A few months back, I was flat on my back coming round from an anaesthetic in a south London hospital, which, with its peeling paint and echoing lift-wells, had the air of something from the Stalinist era in a poor area of Moscow. To pass the time, I thought I would look around for what evidence I could find of the revolution in clinical IT that has, I am told, happened in the past decade. I was in the same hospital eight years ago, and wrote down my impressions of their computer systems. (Computer Guardian, 30 July 1992). Had things changed in the eight long years since then? No, emphatically no. Eight years ago, I took a dislike to the big trolley carrying the folders of patients' records, the central altarpiece of that relic of Victorian pageantry, the consultant's ward round. I dreamed of a future where the consultant would sit informally at the end of my bed with an Apple Newton or other pen-pad, and bring up my x-rays and ultra-sound scans from my electronic patient-record deep in the hospital's database.
In a response to my Guardian article, a health authority in the Midlands wrote to ask where it would find the money to pay for all this. A paediatric consultant asked in a aggrieved way how hospital staff would find the time to plan, train for, and implement such a system. He was much too busy. A cancer consultant recently relocated to Boston, Mass, said his hospital had all I suggested already. A computer manufacturer, Hewlett Packard, sent me a video of the hospital-of- the-future with everything that I dreamed of, with one or two extras, such as doctors talking directly to computers, and smart cards being used for medical records worldwide. It claimed that the technology was already or nearly available.
On my recent visit to the hospital, I saw nothing of this brave new technology. Not much had changed in the eight long years. A computer had arrived in the nurses' room, which they seemed to use for admissions, ordering drugs from the pharmacy and for recording some tests on a patients' database. This was more than can be said for the consultants' offices and consulting rooms in outpatients, which appeared to be computer-free zones. The trolley full of folders still made its triumphal appearance on some consultants' ward rounds. My folder was about two inches thick. Although I did have suspicions that there was a rudimentary electronic patient record somewhere in the hospital, path-lab reports, doctors' notes, memos between hospital doctors and referral letters were printed out. It was clear that the paper folder on the trolley was still the master record.
The defects of such a paper-based system came home to me when I noticed on my first evening that the results of a radio-isotope scan done about a week before my admission was not in my file. I, the patient - albeit that most irritating of breeds, an articulate, stroppy, white middle-class patient - had to point out its absence. It was found quite quickly, but at MY prompting. On the result of this scan depended whether they would do the op. So, it was quite important. Would they have found it if I had not been articulate, white and stroppy?
At my routine follow-up with my GP after my operation, I asked him how he had received the hospital's report on my op: snail mail or email? Snail mail of course, and he launched an attack on all the hospital trusts in our area. Whereas he, working with other like-minded GP practices in the area, had almost achieved a paperless surgery for his internal patient records, he still had to cope with a flood of paper from local hospitals. He showed me my patient record, only three pages of internal paper, but as much as half an inch of path reports and hospital reports coming from outside.
He grumbled that either the hospitals had not thought of communicating electronically with him, or they set up systems to suit their own requirements, with no regard for the needs of the area's GPs. Nor indeed are the hospitals compatible with each other. This lumbers the poor GP with several different bits of software to handle those hospitals which do want to communicate electronically with him. Remember that hospitals have expensive IT departments full of IT 'experts'. GPs don't. They're just doctors. And yet, they have succeeded in offloading their administrative and clinical chores to the computer. The hospitals haven't.
When I asked my GP to explain why this might be, the first word he used was arrogance. Each hospital wants to follow its own agenda. So, the hospital trusts develop their computer systems in isolation, reinventing the wheel as they go along. According to my GP, the hospital cannot see the needs of the patient as a whole. Only the GP can do that. And only he can look at what the NHS as a whole has to offer - or fails to offer - and plays the necessary games for the benefit of the patient. To do this effectively, he recognises that all GPs have to develop common systems, and use common software standards and packages. He admits that they haven't got there yet, but they are on the way.
