Later today, NHS England will release quarterly waiting time statistics for A&E attendances and emergency admissions. This will doubtless spark political discussion about ‘reform’ of the NHS, including greater digitisation.

In the latest Wired, Yinka Makinde (Director of Digital Workforce at NHS England) talks briefly about some of the reasons that ‘digital’ projects in the NHS fail:

70 percent of digital transformation programs in the NHS, particularly complex ones, will fail to meet their desired objectives. There are many reasons for this. For one, we focus too much on technology and often forget to ask what problem our clinical staff and patients are facing and how they want things to change. We also have organizational silos, where digital is still often seen as the IT department with the office in the basement, rather than something more integral to the health service.

I’m not an expert in digital technology, and my personal experience of leading ‘digital transformation’ is limited to upgrading the router at home. Yet, as a doctor, I’ve been on the receiving end of these programmes more times than I’d like to count, sometimes in the NHS and sometimes in allied organisations. It almost always feels like something that is being done ‘to’ me—not ‘for’ me or ‘with’ me—and a seventy percent failure rate sounds about right. Some projects ‘fail’ in the sense of never reaching full roll-out, usually after a last-minute screeching emergency stop; others ‘fail’ in the sense of rolling out, but not delivering the intended outcome.

Today, I’d like to offer a few reflections on where—from my perspective—some of those programmes have gone wrong.

Failing to understand the problem

Lots of projects I’ve been involved in seem to start with process mapping. Someone might ask to interview me, or to observe me, and to diagrammatically represent what I am doing, often concentrating on the ‘information flows’ that I’m generating. This raises a practical problem and a philosophical problem.

The practical issue is that the generated process map is a subjective abstraction of reality. It does not completely record what is done, and some of what is recorded will be scenario-dependent. This ought not to be an issue, as the map ought only to be an aide memoire and understanding of the problem ought to be regularly checked back with the person observed. In my experience, this rarely happens. Worse, the opposite often happens. The process map is redrawn, refined, and reinterpreted, abstracting it further and further from reality.

I vividly remember one occasion on which someone misunderstood what was meant in a process map by ‘agreeing’ a decision. In practice, this meant chatting it over and sense-checking it with a senior member of the team, most often retrospectively, possibly up to a week or so after the decision was made. The resulting software had a mandatory field to be completed at the time the decision is made, including the name of the senior person ‘agreeing’ the decision. The team responded through a workaround, replacing the ‘name’ with a standard phrase regarding delegation; the bug was never fixed. The software misunderstood the process, and the resulting workaround means that records are slightly worse than they were before, as the name of the person providing ‘agreement’ is no longer recorded in a standardised form.

The philosophical problem is that process mapping does not always provide insight into why something is done, which can be valuable information. It appears to be common that processing mapping results in a finding that a particular process is stunningly inefficient: for example, it can be suggested that telephoning someone as part of a process is much less efficient than using some form of asynchronous communication. This is often true, but if the phone call has multiple purposes, only one of which is caught in your process map, then the phone call is still going to have to happen. The ‘more efficient’ approach will be an additional, and therefore inefficient, step.

I’m reminded of an IT-driven project in a general practice surgery which recalled patients for annual reviews pertaining to specific diagnoses—say asthma, or hypertension—using text messages, allowing them to use an automated system to book themselves in at a convenient time. The aim was to reduce pressure on receptionists. The project missed that a large proportion of the patient population had multiple conditions, and that many of them called for multiple reasons. The consequence was that patients ended up attending multiple appointments for annual reviews of multiple conditions, instead of them being covered in a single appointment. Call volumes also dropped less than expected because people were still calling about the ‘other business’ they would have completed during their appointment booking phone call.

Failing to set limits

In large organisations, everyone wants any new IT system to do something specific for their part of the business. Some requirements will inevitably be mutually incompatible—or, at least, not best suited to be completed on a single platform. All too often, the response of the developer seems to be to say ‘yes’ and add to the project cost, rather than setting limits.

This comes up in my field all the time. One common issue is the conflict between surveillance and case management. Surveillance is knowing how much of a disease is in the population at any given period of time. Case management is responding to each individual case. These sound superficially like sensible bed fellows, but they are not.

