NHS staff: please enter password…

5 minutes and 30 seconds: the time it took this morning for me to turn on my computer and have open all the applications required to start my clinic. This process required six different passwords, producing the mounting frustration that is now an inevitable start to each day that I try to disguise from my patients. This battle continues throughout the clinic, with my time spent on a computer/dictating during one clinic session eventually totalling 2 hours and 30 minutes. Unfortunately, this is not unusual: in October the head of the Royal College of GPs reported to Matt Hancock, the Health Secretary, that it took her 17 minutes just to log on to her surgery computer each day!

But all this is apparently about to change with the UK government’s pledge of £40 million to transform slow log-in times. In a review by the government, some staff had as many as 15 different systems to log into. The hope is that this investment will reduce the time clinicians spend on administrative tasks and allow increased time for patient contact. One would hope that a reduction in the immense frustration of fighting ancient technological systems would, in turn, improve patient’s experience as well.

However, the problems aren’t limited to inefficiencies and frustration. Clearly, the issue of multiple passwords also presents a security risk, either with the all too familiar iPhone ‘Note’ containing a list of all the passwords you ever created, or with the same password repeated across multiple systems.

Chief Executive of NHSX, Mathew Gould, said: ‘tech should be something you rarely think about because it works’. This is a great sentiment, but it still remains difficult to envisage a day going by without the odd frustrated bang of a keyboard.

From the point of view of a frontline NHS worker, it is pleasing to see that these most basic technological shortcomings are being discussed and addressed by the Department for Health. This is a welcome change from the usual discussions of how investment in artificial intelligence will revolutionise the health service at a time that we are still the biggest global user of bleeps and fax machines (based on review data from 2018). 

The money for such investment is now available, but this will not be a simple change. Each Trust has its own IT systems, the contracts for which will need to be changed and integrated individually. We must applaud the government for their tech-focussed approach and listening to the biggest complaints we report on the ground. But I think every NHS worker maintains a quiet pessimism scarred from previous promises such as ‘Paperless NHS by 2018’ (Jeremy Hunt), ‘Paperless NHS by 2020’ (Jeremy Hunt) and ‘Paperless NHS by 2023’ (Bob Wachter). Moreover, in January 2016 the government pledged £4.2bn to NHS IT, and if this didn’t manage to tackle the most basic IT issue of ‘logging-in’ then a certain scepticism remains that another £40million will do the job.

On the whole we must encourage the government to continue to invest in our basic technological needs and think about the future. Until then, I can’t help but feel the ‘Note’ of passwords on my iPhone is here to stay for now…

What are your thoughts? Will the new government investment plans into NHS digital innovation have the required impact? 

Comments (14) Add yours ↓
  1. Hannah Warren Urology registrar

    A compounding problem is that NHS workers are very mobile and so essentially working to a ‘hot desk’ model. It means there is little incentive to find a definitive solution for a poorly funcitoning machine if you can just about hobble through your clinic. It takes the individual more time to call IT to fix the problem (and certainly no guarantee of cure) than to just get going and struggle on.

    Regarding passwords, I am also the guilty owner of the iPhone note. It is just not feasible to keep track of that many regularly changing, complex passwords. Some technology we could certainly make use of in the NHS is the fingerprint recognition that has already long-replaced the pass code on many mobile devices.

    February 1, 2020 Reply
  2. Matthew Bultitude Consultant Urologist

    Nicely written blog and I am sure almost every healthcare professional in the NHS will share these sentiments. My initial reaction was that it ONLY took you 5 mins 30 seconds – often it is much longer just for the PC to start-up before opening all the applications that are needed. Clearly a solution is needed and a work around may be found with ‘single sign-on’ but the NHS needs to stop adding separate stand alone applications for each task and invest in integrated systems – which I appreciate is happening in some areas quicker than others.

    Many patients just can’t comprehend that we are not easily able to view GP records, notes from another NHS hospital and imaging studies automatically. Whilst the NHS currently pursues separate EHR’s for each Trust, surely a single system across primary and secondary care is needed with the unique NHS number being the identifier which then allows necessary access to data from other visits.

    Finally one has to consider the clinical risk of having multiple applications. Different specialities recording notes on different systems introduces risk and whilst electronic prescribing has many benefits, this has meant that the drug chart is now often not easily reviewed on a surgical ward round (given it is yet a different system; different password etc).

    Surely it doesn’t have to be this complicated.

