Vision and Value in Health Information

Rigby Michael

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781857758634
• eBook ISBN:
  9781315344683
• Topic: Biological Sciences
• Subtopic: Health Care Delivery
• Index: Biological Sciences

Vision and Value in Health Information offers a significant challenge: to find a place for health information in the modernization of health services in the UK. It comprises a collection of key essays from eminent contributors on the innovative use and development of information in health care.

CHAPTER 1

Edith Körner: visionary, NHS reformer and friend

Alastair Mason

The background

In 1975, Prime Minister Harold Wilson set up a Royal Commission to consider the best use and management of the financial and staff resources of the National Health Service (NHS). It reported in July 1979 to a Conservative government that accepted the larger part of the 117 recommendations.

As usual, implementation was dominated by structural change. The restructuring of 1982 adopted the key recommendation to abolish area health authorities (AHAs). The new structure was to comprise 14 regional health authorities (RHAs), 192 district health authorities (DHAs) and 90 separate family practitioner committees (FPCs).

Royal Commission comments about the need to strengthen local management were also instrumental in the genesis of the management review, led by Roy Griffiths, and the consequent implementation of the general management function in 1984.

The royal commissioners severely criticised the state of the national information systems, which were broadly unchanged from those existing before the previous NHS re-organisation of 1974. In particular, they were concerned about the lack of information available for monitoring and controlling resource utilisation.

The regionally organised computerised hospital activity analysis statistical system contained data about all inpatients discharged from general hospitals. From this regional database a 10% sample was submitted to the Department of Health to form the national hospital inpatient enquiry database. There was a separate mental health enquiry containing information about discharges from psychiatric hospitals and units. A variety of systems collected data about maternity events. The major managerial data sources were Form SH 3, the annual facilities return from each hospital, and Form SBH 203, containing waiting list data. These systems formed a body of statistical data for policy use by the Department of Health, from which standard summary tables were published in report form, inevitably with a time delay. There were major concerns about data accuracy and timeliness, and the relevance to contemporary clinical practice, of the definitions and classifications of all these systems.

However, the royal commissioners also identified some promising information research projects. As part of the ‘clinicians in management’ initiative in the late 1970s, two former district administrators, John Yates and Iden Wickings, were successfully developing new techniques for performance indicators and clinical budgeting. In 1982, concerns about deaths after operations led to the conidential enquiry into peri-operative deaths being set up. Some computing projects were beginning to show the beneits that electronic data capture and storage might bring.

It was against this background that the NHS/DHSS Steering Group on Health Services Information carried out its work from 1980 to 1985.

The steering group

The terms of reference of the steering group were as follows:

To agree, implement and keep under review principles and procedures to guide the future development of health service information systems; to identify and resolve health service information issues requiring a co-ordinated approach; to review health service information systems; and to consider proposals for changes to, or developments in, health service information systems arising elsewhere and, if acceptable, to assess priorities for their development and implementation.

The steering group was to be permanent (to ‘keep under review’), to have primacy in information matters (to ‘resolve issues requiring a co-ordinated approach’) and to be responsible for implementing its proposals. Mrs Edith Körner, vice-chair of the South Western Regional Health Authority, was appointed as chair.

At the time civil servants were very uncomfortable with the concept that an independent, and thus difficult to control, group should be given responsibility to implement its own recommendations. Mrs Körner took her case direct to Secretary of State, Patrick Jenkin, and obtained the implementation commitment that she wanted. The political timing was opportune because in 1980 there was emphasis on greater decentralisation of the NHS, and recognition by ministers that those in the periphery should have more influence on the centre.

