Editor's Choice

The NHS's sewers?

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7512.0-f (Published 04 August 2005) Cite this as: BMJ 2005;331:0-f
  1. Jane Smith, deputy editor (jsmith{at}bmj.com)
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    London's system of sewers, designed by Joseph Bazalgette, is one of the wonders of 19th century civil engineering, admired for its simplicity of conception, its scale, and the beauty of its brick lined, egg shaped sewers.

    Richard Granger, engineer of the English NHS's ambitious programme for healthcare computing, likens information technology in 2005 to the state of civil engineering in the mid-19th century. The technology was immature—yet Bazalgette succeeded. Granger, like most IT experts, thinks that information technology is immature, yet it is clear from his interview with Geoff Watts on p 310 that he believes it can deliver the NHS's systems for booking appointments, transmitting prescriptions, and storing patients' records. He also, more controversially, thinks that many more doctors have come to believe so too.

    Granger doesn't deny that his job of leading the NHS's 10 year programme is stressful, but it doesn't feel so comfortable on the ground either. Just as the citizens of 19th century London had to put up with the upheavals and uncertainties of major construction—the price of bricks rose by 50% and work continued through the wettest summer and the coldest winter of the 19th century—so the citizens of the 21st century NHS have to put up with the uncertainties of installing major computing systems. On p 331 Jane Hendy and colleagues report their qualitative study among clinicians and managers of four hospital trusts faced with implementing the new IT programme. Some of the challenges are familiar: lack of communication from the top, and the need to spend on IT infrastructure at a time when trusts are facing financial difficulties. But some arise out of the inevitable tension between a centralised, nationally rolled out programme and local innovations. “All trusts… reported having effective customised pockets of IT.” If these systems can't be integrated, then clinicians will lose systems that work well for them. Relationships with suppliers who know that their systems will be superseded may be strained, and trusts at the end of the queue for implementation suffer “planning blight,” with no new IT developments until their new system is implemented. The authors conclude that the managers of the IT programme need to show as much commitment to overcoming the sociocultural challenges of implementation as they have to its the technological and logistical challenges.

    But at least one GP seems to be making good use of this new technology. On p 352 Graham McKenzie describes how his practice does its “daily evidence based peer review.” Journal articles are emailed around, the audit clerk measures the practice's performance against the standards set by relevant articles, and clinical cases are shared by email. “It means I can do a full eight sessions of contact with patients a week and still be home for tea… while in many ways being better informed and educated than ever.”

    If Granger succeeds in implementing his IT systems for the English NHS, it will be like the sewers: we'll wonder how we ever did without them.

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