I’ve been meaning to visit the Wellcome Collection for quite some time – I’ve been received the Trust’s newsletters via post for years. I finally found half an hour to pop in this morning, and would highly recommend it (though 30 minutes is clearly not long enough!). Above is William Cobbing’s Palindrome, an artistic expression of the fact that the pelvis and the skull are thought to share a common evolutionary bony ancestor.

And below, since I just couldn’t choose which photo to use today, is the complete human genome in printed form. Not only is it an impressive display of human achievement, it also provides a slightly depressing reminder of the relative weediness of the Y chromosome!

Both of these exhibits are from the Medicine Now exhibition, which is permanent, free, and well worth a visit.

Whilst portfolios may encourage students to reflect, the quality of those reflections cannot be assumed. The substantial time commitment required for completion of a portfolio may detract from other important aspects of learning. It is vital to ensure that portfolios can be completed as easily and efficiently as possible, perhaps through encouraging students to include fewer pieces of evidence.

Select sentences from Buckley et al, 2009, Medical Teacher 31: 282-298. Just thought this might brighten up the day of some of my medical colleagues.

The problem faced by public health campaigns in the UK is the tendency for people to react to being told what to do.

Benjamin Daniels, Confessions of a GP

Perhaps it’s simply the word ‘failure’ that needs addressing: let’s change the name of the diagnosis to ‘reduced cardiac success’ and see if that makes any difference.

Dr Tony Copperfield, Sick Notes

Five reasons why this video (whilst it makes an important and valid wider point) irritates me:
1. It doesn’t acknowledge that both A (on the left) and B (on the right) are both, ultimately, working for profit rather than purely for the benefit of patients.
2. It doesn’t acknowledge that A likely employs salaried doctors like B, with similar issues.
3. It doesn’t acknowledge that since A opted out of providing out-of-hours care, B has stepped in to provide it. In fact, it’s B who’s illustrated at walking out at the end, just when B’s colleagues are kicking into action.
4. It suggests that non-partner doctors hold less professionalism, and are less concerned with patient welfare. Such doctors include many GPs, as well as virtually all secondary and tertiary care physicians and surgeons.
5. It doesn’t acknowledge a single advantage of the corporate model. A’s approach may well be preferable as a whole, but B’s approach is not without merit, and it’s idiotic to suggest that it is.

This #nhsreform mythbuster from DH is overtly party political (“we will never, ever privatise the NHS”).

I’m not comfortable with statements which are so clearly partisan being ascribed to DH, and I’m surprised the Civil Service didn’t prevent it. Such bodies shouldn’t be political puppets.

Also, some of the “myths” are blatantly not “myths” – e.g. “You are introducing competition in the NHS”

This has really got me riled – and I’m not the only one.

Re: this article.

A mother chooses to disclose the contents of a private letter telling her that her son that he’s on the 98th centile for BMI. She does this by calling him “fat”. This upsets him. So she has a picture of him printed in a national newspaper with a report explaining that he’s reportedly “fat”. And then blames the NHS. Exasperating!

Perhaps the letter she received needs refining. Perhaps a letter isn’t the appropriate way to communicate this info.

But the bare choice is between:
a) Not monitoring children’s health
b) Monitoring but not disclosing the results
c) Monitoring and giving advice to parents of children with a high BMI

I can only ever see “c” being the ethical option.

Would this mother really have preferred not to know that her child is at statistically increased risk of a variety of diseases? Would she really rather not have been given advice on how to help? Was it really ethical of the Daily Mail to cash in on her unhappiness rather than pointing her in the direction of her GP?

I suspect the answer to all three is “no”.

Rant over.

There’s a certain air of truculence on this blog at the moment. Yesterday, I took NatWest to task (again) over their awful customer charter, and only last Thursday, I slated Who Wants to be a Millionaire HD. And now, I’m about to moan again. Sorry about that – I know it’s spring, and perhaps my disposition should be sunnier, but there seems to be a queue of things I have to get off my chest at the moment.

Today, I want to moan about NHS Mail. This may seem utterly irrelevant to those outside of the NHS, and, in fact, to the majority within the NHS who choose not to have an account, but actually I hope it gives a reasonable insight into how not to design a user interface.

The user interface of NHS Mail is bloody awful. Really, really terrible. It’s designed by Microsoft, which perhaps goes some way to explaining that, but even for them, it’s bad. Let me give you a tour.