Although the remit of the steering group was theoretically wide-ranging, in practice it was seriously limited by not covering primary care or IT and computer systems. The 1982 restructuring had kept the management and delivery of primary care services separate from the hospital and community services and those responsible for policy in the Department of Health and Social Security (DHSS) fought successfully to have general practice information omitted from the scutinity of the steering group. NHS computer personnel, worried about their perceived loss of power, managed to persuade the DHSS to set up a separate NHS Computer Policy Committee in 1981. Despite the original commitment in its remit to the primacy of the steering group, the Computer Policy Committee was given prime responsibility for IT, thus setting the pattern for the next 20 years, with NHS computing firmly in the hands of ‘technocrats’ and not users.

The steering group focused on information for health service management. Although extremely interested in all aspects of information, it did not directly consider epidemiological information about the occurrence of disease, the health needs of populations or health status. Information for clinicians to evaluate their care was not considered unless there were clinical groups willing to work with them. Sophisticated data sets were developed only for accident and emergency consultants and maternity services professionals.

Mrs Körner controlled the membership of her group tightly. Members were chosen for their expertise and experience. The only people there as representatives were consultants nominated by the Joint Consultants’ Committee. NHS administrators, finance officers and information experts heavily outnumbered the few civil servants.

An innovation insisted on by Mrs Körner was that the secretariat should be chosen by her and owe its loyalty to her and not to the civil service from which it came. Indeed, in the first three months a founder member was replaced for failing to comply with this requirement. Although essential for the smooth working of the steering group, such allegiance did not necessarily advance the future careers of civil servants forming the secretariat!

Much to the consternation of the civil service, Mrs Körner insisted that all the papers of the steering group should be made available to anybody who wished to see them. The thoughts and deliberations of the group were not to be kept secret, and interested people were actively encouraged to contribute to its work.

The chair

By choosing the hitherto little-known vice-chair of the South Western RHA to become chair of the steering group, ministers cannot have imagined the force they were unleashing. Mrs Körner may not have had a reputation outside her region, but within it her ability to tackle and solve the really difficult problems without fear or favour was legendary.

I find it very difficult to write objectively about this extraordinary woman As so many adverse things have happened to the NHS it is impossible not to look back at the early 1980s as a golden age. Memories thus tend to be rose-coloured However, David King, one of Mrs Körner’s closest NHS friends, summed up her qualities admirably in Walk Don’t Run, the original set of essays to honour Mrs Körner, published in 1985:

She established her authority by brute ability, being better informed and working harder than anyone else. Everyone accepts that she knows more about the subject and has read more (in several languages) about it than any two other people. Hers is not merely a detailed knowledge of a limited technical subject, for her grasp of health services internationally and the changes they are undergoing provide a general context into which the invaluable auxiliary information fits.

Mrs Körner’s commitment to the task and her capacity for hard work never lagged, even when, in addition to everything else, she was found to be rattling over every inch of British Rail’s track to attend or address meetings. Happily, these formidable qualities are leavened with a keen sense of humour, and when Körner activity was in full flood, it was rare to meet anyone engaged in it who did not start the conversation with the latest anecdote or bon mot.

Powerful intellect and incisive humour are not always an endearing combination unless, as in her case, they go with a genuine regard for others, whatever their station and ability. This respect and affection for the NHS and its staff were apparent to all, and people sensed that here was a reformer with her heart in the right place.

The friend

Colleagues who have suffered over the last 15 years with chairs, bent solely on supporting the political fancies of the day, will envy the relationships we had within the steering group. Mrs Körner was a Jewess, born originally in Czechoslovakia, and blessed with many of the talents of this culturally rich group of immigrants who arrived during the 1930s.

Like the archetype Jewish grandmother she worried. She worried about the progress of the work; she worried about us in the secretariat, and she worried, above all, from day one, about how recommendations were to be implemented. Indeed, Mrs Körner was only happy when she was worrying. Many a Friday evening I received a telephone call about a new danger facing us, allowing me to share it with her over the weekend. This constant concern about what was, and what might happen, underpinned an attention to detail and the rapid resolution of potential conflicts that were essential to the successful completion of the work

Mrs Körner’s command of the English language was unsurpassed. Tom Stoppard, a fellow countryman, sent her his plays in draft for comment. She wrote brilliant satirical pieces for the health and social services journal, including the cult-status column ‘Dear Charles’. Although we in the secretariat did the technical writing, Mrs Körner meticulously corrected the punctuation, added a final literary gloss and chose the frequently obscure but always apt quotation associated with each publication. The clarity of the writing was a major reason for the ready acceptance of the recommendations by NHS staff.

