Evidence submitted by Ivor Perry (EPR
My area of research is in the deployment of
systems that enact business processes, and the effect they have
on organisational culture. A list of my publications can be found
1. Scope of evidence: this document discusses
the delay in implementing Electronic Patient Records systems in
the NHS, and the inefficiencies and inadequacies of planning that
have led to it.
2. Prior to the inception of the NPfIT,
some useful work on modernising the administrative and "customer-facing"
systems in the NHS had already begun. For example, work done between
1995 and 1999 at The Robert Jones & Agnes Hunt hospital in
Oswestry, producing electronic patient records, was described
by an independent report as "exemplary". During this
period, Trusts were largely allowed to make their own decisions
on IT expenditure. At the same time, the Government was establishing
standards for the use of interactive systems; for this type of
system, the use of XML standards and associated techniques was
(quite properly) recommended.
3. Inevitably, with such an approach, there
will be issues of control (if systems are to interact across some
kind of national communications infrastructure, there have to
be agreed standards of data structures, for example). Also, there
would be problems of speed of deployment (there would be little
pressure on Trusts to conform to some national timetable). On
the other hand, Trusts would be able to set their own priorities,
to engage suppliers that served regional (geographic) areas and/or
were truly specialist in their field.
4. At this point, it is worth noting the
history of large systems development in the NHS. These have mostly
been failures, or at least partial successes, and have been comprehensively
written up in the literature. (1) Further, the NHS had been subjected
to around 20 major IT initiatives in the previous 21 years. (2)
The result of those experiences was, according to writers on both
the NHS and on organisational culture, to increase resistance
to IT-mediated change and to reduce the likelihood of IT success,
where it was imposed on user populations. The impact of such numerous
and major IT changes cannot be underestimated; no private company,
so far as I am aware, has been through so many, so public, and
so unsuccessful IT changes in a similar period.
5. There have been a number of fundamental,
structural problems with the way NPfIT, and Connecting for Health
have been implemented.
(a) The decision (if that is what it was)
to impose a national system on an unwilling and "bruised"
user population was unwise in itself.
(b) The process of enforcing the acceptance
of systems providers who had not been clearly chosen by the local
IT and user communities only added to the burden.
(c) The major suppliers were chosen for their
ability to deliver large systems, which appears sensible; however,
none of them had any real expertise in the area of EPR, and mostly
they selected as subcontractors companies who either had "big
company" pedigrees, or who had experience of EPR in the USA.
Neither of these bases for selection was going to be successful,
unless by chance. The USA practice in regard to medicine delivery,
let alone EPR, is very different from the UK, and an assumption
that "what works in Little Rock Arkansas, will work in the
UK" is dangerously wrong.
(d) The promised control over major suppliers
has not materialised. Despite the public statements by Mr Granger
about disciplining suppliers who did not perform, the suppliers
have not been held to account significantly, further reducing
(e) Arguably, the sums of moneyfor
example, the proposed £30 million for just six pilot siteshave
been vastly in excess of what was actually needed. In what I have
seen so far in both the UK and the USA, that figure should be
nearer £3,000. The prospect of very large revenues will always
attract large, expensive undertakings to justify, or at least
accommodate, the budgets.
6. The future? Curiously, in view of what
I have said, it is worth looking at what is happening in the USA.
I am not advocating their healthcare model, but the sheer fragmentation
of their healthcare system has resulted in some interesting approaches
which we could learn from. Having attended a series of workshops
at Claremont University, California, recently, I was impressed
by a number of the EPR systems that are being developed in America.
In default of a Federal initiative, let alone a Federal budget,
for EPR systems nationally, individual counties, hospitals, companies
and charities are all developing their own systems.
7. A side effect of this lack of national
planning is that most systems are quite small developments, designed
with the needs of their user community in mind, yet built according
to well documented IT standards that mean that data can be exchanged
easily between say, that charitable hospital that administers
healthcare, the patient's company that pays the bills, and the
insurance company that underwrites those payments. In this context,
the differences between the UK and US models of healthcare serves
to demonstrate that systems are being developed with the right
kind of flexibility and communications ability.
8. The US companies that are developing
these systems are not always the large US companies that we have
seen in this country. Mostly they are small organisations, able
to focus on certain areas (eg social care units, geriatric care
centres, local hospitals etc) so that the EPR is customised to
suit the needs of the user community.
9. Does similar expertise exist in this
country? Undoubtedly. There are a number of small, specialist
companies operating in the EPR area, at minimal cost, but with
quite impressive track records of customer satisfaction.
10. The challenge in using this kind of
development model will be control. However, a strategy- and standards-based
body at the centre of the NHS should be capable of ensuring that,
where required, such systems can communicate with others.
(a) The opportunities of such an approach
(b) Enormous cost savings.
(c) Speed of deployment of individual systems,
delivering results where needed, rather than according to a national
(d) Conformance to local and/or specialist
(e) Ease of replacement: if these systems
are design and built using generally accepted standards, then
they will not pose major problems of replacement should user needs
change or should the systems become obsolete.
11. I am aware that this is a brief note,
and I apologise that I have been unable to frame a more detailed,
and closely argued, response. I have just returned from teaching
overseas, and was unaware of the call for evidence.
Brown, A, Organisational Culture. 2 ed. 1998, Harlow, England:
(2) Fairey, M, Culture Change Ahead. British
Journal of Healthcare Computing and Information Management, 2002.
Vol 19 (8).