Surveillance requires very rigid, fixed case definitions: a person is a countable, confirmed case of Disease X if liver enzyme Y is above standard value Z. Absolute certain is required. The real world of case management is much murkier: the validity of interpreting a person with liver enzyme Y above standard value Z to be a confirmed case of Disease X might be questionable if their liver is already inflamed by disease A. The case might be epidemiologically confirmed, but in terms of individual case management, found to have something else entirely. Keeping those two seemingly contradictory facts in the same system is probably not advisable: the potential for confusion is endless, even with the best system architecture in the world. But that doesn’t stop people…

Failing to understand the environment

This is the error I find least straightforward to understand: people creating ‘IT solutions’ that fail to understand the environment in which they are being deployed. Some of these seemed screamingly obvious: rolling out electronic prescribing to wards with one or two computers, or asking care homes without computers to fill in an online dashboard.

Others lacked a more subtle kind of awareness: developing a system to communicate with staff across multiple Local Authorities which required the IT teams in each Authority to install specific software on their systems, for example, or expecting a website which required an up-to-date browser to be accessible in NHS hospitals running on ancient versions of Windows.

The common factor tends to be that it’s the environment external to the organisation commissioning the ‘IT solution’ that is often poorly understood. For a project to succeed, it needs to understand the limitations faced by its users, not just its commissioners.

Failing to plan to evaluate

In medicine, we’re almost obsessive about assessing outcomes. All too often, IT projects only plan to evaluate processes. This is a mistake: an inability to show that a system improves outcomes is often an inability to argue for continued funding.

I was once involved in a project which replaced emailed reports with an online dashboard. The function of the reports was to generate ‘awareness’: for example, to give people a bit of background awareness as to where in the country there might be outbreaks of a specific disease, to help inform risk assessments about individual potential cases who have travelled to the area.

The evaluation plan was entirely about the accuracy of the data on the dashboard and whether the dashboard was accessible to staff. That makes sense if viewing this as an ‘IT problem’: but the actual requirement was for awareness: moving from a model which pushed information to staff to one where staff had to pull information in from a dashboard was an unlikely way to achieve that goal. If those designing the system had planned a proper evaluation up front, that significant hurdle would have revealed itself early on, and they may have taken a different approach.

It’s interesting to reflect that these problems are not just problems with ‘digital transformation’: the broad topic areas are exactly the same as those that trip us up in outbreak management. Sometimes, we don’t understand the problem, perhaps because we misinterpret clinical results or talk to each other in language that means different things to different groups.¹ Occasionally, we don’t properly set limits around what we’re managing, and so end up with outbreak control groups that last for eternity and consider every issue under the sun. We don’t always properly understand the environment, and can give advice that makes no sense on the ground.² And we aren’t perfect at remembering to evaluate our approaches and share our learning, however much we try.

Perhaps these issues are universal. Perhaps they are problems of professional life—or just _life_—rather than anything specific to IT projects. The thing they have in common is that they seem superficially simple, but are hard to both spot and tackle in practice. Communication and teamwork are crucial to solving them: as Makinde says, organisational silos are unhelpful.

And, perhaps, we all need to be a bit—or maybe a byte—more humble in the face of complexity.

1. Communication is the hardest bit of my job. I’ve reflected before about how I’ve gone wrong by fundamentally misunderstanding what someone is saying to me. I’ve mentioned the example of ‘vulnerable’ prisoners, which are two completely different groups of people from a health perspective (likely to become unwell) and from a justice perspective (likely to be attacked by other prisoners). Another example, which often caused confusion in the covid pandemic, is ‘contact tracing’, which can sometimes mean tracing those who have been in contact with an infectious person (to see if they’ve caught it) and can sometimes mean tracing those who were in prior contact (to see where the known case has caught it. The result is that doctors in my profession spend a huge amount of time and effort in trying to make sure that everyone has a shared understanding of what we’re trying to say, but even then, we sometimes fail. ↩
2. I’m a big advocate of visiting places and seeing them with my own eyes when trying to give outbreak advice… which has made recent times challenging.
   

The image at the top of this post was generated by Midjourney.

The third in an occasional series of posts listing things I’ve enjoyed on the web recently.

We Tried On a Kylie Jenner Swimsuit so You Wouldn’t Have To

I’m in the perhaps fortunate position of having really no knowledge of Kylie Jenner. I don’t know what she’s famous for, and I couldn’t pick her out of a line-up. Yet, it seems she has designed some bestselling swimwear, and Flora Gill’s review in Air Mail made me laugh out loud.

While wearing the triangle bikini top, every crevice of my breast was clearly visible; if my nipples were braille, they’d be in caps lock.

But for me the real issue came with the bikini bottom. Here I found myself having to make a decision I don’t often debate with my clothing: Would I rather show my butt crack or my entire bush?

It appears that the power of celebrity to sell knows no bounds.

A decent death

I’ve long been in favour of assisted suicide in theory, though never been entirely convinced that the necessary safeguards could be implemented in practice. I’ll admit that it’s not a topic I’ve given a great deal of thought to recently, but knowing that there have been successful schemes around the world for decades now, I’m probably willing to concede the latter point.

