Why NHSNet can never be good
In 1991, I lived with my grandmother in Bahrain. The room she gave me was originally my uncle’s, which meant I had access to all his books. This is a true education.
One book I read was about the Fifth Generation effort in Japan. Written in the 80’s, it described the Japanese government’s efforts to catch up and overtake the USA in IT. The book spoke of billions f dollars and hundreds of bright minds, all devoted to this giant governmental vision.
I was gripped.
All through the 90’s, I followed the Japanese computer industry for signs of their inevitable success. Nothing materialised. The billions spent have done nothing to change the nation’s fortunes. Indeed Japan’s gap widened as it was late to catch on to the internet revolution.
It is remembering this that I think of NHSNet.
What is NHSNet?
NHSNet is network designed with the NHS in mind. Its guiding principles were clinicians’ needs for a system to cut through the paperwork of healthcare. This system would be fast, delivering lab results instantly to the doctor that ordered them. It would be secure, insuring the confidentiality of clinical information. And it would provide timely trusted information that doctors would use to make clinical decisions.
What went wrong?
From the start, there were problems. This led to several rounds of delays and extensions. Now, several years on, the governments targets of having all GP’s on the system have still not been met. Let’s start with the governments’ plan. It was, august. A bold vision ideal for a politician’s speech. Consider X400, the standard proposed for transferring messages such as lab results. The requirements were so large and complex, that to date, only one manufacturer has implemented them – Microsoft.
Furthermore the standards set out were only really accepted in the UK. The market available is thus immediately limited and unattractive in size considering the investment required.
Contrast this with Health Level 7 (HL7). This is an international set of standards for medical software. As you can guess by the name, there are 7 levels of compliance. From the outset, it thus provided software developers with a gentler slope to climb, rather than the all-or-nothing mentality of NHSNet. In addition, this is an open international body. Developers that stick to it know that their market is worldwide. It is with this understanding that so many solutions have been developed and deployed worldwide.
Secondly, this effort has created monopolies. The knowledge that X400 compliance will be forced upon them has caused most health authorities to switch to one provider – Microsoft. Furthermore all spending on IT solutions other than NHSNet’s has been frozen. Innovators in the UK cannot find a market at home for their products without the government’s blessing.
By contrast in the US, the kinds of solutions that NHSNet was meant to provide are being met by several small innovative companies. With time, the more successful will acquire the less successful, or consolidate with bigger companies. HL7 compliance means their software may work with others’ without a monopoly arising.
Thirdly, the funding priorities were wrong. GP’s must invest thousands of pounds to ensure their surgeries are compliant, and wait several years before they can see the investment recouped in savings. Understandably, health care trusts have seen the scheme as a burden rather than an opportunity, and have only taken it up due to legal requirements.
More controversial is whether or not there will be any saving at all. There are some areas where large cost savings can be made quickly, and with a low initial investment. Further, the investments must be made in the right sequence, to affect the limiting steps in order of importance. Rather than identifying and targeting these, NHSNet’s creators pursued complete compliance with the grand vision from the start.
It’s the government , stupid
The main problem behind all this is that big government efforts do not work. It’s not about the Conservative or the Labour government. It’s about government. So this time round, I shall not wait eagerly for big results to flow from big efforts. I know they never will.
Published April 2001 as editorial in the newsletter
of the British Medical Informatics Society