Lear and uncertainty
“I will do such things — what they are yet I know not, but they shall be
the terrors of the earth.” This quotation from King Lear figured in a
presentation to the 1969 Medical Computing Conference, to illustrate the
dilemma that at that time was facing managers of all disciplines.1
Healthcare computing was obviously a Good Thing — but what exactly did it
do? And how did you do it? Thirty-six years on, the same cannot possibly be
true — can it? Compare and contrast, as examination papers used to ask, with
the following: “It might be a policy disaster, but it isn’t an IT disaster.
The system was delivered to spec. If some of my colleagues do not think
sufficiently through as to what was wanted then it’s a specification
error.”2 If this was an aside by a recalcitrant IT manager, then a wearied
manager might grit his teeth at yet another excuse and labour on. But it is
not. In a report by
E-Health Insider from the recent Health and Social Care Exchange Conference,
it is attributed to the Director General of NHS IT and the Chief Executive
of NHS Connecting for Health.
Can it really be the case that with almost four decades of experience,
and with many large successful installations from which to learn, it is
still not possible to develop an accurate and comprehensive specification
for a major healthcare system? It is of course possible that the speed with
which the process was conducted (and the political imperative that drove it)
made comprehensive specification impossible. Anyone who has been responsible
for the design of large systems will know how demanding that task is, even
within one organisation. A specification for an organisation as large as the
Health Service cannot fail to have rough edges. It is one of the factors
that will have to be taken into account if the National Programme for IT is
to get under way.
This issue of the Journal examines, in particular, two aspects of the
tasks ahead: the dynamics of implementation, and the legal challenges that
implementation will undoubtedly throw up. In his article, Professor Ken
Eason, Director of the Bayswater Institute, draws on a wide field of
implementation practices for large systems and the range of organisational
responses to them.
He cites an American report of surveys showing only 28% success rates for
large systems where the technology is pushed from the centre: of the balance
23% were failures and 49% ‘challenged’ — that is, showing major problems in
achieving objectives.3 Alarmingly, however, the surveys seem to indicate
that the bigger the project, the higher the likelihood of failure. As a
counterbalance, Professor Eason then advances six principles that might with
benefit be applied to the task ahead.
Our second article, from Rebecca Carter and Rosemary Mulley of Nabarro
Nathanson, turns to the management of the contracts with suppliers for
installing the systems of the NPfIT and their impact at ground level, where
those contracts will need to be performed. This is advice that is
particularly timely. With one major contract already ended for
non-performance, and another threatened “with a bullet in the head”,4 there
can be no doubt that lawyers for the contractors will, quite understandably,
be seeking every small failure at ground level to defend their position
nationally.
Authorities where the services are being implemented will need to be
absolutely clear about the responsibilities placed on them by the national
contracts, and the exact range of services those contracts are required to
provide. Amongst the other problems that the implementation of the NPfIT
cannot but encounter, prolonged legal wrangles will be the least productive.
Our third article takes us away from the immediate problems of the NPfIT
and into a wider field. In it Malcolm Teague, Co-ordinator of the NHS–Higher
Education Connectivity Project describes the work to enable two-way
communication between electronic networks in the NHS and higher education
and the problems that have to be tackled in making that possible. This is an
encouraging prospect for the many, and increasing number of, NHS staff who
now have a research responsibility.
It is of course inevitable, as the NHS in England moves further into the
implementation of its new national systems, that more obstacles will become
apparent and need to be overcome at ground level. That is an inevitable
concomitant of adopting a central ‘push’ approach. Organisations develop
their own ways of dealing with this approach, but as Professor Eason points
out, it is possible to incorporate elements of the ‘pull’ approach to draw
in the active participation of the end users. Those ways have to be actively
pursued, if the NPfIT is to succeed. There needs to be an explicit and
highly publicised plan for the implementation. We cannot afford to echo
Lear: we cannot afford to do such things, what they are yet we know not.
Neither do we want them to be the terrors of the earth: we want them to
work.
Michael Fairey
References
1. Fairey MJ. Information systems in hospital administration. In: Abrams
ME, ed. Conference proceedings: Medical Computing: progress and problems
1970. London: Chatto and Windus, 1970: 384–9.
2. Granger issues stern warning to failing suppliers. E-Health-Insider 7
July 2005 (news).
www.e-health-insider.com/news/item.cfm?ID=1305
3. Standish Group. Extreme chaos. The Standish Group International Inc
2001.
www1.standishgroup.com/index.php
4. BT warned it may face chop in London. E-Health-Insider 15 July 2005
(news).
www.e-health-insider.com/news/item.cfm?ID=1318
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