1.2.1 : Policy Review : Chapter Two
This chapter explains the rationale for the National Programme and sets it in the context of wider political and societal concerns.
1.2.2 : Literature Review : Chapter Three
Four sets of oppositions emerge from this review of relevant literature.
The problem situation is first presented as the insertion of technology into a mechanistic organisational structure. The relationship between structure and action is discussed and the problem situation is then presented, not as the insertion of technology but the appropriation of technology by people doing their jobs.
Problem solvers are discussed in terms of opposed positivist, interpretivist and critical paradigms. Critical Realism is then discussed as a potential means of their unification.
The problem solving methodology is initially modelled on the clear conceptual separation of definite entities, proposed by the seventeenth century philosopher, Rene Descartes. He is placed in opposition with a twentieth century philosopher, Maurice Merleau-Ponty, for whom entities define each other and, therefore, cannot be conceptually separate ; only interdependent and contingent.
The problem solving methodology is discussed in practical terms, ordered around aspects of information systems strategy, their design and development, their implementation and their evaluation. A variety of individual methodologies are discussed but the principal theme to emerge is that method as theory is opposed against method as practice. Process is set against improvisation.
Overarching these themes is the opposition between globalism and localism. Globalism represents the hierarchical supremacy of one idea over its rivals. Issues are viewed from the standpoint of the structured whole, considered as a closed system.
Localism tests every idea against the detail of a local context. Global causes (interventions) produce global effects (outcomes) but the expression and intensity of effect are mediated by contextual factors, whose essence and variability are local. The global intervention loses its systemic integrity because its various points of contact with separate local sites constitute “boundary objects”, made ambiguous by membership of both the global intervention and the local site.
Rather than cementing the global intervention and each local site as modules of a greater, physically intersecting whole, in fixed, hierarchical relationship, boundary objects mark points of coalescence and dissolution between closed systems that have now become open to each other, by virtue of functional intersections. These render system boundaries fluid and hierarchical relationships uncertain because the intersections are contingent, provisional and bi-directional.
1.2.3 : Research Approach : Chapter Four
The research approach will be developed in chapter four of the thesis.
1.2.4 : Research Findings : Chapter Five - Developing a Diagnostic and Therapeutic Approach to the Local Problem Situation
Chapter Five of the thesis will apply NIMSAD once more ; this time, to construct a diagnostic and therapeutic approach to the practical situation.
Chapter section 5.1 presents a first background understanding of the “situation of concern”, based on an interview with the Trust’s IT Manager. There is a perceived need to introduce information systems. The need and relevance of information systems is unclear.
In section 5.2, this understanding is widened by discussion with members of the Trust’s Executive Team. Two distinct systems of activity are identified : the IT delivery system
and the business delivery system. The problem situation is seen to contain several constituencies (managers, clinicians, patients ; information systems users and suppliers) and a mix of ‘hard’, institutional (National Programme for IT, external regulators, the Trust ) and ‘soft’, social (clinical practice) structures. This chapter reports activity under NIMSAD’s phase of “diagnosis”.
Section 5.3 explores the Trust’s future direction, to which information systems are expected to contribute. This is NIMSAD’s “desired future state”. The ‘IT delivery System’ needs to be more closely aligned with the ‘business delivery system’. The new Chief Executive has brought about a distinct climate shift, from static organisational reporting in a command and control environment towards dynamic organisational learning in an organisational development environment. The ‘business delivery system’
is, in effect, being transformed into an ‘organisational development system’.
The “desired future state” is to integrate the IT delivery system with organisational development. IT will satisfy organisational development needs in the broadest sense, including changes in clinical processes and methods resulting from organisational development activities. The outcome will be to deliver the Trust-Wide Objectives which encapsulate the Chief Executive’s organisational transformation agenda.
Section 5.4 identifies “problems”. NIMSAD refers to entities that are either missing or mal-aligned. This chapter identifies the need to establish a conscious link between the Trust’s ‘IT delivery system’ and its ‘Business Delivery System’. From a functional perspective, this implies the stronger definition of purpose for these two systems, of which the former switches its focus from technology to information and the latter from
organisational development. Reflection from other perspectives deepens and broadens this analysis.
Section 5.5 identifies strategies, in the form of “notional systems” which, if they were brought into existence, would address the ‘problems’ identified in the previous chapter, making it easier to attain the “desired future state”, where the Trust’s information systems were more closely aligned with the Chief Executive’s Trust-Wide Objectives.
