Back @ the EPR Arms: March 2020 Sean Brennan's Farewell to Arms

There was a nip in the air – made worse by the icy breeze that was the remains of a storm called Cecil or Denis or a Spanish name. I can’t remember – and I don’t actually care what it was called – but I tell you this, I had a name for it, which we’d better not go into.

A sombre evening tonight. I’d just watched residents and businesses ‘round our way’ bailing out their buildings again so soon after the last flood. We’re getting weird weather for February. Is Global Warming now accepted as a real thing?  I mean - where’s the Winter been? ‘We need a good old frost to kill our germs’. Not happened yet, so I can’t look forward to daffodils until I’ve earned them by having that winter. Speaking of germs, Coronavirus is upon us. I remember the Corona van man used to come selling us pop when I was a lad; this is more serious than that. Or so they say. The Media are certainly doing their bit to stoke up the panic- ‘Breaking News: Supermarkets in Australia are running low on toilet rolls!’

I need a pint.

And so, with a heavier than normal heart, I pushed into a very busy EPR Arms. Noisy, hot, bustling with activity. Lots of faces I recognised - faces from a long time ago. I was flummoxed. I got my hand sanitiser ready.

‘Why? What? How?’

‘It’s for you!’ one person said.

‘Me?’ I asked incredulously.

‘You – we heard you were leaving.’

By ‘eck that didn’t take long to do the rounds did it.

‘I’ll have a pint of your best Badgers Crushed Paw bitter please landlord!’ I shouted over the din.

‘No need to order – you’ve a table full over yon…...’ ‘Landlord Bill indicated with his damp pot cloth. ‘…..and some scratchings - bags of ‘em! ‘

‘So Why? How? What?‘ I asked, simply re-arranging the order of the words in case it made more sense that way round. Jamie Beattie the Information Manager from the hospital across the road answered.

‘We’ve all worked with you or heard you speak or read your book or that column in that journal’

‘Down at the EPR Arms?’ I offered.

‘That’s the one innit!’ interjected Adam with a single earring. ‘We thought what better place to have a leaving do than here – at the EPR Arms. In fact, isn’t that a co-incidence. This pub’s called The EPR Arms’!

He was never at the front of the queue for anything that lad!

‘So, before we start with your leaving do,’ said Jamie – always ready to focus down on the point, ‘why don’t you fill me/us in on your career a bit? I mean - when did it start? What have you done? What now? That sort of thing.’

I focussed in on my point! Bitter that is. (That’s the Irish in my DNA coming out!)

‘Look, this is going to take a while. Can we sit down over there in that corner?’ as I led Jamie away from the hubbub and found a table near the window.

’I’ve had a long and varied career in the NHS, starting out as a young lad - well – 16 actually, when I joined the NHS as a trainee laboratory technician at Bolton Royal Infirmary in 1968.’

‘Fillpin’ ‘eck. 1968? Whoa! Whoa! Whoa! No way Jose. I mean, you don’t look a day over ….. over …. Well!  Oh ……OK carry on!’

‘Well, nearly ten years later, after following that Pathology career and educational qualification route, I ended up with a Fellowship of the Institute of Medical Laboratory Sciences.’

We’d lost Adam by this time with his attention-span of a gnat.

I continued, more for myself than to anyone else who may have been listening.

‘In 1984 I moved from Bolton (in Lancashire) over here to Huddersfield (in Yorkshire) for promotion to Chief Medical Laboratory Scientific Officer in Immunology. Not many miles between the two towns (33 actually) but a huge, huge leap for a Lancastrian.’

‘Brave Lad!’ said Fred, the resident oldie at the bar, who had overheard. ‘Lucky we let you in!’

I wasn’t going to mention the War of the Roses - some things are best left alone.

‘So, what then then?’ asked Jamie ignoring Fred.

‘Well, the early 90’s saw me taken away from my cosy career in Pathology to be re-trained as a General Manager which resulted in me being asked to establish a Medical (which became Clinical) Audit unit in a hospital (pre-Trust) that was one of four Resource Management pilot sites in the NHS’.

