Richard Smith: Can the NHS get digital?

Richard SmithWhy has the NHS been so much slower to use information technology than other sectors and what might be done to encourage it to speed up? These were questions addressed yesterday at an NHS Confederation seminar, but we were urged to talk opportunity not barriers and to avoid answers like change the culture and the medical curriculum and introduce more leadership, all bullshit answers to every NHS problem.

Joanne Shaw, chair of NHS Direct, began the seminar by drawing an analogy with banking. Twenty years ago you had to go into a bank to withdraw money, and you might even have had to make arrangements with your own bank to withdraw money from another bank. The bank was dominated by the manager, caught for ever for middle aged Britons by the television character Mr Mannering, a pompous and officious fool. Shaw said she felt a supplicant not a customer when she visited the bank. But now millions use telephone and online banking. I haven’t been into a bank in months.

Could something similar happen with the NHS, improving the patient’s experience, raising quality, and reducing cost? Local authorities and government departments other than health (for example, Her Majesty’s Custom and Excise) have made real progress—so it is possible within the public sector.

Marlene Winfield, a patient representative, sketched a highly optimistic picture of what a digital NHS might look like in 2020. We would all have a lifelong, online, personalised medical record that we would control and share with whom we wanted. We would have access to tools for maintaining health, diagnosis, and therapy, and we would be able to consult clinicians online. Face to face encounters would still be an important part of the system, and we would be able to make appointments, arrange repeat prescriptions, access test results (with tools to help us interpret them) and undertake most transactions online. This digital future will be expected by a generation for whom the information technology is not something extra to real life (as it is to most middle aged people) but an integral part of it, and such a future might help “defuse the demographic time bomb,” which is due to explode any day now.

What struck me as I listened to Winfield was that the technology she described is all available now. It’s just not the way we do things in the NHS. Carl May, a professor of sociology from Newcastle, has spent more than 10 years studying the implementation of telemedicine, e-health, call it what you will into the NHS and social services, and he has observed that mostly implementation is in small, fragmented, research led pilots and that evidence on whether the technology “works” is highly contested with people not even being able to agree what is the right kind of evidence. “The evidence is never enough,” and “the champions cannot overcome internal resistance.” So mostly it doesn’t happen. One insightful doctor said to him “If it’s telemedicine it doesn’t work. If it works we call it medicine.”

One fascinating part of the discussion was to question whether face to face consultation is necessarily better and safer than consultation by phone or online? Most of us, including me, have assumed that it is, but there’s no evidence that it is so. Clearly face to face consultation allows the reading of body language and physical examination, but many encounters with clinicians do not involve physical examination and we were all taught as medical students about the fundamental importance of the history. Many telephone or online consultations use protocols, and the questions asked have been honed over years to increase their sensitivity and specificity. Those protocols may be less likely to miss something than a harassed clinician, and then machines do not get bored, irritated, tired, and exasperated the way that human beings do.

The NHS and the Department of Health may be going slowly with moving to a multichannel NHS, but the Cabinet Office, explained Bernard Quinn of the digital delivery programme in the Cabinet Office, is keen to speed things up because it sees great opportunities for improving patient experience and satisfaction while reducing duplication and cost. A 1% shift from face to face to online or telephonic contact would save £400 million. But how to make it happen? The government’s answer seems to be a leader, and evidently Martha Lane Fox, the founder of, is about to be unleashed on the Department of Health.

But there is understandably deep scepticism about another top down initiative—remember Connecting for Health? Might a better way be for the government to legislate to say that everybody’s health data should be available to them in machine readable form and that any willing provider can compete to provide services using those data?

Competing interest: RS is the chair of Patients Know Best, a start up that uses information technology to enhance the relationship between patients and clinicians. He doesn’t get paid but has a small equity stake. If the company flourishes in a digital NHS then he might get as rich as Croesus, or he might lose his small investment altogether. He was the editor of the BMJ until 2004.