS IT isn’t all sorted out. The Power of Information strategy might be a bit woolly and CSC/Lorenzo remains unresolved.

But on that afternoon last November it looked like the madness would stop at some point, and for that I remain grateful to Katie Davis. I hope she enjoys her time with her children. I, for one, consider her a loss to NHS informatics.

What we need now is more information about who will lead in the future; and on who will take up the key jobs at the three organisations now involved with NHS IT.

Interestingly, at a time when the Power of Information suggests every NHS organisation needs a clinician with responsibility for IT, the NHS Commissioning Board still lacks a chief clinical information officer.

About the author: Joe McDonald is a practising NHS consultant psychiatrist. Over the past five years he has been an NHS trust medical director and national clinical lead for IT at NHS Connecting for Health – a stint that included 18 months as medical director of the Lorenzo delivery team!

His experiences in the National Programme for IT in the NHS have left him with a passion for usability and "end user knowledge networks.” He is the founding chairman of the National Mental Health Informatics Network. Motto: we don't get fooled again. Follow him on twitter @CompareSoftware

 

 


Related Articles:

3 News: Poor data stops mental health tariff | 25 July 2012
10 Insight: Joe’s view: of The Power of Information | 26 June 2012
4 Insight: Joe’s view: of a four year journey | 30 April 2012

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Clinical engagement then and now

Nick Tordoff 103 weeks ago

Clinical engagement is a two way process. Clinical leaders in hospitals need to start taking SOME responsibility for the failures of the past 10 years.

Ten years ago I sat at a dinner party with two friends, one a GP and one a hospital consultant. I had joined the NHS fairly recently and inevitably discussion turned to NHS IT and the newly annonced NPfIT.

"The idea is that Hospitals will have electronic clinical records." I said to the consultant. "But we will still need paper records so what is the point" he replied. I said, "The idea is that you will use the system to access the record and then record the outcomes" "Not possible" he said. "Why not?" asked the GP friend "I do". "Yes but you still have the paper notes" he pointed out. "No we don't. We are paper light". "But you don't use it in the actual consultation, do you?". "Oh yes. We only use paper for prescriptions and patient leaflets!". The look on the consultants face was of someone who had seen into a parallel universe and didn't really like what he saw.

Fortunatly the conversation moved on to more interesting topics but it left me with a clear understanding of the challange for my acute trust colleagues.

The point of this anecdote? When people start holding forth about Clinical engagement is is difficult to remember just how challanging that was 10 years ago. That is not to support the entirely cack-handed approach of CfH and the cock-eyed nature of NPfIT. But unfortunately one of the benefits of some of the appalling experiences of NPfIT is that medical and nursing colleagues have decided that they will not let that happen again and that has been one of the biggest driver of clinical engagement of recent years.

If the NHS is to survive it will have to be paper light within the next five years. If clinical leaders carry on thinking of electronic patient records as something imposed by "Management" they will have systems which management choose. If they grab the opportunity to modernise and streamline clinical practice and administration they will be in a position to lead, shape and ulitmatly control how that happens in their organisation.

<flameproof jacket on>


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As long as using a computer during a consultation enhances not distracts.

It is I, LeClerc 103 weeks ago

Though i do agree with the point being made (will acute docs ever mover away from the paper notes they love to hate). When i see my GP some tend to be looking at the PC as much as me, when this happens i do wonder if it is similar to someone driving using "satnav", and that they may be partly in some kind of autopilot mode ("computer says no, etc").


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True or not, that can be the perception.

It is I, LeClerc 102 weeks ago

But Hashim, as the customer that is what I wa wondering, is my GP on auto pilot.


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Computer distracts, paper does not!

Hashim 102 weeks ago

Has LeClerc ever been concerned when his doctor spends some time looking into paper notes? Computer distracts is a myth that needs challenging. When the technology enables the doctor/nurse to use computer without struggling with the keyboard, it need not distract any more than looking into a file of paper notes does. Then there are clinicians who are equally bad in their "bedsdie manner" with heads buried in the paper notes and no eye contact with the patient.


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No Surprise

OzLurker 103 weeks ago

In 2007 and 2008 I called for a open enquiry into NPfIT from the floor of the BMA's Conference.

Because;

1. The whole architecture of the top down project was fatally flawed from the get go. Unclear in scope or goals, lacking clinical engagement or real understanding of clinical work and it's inherent uncertainties and potential for rapid evolution and change of patient management.

