The wonders(?) of early NHS Computerisation

In the mid 1970’s The DHSS managed to get approval to spend money on 3 experiments in Hospital Computing. 2 London Hospitals were to set up computerized In Patient systems and a Northern Regional Hospital was to set up an Out Patient System (A much more daunting task in may ways because of the much larger number of potential patients whose details needed to be part of its initial patient index.)

The Public Accounts Committee a few years later enquired what the outcome of this expenditure was. The ambitious Out Patient project (not surprisingly) had failed and one of the 2 In Patient projects had achieved nothing - in fact the money assigned by Parliament to the DHSS for this project had been swallowed up in the day to day running costs of the hospital concerned. Red faces all round among the senior civil servants accountable to the PAC for the use of public monies! The only project where they could point to the money still being used (however successfully) for the purpose intended was the London Hospital Whitechapel. Its Chief Administrator had the vision of the computer replacing the telephone system for the ordering of tests and feeding back the results in place of the paper trail in situ at the time - a praiseworthy objective. This site and its IT staff were held up as gurus and were much consulted by DHSS Civil servants for years to come not because they had achieved what they set out to do but because they had not given up and were still there…. trying.

One of the expected benefits to have emerged from the computerization of records and order requests was a reduction in the numbers of clerical staff employed to file and recover medical records. A few years in to the project it seemed a good idea to evaluate if this aim had been achieved. I got involved peripherally around 1978 when the Chief Administrator of the hospital had been appointed Regional Administrator and had in fact ordered that the highest priority capital development for the City & East London Area should be the urgent replacement of this Computer system (on which by then the hospital had come to rely). In those days of supposedly rational comprehensive planning, major capital developments would be proposed evaluated costed and scheduled into a rolling 3 year programme. It was not unusual for major patient centred developments to languish in year 2 of the short term programme for 3 to 4 years before funds were eventually allocated. It upset a number of people then when the computer replacement had to be number one for expenditure in the next year, not having been in the programme before. As a result a visit was made to see why the hospital had become so dependant on the computerized system that its imminent failure, unless replaced, was a danger to patient care.

The visit ascertained that the 20 evaluation staff had for many years been so busy fighting fires with the system that to all intents and purposes they were additional medical records staff and when added to the clerical staff who were recognized as such meant that the hospital employed nearly 3 times the number per 100 beds than any other hospital in the country. So much for replacing inefficient paper based systems. However not to be daunted, in the afternoon the Computer Manager showed the visitors the impressive high speed printers pumping out hundreds of post paid cards to patients notifying them of a clinic cancellation. Now this must be better than the previous system of notifying patients of late cancellations thus saving them the waste of time and expense of arriving only to be told the clinic was postponed.

At the sight of the mammoth pile of personally addressed cancellation notices being spewed out from the noisy printer, all present agreed it was a most impressive illustration of the benefits to patients of the computerization of records and maybe even offset the additional running costs of the system. That was until one inquisitive visiting nurse picked up one the cards and read it loud to everyone. The essence of which was to notify an individual patient that the clinic they were due to attend had been cancelled and that a new appointment had been made for 3 weeks time …. unfortunately their appointment was for 10:15 that morning and the earliest they would receive the notification would be the next day!

A couple of years later it was argued that a lower cost solution at St Bartholomew’s hospital using mini (not mainframe) computers and supported part time by only 3 Medical Physics staff, should be discontinued and instead St Bartholomew’s should make use of the London Hospital Whitechapel system (described above). I was to attend some user group meetings at the London Hospital as the representative of Barts.

The cheap and cheerful system at Barts was able to make use of printers that could print lower as well as upper case, which meant that any patient correspondence looked decent. The London’s mainframe printers however could only manage upper case and letters were not always aligned. (I knew this because I had received such letters from the hospital notifying me that although I had already waited 1 year for a hip replacement that because of consultant staff disagreeing about where to do such operations in the future all lists had been abandoned and once they had sorted it out I would be allocated to a new waiting list and could expect to still wait a further 12 months.) When I asked if we could continue to have lower case letters used in correspondence with patients I was told that this was too expensive for the mainframe printers and we would have to get used to Upper Case only, like every one else using the system.