‘Resource what?’ piped in Jamie again.

‘Resource Management – I remember that!’ said a loud voice as a man approached the table and sat with us.  ‘I was just a SHO in those days and look at me now- Medical Director for my sins!’

Yes, it was Michael Wood – a surgeon by trade. Our times at the hospitals overlapped for a while.

‘Yes, I remember it well. Another of those exciting ‘Visions for a Better Future’ projects underpinned by substantial technology. I mean – what on earth could possibly go wrong eh?’

 ‘Yes, but what exactly is or was Resource Management?’ asked Jamie

Michael continued. ‘Resource Management resulted in the re-design of our hospital management to be more clinically-led, with the creation of Directorates. Many clinicians, including myself became involved in management roles for the first time. It was a really exciting time with a bright and energetic CEO leading the way.’

I joined in as it was MY story after all! ‘But underpinning this re-organisation was the realisation that good quality, and timely, clinical and financial data was needed to support this new model. Every hospital had to implement a clinical database (aka ‘Clinical Case-mix’ box) which took clinical activities and attached financial information to it.’

‘Yes, before my time,’ said a new occupant of my increasingly busy table - Bob Smithson the Director of Finance, ‘but I read about it at college!’ He almost made it sound like something his Granny told him about while he sat on her knee. That didn’t make me feel any younger I tell you.

He continued, ‘for the first time, we could look at the resources required to undertaken certain procedures! How much each and every item used in the delivery of these ‘interventions’ was calculated. £2.56 for a full blood count. £100 a day for ‘hotel costs’ of an overnight stay. £69/minute in theatre[i]. Armed with such data we could accurately manage the total costs of running a hospital. Total!’’

‘Yes Bob, we know!’ said Michael, ‘It was US that had to measure and calculate those costs. Didn’t go down well with us clinicians at the time I tell you! ‘The NHS is NOT about money. It is about clinical care!’’

A statement guaranteed to get a response from any Finance Director. It didn’t disappoint. ‘But you had a finite budget. How did you know how to spend it appropriately if you didn’t know how much a hip replacement cost? How? How do you know how many you can afford to do in a year? How? How?’ asked Bob sounding more and more like Sitting Bull than Sitting Bob.

‘I know that now but at that time it was all new to us guys and gals I tell you,’ continued Michael. In his role now as Medical Director he knows too well the turmoil and tussles that go into agreeing what gets done and what doesn’t.

 He continued, ‘I remember, we had to time all activity and count all consumables used so we could work out a total cost of everything. In fact, when I was a SHO in Surgery, we had to cost not the theatre in total but the cost of every minute in pre-op/anaesthetic room, the theatre itself, and the recovery area to allow us to accurately assign a total cost to the total operative experience. It was great fun – NOT!’

I wrestled the conversation back to ‘the Leaving Boy’ – me! ‘This is where I first encountered clinical coding. If you want to perform analysis on clinical activity, you need to accurately identify what that activity is/was. This was where I learned to ‘code’ with ICD 3 (or whatever the number was at that time – actually ICD 9 I think[ii]!’

(On a similar note, it was slightly depressing to note that I remember buying the first ever ‘Now That’s What I call Music’ album which had NO NUMBER!![iii]’)

‘It was also where I first ‘got into’ health informatics and Clinical IT. In my mind, where this initiative failed, and why eventually ALL these clinical case-mix boxes were switched off, was that the NHS wasn’t quite ready to capture all this data in real-time. Remember, this was before mobile computing. Drugs that had been administered were recorded on paper and then transcribed into the clinical database at the end of the working day (except at Arrowe Park hospital on the Wirral where they had put in electronic prescribing - more about this below). It was never really seen as being ‘mission critical’ for clinicians and perceived as more of a ‘management tool!’

As hinted at above, one of the four RM pilot-sites (Arrowe Park) delayed their implementation and central funding of their ‘Case-mix box’ until data could be captured operationally ‘off the back of the clinical process.’

