In the past couple of weeks, two weighty reports have added to a mountain of literature analysing the grand campaign to computerise the NHS in England. One, from the National Audit Office, tells a familiar story: while lots of digital plumbing has gone in on time and on budget, the important bit - the electronic medical record - is running five years behind schedule.
The other report (ucl.ac.uk/openlearning/research.htm) is harder to boil down into one sentence, which may be why the news pages largely ignored it. Bear with me, though, because it is one of the most thought-provoking analyses yet of the Blair government's infatuation with reforming public services with the help of big IT.
Professor Trisha Greenhalgh and colleagues at University College London, were commissioned to evaluate a small part of the programme: the experience of the first primary care trusts making summaries of patients' medical data available across the NHS care record's "spine". It's an exercise charged with significance. The summary care record (SCR), which the IT programme's technocratic founders saw as a classic low-hanging fruit, has become the main bogey of the programme's critics.
Greenhalgh discovered that the two sides were polarised. The IT agency NHS Connecting for Health made it clear that the evaluation would be used to "inform the wider rollout" of the shared care record, not to decide whether it should go ahead at all. The critics, meanwhile, wanted an answer to the question: "Should large amounts of money have been put into the programme in the first place?"
As it happens, the 138-page report has ammunition for both sides. The IT programme is rapped for its obsession with implementing technology for its own sake, in a manner that flies against the structure and culture of the NHS. More significantly for critics, it recommends that patients be required to give specific consent for their information to be viewed across the electronic system. (The NHS has always insisted that patients can be presumed to have given consent when they register for services.)
But critics get a hard time too. The one-sided focus and emotive language of lobbies such as The Big Opt-Out makes it "difficult to take these campaigns seriously". Professional groups are chided for trying to impose blanket rules about the electronic record's use.
Both sides make polarised claims that are "simplistic, entrenched, moralistic and generate more heat than light".
Has the summary electronic health record been of benefit to patients and the NHS? Not only is it too soon to say, the report concludes, it is too soon even to start constructing useful metrics of success. And here is the crucial point. The national IT programme is what's known in policy-making circles as a "wicked" problem. "It raises complex questions to which many people expect science to provide 'objective' answers, but which are actually questions about social priorities, and which therefore require citizens and policymakers to deliberate about ethics and values as well as about scientific and technological facts." (The same could be said of the national ID card programme and the ContactPoint children's index, of course.)
Without such deliberation, we can't begin to draw up measures of success that are acceptable to all sides. Up to now, Greenhalgh says, the standard of deliberation has been dismal. It certainly hasn't been found in the press, which stands accused of contributing to "mutual demonisation" and a "lamentable lack of criticality" overshadowing sensible debate. As a journalist writing for a paper which has sometimes shown such faults, I can only agree.