What my GP said about arrogance reminded me of a visit I paid with a group of MPs to a teaching hospital two and a half years ago. They showed us a marvellous patient administration system and a cardiothoracic imaging database, and were looking hard at palm-tops on the ward and voice-recognition and many of the other things I had dreamed of eight years ago. They also had admirable ideas about a "continuum of patient care" from primary care (GPs), through secondary care (general hospitals) to tertiary care (teaching hospitals).
But, when the parliamentarians asked whether there was any mechanism to replicate such "golden examples" elsewhere, so that the whole NHS benefits, they got a very sharp reply. National standards would inhibit the developers of advanced systems, and general hospitals are so far behind, particularly on their network infrastructure, that "we would be held up waiting for them to implement what we are doing. Besides, our advanced sys tems that our consultants have developed are the responsibility of those consultants. We are happy to show people what we are doing, but that's as far as we will go. And, when we get help for an advanced system, we go to the research councils, not the NHS."
With these attitudes from a centre of excellence, it is no wonder that my local general hospital has not got very far in eight years.
Then there is the political dimension. After the parliamentary visit, an ex-Secretary of State for Wales told me that he had built up a structure in Wales to encourage hospitals to replicate their successes. But then "John Redwood came along and tore it all down, because he expected hospitals to compete not cooperate in the internal health market." Thus, political dogma, added to the natural arrogance shown by the various tiers in the health service, did not exactly help progress for most of the eight years between my operations.
Another inhibitor to progress is the NHS itself. Last year, I was amazed to find that it gave no central guidance on the millennium bug, so that each hospital trust had to research the problem itself, and devise its own plan. The wheel had to be reinvented hundreds of times throughout the NHS. No wonder money ran short last winter.
There is another tendency in the health service that stops progress. It funds a pilot in one hospital for, say, research into tele-medicine in dermatology. The research is done, benefits and savings are identified, but no mechanisms are put in place to generalise the technology across the NHS. The money runs out, the research report is filed, and the project dies. One researcher, who is engaged in such a tele- medicine project, calls such pilots "Ozymandian corpses", which litter the sand of the NHS desert. She admits that restricting her initiative to dermatology is a waste of money on its own, and would like to widen her pilot into other disciplines such as ophthamology. But finding money for cross-disciplinary research is almost impossible.
It is difficult to see how, in the present NHS mode, she can stop her project becoming just another trunkless leg of stone.
Perhaps most damning is the history of the NHSNet. It was installed almost 10 years ago, but then the NHS failed to show the health community how to use it or even why to use it. And the professional bodies sneered at its lack of security. Today, after five years of hesitating and messing around, only about 50%of GPs are connected.
All this is against a backdrop of the internet and world wide web, where far-sighted standards-makers have ensured that all industries and all people have been able to talk to each other across the world for almost any purpose for the past 10 years. That is the measure of the failure of NHSNet.
An NHS Information Authority was set up as late as April 1999, to impose some standards in this Tower of Babel. It hopes to get all GPs connected by 2002, but does not plan to implement a working electronic health record until 2005. There is also a target for implementing telemedicine by 2004. Hardly challenging!
Setting targets from the centre is one thing, persuading the hospital trusts to make them happen in the fragmented culture of today's NHS is another. I asked a niece who is a hospital administrator whether there was any hope of speeding things up. She said: "The trouble is that the questions you are asking are too big. There is nobody with a wide enough view to answer you." I fear that in the meantime all the lovely new NHS money granted by kind Gordon Brown will just be spent by small people with narrow vision reinventing wheels.
No wonder I saw so little progress from my hospital bed. As a taxpayer and ageing patient, becoming year by year more dependent on the NHS, I object. I am not asking for top-down NHS diktats, just for hospital trusts to talk to each other, and for the NHS Information Authority to be given more teeth.
Then perhaps the hospitals will learn to use standards, and even replicate their better systems. And perhaps, on my next visit to hospital, I will see on the ward the technology which was available way back in 1992.