2. Cerner in our NHS hospital was a basket case leaving admin staff and secretaries crying in their offices and was almost impossible to link to existing systems. It has produced no useful data in five years and may be discarded soon

3. The appalling "yes men" at C4H, some with medical degrees, who just pushed out the correct Govt. 'Health It will cure everything' messages and refused to listen to what was happening on the ground - something I experienced personally. (I could name names but Joe H might not like that)

It is no surprise that the behaviour at C4H towards whistleblowers was exactly how RBS treated it's own risk managers when they suggested there might be a little problem with mortgage based derivatives and buying ABN Hambro!

This is all now public knowledg, so I ask again where is the public enquiry concerning the biggest waste of tax-payers money in the history of the NHS? When will some of the New Labour Ministers and DoH officials and C4H managers be held to account (rhetorical question, given that the UK's Banksters aren't in jail either)


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Its No Surprise

Infoman 103 weeks ago

OzLurker - Its very unlikely that (a) there will ever be an open enquiry or (b) that anyone will ever be held to account for the failures of NPfIT.

Because just like in other cases of major Gov procurement failure (e.g. MOD) neither our politicians or members of the public are directly impacted so not incited to take action. Its the "troops" on the ground who have to bear the consequences and we'll just roll-up our sleeves and get on with the job of delivering health & care services.

Meanwhile Gov will talk about learning the lessons and the value of a retaining a corporate memory but you can guess what will happen the next time the new NHS 5 star IT general puts on his/her shinny new uniform - its ministry of truth and firing squad time all over again.


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not a lotta spine

morefedup 105 weeks ago

"Good news kept the show on the road and the longer we could keep the show on the road the greater our chance of success.

Messengers with bad news were routinely shot pour encourager les autres. We all had to become %u21Cgood lieutenants%u21D to survive and keep paying the mortgage. Doubly true if you were on a short term contract".

a pack of lame huskies it would seem


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"Speak truth to power" - and get shot

Mary Hawking 105 weeks ago

I was also impressed with Katie Davis: she was answering questions at EHI Live, and was clear that the long awaited Information Strategy was unlikely to be useful in addressing the problems of IT at the GP level: I don't think anyone ever had hopes it would address anything else!

Was that the reason she was replaced?

And will the replacement have the knowledge - or nerve - to speak truth to power?

No 10 - regardless of occupant - has a long and inglorious record of appointing people without suitable experience (what *is* the similarity between the London congestion charge and the NHS?) but willing to promise that the latest fad can and will be delivered in time-scales which one would have thought even minimal real life experience would have sounded highly improbable.

It would be interesting to see any risk assessment produced at the time: and even more interesting to know, supposing a risk assessment *was* produced, who actually read it..


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Mary Hawking
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Don't forget to consultancy firms who profited from such rubbish as well.

It is I, LeClerc 105 weeks ago

Although i hold many (some current) senior NHS people responsible for not speaking out at NPfIT's obvious failings, let us not forget the number of commercial consultancies and consultants, that swore "black was white" as regards product quality and availability. Hired by poor senior PCT/SHA managers to influence our Board members that we (local IT leads) were so wrong. Where is that wall?


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Some success, despite the contract

Hashim 105 weeks ago

Well written, Joe. Like this summary as a milestone on a journey the destination of which remains unclear. I am also struck by the irony in the comments: we need people familiar with NHS but those we have in position of power were not able to tell the emperor the truth about his new clothes. I am not convinced that NHS benefits from the introverted approach that commonly prevails and some one from outside looking in can also have its advantages. In fact, I think its almost necessary that NHS IT/informatics need some one in leadership role who does not carry the NHS baggage. But the leader needs to choose his/her lieutenants wisely. Akbar, the Mogul king, is said to be illiterate but he had nine brightest men in his empire sitting in his court.


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Different rules

Daniel Defoe 105 weeks ago

Hashim, Akbar didn't have an HR Department telling him he couldn't behead any of his nine brightest men (or even replace them) if they failed...


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good point Jacques

Joe McDonald 105 weeks ago

Tim Kelsey might need one of the rare individuals who can speak NHS, IT and DH. There aren't that many around.


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This charming man...Mr Kelsey

JacquesOuze 105 weeks ago

Indeed, although my reading of the bones doesn't give me a very warm feeling. Kelsey's background in journalism, Dr Foster and Choices has been focused on the consumerist side of health information and trying to use that to drive change in the NHS. I suspect his attention will remain there - which is fine as far as it goes. Unfortuntely, I don't think that's very far.

