Comment by Peradine | Hacker News Reader

Comment by Peradine | Hacker News Reader

I work in the NHS, this is the current user experience

1. Type in user name and password onto computer

2. Logs in to windows, normally taking ~60 seconds, unless you've got the computer where the WiFi signal is poor (yes, WiFi on desktops!) and you get a 'no log in servers'

3. Windows finally loads, click the icon for the software for viewing blood test results

4. An internet explorer window opens, then closes, then after 10 seconds the software opens

5. Type in your username and password, wait 10 seconds

6. Now I want to prescribe some medications, close the first software (computer can't cope with two things open at once), click the logo for the prescribing software

7. A Google Chrome window opens, slowly loads the prescribing software website

8. Type in username and password

9. Navigate through the slow and unintuitive prescribing software

10. Oh wait, I can't prescribe this particular drug without checking a blood test result, close the prescribing software and go to step 4

11. Some alarm goes off, so I have to lock the computer and run. Return from dealing with the alarm, go back to step 1

Likely causes:

1) PC is desperately under-provisioned, probably several years old and upgraded to Windows 10

2) Too large roaming profile (easy situation to get into and hard to spot other than "it's slow")

3) Too slow AD profile server to get the large profile from

4) Internal websites "should" use NTLM authentication if available, which would remove the requirement to log in again, but forwarding this outside the domain properly is remarkably hard

5) Smartcard auth can offer the dropin use case with no typing, but it's a pain to provision and costs more

In many cases you'd be better off with an IBM 3270 terminal but with higher resolution text and images...

In my previous job we built a Windows CE-based system that let you log in instantly by tapping a keyfob and brought the screen you were last using up anywhere on the site, running on fifteen-year-old hardware. It was for selling beer.

Also 100Mbps networking, still a possibility even in 2020

Are you implying that 100Mbps is not enough? Most people live fine with 20Mbps, why would they need 100?

If you have a server that is connected via 100Mbps link to the entire network, yea, it's not enough. When multiple clients are hitting it e.g. during login, downloading updates from wsus etc. it will be painfully slow

My sister works in the NHS. It's all smartcard based. Also kerberos could achieve the same as NTLM for SSO and is more secure, and less complicated in multi-domain setups, since the client does all the hard work rather than servers having to contact remote DCs themselves.

> probably several years old and upgraded to Windows 10

...probably still running Windows 7.

...upgraded from Windows XP.

Probably 5 years old or older, maybe only 2GB of RAM, and back then already underpowered.

Ah roaming profiles, one of the best worse ideas in the MS world

Better if you can replace it with a CIFS mount

Instead of IBM, just use a Bloomberg terminal. It is as secure if not much more than all those security checklist-ticking healthcare software. For good or for bad, a lot more money is on the line for Bloomberg than e.g. a personal data breach in healthcare.

anti virus is way more likely and I agree (been in a hospital setting before) that a terminal/ssh-based system would be better for most stuff.

First the IE-only website, then the Chrome-only one. In the future, archaeologists will be able to date web apps based on what browser they support.

The notion that it should take 40 million pounds to fix this is just so reflective of the disconnect between the bureaucracy and the people that actually get work done that I probably couldn't think of a better example if I tried.

I can think of a couple ways to make that faster for free. Many dozens more for a lot less than a million pounds, forget 40. Arguments about "but corporate / compliance / vendor contracts / red tape" be damned. (Edit: Most of the replies to this comment are exactly this sort of thinking - It's too complicated, there's too many vendors, we can't do it, it's too hard, no one will do it for free. This is the exact kind of lack of political will to get anything done that I'm talking about. It's someone's existing job to do IT, task them with making it better - plugging in the computers to the wired network is a good free first step. Cleaning up the GPOs so Windows login doesn't take 60 seconds (!) is another freebie. Yes, these systems are complicated. That's not an excuse for them to be garbage).

The decadence of IT spend is horrifying. I suspect most of it winds up lining someone's pocket.

> I can think of a couple ways to make that faster for free.

Such as?

Auth0

And who will set that up for £0/hour?

Taking a lead from GDS and starting to create user-friendly, predictable applications with a shared design language and reusable components (like SSO, email/SMS/letter sending) would be a step in the right direction.

They've already stated but it will take a long long time.

https://beta.nhs.uk/service-manual/

That isn't free, and won't solve the same problem - logging in to existing applications being used today and for a long time into the future.

Nothing's free. You can't really deny that taking that approach is more sensible than the current, fragmented mish mash of propriety systems.

The fact that they've already started down that path is a good sign.

Of course nothing is free, that’s the point. Yes it’s a good approach but as I said its solving a different problem.

It's free? Does that mean you'll work for free until it's done?

The idea that anything is free is ludicrous. You are either spending time (wages) or money (buying solutions).