The relevant systems reflect agenda definition, values alignment, conflict surfacing and agenda critique.
Section 5.6 reflects on the problem solver, the problem situation and the problem solving methodology and brings together conceptual understandings of the design, implementation and evaluation of information systems that reflect the propensity for technology to be “translated” from the designer’s conception of use into the user’s personal relationship with his own practical situation. This represents the “conceptual / logical design” phase in NIMSAD. The chapter suggests a ‘plane of cleavage’ between, on the one hand, groups, processes and technology and, on the other, individuals, tasks and technology. The two positions separated by the ‘cleavage plane’ represent fundamentally opposed philosophical positions with practical significance.
Section 5.7 situates the conceptual / logical model described in section 5.6 within the wider activities of information systems design. The components identified in the last chapter are now presented as a unified whole. The model is then placed amid specific zones of interest, originally identified as relevant to design, but incidentally relevant to strategy, implementation and evaluation.
1.2.5 : Research Findings : Chapter Six – Applying the Diagnostic and Therapeutic Approach to the Local Problem Situation
The final phase in NIMSAD is “implementation”, putting the physical design to work in the real world. Chapter Six applies the concepts and model developed in the three preceding sections to a set of case studies to illustrate, in their practical context, issues relevant to the design, implementation and evaluation of information systems to be provided under the National Programme.
1.2.6 : Reflections and Conclusions : Chapter Seven
Section 7.1 will reflect on the research process.
Section 7.2 will present my critical reflections on the problem situation represented by the introduction of the National Programme.
Section 7.3 will reflect on my own intellectual development as a ‘problem solver’
during the ‘research journey’.
Section 7.4 will review the problem solving methodology.
Section 7.5 will present the contributions and limitations of the research.
Section 7.6 will suggest the direction of future research.
1.2.7 : The Practical Outcome of the Research : Chapter Eight
Chapter eight will present a review of the practical outcomes of the research project as an internal consultancy document for the Trust where the research was conducted.
1.2.8 : The Policy Implications of the Research : Chapter Nine
Chapter nine will present the implications of the research for future policy relating to large scale information systems in the NHS.
1.2.9 : Conclusion of the Thesis
Chapter ten closes the thesis and summarises briefly the intellectual journey it represents.
C H A P T E R T W O P O L I C Y O V E R V I E W
2.0 : I N T R O D U C T I O N
The purpose of this chapter is to appreciate the expectations of the information system’s institutional sponsors.
The expectations of these corporate strategists and planners represent a global view and vision of the NHS. The public-funded provision of local information systems is expected to be coherent with this vision and with the overall framework provided by NHS policy and NHS information policy.
Section 2.1 outlines NHS information policy and the National Programme for IT.
Section 2.1.0 explains NHS information policy since 1998. Section 2.1.1 briefly summarises information initiatives prior to 1998. Section 2.1.2 summarises the policy context of the National Programme. Section 2.1.3 explains the areas of public concern that have influenced thinking about the programme. Sections 2.1.4 and 2.1.5 explain the programmes implementation and success.
Section 2.2 presents brief conclusions.
2.1 : N H S I N F O R M A T I O N P O L I C Y A N D T H E N A T I O N A L P R O G R A M M E F O R I T
2.1.0 : NHS Information Policy since 1998
The White Paper, The New NHS, Modern, Dependable (United Kingdom. Department of Health, 1997) set out the plans of a newly elected government for healthcare in the United Kingdom. Its associated information strategy, Information for Health (United Kingdom. NHS Executive, 1998) provided an overall verdict on the previous (1992) strategy (section 1.33).
“While it did deliver some important national infrastructure, the previous strategy………was over-concerned with management information, and failed to address the real needs of the NHS for information to help clinicians and managers to deliver more effective healthcare and improved population health.”
Information for Health (section 1.3) committed to a clinical focus in the form of :
• lifelong electronic health records for every person in the country
• round-the-clock on-line access to patient records and information about best clinical practice, for all NHS clinicians
• genuinely seamless care for patients through GPs, hospitals and community services sharing information across the NHS information highway
• fast and convenient public access to information and care through on-line information services and telemedicine
• the effective use of NHS resources by providing health planners and managers with the information they need.
It was based on the following “principles” (section 1.30) :
• information will be person-based
• systems will be integrated
• management information will be derived from operational systems
• information will be secure and confidential
• information will be shared across the NHS.