Of course it's not impossible that, as Hashim suggests, he's wise enough to surround himself with capable and knowledgable people, and gives them the direction, latitude and resources to get on with all of the other things necessary to forge some silk purses out of the sowe's ear of an information strategy. I just think his attention will be elsewhere - principally on the reworking of internet components of NHS Choices / NHS Direct / NHS 111 / Healthspace, old uncle Tom Cobbley and all.

That's because, as an inveterate self-publicist, he'll want to be associated with something very modern, visible and demonstrably successful, rather than getting bogged down in stuff about the wiring and plumbing of national or local IT.


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Mitigation

JacquesOuze 105 weeks ago

Sorry if I overdid the gloom - you'll have to put it down to seeing un rosbif winning La Grande Boucle. I mean, it's like the French winning the cricket world cup. It's not natural.

Good luck with the website though, it sounds like something with legs if you can get the finances sorted.

Back to weeping into my pastis.


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Come on Jacques cheer up!

Joe McDonald 105 weeks ago

A new broom is a new broom. I don't know Tim Kelsey but if he can bring some openness and transparency to the Health IT market I would consider that a result. Better still if he can take Hashim's advice and surround himself with people who know what they're doing and are willing to "speak truth unto power" (thanks Mary) Anyone who knows me will know I have been trying to get a clinical system comparison website http://www.comparethesoftware.co.uk off the ground in recent months so that the NHS can get the information they need but potential funders always back away for fear of the deep pockets of system suppliers legal departments. Maybe the NHS needs to fund something like it. Maybe Tim Kelsey and his transparency agenda is just what we need! Things can only get better (but, I suspect, not while the quality of systems remains "commercial and in confidence"). As we say round our way, "give the lad a chance".


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Why have the "lieutenants" not been called to account?

It is I, LeClerc 105 weeks ago

Well yes, the people at the top set the agenda and style, and i can well see how difficult, in fact career limiting, it would be to raise issues.

Never the less, that is exactly what experienced DoH,NHS Exec, SHA and PCT, CIOs and CEs should have been doing. It galls me that so many well respected senior persons, right down to SHA and PCT level, "bullied" us Acute IT Directors to accept NPFIT (especally Lorenzo) as a working product (some 5 years ago).

When we asked the questions of how, when and why, we were told we were off message. Yet many of these people are still in positions of authority and power. Have they no shame, why was there no review and accountability? Or is it a matter of the collective amnessia. Their collective actions set NHS Acute IT back a decade, they should be held to account.


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Hear, hear!

Daniel Defoe 105 weeks ago

Absolutely agree wholeheartedly LeClerc. Many of these "well respected senior (and highly paid) persons" as you call them (and I hope you're being ironic) have done nothing for the past 8 or so years other than to bury their heads in the sand and pretend that everything will be sorted eventually. Some have been downright obstructive when a trust has grown tired of waiting and made proposals to do something outside of NPfIT rather than watch NHS IT wither and clinicians' faith in ever getting anything worthwhile die completely.

Of course the trouble is that, as usual, we're soon going to see these same people popping up somewhere else in the NHS and having fingers in the IT pie again. Mark my words.


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Informatics Futures

JacquesOuze 105 weeks ago

Interesting take on events Joe. One thing that I think comes over is the advisability (or otherwise) of appointing people from the private sector to lead NHS IT. A significant factor in the failure of Granger and Connelly was their inability to negotiate the politics of the NHS, or Richmond House, or both.

Katie D with a small amount of experience in LSP land and the Cabinet Office still faced an Alp D'Huez of a learning curve in grappling with the NHS and its dysfunctional relationship with the DH. And that's without the chaos of Lansley's 'reforms' or the need to negotiate the other Nicholson Challenge (the one that Connelly failed - of finding favour with Sir Dave).

Out of the wreckage of the last ten years, one thing stands out as potentially useful, and that's Connelly's idea of 'connect all' as a strategic doctrine. This could have been more of a centrepiece of the information strategy as a kind of universal truth, had the authors not got bogged down trying to frame things in the context of the wider reforms. What emerged as tPoI is as incoherent as those wider reforms, although some of the ingredients of a realistic strategy are retained.

The problem now is that informatics leadership is utterly fragmented, and again, some key appointees have no background in or understanding of the NHS let alone [NHS] informatics (Kelsey), although they do have friends at No10. Until someone emerges that has both an understanding of how to get things done in the NHS, can negotiate the politics at the DH and appreciates the benefits and limitations of IT, I can't see that things will change.

At least we all know the current arrangements are just transitional, and the really bad bits will be unpicked in a year or two.


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