‘That’s right,’ said a new voice with a hint of Geordy; it was Alan from Arrow Park hospital who had also turned up to wave goodbye! ‘We had started implementing our HISS (Hospital Information Support System) which was to be operationally widespread across the whole hospital. We not only did the admin stuff on it, but also lab and rad requesting, and electronic prescribing. We reckoned that these clinical things had to be done first electronically before we started doing the fancy costing stuff!’

 They were right. Capturing clinical data AFTER THE EVENT proved too problematic for most hospitals so they switched their ‘boxes’ off.

Michael took up the story. ‘It wasn’t just about the money though. One great benefit of our ‘case-mix box’ was a clinically rich database which supported a very active Clinical Audit programme here at this hospital. Medical Audit was all very new to us and being in a room with our peers looking and analysing clinical data was challenging at first. We couldn’t have done that without good clinical coding.’

I continued with a summary of my CV to an increasing crowd now including medical records staff and coders. ’Then, as a result of being seen delivering an ‘interesting’ PowerPoint presentation on an ‘Audit of Pre-operative Pathology Tests……………..’

‘Oh yes I remember that one!’ said Michael.

‘…….I was seconded to the Department of Health, initially in London, and then to the brand new Quarry House building in Leeds, on a part-time basis to ‘spread the word’ about clinical audit. My hospital was very supportive of this and I thank them for the opportunities that then arose.’

‘You’re welcome’ said another new voice. ‘So, what then eh? Where did you go?’ It was actually the CEO of the hospital at that time who had given me the chance to develop and grow. She came with a G&T for herself and another pint of Badgers Crushed Paw Bitter for me. She must’ve thought I’d had enough pork scratchings!

‘I heard you were finally packing it all in. Here, have a pint!’ she said.

‘Oh hello again! Well I ended up going full time as Clinical Audit Advisor at the DoH having left my (your) hospital behind’. (A brave move as the contract was only for a year or two!!)  ‘At the end of that, I joined an EPR Computer vendor (Supplier) Northgate Information Solutions.’

‘Yeah Whoop! Whoop!’ said a voice I recognised at the bar. ‘We shared an office didn’t we!’

A computer vendor colleague had also just arrived. We shared many a year on our EPR circuits and he was now a famous author [iv]of great renown but still successful in the EPR field.’

‘But why a computer supplier? Why did you go to ‘the other side? Why?’ asked Jamie.

‘Well, I wanted to better appreciate what life was like on their side of the EPR fence. It’s all very well us (NHS) writing a lengthy requirements document if the Suppliers can’t deliver it. So now I had collected the full set: NHS operational person to NHS manager. Civil Servant at DoH followed by computer vendor. It was time to go it alone and so as I tentatively stepped into the new Millennium, I became self-employed working on various and varied IM&T and clinical change projects including interactive workshops (investing in Who-Wants-to-be-a-Millionaire ‘Ask the Audience’ keypads) which I did for 15 years including workshops in Dubai for 5 successive years, and implementing Clinical Portals in a couple of sites!’

‘I remember those Dubai workshops!’ said the voice with a hint of Geordy who had helped me run them.

 ‘And about that time that’s when we all met you,’ said a gaggle of new people with accents that were more North than Northern entering the pub and brushing off flakes of snow. A mixture of accents came in including one with a bit of an Aussie ‘twang’. People that I’d worked with in Scotland for eight years had all just popped down for a free sausage roll and a wee dram.  Bless them!

‘New Ways of Waiting and Clinical Portals, that’s you Jimmy Ay!’ one said in a very stereotypical way.

‘And you wrote that book didn’t you?’ said the computer vendor, who we shall call John (‘cos that’s his name!)

‘Yip that’s right - I wrote a book (The NHS IT PROJECT. The Biggest Computer Programme in the World Ever)’ This became a ‘best seller.’ (Note: A best seller for a ‘reference book’ is not exactly in the Harry Potter class.) Sadly, it is still quite relevant today and also available on eBay for [v]about a quid! (£4.36 actually - but FREE postage! 

‘And that columny thing!’ added John.