I was however more shocked to find the discussion at the user group taking a bizarre turn when a consultant representative asked the Computer department to produce a 3rd copy of the daily Lab Results print out. It appeared that each patient specific report was printed out in the Labs and sent by internal post to the medical records department where it would be filed in the patient’s paper record. (This could take a week or two). To assist in responding to urgent requests a bulky fanfold print out of each day’s results was retained in the Path Lab so staff could refer to it to respond to doctors wanting urgent results.

Although this seemed to work well someone had the bright idea that a second copy of this daily printout should be located in the Out Patients department to be consulted when required, thus avoiding the frustration of ringing the Labs to get an urgent result only to find all phones were engaged. This worked quite well but because of the underlying delays in getting results onto the patient’s records some medical staff had decided they should cut the required results from this 2nd copy of the batch report of daily Lab Test results and stick it in the patient’s paper record themselves. However the extracted report was not always cut out neatly and might include part of the report from the lines above and below. This meant that those results could not be read in Out Patients as they had been “vandalized” by colleagues.

The meeting I attended therefore considered whether to provide a 3rd copy that would not be cut in this way to ensure that urgent results could be accessed. Everyone (except me) thought this was an excellent idea and a good use of the limited computer development funds.

Of course these days, with networked computers, results can be called up on screen by those authorized to view them “any time, any place any where” so it might be difficult for some to imagine this crazy state of affairs. However this pattern of “patch and mend” and then patching the patches does reflect that side of human nature that seems more comfortable with incremental adjustments than any rational reappraisal of systems to evaluate if they achieve objectives – so I trust that this account rings true into the future because we continue to experience similar behaviour in many other fields of human activity.

The Hospital that was Stolen in the Night!

In the Ilford District of East London there were a number of small “local” hospitals providing what would now be provided by a single “District General Hospital”. One of these was in Dagenham and was sited relatively close to the Thames on land that was rich in gravel which would be excavated once a new Hospital opened thus allowing the small hospitals to close.

This particular hospital had been erected by the Army about the time of World War 1 and consisted of around 8 temporary huts. These had a low brick wall and rounded sheets of corrugated metal to provide walls and roof. The inside skin of the buildings consisted of wooden lathes and plaster fixed to the same low brick walls. This was typical of a fair proportion of the 1948 building stock of the NHS as in the 2nd World War the Americans built something similar but used single story brick built out houses. These hospitals were classed as EMS (Emergency Medical Service) hospitals. Dagenham hospital was one of the last remaining 1st World War EMS hospitals in 1984. It was located at the end of a narrow badly lit lane between houses on a 1950’s housing estate – so few people even knew it existed. An ideal place to house elderly patients who had few people to visit them then!

Despite all of that the interior of the huts were great for the nursing care of elderly patients. The width of a typical ward was around 30% greater than today’s designs and with regular licks of paint and a willingness to pay for the wasted heat that escaped through the uninsulated buildings actually provided comfortable patient accommodation.

As was the nature with NHS capital programmes at the time the new buildings kept getting postponed so that in my time we could no longer put off doing some remedial work at the hospital to make it last about another 3 years. Unfortunately this proved impossible as the structural survey, we felt needed to be carried out to make sure any remedial work could be done safely, was itself deemed dangerous. The report I received stated that normally the integrity of the external cladding would be best inspected from inside by probing through the internal lathe and plaster skin. However Structural engineers soon realised that the internal skin was in fact holding up the rest of these buildings so it was deemed unsafe to disturb them….. oops and a case of fingers being crossed!

A couple of years after I left I spoke to the acting general manager who told me how he had been called at his home over Christmas to be told that the by then deserted hospital had been stolen!Apparently some enterprising entrepreneurs had driven lorries unnoticed down the badly lit lane to the disused hospital and stripped the huts of their metal cladding and any other recyclable material they could find. So sometime between Christmas and New Year the hospital disappeared or was stolen.

The acting General Manager pondered whether he should report the “loss” to the police and decided it was not necessary as the entrepreneurs had actually saved the authority some money. The Authority was in the process of inviting tenders for the clearing of the site so that it could then be sold with mineral rights for gravel extraction without encumbrance. The health authority had in fact been prepared to pay someone to do what these unknown “public spirited” opportunistic East Enders had done. He thought it was a great Christmas present for the health authority