EmailHis 1998 Information for Health white paper set out an ambitious agenda, much of which has already been achieved in areas relating to connectivity and infrastructure. But there is still a great deal to do, most of which is being reiterated through the National Programme for IT.
Perhaps a less well remembered aspect of the white paper is the reference relating to how skills and resources should be harnessed in order to achieve the objectives set out in the strategy.
It said: "The successful implementation of the information strategy relies upon specialist informatics, technical, change management and project management skills at the local level. These skills will become increasingly scarce and expensive and it is inevitable that the benefits of economies of scale will have to be maximised whether support is provided in-house or externally."
Technical priority
Upon reading this in 1998 many in the IM&T community rightly questioned the meaning of the statement, and the benefit of working in a more collaborative way. There was a preference to remain focused on the more technical aspects of Information for Health, with a rush to ensure that all GPs had email addresses and internet connections. Reorganising our people did not appear to be a priority or even a necessity at the time, and for many this situation has remained the same ever since.
In further sections of IfH Frank makes clear his meaning: "A logical consequence of the move to local collaboration in the development of implementation strategies will be the formal or informal pooling of specialist IM&T personnel."
The paper and the proceeding local implementation strategies described how local communities were going to work together to ensure that implementations were successful. This was the first mandated example which in many communities created a spirit of collaboration, and a platform from which to create the sort of service being described by the author.
"The creation of larger specialist health informatics services to serve a combination of NHS organisations will ensure the full and appropriate employment of the different skills required and allow some scope to offer greater personal rewards to the most senior and experienced specialists. These services will be of a very different nature from most of the existing IT departments as they need a broader clinical informatics and cross-organisational remit. To address important skill and resource gaps, this pooling approach may benefit by some outsourcing from the private sector, thereby complementing NHS skills."
Unfortunately the creation of health informatics services (shared services) was not associated with a target or any specific funding. Instead it was left to the local IM&T communities to implement, almost as an optional extra.
Could this be one of the reasons that for many, working as a shared service remains on the 'too hard to do pile'? The final excerpt from the author is perhaps enough to send a shiver down the spine of the traditional IT manager striving for recognition in the bowels of a district general hospital.
It describes having a "new image and purpose" and reads:
"Such services also provide an opportunity to establish a new purpose and a new 'image' for the traditional IM&T specialists and to discard the perception that they are principally providers of management information. In the new health informatics services IM&T specialists will work alongside clinicians, clinical informaticians, public health experts, epidemiologists, clinical audit staff, librarians and others who contribute towards meeting local health information needs."
Sir Peter Gershon, in his 2004 review of public sector efficiency titled Releasing resources back to the frontline, made another attempt to describe how working in a more collaborative way could rationalise the back office, remove duplication and produce economies from the investment.
So why in the presence of this overwhelming evidence do we still see a plethora of IM&T service providers within our local health communities and occasionally within single organisations? Why have the majority of IM&T leaders decided not to get together and work in a more collaborative way, protecting this scarce resource and providing a more customer orientated service to the organisations that they serve?
The reasons are many and varied. There was perhaps a unique window of opportunity between 2000-02 when traditional health authorities were handing over their responsibilities to PCTs and the Payment by Results regime was still very much in its infancy. The NHS appeared to have a little more time on its hand, although it probably didn't feel like it back then.
Is this window of opportunity now closed, as PCTs have now merged to once again form larger organisations who appear to require information specialists of their own? Maybe so!
Providing a high performing health informatics service is not an overnight process: it can easily take two or three years to reach a stage of maximum performance. Would the NHS of today, highly dependent on information flows, activity analysis and the money following the patient actually have the time to establish a shared IM&T service and risk disrupting any aspect of its knowledge or IT infrastructure?
Lion's share
Perhaps another reason that very few IM&T providers appeared to have joined this rather elite club is that at times it can be jolly difficult working across several organisations simultaneously, especially when they all appear to have different priorities, and chief executives and performance directors will all at times demand the 'lion's share'.
It is also about the willingness to expose oneself and one's service to internal and external scrutiny. The moment that we begin to provide services to more than one organisation is the time that we enter the customer/supplier relationship and subject ourselves and our services to performance measurement, financial inspection and a constant examination of all that we say and do.
Quite rightly the customer instantly demands to know exactly what level of service they are receiving and how much they are paying for it. Hard evidence is required to provide assurance that service levels are equal to the level of investment, and that organisation A is not receiving more than organisation B. This incentive alone is enough to encourage most IM&T shared services to become more business like, and perhaps even more commercial, while trying to retain the values of the NHS.
As such it is likely that the providers of a shared IM&T service can offer greater value for money and services of a higher quality when compared to the more traditional internal providers within single organisations. This is little to do with the former having greater technical or analytical expertise, but is more often related to their higher levels of customer awareness and care.
Indeed, many traditional internal IM&T providers may not want to subject themselves to this level of scrutiny, and may not want to exist in a customer/supplier environment. As such, and maybe by default, they do not tend to provide services that are customer orientated, regularly reviewed or indeed benchmarked with the services provided by competitors.
They are happy to be average. But in a shared service environment average probably means losing business, going out of business or being taken over by an organisation that is able to demonstrate its commitment to customer excellence in a more obvious way.
John Rayner is director of The Health Informatics Service hosted by the Calderdale and Huddersfield NHS Foundation Trust
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