Select Committee on Health Written Evidence

Evidence submitted by Ivor Perry (EPR 58)

  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 at

  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 user acceptance.

    (e)  Arguably, the sums of money—for example, the proposed £30 million for just six pilot sites—have 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 are obvious.

    (b)  Enormous cost savings.

    (c)  Speed of deployment of individual systems, delivering results where needed, rather than according to a national prescriptive plan.

    (d)  Conformance to local and/or specialist need.

    (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.

Ivor Perry

March 2007

REFERENCES (1)   Brown, A, Organisational Culture. 2 ed. 1998, Harlow, England: Prentice Hall.

(2)   Fairey, M, Culture Change Ahead. British Journal of Healthcare Computing and Information Management, 2002. Vol 19 (8).

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