We travelled endlessly to market our proposals and to hear the views of the NHS face-to-face. However inept the comment or malicious the intent, she treated all questioners as intellectual equals and never put down or embarrassed them in public. This active engagement with NHS rank and ile engendered a respect and affection still held today by all who were involved. There was feeling amongst many that although they may not have understood the technical merits of the recommendations they must be good because she was.

Mrs Körner took a genuine interest in our families, sharing concern about childhood ailments and offering excellent advice about educational and behavioural problems. One of my children in his teens needed some time and space to himself, and she and her husband, typically generous, entertained him for a week with very successful results.

Indeed, the most memorable experience of that period was a personal moment not a work one. Three years into the project we were invited to a World Health Organization (WHO) conference in Düsseldorf. This was the first time she had returned to Germany since travelling through it alone in 1938 in a sealed railway carriage as a 17-year-old girl on the way to freedom in England. Though very apprehensive she behaved with dignity and supreme professionalism. The only clue to the inner turmoil of emotions was the doubling of an already significant nicotine habit. It was a privilege to have been with her.

The vision

The work done by the steering group was informed by the clear vision developed by its chair. The activity focused on information for health service management. The guiding principle governing the approach was that data should be collected because they are essential for operational purposes. User-orientated information yields benefits to those who collect it, and thus provides an incentive for accuracy and expedition. From this simple central vision there emerged a number of logical consequences.

• The central DHSS returns, which at that time totally dominated the development of information systems, must be determined by the data required locally. The information needs of district management should be paramount and the data submitted to the DHSS confined to a small subset of the district data set.
• Every DHA and its officers need a minimum amount of data available to them, collected as a by-product of operational processes, to carry out their management function. An authority not regularly using such data is handicapped by being inadequately informed when fulfilling its responsibilities.
• The recommendations about data items to be included in the district minimum data set should be a compromise between the desirable, the feasible and the affordable. It was felt that this pragmatic approach would lead to proposals adopted in a reasonable timescale, with feasibility being defined as implementable within three years
• In order to make informed judgements about their own performance, members and officers require information not only about their own district but also comparable information about others. To enhance the validity of such comparisons, standard definitions and classifications should be developed for each requisite data item.
• Although the district minimum data set is relevant to operational managers, most units and departments will wish to collect more data for their own purposes. However, the variety of local arrangements militates against the national prescription of standard data sets for every managerial entity.
• To meet the increasing need for IT within districts, considerable design work is essential to ensure compatibility between different computer systems. Investment in computer systems was considered by the steering group to be only justified when the benefits of better information were added to the improvements in operational processes.
• As clinical and management practices ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Dedication
• Foreword
• Preface
• About the editor
• About the contributors
• Introduction
• Chapter 1 Edith Körner: visionary, NHS reformer and friend
• Chapter 2 Learning from history
• Chapter 3 Improving the United Kingdom’s health system: an adaptive model to harness information and evidence
• Chapter 4 The need for a new healthcare paradigm: patient-centred and knowledge-driven
• Chapter 5 Information as the patient’s advocate
• Chapter 6 Information for practice improvement
• Chapter 7 Information for good governance
• Chapter 8 Information for the assessment of health outcomes
• Chapter 9 Principles and purpose for child health informatics
• Chapter 10 New methods of documenting health visiting practice
• Chapter 11 Using information for public benefit
• Chapter 12 Globalisation or localisation: common truths or local knowledge?
• Index