It’s the former point on which Stephen Sedley concentrates in his article for the LRB, plus the politics of the topic. It’s one of those articles that is fascinating from beginning to end, though I accept he’s preaching to the converted. These sentences in particular struck me:

The theological interdictions were not limited to the belief, spoken or unspoken, that all terminal suffering, whatever its degree and duration, was God’s will and not to be curtailed. Anaesthesia was for years opposed on the same ground.

I had no idea that there had been a religious objection to anaesthesia. It’s a fact that feels so loaded with potential for analogy that I’m amazed I’ve never come across it before.

In the same issue, Frederick Wilmott-Smith has a short piece on the US Supreme Court and Texas’s Senate Bill 8, severely limiting access to abortion, which contains this harrowing pair of sentences:

One child, raped by a family member, took an eight-hour journey from Galveston to Oklahoma to get an abortion. Many – principally those without the means to travel out of state – will simply be unable to obtain abortions.

Combined with much else from the last few years, it’s hard not to wonder whether the still-young experiment of the US approach to Government and democracy may be taking a dark turn.

Stop telling kids they’ll die from climate change

According to an article in Wired by Hannah Ritchie,

A recent survey asked 10,000 16- to 25-year-olds in 10 countries about their attitudes about climate change. The results were damning. More than half said “humanity was doomed”; three-quarters said the future was frightening; 55 percent said they would have less opportunities than their parents; 52 percent said family security would be threatened; and 39 percent were hesitant to have children as a result. These attitudes were consistent across countries rich and poor, big and small: from the United States and the United Kingdom to Brazil, the Philippines, India, and Nigeria.

I was quite convinced by the argument that we ought to look at the positives associated with climate change action in their own right, not only as methods of averting disaster. This is also an argument Caroline Lucas often makes, but Ritchie’s framing of the argument in terms of protecting the mental health of young people felt fresh and newly convincing to me.

This government has unleashed something far worse than “sleaze”

For Prospect, Nicholas Reed Langen has written a short but pointed article on the current Government’s attempts to avoid scrutiny.

Throughout his entire premiership, Johnson has shown contempt for anything and anyone who subjects him to independent scrutiny or who holds him to account. In anticipation of opposition from MPs, he tried to prorogue parliament in the weeks leading up to Brexit, and after the Supreme Court struck down his decision, turned his fire on the courts, trying to intimidate the judiciary into a more deferential stance—something which has arguably been achieved, given government ministers’ praise of recent decisions.

And Stuart Heritage covers the same ground in more humorous terms in Airmail (“Short of being an armorer on an Alec Baldwin set, it’s hard to see how his situation could get any worse.”)

Votes for children! Why we should lower the voting age to six

David Runciman has long been arguing for children to have the vote; this Guardian article is as good an exposition of that view as any.

There is no good reason to exclude children from the right to vote. Indeed, I believe there is a strong case for lowering the voting age to six, effectively extending the franchise to any child in full-time education. When I have made this case, as I have done in recent years in a variety of different forums, I am always struck by the reaction I get. It is incredulity. What possible reason could there be to do something so seemingly reckless and foolhardy? Most audiences recognise that our democracy is growing fractious, frustrated and frustrating. Our political divisions are wide and our institutions seem ill-equipped to handle them. But nothing surely could justify allowing children to join in. Wouldn’t it simply make everything worse?

It would not.

I always enjoy listening to Runciman make this argument. My initial reaction was one of incredulity, assuming that it was a terrible idea for reasons I couldn’t quite articulate. Runciman then does a good job of explaining why it feels uncomfortable, and demolishing those arguments.

The argument is an interesting thought exercise, and also a little more convincing each time I hear it.

1: It feels great, if a little anticlimactic, to finally be able to delete “Locum” from my email signature.

2: The North Shields Fish Quay has really smartened up since Wendy and I last visited. It would be nice to live somewhere with a river view, if only it didn’t have to be near a river.

3: Going to Ikea for the 10.30 Sunday browsing opening time isn’t a successful crowd avoidance strategy.

4: Barriers between healthcare organisations can make simple things—like arranging urgent vaccinations—more difficult than they ought to be. Perhaps someone should invent some sort of national health service which provides care based on need rather than budgets, contract provisions and organisational mission statements.

5: Telling patients that they look far too young to have donated blood 61 times makes them want to go back and donate again as soon as possible to receive more flattery.

6: Sometimes, people who use irritating business chatter do actually understand what they’re on about.

7: Business planning isn’t my bag.