Firstly, the homepage, conveniently located at nhs.net. This looks utterly different depending on whether you are accessing it from an N3 connection, or a plain old internet connection. Neither of the homepages is particularly pretty, but the inconsistency bothers me in particular.

This is a bad thing for a whole plethora of reasons, but primarily because a lack of consistent branding surely presents a security risk. Anyone could knock up a log-in page in a couple of minutes, and a lack of branding would not make it appear untrustworthy.

Now, let’s look at that ex-net login page more closely. The password must be entered in two parts – the first three characters must be entered using the on-screen keyboard, presumably as some sort of protection against keystroke logging software. Yet this isn’t explained anywhere on screen, and it clearly reduces the accessibility of the site for those with disabilities. And the username and password boxes don’t even line up, which is just irritating.

You’re also asked to select whether the computer is private or public – but no explanation is given of the impact of this choice. It took me some considerable time to discover that the impact was actually that selecting ‘public’ prevents download of email attachments. This is hardly common behaviour for email systems – perhaps a little explanation might have been useful.

Assuming you manage to log in, you’re presented with this page.

Now consider some common – perhaps predictable – workflows.

Let’s imagine that  I want to send a new fax message. Where do I click? Logically, I would choose to click “New Message”. That sounds sensible. But it’s also very wrong. Perhaps the envelope in the blue bar at the top? No, that just reloads the current page.

In fact, the correct place to click is the “Spanner and Screwdriver” icon at the top – tool-tipped as “User Tools”, which brings up the following page.

From here, you jump to the icon at the bottom-left of the page labelled “SMS and Fax”, followed by a button on the top-left of the resulting page labelled “Create Fax”.

In precisely whose world is that a logical series of clicks?

Another example. We’re back at the inbox, as pictured above. I want to change my password. Simple – I click “Options” in the top-right. Wrong. On some pages, there’s a “Preferences” button appears the top-right, above “Options”. Is it there? No. Sharper readers will already have noticed from the above screenshot that it is, in fact, in “User Tools” again. Bizarre.

Something I frequently forget is the IMAP settings for NHS Mail. So where would one hope to locate those? Perhaps you’d consider clicking the “?” help icon? You’d be wrong. “User Tools”? Yes.

Perhaps you’d then be tempted to click on “Configure Microsoft Outlook”. That would be wrong. Perhaps you’d click “Help”. That would also be wrong. You must click “Guidance”, down on the bottom right, followed by “Training and Guidance” – not any of the other options, which include “User Guide”.

Again, something which should be really easy to locate is hidden away.

Frankly, the organsiation of the UI of NHS Mail is not fit for purpose. It’s virtually unusable, and I suspect that goes a long way to explaining why so few NHS people have NHS Mail accounts. And yet, I understand that Connecting for Health pays Microsoft £1.90 per user per month – that’s over £12m per year – for the service.

You’d think that, for that money, there would be at least some usability testing, yet it’s hard to see that assumption evidenced by results.

A story is doing the rounds today, much like recent similar stories, about a child called Tom Halton and receipt of a letter telling his parents that his BMI was higher than expected for his age.

Before I go any further with this post, I need to point out that the BBC are talking rubbish about the story. Their second paragraph:

Tom Halton, 11, of Barnsley was told he was overweight after taking part in a national scheme which measured children’s body mass index.

Not true. The letter was sent to Tom’s parents, not Tom. They chose to share it with him. This upset Tom, and he didn’t eat his dinner that night.

The facts are these: Tom’s BMI is heavier than 93% of children his age. The World Health Organisation classifies him as overweight. An increased childhood BMI is associated with lifelong adult illness, in particular Type II Diabetes.

Yes, there are problems with using BMI for purposes like these, particularly in children, and the letter should have acknowledged those more clearly. But it is wrong to simply ignore the best indicators we have in children of their future adult health.

Tom’s dad said:

These letters are doing more harm than good. You might as well send a T shirt with FATTY on it. The impression it gives is that your child is fat, it’s your fault and they will die from a horrible disease.

The letter is not the best written in the world, but it makes the point fairly clearly that the high BMI increased Tom’s risk of future illness. Which, to be blunt, it does.

As for the T-shirt comment, it strikes me firstly that it was the parents who shared this letter with their child, and have now plastered him over the papers with headlines calling him “fat”. Why?

