National Health Service: Not National At All!

Back in the mid-1980s when (as a freshly-minted science graduate) I joined Shell International Trading Company as a programmer, PCs were only just starting to appear on people’s desks: most of the ‘real’ work was done by big old mainframes located in Shell’s data centre at Wythenshawe, just outside Manchester. Oil traders, just like those involved in financial markets, are an impatient bunch and so whenever their systems didn’t perform quickly enough, they’d beat up on the Information Technology department to improve performance. The knee-jerk was always for the mainframe people to want to buy more hardware: faster disks, more CPUs, more memory, etc. My view then – and now – is that throwing more cash at the problem without really understanding the issues is basically throwing the money away. I think there’s a risk that’s what is happening in the NHS today. The NHS is seen by British people and politicians as so much a part of the fabric of the nation that its budget is not only sacrosanct – the political parties are actually competing to throw more money at it, even in these straitened times.

The NHS has a budget of £110 billion and employs 1.4 million people.

On a recent ski trip with my sons, we met three young British medics. They were a lot of fun, as well as being (of course) intelligent and I had some interesting and surprising conversations with them about medicine and Britain’s National Health Service. It turns out we don’t really have a National Health Service at all: at best, I think you could describe it as a loose alliance of healthcare service providers who all happen to be funded by central government.

One of our skiing medic friends was a pathologist. He told us how money was often wasted in his department. Here’s a typical example: a patient visits their local doctor (GP) with some ailment; perhaps fearing some form of cancer might be the cause, the doctor refers the matter to a consultant for further study. The consultant asks for a biopsy and in due course this is passed to the pathology laboratory for analysis. So far, so uncontroversial. Perhaps by this time it’s a few weeks since the patient first visited their GP. Eventually, a pathologist gets around to putting the sample under a microscope and inspecting the cells, trying to figure out if there’s some malignancy. Having done so, they telephone or write to the consultant with their conclusions, at which point they discover that in the meantime, the patient has died. This is not an isolated occurrence. Now, training a pathologist takes many years and in the private sector one imagines that their charge-out rate would be of the same order as decent lawyers: maybe $500 per hour? So if they spend a couple of hours on a slide for a dead person, the NHS has just wasted $1,000 because nobody told them not to bother. It’s easy to see how this can happen – after all, the GP and the consultant will both have dozens if not hundreds of patients on their books at any one time, and they’re expecting to have to react to new information, without time to proactively be monitoring on the situation for each person. It’s also easy to see how one, simple, joined-up computer system could help avoid the waste.

But the NHS doesn’t have one, single computer system. It has hundreds – perhaps even thousands. I was told about one hospital that had developed a pretty good computer system for handling patient records, including as much medical background as they were able to obtain, so that all departments in the hospital had the same information. They discussed with other local hospitals and doctors’ surgeries rolling out the same software so that, for example, a patient in a road traffic accident brought into one hospital would immediately have available all medical data regardless of which local doctor they used. Sounds entirely logical, but it didn’t happen because each technology department had their own, specific, mandate and there was no financial incentive for them to adopt another hospital’s system. Some hospitals even have different computer systems for different departments, and of course they don’t speak to one another…. Now, all that incurs massive costs for the system collectively: for every patient admitted to each hospital, someone has to ring around the other hospitals and GP surgeries to find that patient’s medical data before treatment can occur. The Data Protection Act doesn’t help, as often the gate-keepers to these (paper and electronic) records see only downside risk in sharing a patient’s medical files with another hospital – even in a life-or-death situation. Again, this is a pretty easy problem to cure: if the NHS is to have an internal market, there needs to be an internal market for data, too. So if I have to call up and get records manually, there’s a price. Add up the cost and pretty soon the bean-counters would figure that harmonizing their systems with neighbouring healthcare providers would make sense. And NHS has a data ‘backbone’ capable of handling all this securely: N3.

Scheduling is another area that seems to be handled sub-optimally. Here are two examples.

I’ve heard of patients being sent by taxi from Cornwall to London (at least four hours drive) in order to visit a cardiologist because there isn’t one in the southwest. That can’t be a good use of NHS funds. Surely it would be possible to collect together all the patients in need of a cardiologist in that region and fly one down for a day? And why isn’t there one there, anyway?

I’ve also heard of ward beds being ‘blocked’ by a patient that should really have been discharged, but no ambulance or relative was available to take them home. I’m guessing a ward bed costs £1,000 per day, so put the patient in a taxi, for Heaven’s sake! In the end that’s what the registrar did, but of course there was much consternation over how to account for that, financially.

Bottom line: there’s inefficiency within hospitals and there’s inefficiency between hospitals, and the system’s not currently set up to deal with either particularly well. And throwing more money at the problem isn’t going to make it go away – in fact it’ll probably just make it worse.

Now, large government-backed computer projects are famously disaster-prone the world over. In 2011 NHS scrapped a £12bn computer system, for example. But that’s not what is needed here. The technology departments in hospitals and surgeries can learn from the way modern software projects tend to work: a cycle of prototype and refinement, and gradual adoption rather than a “big bang”. So, one hospital develops some software with nifty features, neighbouring hospitals adopt it and pretty soon you have a large enough collective budget to tweak version 1.0 to add all the features those other hospitals need. So then more hospitals join and so forth.

Next time someone tells you, “The NHS is in crisis,” think about why that might be.


This article first appeared on LinkedIn 30 December 2014