8: Th Guardian Daily app doesn’t work properly on Kindle tablets.

9: Loud Christmas music in coffee shops makes settling down with a coffee and a good book difficult. Headphones and white noise on Spotify are an imperfect and antisocial solution.

10: It’s not easy being green: should I buy second-hand books and support the planet or new books and support the author?

11: Durham County Council has meeting rooms with quite spectacular coastal views in Seaham:

12: Dementia friendly parking spaces are now a thing… at least in Hemlington:

13: “At this time of year, it is not uncommon for viruses including influenza and norovirus to circulate in schools. The risk of infection can be reduced by practising good hand hygiene, particularly after using the toilet, after using a tissue to catch a cough or a sneeze, and before eating.”

14: Our TV needs re-tuning. Broadcasts are moving away from the 700MHz band of frequencies to free up spectrum for mobile data instead. Given the profitability of mobile data services and the proliferation of home broadband (especially in the context of PSTN switch-off), I wonder how long over-the-air television broadcast have left?

15: Arguments opposing the Public Libraries Act 1850 included a Conservative view that people “have too much knowledge already” and that “the more education people get the more difficult they are to manage.” In fairness, I suppose people now carry the sum of human knowledge in their pockets and do have a tendency to be rebel against authoritarian control, so perhaps he had a point.

16: The TLS has relaunched with a rather stylish new look. Dr Brian Klass’s comparison of politics in Trump’s America and that in Brexit Britain through the medium of cheese was a particular highlight of this issue for me.

17: Coffee shop Christmas music irritates Wendy even more than me. It’s depressing, or so I’m told.

18: A replacement wing mirror for a 2009 Aygo costs less than £50. I was expecting a much bigger bill after someone completely snapped mine off (and didn’t leave a note!)

19: The brand new Sunderland medical school has some impressive facilities.

20: Colleagues at Middlesbrough Council taught me that routine air quality monitoring still uses diffusion tubes fixed to lampposts; people have to go up in cherry pickers to change the tubes every month.

21: Research into treatments for interstitial lung disease includes a lot of discussion about disease taxonomy and the problem of lumping and splitting: considering diagnoses with the same underlying pathology together (lumping) or as distinct entities (splitting).

22: Cleveland Fire Brigade taught me about their Stay Safe and Warm free one-hour response service for boiler breakdowns where they lend people emergency electric heaters.

23: A wet and dreary Saturday can be a good prompt to light the fire and relax at home.

24: I didn’t know that Sheffield had a hybrid tram-train system until I read this Wired article.

25: Purdah rules can be really annoying sometimes, especially when I’ve done a lot of work to prepare for a meeting I’m no longer able to attend.

26: I thought I learned the etymology of the word “syndrome” after it was featured in a lecture. Yet after thinking about it for a while, the suggestion that it was derived from words for “before” and “diagnosis” didn’t ring true, so I looked it up in the OED online. The lecture version was thus proven to be completely wrong, so I suppose I learned not to take the content of lectures on trust.

27: Only a decade late to the party, I learned that Ecosia—the search engine that plants trees—is a thing.

28: People really don’t know what I do all day. This month, in my health protection role, a meeting of vascular surgeons has invited me to talk about knife crime, a univeristy course has asked me to teach about rural medicine, and a meeting of intensivists has invited me to present on recreational drug toxicology. They may be disappointed at me turning down their kind invitations, but they’d be far more disappointed if I accepted given that I know naff all about any of those topics.

29: Via Lana Greene’s column in 1843, I leaned of the German word “Multioptionsgesellschaft”. It was apparently coined by Peter Gross, a Swiss sociologist, in the early 1990s. It refers to a world swamped by choice, which feels very current: I frequently open Netflix for something to watch and close it a few minutes later with the resignation of not being able to decide.

30: I heard a snippet of a radio programme in which an older person was being interviewed and the subject of loneliness among the elderly came up. The interviewee suggested that while lots of attention has been paid to loneliness recently, too little has been paid to the loss of solitude for many other older people, such as those in care homes. I’d never heard that point made before, and I suspect it will stick with me: solitude is something very important to me.

My recommended read for this weekend is this Wired article by Kyle Vanhemert on what Netflix can learn from the user interface of linear TV. It makes some great points, and it’s great to read someone celebrating older user interfaces instead of another article praising social integration and flat design!

The picture at the top of this post was taken from here, and is used under its Creative Commons licence.

In order to better understand how password crackers crack passwords, Nate Anderson decided to teach himself the technique in a day. His Wired article describing both the process and the lessons he learned from the experience is a must-read for anyone with even a passing interest in the topic. It fascinated me!