I note that the “grovelling apology” from the DoH actually apologises for causing the parents offence if they felt their parenting skills were being derided – which is not suggested at any point in the letter.

So where do Dan and Tracy Halton suggest we go from here? I’m genuinely interested to hear their views – and yours. Do we inform parents of modifiable statistical risks to their children’s health and wellbeing, or not? If so, how do we go about it? Is writing to parents not the best way to tackle this? Would individual consultation where the full facts could be clearly explained be a better option? Or does that come across as being “summoned to the headmaster’s office”, and yet more punitive (and expensive)?

What do we do? How do we tackle this? I’d love to know your thoughts.

The inefficient status quo - surely there's a better way?

There’s been a lot of heat about the NHS National Programme for IT recently, with both Labour and the Conservatives suggesting that it will be, at best, scaled back. Often referred to as “the £12bn NHS Computer”, the idea of having a national IT system for the NHS is often ridiculed as one of Whitehall’s biggest white elephants.

But, contrary to what almost everyone else thinks, I firmly believe that a national NHS computer system is a good idea. I think it has the potential to revolutionise healthcare, and vastly improve the health of the British population in a much more meaningful way than anything else the NHS has ever done.

As a doctor, I’ve worked with a variety of NHS IT systems, some of which are brilliant, and some of which are terrible. On the one hand, I’ve worked with an electronic patient record system in a hospital Trust that is an absolute disaster of a system. It does not fit in to the way anybody works, it is obstructive, and it actually provides less data in a less useful manner than the paper system it replaced. It is terrible, and should never have been introduced. Projects like this give NHS IT a bad name.

On the other hand, I’ve worked with SystmOne in Primary Care, which is a Department of Health endorsed Über success of a computer system. The data is stored in a secure cloud, the program auto-updates, and it is constantly being improved. It’s a massively powerful system. When recent research showed that a high proportion of patients with diabetes and a history of heart attacks would have undiagnosed heart failure, it was the work of moments for a practice near me to generate a list of such patients and invite them for screening. The upshot was that the detection rate for heart failure soared by a factor of ten, and those patients are on the right treatment for their condition.

Without the IT system, this could not have been efficiently acheieved. It would have involved looking through thousands of sets of paper notes, which is just not practically possible. The implications for the availability of this sort of intervention are manifest. And that’s on top of the often sold benefits of all doctors, wherever you go, having access to the same set of complete medical records.

The disease-coding in SystmOne is done in an intelligent and unobtrusive way. If I type someone’s blood pressure in as part of a consultation, this is coded instantly and automatically by the computer, which merely highlights the data to show that it has been entered into an encoded database. Similarly for when I enter a diagnosis – coding is quick, automatic, and accurate. If, for example, I note that someone has diabetes, this is automatically captured and the patient is automatically sent letters for diabetic annual reviews. That is astoundingly clever, and stops individuals falling through nets.

Incidentally, the crap IT system does none of this. It is badly designed by people not familiar with the day-to-day workings of individuals in the hospital, and is actually obstructive when it comes to getting things done.

In most hospitals which remain paper-based, data intelligence just does not exist. The data on millions of pages of paper notes cannot be effectively mined. In order to receive payment for the services an NHS hospital provides, all the paper notes are shipped to a department named ‘coding’, where they are combed through by a team of non-medically trained secretaries, who decide from the often illegible medical notes how many patients with a given condition have been treated, and what interventions have taken place. It is slow, innaccurate, labour intensive, and doesn’t result in a patient identifiable database for mining. It is an extraordinary waste of time and money.

If a system like SystmOne could be extended to cover all NHS care, all over the country, the database it would produce would be immense, and the opportunities for mining of that data would be far more advanced than anything else undertaken by any country on earth. We would know at a glance if an outbreak of a disease was happening in a paticular area of the country. Research could be acted upon in a flash with intelligent, national, targeted screening programmes. And that is just the start.

A well implemented national NHS IT computer system would revolutionise care in the NHS – and frankly, for that, £12bn is an absolute steal.

This post is based on my contribution to Episode 17 of The Pod Delusion, originally broadcast on 15th January 2010. Other topics that week included “The Big Freeze”, Google, and ITV’s regional decline. How could you not want to listen to the whole thing at poddelusion.co.uk?