The principal innovation within Information for Health was the patient-based Electronic Record, subdivided as follows :
“2.10 Electronic Patient Record (EPR) describes the record of the periodic care provided mainly by one institution. Typically this will relate to the healthcare provided to a patient by an acute hospital. EPRs may also be held by other healthcare providers, for example, specialist units or mental health NHS Trusts.
2.11 The term Electronic Health Record (EHR) is used to describe the concept of a longitudinal record of patient’s health and healthcare – from cradle to grave.
as well as subsets of information associated with the outcomes of periodic care held in the EPRs……”
Systems integration was to occur at six levels (section 2.64) :
1. Clinical Administrative Data (Patient Administration Systems)
2. Integrated clinical diagnosis and treatment support (Departmental systems integrated with Patient Administration Systems)
3. Clinical activity support (Electronic ordering, results reporting and prescribing, multi-professional care pathways)
4. Clinical knowledge and decision support (knowledge bases, embedded guidelines, rules, electronic alerts, expert systems support)
5. Speciality specific support (specialist clinical modules, document imaging) 6. Advanced multi-media and telematics. (Telemedicine, Picture Archiving and
Communications Systems).
Information for Health had cast the information strategy for the NHS as a national programme for local implementation, focused around the delivery of Local Health Improvement Plans, themselves geared towards the delivery of National Service Frameworks∗ addressing key health challenges.
In contrast, Delivering 21st Century IT support for the NHS (United Kingdom.
Department of Health, 2002) focused on the nationally co-ordinated delivery of
infrastructure in the form of “ruthless standardisation” (ibid: para. 1.2.1) at a technical level, national arrangements for procurement (recapturing the market from its suppliers) and clearly defined channels of centralised responsibility and authority : in other words, a national programme for national implementation. A local process of implementation became a global one. Local functional sensitivity gave way to national technical uniformity.
The resulting “National Systems Architecture” (ibid.: p.2). introduced electronic prescribing, electronic booking of appointments and electronic records, and supported these with the “N3 National Network” that was to form the “spine” for the national electronic distribution of patients’ confidential medical data. Respecting the important issue of confidentiality, access constraints, authentication procedures and encryption were given development priority.
Subsequently, the National Programme’s delivery arm has been named, “Connecting for Health” ; recognising that tight project-management had lent an undesirably self-centred aspect to the Programme and re-asserting its purpose as an instrument of wider change.
A national local ownership programme (NLOP) has been launched, to strengthen the engagement of the broader NHS with the ICT programme.
In this form, the programme has reverted to a national programme for local implementation, focused on the integration of clinical services and records around the individual patient. However, the decisions about what is to be implemented locally have now been taken in isolation from a clinically led view of health improvement or a locally led view of the way local elements of healthcare ought best to interact .
Chantler, Clarke and Granger (2006) have described the content of the IT programme in terms of its technical infrastructure.
The aim has been to build a national broadband network that can handle vast volumes of data traffic without degradation. Information is modelled around a national data “spine”, to which a summary care record for every patient is linked. The summary care record is populated with information fed from more detailed, local records held by individual healthcare providers, or in each patient’s personal health webspace [“My HealthSpace”].
The “spine” also manages the exchange of digitally stored X rays and other images, electronic prescriptions and pathology results, and outpatient or other appointments. The ability to integrate “to enable a single, immediately updatable record to be available irrespective of the location in which the patient is treated” is a core goal of the National Programme, as is the ability to integrate electronically all the disparate elements of healthcare provision which constitute the ‘patient’s journey’ through the processes of treatment for a given condition such as a cancer.
Additional to the ‘spine’, Bacon and Pugh (2006) identify “the replacement of local systems at hospitals and GP practices throughout the NHS with centrally selected software” as the second principal component of the National Programme. They maintain that : “The fundamental error made when setting up the programme was to assume that centralised procurement of national systems would be more efficient than local decision making guided by national standards. ….……. Central selections mean that all local ownership of such systems is lost …… this makes the systems even more difficult to deploy”.
2.1.1 : Background - Information Initiatives Prior to 1998
Since the 1960’s, the Patient Administration System (PAS) of each hospital has recorded and administered hospital ‘activity’ in terms of in-patient and out-patient
‘episodes’. It is essentially a clerical function but also contains, for each episode, a
‘diagnostic code’ that indicates broadly the clinical purpose of the activity undertaken.