‘Yes. I had started writing a monthly column for the magazine - British Journal of Healthcare Computing. My column was set in an imaginary Pub in Yorkshire (The EPR Arms) opposite a busy hospital where I had the opportunity to ‘meet’ various NHS and others to talk about all things Health ‘Informaticky’ (although at that time we didn’t know what Health Informatics was!).

I continued to no one in particular and noticed a few looking at their watches. ‘I was still working (mostly in Scotland) on IT projects which meant I missed all the Connecting for Health shenanigans, returning to work back in England when that was all just a bad memory.

Michael went a funny colour when I mentioned the CfH word – or actually not a word – a TLA (Three Letter Acronym). He spat ‘Another waste of hot air and more broken promises!’ with venom. ‘Do you realise how difficult it was getting our clinical lot enthused over clinical IT after we’d been let down time and time again?’

‘Well for my twopenn’orth, whatever the formal reviews say, in my mind the biggest failure of the CfH debacle was that those brought in to deliver it locally and nationally often did not have a feel for our NHS and whilst a fresh pair of eyes can sometimes be a good thing, ignoring the clinical culture and clinicians is dangerous. Going in with an overtly technically led (and American) solution at that time would never have worked and going in with ‘vapourware’ was even worse!’

‘So, didn’t you join our Institute a few years ago?’ asked a Medical Records person – Lorraine, I think.

‘Yes. Well my career as a self-employed contractor was slowing down, I decided to apply for the voluntary role as Director of Communications in IHRIM – The Institute of Health Records & Information Management’

‘Why?’

‘Well, my thinking was that the transition from paper to digital would be very challenging and many inexperienced individuals at all levels of the NHS were assuming that the paper would disappear overnight, and computers would ensure the records were all well managed. They couldn’t be more wrong. Just because the record is on computer instead of paper doesn’t mean it doesn’t need rules and active management. But after 50 years in or around the NHS, and four years with IHRIM, I’ve decided I’ve done enough. I’m off.’

‘So, you’re not going to drink here anymore then? You’re not going to share your stories with us?’ said a voice from beyond.

‘I’m not saying that! I’m not going ‘tee total’. I may still pop in from time to time and talk about my new experiences – experiences of life in general. And I guess we are all potential patients aren’t we, so our paths may cross again, and I am sure I will have ‘stuff’ to talk about. So, thanks for coming. I really do appreciate it and I must say I have enjoyed working with each and every one of you.

I think Bill has put on some sausage rolls or pie and peas for us all, so your trip down from the far North wasn’t a complete waste was it!’ I winked at the coach load from ‘Up Norther’’

Someone raised his glass ‘Well I’d just like to say, ‘Good riddance and good luck’!’ and with that thankfully the formalities were over as they all joined in with raised glasses, said ‘Cheers!’ and turned to look for the grub.

It has been an incredibly interesting journey and one that I have thoroughly enjoyed. I have met so many good and interesting individuals internationally, nationally and, more importantly, locally that I couldn’t mention all here. So where to now? I hear you ask.

Well – I’d heard that Donald Trump has got rid of his car as he thought it was a car owner virus circulating the world!  

What? -  In answer to your question what kind of work could a man who has spent over 40 years in Health IT do?

Write pantomimes that’s what! Come along and see one why don’t you! (www.brighousetheatre.co.uk) Thanks to you all.  It’s been a pleasure.

(And keep an eye on my www.eprarms.com website. I may well pop in from time to time for a chat. I hope you do too.)

Sean

[i]

 (These figures are guesses now but at the time they were accurately calculated).’

[ii] https://www.who.int/classifications/icd/en/

[iii] https://en.wikipedia.org/wiki/Now_That%27s_What_I_Call_Music!_discography#United_Kingdom_and_Ireland

[iv] https://en.wikipedia.org/wiki/John_Ironmonger_(writer)

[v] https://www.ebay.co.uk/itm/Nhs-It-Project-The-Biggest-Computer-Programme-in-the-World-Ever/113788284256?epid=87119393&hash=item1a7e4f6d60:g:X-8AAOSwKz5eQvrC

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