Newcastle Abandons NPfIT
posted: Thursday September 18, 2008

At last! Someone still working in the NHS has the guts to tell it how it is.

The news that Newcastle NHS Trust has given up on NpfIT is a breath of fresh air in the suffocatingly horrible debâcle that is NpfIT. Could it actually now be, that shamed by the enormity of their error, our public servants (by whatever unaccountable organisation they are employed) will now accept that they are totally unfitted to the task of commissioning mega-scale and mission-critical computer systems? Such systems cannot be built to order (especially when those orders are constantly countermanded by detached and unrealistic bureaucrats) and be expected to work, because the requirements of their design are way too complex. Like all complex but successful entities, huge IT systems have to evolve from simple and successful building blocks and combine organically. Trial and error, natural selection, order from chaos, call it what you will, only an evolving organic approach can hope to grow a system where every working sub-system is dependent on working sub-sub-systems almost ad infinitum.

Could this complexity have been reduced? Probably not to any great extent. The tortuous route of a beetle crossing a ploughed field is not a function of the beetle’s navigation skills, it is directly related to the complexity of the terrain; and make no mistake, the complexity of an individual’s medical records, and the structure needed to store, retrieve and analyse it, is often very complex terrain indeed.

Now years behind schedule and billions over budget, NpfIT gets ever closer to an horribly expensive and embarrassing demise. From the outset, despite protestations from the higher echelons of both government and the NHS itself, many independent commentators have been saying that the whole project was doomed to failure at conception. No doubt many senior insiders also knew this but anyone who dared say so was ignored or sidelined. NHS administrators, fed on and mindlessly regurgitating sound-bites and acronyms, quickly become deluded by their own ‘expertise’. The contractors also had their doubts, but knew they would make a killing anyway. In any case, there are now just too many voices singing the same song for any objective individual or organisation not to accept that cancellation is now, at the very least, a distinct possibility.

Unfortunately, NpfIT is merely the latest and greatest failure in a long and dishonourable line of huge government IT projects managed by the over-promoted idiots who never seem to learn anything from the last disaster.

Having resigned, after 5 years in an NHS IT department, totally disillusioned with the whole set-up, I can no longer sit back and keep my thoughts to myself. Although you may not totally agree with them, many probably won’t come as a surprise; but they do represent a fairly typical view from an ex-insider. I accept that office, canteen and dinner-party gossip, do not constitute a scientific survey, but combined with first-hand experience they can offer valuable insight.

Let’s have a look at what went wrong – it’s all pretty basic and has the all-pervasive smell of inevitability.

The whole project was horribly over-ambitious and over-specified. Quite simply, it was never a realistic expectation that a single computer system could be designed from scratch to handle the wildly diverse data in the healthcare records of 60 million patients - especially across such a sub-divided and chaotic organisation as the NHS.
There are Primary Care Trusts (the GP bit), Acute Trusts (the hospital bit), Mental Health Trusts, Ambulance Trusts, Foundation Trusts, national and regional authorities, NHS Direct, NHS Walk-in Centres – literally thousands of interlinked, overlapping and heavily interdependent organisations. Paradoxically, many are largely autonomous, with their own goals and agenda, sometimes at each other’s throats. All are fighting for a greater share of the available finances. Money is power and within the NHS is ruthlessly used by largely unaccountable management for parochial gain rather than for the benefit of the organisation as a whole.

Between them, these organisations are the NHS. They employ a staff totalling 1.3 million, encompassing the clinical (doctors, dentists, opticians, nurses, therapists, pharmacists, radiographers etc.), the administrative (accountants, managers at all levels, clerical staff etc.) and a whole raft of support staff such as porters, cleaners, caterers, maintenance staff, security people, engineers, IT people – the list goes on and on.

Unfortunately many of these employee groups also have conflicting interests, often for the most worthy of reasons. For instance, clinical staff want to treat people free from administrative interference, administrative departments often have conflicting interests (finance and almost any department you care to mention for example) and the whole sorry mess is subject to interference and targets from pettifogging bureaucrats both external (government) and internal (a central NHS management that long ago lost touch with the grass-roots even if they had ever mown a lawn in the first place).

Of course, across the NHS are thousands of isolated and/or non-compatible computer systems; often many in a single organisation. But at least all these systems work after a fashion. Like all complex systems that exhibit stability (a swarm of bees, a human, a successful business), the existing computer systems have largely grown organically – most of the parts work fairly well in isolation and have gradually evolved within the NHS structure so they largely do their jobs, albeit sometimes not as well as everyone would wish. It is therefore understandable that a single integrated IT system should be such an attractive goal.

Unfortunately, NHS management is, on the whole, woefully inadequate – too distant, isolated, unaccountable, inexperienced, unaware and plain stupid to specify a new blue-sky system. That is not to say that management per se is a waste of resources. It is (or should be) a vital, perfectly legitimate and respectable means to an end – but administration is a service, a foundation, a framework; its sole function is to support the clinical staff deliver healthcare. It should, within the financial restraints, provide an optimum environment in which the clinical staff can operate to the best effect. But all too often NHS management serves only itself. NHS managers discourage or even fear individual initiative or lateral thinking, especially when an underling suggests or produces a simple and, in hindsight, obvious solution to a longstanding problem. In the NHS, career progress is for those who toe the party line; it is foolhardy to stick your head over the parapet.

These people (not of course the underlings at grass-roots level – the very people who actually understand the requirements of, and operate the existing system) were asked to tell the system designers what they wanted. Unsurprisingly the conflicting requirements were complex and often contradictory. Those mediating the conflicts didn’t really understand the issues so everyone ended up dissatisfied with the final specification. Changes to the specification inevitably followed adding to the overall confusion. Those in charge could not be seen to be leading a failing project so they talked it up. The supremely arrogant phrase ‘it will succeed because it cannot be allowed to fail’ became the stock answer to those who could see what was coming and dared to speak up. Many good people jumped ship (and continue to do so) and the remaining became more disillusioned and disheartened.

The problem is not, and never was, the technical requirements – the system is founded on large-scale industrial-strength databases and communication systems; these are tried, tested and reliable technologies. No, the problem is ever changing goals, the need to keep things going in the changeover period and horrendously over-ambitious expectations of what can be achieved with a ‘big bang’ approach.

I don’t pretend that this post is comprehensive or totally accurate or represents anything other than my slant on matters. However, I do believe it to be a rough approximation of the actual situation.

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