As emerged in the Bristol Inquiry (Kennedy, 2001 : Annexe A, paras. 57-67), coding and the maintenance of PAS are ‘back room’, administrative functions, carried out in isolation from front-line clinical activity, essentially for planning purposes. Having no relevance apparent to clinicians, their execution has tended to be correspondingly poor (Kennedy, 2001 : Ch.6 : paras 26-27). However, extracts from each hospital’s PAS are published in NHS Hospital Episode Statistics and are used to compare one hospital’s performance with another. In this sense, the figures intended for planning are published
‘over the heads’ of clinicians, purporting to compare clinical performance. Public debate over health services is founded on fallible representations, whose relation to the truth is not necessary but only coincidental.
The NHS information initiatives which preceded Information for Health are described by Brennan (2005 ; ch.7). They include Hospital Information Support Systems (HISS), the Resource Management Initiative (RMI) and Clinical Audit. All of these have or had the potential to refer back to the Patient Administration System (PAS). Brennan paints a picture of a market for NHS information systems that had suffered ‘provider capture’.
HISS were intended to ‘integrate’ the different administrative systems that existed to
sense that the output of any of these systems could be processed in a central system such as PAS.
Brennan (2005 : p.54-62) and Perrin (1998) explain how the Resource Management Initiative (RMI) resulted from efforts to assemble information about the costs of capital assets, human resource and clinical procedures with the number of patients treated and their severity of illness. Coding structures were revised and the level of detail available was enriched. This was to allow efficiency comparisons, first between hospitals and subsequently between individual clinical firms.
Brennan explains that HISS was implemented independently and sporadically by individual NHS hospitals, purchasing ‘solutions’ from a variety of providers whose systems were electronically incompatible with each other. However, departmental systems had often been supplied by different manufacturers and their functional
‘integration’ required manual transcription of output from one system to another.
Despite their promise, both HISS and RMI have suffered from the incompatibility of their component information systems.
2.1.2 : The Policy Context of the National Programme
Electronic information systems are central to the e-government strategy, outlined in Transformational Government (United Kingdom. HM Government Cabinet Office, 2005 ; p.3-4). Here, the aim is to transform and ‘modernise’ public services, making them responsive to personal needs as well as improving their economic efficiency and eliminating process steps that confer no added value.
The Wanless Report (Wanless, 2002) to the Chancellor of the Exchequer made recommendations which instigated the National Programme for IT and provided a foundation for subsequent health policy.
Wanless' terms of reference asked him "to determine the resources needed for high-quality service". The result was "the Review's vision of such a service in 2022".
To achieve parity over the next 20 years would require "a very substantial increase in resources for health and social care" as well as radical reform. Both would need support from a major programme of “effective investment in IT”. Funds intended to purchase IT resources must be ring-fenced against diversion for other purposes. The proliferation of incompatible IT systems would need to halt.
Wanless’ interim report (Wanless, 2001) had identified chronic underfunding, inefficient spending, and lack of capacity contributing to health outcomes below the European average.
Productivity improvement would stem from better use of information, reduced bureaucracy, clinical as well as financial effectiveness, successive devolution of responsibility for direct care from one sector of the workforce to another, better integration of social care with health care, and better recognition of inter-relationships between resources in the system.
Public funding of healthcare need not be equated with public-sector provision. To take greater responsibility for their personal health the public needed information on health
matters, and to make informed choices when seeking healthcare, they needed improved information about health outcomes.
In making his recommendations, Wanless pointed to the need for a full information base about health inequalities and the relationship between socio-economic need and health need.
The United Kingdom House of Commons Public Administration Select Committee (2003) identified a prevailing “measurement culture” in the NHS, characterised by centripetal reporting of summary information to assure the confidence of an external public or parliamentary audience. They wished public services to develop a
“performance culture” characterised by the capacity of an internal organisational audience, to generate organisational learning from its own informational resources.
In the same vein, the Gershon Efficiency Review (Gershon, 2004), advocated the recycling of resource, from unproductive supervision to the facilitation and emancipation of front-line interactions in all sectors of public service. A key aim within efficient reconfiguration at the level of service delivery was to maximise the productive
In the same vein, the Gershon Efficiency Review (Gershon, 2004), advocated the recycling of resource, from unproductive supervision to the facilitation and emancipation of front-line interactions in all sectors of public service. A key aim within efficient reconfiguration at the level of service delivery was to maximise the productive