    February 1, 2020 Reply
    • Tom Stonier Urology ST3

      Thanks Mr Bultitude. I think this is right about a single system. The govt/NHS is in a unique position as one ‘company’ to enforce a single EPR system across every primary/secondary care institution which would finally put all the data in one place. This would clearly not be possible in somewhere like the US. And imagine the research potential with that system as well if data collection was properly integrated… (Would be a mega payday for ‘Epic’ or whichever system won the tender!).

      February 3, 2020 Reply
  3. Roland Morley Consultant Urologist

    In the development of IT and protection , efficiency has to be the key to ensure that clinicians , practitioners and staff spend as little wasted time as possible in logging in and the systems must be more integrated and we need less piecemeal individual development as bolt ons!

    February 2, 2020 Reply
  4. Ben Challaocmbe Consultant Urologist

    Tom
    You make some excellent points. It is so frustrating and a waste of time every day logging in.
    I personally don’t understand why we can’t have a fingerprint or optical login once for all systems. It can’t be that hard?!
    I also have 5-8 systems to log to depending on the clinic. If you try and wing it by calling the first patient in to your room you will inevitably get caught out by not knowing key data, so you have to wait. Also playing with the PC whilst speaking to a patient is a communications disaster particularly in cancer clinics.
    For me another huge frustration is the LOGOUT timing. It does this after about five mins so i have to keep putting the password in between patients. In theatre this can be particularly dangerous when the PACS systems logs out mid nephrectomy. There is no facility change these timings either.
    On another note there is no local It integration. As a result patients don’t understand that our two local referring hospitals have different IT systems, so no i can’t get your blood results or scans from 3 miles away, and no i don’t know the results of your tests sent by your local GP.
    the fact we are still talking about bleeps and faxes is outrageous too! We should all be using an NHS specific encrypted communications App such as Siilo- it wouldn’t take long to bring in and then we all use it. It would cut down email traffic too!
    Like you i am pessimistic about the proposed implementation plans, but it has to improve. We owe it to the patients.

    February 2, 2020 Reply
    • Tom Stonier Urology ST3

      Yes playing on computer and discussing cancer not the best. In America I saw one or two consultants who have someone in clinic with them that does all the computer based activity (bringing up letters/images and booking everything) leaving the consultant to only do what they spent so many years training to do – speak to the actual patient!

      February 3, 2020 Reply
    • Jonathan Noël Robotic Fellow

      Great blog Tom.

      Just to say Ben, with respect to the LOGOUT timing, try opening their browser and live stream any radio station. It keeps PACS running…at least where I am currently. I agree, very tricky position to be in during a partial nephrectomy.

      February 16, 2020 Reply
  5. Christian brown Urologist

    Thanks for the update of the newest NHS IT plans. I am very sceptical. Some of the day to day process such as triage of referrals have been ‘modernised’ with online platforms that are totally not fit for purpose and don’t interact with any of the hospitals systems. Last week it scanned through over 40 pages of GP notes until I found the phimosis referral.

    If there is to be an NHS IT solution for the UK it must have significant medical input and not be written with a budget to cut corners and make the users frustrated at its lack of usability.

    February 2, 2020 Reply
  6. Ben Eddy Urologisy

    Great bog and an area that really needs to be addressed in our busy lives. IT systems can be invaluable but have to work without delay and without compromise, poorly thought out digital plans can be a huge hinderance to our practice and I’m not sure we don’t really understand how big the problem is. Our current battle is with automated digital transcribing services that are profoundly slower and prone to error meaning we have to spend more time checking. Our trust recently hit the news when “candida” was transcribed as “cancer” and the mistake was not corrected before the letter was sent out. I agree that a good system is one that we don’t notice and just works! All this means more time spent staring at the screen and less time engaging with the patient.
    So thanks for bringing this to our attention… oh and don’t get me started on emails!!!

    February 3, 2020 Reply
  7. Tim obrien Con urol

    Feeling everyone’s pain …

    Agree with Matt re ‘ only 5 mins ….’ 😀

    The contrast with other industries is startling. The booking and checking-in process for an easy jet flight is now so easy and involves no staff. The customer ie the patient does everything. Compare that with Opd referrals …🤔
    Easy jet aren’t trying to reduce demand though and can put up the price !

