Britain ponders its sickly $20 billion e-health experience

BRITAIN’S push for e-health records won the “most appalling project” prize in the annual Big Brother awards of Privacy International in 2004. That, it turns out, was only the beginning of the project’s troubles.
It is eight years and £12 billion ($19.9 billion) since Britain set out to establish a shared e-health record for 50 million citizens as a central plank of its overhaul of health and computers, in what was dubbed the world’s largest civilian IT project. Now the rollout of e-health records is over time and over budget, dogged by savage criticism and languishing from lack of use.
Earlier this year, doctors called for a boycott of the system after it was found one in 10 records uploaded contained out-of-date information, including errors about patients’ medication and drug allergies. This threatened patient safety, they said.
Earlier controversies erupted over patient consent. Britain has an opt-out system; patients must apply to be exempted from having a shared e-record and, if they don’t, their consent is “implied” and the record uploaded. But research showed many people had not received notification of the system and did not know it existed. Some who tried to opt out were told they must first have a face-to-face session with an “adviser”, and others were told they could no longer receive health care if they did not have an e-record.
A study published this year in the British Medical Journal found doctors did not often use the new records. They were accessed in only 20 per cent of medical encounters in which one was available (1.5 million are uploaded to date). When they were used, e-records led to longer consultations. While they “added value”, particularly with complex medication regimes: “We observed no cases in which [they] unequivocally made care safer, or in which absence of one seemed to make care unsafe.”
The authors concluded the benefits of shared e-records were “more subtle and contingent” than anticipated and that implementation was a lot of work. They also noted: “No country with a population above 5 million has successfully introduced a shared electronic patient record.”
There are fears the health IT revolution might end up costing up to £50 billion – half the annual health budget. In 2007, when the House of Commons public accounts committee found the scheme’s pilot projects were two years late and unlikely to offer any benefits to patients any time soon, its chairman warned the project was turning into “one of the biggest IT disasters of all time”.

First published in The Age.

Brumby plays fast and loose

POLITICIANS dealing with the aftermath of Black Saturday often wear a yellow ribbon pinned to a lapel. Like the red poppy of Anzac Day, it is meant to be for remembrance. The yellow ribbon was popularised by a 1970s pop song in which a woman tied a hundred of them around an old oak tree to welcome home a lover. Long before it became associated with loyalty, however, yellow was seen as symbolic of another quality: cowardice.
Premier John Brumby wore a yellow ribbon to media appearances last week where he rejected the two big-ticket items recommended by the Bushfires Royal Commission. Victoria will not buy back houses in areas of extreme bushfire danger, nor will the state replace its ageing powerlines with technology that would prevent them sparking fires.
The arguments used to justify these decisions were deeply flawed, if not downright disingenuous.
This is what Brumby told the ABC about rejecting buyback: “The commission highlighted a particular road in Kinglake where lives were lost on February 7. The fact is that many people after the fires . . . wanted to go back and to rebuild on that road and there are many similar roads in Kinglake and other places like Marysville that are just as dangerous, just as forested . . . And how you would ever make a judgment about who would be in and who would be out? I don’t think you could objectively do [that] . . .
“In all of the consultations that we had, nobody could explain to us how this could practically and objectively work, and that’s why we rejected it.”
I had angry phone calls from residents in bushfire areas about those consultations. They were outraged by what they saw as a sham process.
The 24 hearings, attracting 1600 people, seemed to have been cobbled together in a rip-roaring hurry following a report in The Age in which a Callignee resident sneered at what he saw as window-dressing. “You have more press people here than you have members of the community,” the man told the Premier early in his “listening tour”. “If this is community consultation, where are we at?”
One has to wonder whether the bushfire response, like the Windsor Hotel plan and, now, the proposed rail link from Little River to Southern Cross Station, were all designed to be pushed through by those who think they know best with no real input from the community. Perhaps yellow is now the colour of arrogance?
The government has also fudged the extent and the costs of both the buyback proposal and the upgrade of the electricity system. Brumby said putting all powerlines underground could cost as much as $20 billion. He did not reveal the source or detailed costings associated with that figure. He did not say what it would cost to implement the alternatives suggested by the commission, which include the aerial bundling of wires. And he did not acknowledge that the rural power system is coming to the end of its engineering life and needs replacing soon anyway. This means what we should really be examining is the difference in cost between replacing the system in its current form, or upgrading to safer technology.
Electricity failures sparked five of the big Black Saturday fires, including the Kilmore East blaze that killed 119 people. Any decision about replacing the system must take into account such loss of lives, homes and businesses. The commission conservatively estimated the physical cost of the disaster that day at $4.4 billion; the human cost is incalculable.
Residents at the consultations were divided over what should happen with powerlines. The consultation report also concluded that there was “little or no support” for the housing buyback. Some residents wrongly assumed the buyback would be compulsory. Others were concerned about its cost and how it would affect those choosing to stay. (Neither residents nor the Premier seemed to touch on the moral dilemma in this: why should the safety and happiness of those who want to leave be sacrificed to their neighbours who want to stay?)
The commission was too vague on the buyback, a vacuum the government has exploited. The commission said land in areas “close to bush and posing an unacceptably high threat to human safety” should be bought so that people can afford to move elsewhere without passing the risk on to someone else.
Commissioner Susan Pascoe later clarified that it was not meant to encompass whole towns but to apply to “micro-zones” in which people lived on heavily forested spurs, for example. Bushfire expert Dr Kevin Tolhurst thinks “we’re talking about tens or hundreds of properties, not thousands of properties”. He said the buyback could be spread over a long period, perhaps 30 years.
The government has taken this modest and sensible proposal and blown it up into a gargantuan threat. Planning Minister and bogeyman Justin Madden said buyback would depopulate some country areas and that it would cost more than
$20 billion to buy the 54,000 homes in the 52 most at-risk towns in Victoria. That is never what the commission intended. The government is playing a cynical and manipulative game.
As for Brumby’s argument that no residents came up with an objective way the zones could be nominated — bosh. Since when did any government rely on residents for the expert crafting of policy details? Implying that assessment was too difficult made Victoria sound like some hick backwater rather than a first-world state that runs sophisticated systems across complex areas such as education, health and the law.
Get a bunch of bushfire and planning experts, assign them the task, and follow their recommendations. How hard is that?
Oh, but hang on — isn’t that what we were supposed to have done with the bushfire commission?