It certainly appeared working through this period in an IT department in the NHS that NPfIT made very deliberate attempts to talk to (a few) clinicians over the heads of local IM&T expertise, and belittling or ignoring the wealth of experience, and hard learned mistakes, that went before.

These NHS staff do have expertise to interpret the needs, represent the users at remote meetings, get debates going locally with far more clinical and administrative staff than remote or external teams could connect with. They generally have a passion to get things right, to support users that they are in constant contact with, and will be supporting the results directly.

I see re-engaging, energising and showing support and trust for local IT teams, who have kept all the local systems going (despite these being starved of investment pending NPfIT solutions), as a key element for future success. These staff rarely limit themselves to the 10% technology, but often get involved in identifying, highlighting and fixing clinical and administrative processes right around their NHS organisations.

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Sociotechnical change may be about appreciating the whole, the integrated sum of parts rather than concentrating and reducing to individual components. Prof Clegg put that point, in common with the UK Strategy Unit and many others involved with complex situations.

But systems are an abstraction. It depends whose summary and interpretation you're prepared to accept when different groups have different perspectives, levels of knowledge and motivations. Complexity increases when the 'systems' we're reviewing are also hit by multiple initiatives from outside (Darzi, HI, etc). Systems then become much wider and even more difficult to understand.

I look at this as a disabled researcher. Those with disabilities (and long term conditions) apparently place the biggest burden on the NHS. Yet an expert at the Masterclass described diagnostic data in primarycare records as "a disaster". I personally have difficulties using Wikis and Discussion Boards via assistive technologies. Note also this from the Equality Impact Assessment accompanying the HI Review:
"2.8.1 There are no current nationally-agreed NHS code-sets for disability".

We call for clinical leadership. But does 'clinician' mean 'doctor' or all involved in direct care? Look too at the structure of medicine. Do you see multiple specialities who, like my eye and ear specialists, rarely talk to each other? Do you sense some contradictions emerging?

So the sociotechnical approach based on systems thinking is laudable. The problem may be turning the mantra into true systems thinking and realistic systems practice by all involved from top to bottom.

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The presentation from Trish Greenhaulgh resonated with me when she said that the Walk-in Nurse in Bolton avoided using the Summary Care Record because it was too slow to log-on, and too difficult to use.

The business change can only be enabled when the technology is fast enough, and developed around the user needs. Far too many of the NPfIT systems are designed around theoretical models of how someone perceives the world should be, not real-world practicalities. And they don't seem to concentrate adequately on the user experience, and end-end performance.

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