    Robert wachter the American who advised the nhs and who Tom mentions gave a great talk about this at baus in 2018. A central theme was that everyone everywhere is going through the pain of using what is essentially an electronic paper record without the interface and usability that make iPhones so brilliant. He felt our generation would feel the pain, the next would see the transformation. Even the transformative ones like PACS which have been amazing ( “the best change in my time as a doctor” @Tsoburol ) frustrate when one has to look at ‘images from outside’ so people resort to exchanging videos on WhatsApp, an interface that does work.

    Not sure how one deals with the concern that an organisation might invest £££ in something horribly clunky ‘2020’ and in 2026 it just looks prehistoric. There is scope for monumental waste of money

    It’s coming but not in my working lifetime…

    February 4, 2020 Reply
  8. Brian Dye Lawyer

    The situation described is a classic economic exam question. Plainly, patients’ utility/welfare would maximised by the NHS having IT systems that are efficient and talk to each other. Doctors’ welfare would also be maximised by this, because they’d carry out their jobs more efficiently and have greater satisfaction in doing so.
    Yet since a healthcare system that provides healthcare free at the point of delivery doen’t have a pricing mechanism to signal to healthcare managers that IT efficiency is valued and is paid for, the result is that, when managers choose the IT systems they develop or buy in, they choose the cheapest, not necessarily the most efficient IT system.
    Once the inefficient systems are installed and operational, there coms into being is what economists call a “prisoners’ dilemma”. Although patient welfare would be maximised by spending money to make the disparate systems talk to each other, managers don’t do this, because it would involve two extra costs: (a) the cost of rectifying the disparate systems and (b) the cost of treating more patients per year, since the generic effect of the inefficiency of the systems is to impose an element of delay in treatment and queuing, over an above the delay and queuing already built into the NHS, so reducing variable costs by the additional queuing element. On a cost-benefit analysis, managers are better off if the issue is not tackled; they don’t get paid for tackling it, but their hospital faces additional costs if they do. Equally, when one looks at the cost benefit to doctors of making, say, political, interventions at managerial level to try to sort things out, they face a big cost in terms of time and effort doing so, perhaps sacrificing time with patients, with not much expectation of benefit, because they perceive the NHS system as fairly immovable.
    In short, therefore, one has a situation where the welfare of many would be maximised by improving the system, but the NHS system itself does not generate the incentives to prioritise improvement of IT.
    What can one do?

    February 4, 2020 Reply
  9. Alastair Dick Orthopaedic Surgeon

    Very interesting blog post Tom. With the huge issues facing the NHS the modernisation of its creaking IT systems seems ever more crucial. The antediluvian state of many NHS IT systems is put into stark contrast with the seemingly endless revolutions in smartphone technology and apps we use every day.

    Though welcome, £40million seems a drop in the ocean compared to the huge investment needed to bring about the sea change required to take us from the current systems (some of which were barely fit for purpose a decade ago) to the nirvana of a universal, fast, secure, easy to use, portable IT system that provides instant access to the entire medical record of any patient, anytime, anywhere. Anything less than this level of aspiration and investment will result in small, piecemeal changes that may shave a few minutes off logging in times, however, will not secure the huge efficiency improvements that a universal, fit for purpose IT system could bring the NHS, its patients and staff.

    February 6, 2020 Reply
  10. Mr Vaibhav Modgil Consultant Urological Surgeon & Andrologist

    I think you’ve summed it up very nicely Tom. I have been baffled by this for some years now. Why is it that we can’t have one card (a passport if you like) that allows us to access all software required to do our job safely and efficiently.

    Furthermore, why oh why can’t we have the same operating systems in every hospital. Most trainees share the dread of having to learn new systems every single year, only to then move to get another system.

    Common sense, surely.

    February 16, 2020 Reply
  11. Jake Patterson Consultant Endourologist

    Nice blog which neatly sums up problems everywhere. We share the frustrations others describe. Brian Dye’s comments about the problems of costs is absolutely spot on too.

    We have a “single sign on”, yet several systems aren’t included and for the last 3 months, my log-on time has been between 6m40 and 43 minutes. Again patients are frustrated that we can’t see images or GP consultation details and wonder what their tax is being spent on.

    Centralised systems have to be the solution, but the cost might be stifling and once implemented the cost of keeping the system contemporary would be an order of magnitude greater than the costs for each standalone trust trying to update their own systems.

    What is the solution? No idea, but the present is not sustainable, and if all the wasted minutes of our expensive time were added up, I’m sure we could go some way to replacing what we are currently stuck with!!

    February 17, 2020 Reply

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