Why would £40 million be a lot of money for the IT systems of the entire public healthcare system in the UK? The NHS has a yearly budget of £114 billion, so this particular IT spend is only 0.03% the size of their yearly budget.

There's nothing decadent about this. It's essentially deferred maintenance that is long overdue, probably overdue because the government had to wade through people like you who can't help but complain every time a government organization wants to invest in modernizing.

> The NHS has a yearly budget of £114 billion, so IT spend is only 0.02% the size of their yearly budget.

You might want to double check you math.

But yes, it's such a small amount of the overall IT budget I almost wonder why it's being given separately.

My original calculation added in an unintended currency conversion (Google assumed that "40 million" meant "40 million US Dollars), and I also meant to clarify that I was talking about this single initiative, not the overall IT budget. I've since edited my number (0.03 instead of 0.02%)

This is a pretty simplistic comment that seriously underestimates how complex this stuff is. (Are you Dominic Cummings by any chance?) IT systems like the one in the NHS are huge, have grown organically over time and are mission-critical. You can't just trash one system and start from scratch (witness the Universal Credit debacle in the UK). It's like repairing a ship while it's sailing. Yes, there's quite a bit of money involved, but I can only imagine someone who writes a comment along the lines of "it's easy, just do X" has never touched a system like this, or had to write budgets for it.

I'd also like to see you walk into a situation like this, no matter how much power you had, and see how far 'Arguments about "but corporate / compliance / vendor contracts / red tape" be damned.' gets you.

Ah no, you clearly misunderstand that NHS doesn’t actually use a single system f or everything. What IT systems are used depends on the hospital discussed, and thus 40M isn’t really about the complexity of a single system - it’s simply a paycheck to pay for upgrades of many systems running in parallel and barely having any interop whatsoever.

I was like "40 million won't be enough to make a dent" :D

You are dealing with multiple vendors, who all bring their layers of customer support and sales people before you even get an estimate of the required change.

Contracts might include processes that must be followed for any modification so nobody gets sued afterwards.

The developers who implemented the software might not even be with the contractor anymore. So you pay for training someone else, too.

I personally think £40million is outrageous but how much does a system that cannot go down cost?

Previous attempts to fix this cost huge amounts, and none of them worked properly.

care.data (about 10 million) https://en.wikipedia.org/wiki/Care.data

Connecting for Health: (over 10 billion!!!) https://en.wikipedia.org/wiki/NHS_Connecting_for_Health

This is an unwarranted slight on CfH, which _did_ produce lots of useful work.

Unfortunately it was far too ambitious and effectively killed private development of healthcare software for the U.K. market in the process, making (for an example relevant to one area of my expertise) dose-based eprescribing a pipe dream despite having produced a ton of useful standards.

> It's someone's existing job to do IT,

That would be Simon Eccles at NHSX. https://twitter.com/NHSCCIO

NHSX is reasonably new. https://www.nhsx.nhs.uk/

They've been having some trouble recruiting and retaining staff. https://www.healthcareitnews.com/news/europe/nhsx-reviews-st...

I do feel that you haven't understood the complexity of the landscape. Not of the vendors, because in theory we could just impose standards of interoperability upon them with RFC like documents. But the complexity of NHS providers. There are thousands of GPs, hundreds of NHS trusts, and they've all got to talk to each other while providing strong access controls and audits.

EDIT: I don't normally ask about downvotes, but I'm curious about the votes in this post, and I'd be grateful for any explanation about downvoting.

Their pay is 30% below market, so they wind up blowing even more money on contractors. I’m pretty sure increasing pay will save them a chunk of change, but the NHS ties itself up in knots to prevent sensible changes.

If they're only 30% below market, the NHS is in a lot better shape than many government organizations.

They've been having some trouble recruiting and retaining staff.

And yet I didn't see any obvious job openings. I didn't see an obvious way of checking civilservicejobs.service.gov.uk as neither NHSX nor National Health… turned up any results when plugging them into the organization filter. It's an interesting mission, but if they're not hiring then I can only imagine they're starved for funding or they've successfully retained enough folks.

> if they're not hiring then I can only imagine they're starved for funding

The overall context is a government that has been openly antagonistic to the NHS for at least a decade, pushed for disastrously expensive "privatisation by stealth" efforts [0][1][2], and is now effectively trying to outsource the digital side of NHS operations to private companies [3]. Strategically starving certain departments is par for the course.

[0] https://www.theguardian.com/society/2014/apr/04/gp-local-nhs...

[1] https://the-probe.co.uk/blog/2019/12/hancock-urged-to-halt-n...

[2] https://www.bmj.com/content/346/bmj.f1322

[3] https://en.wikipedia.org/wiki/Babylon_Health#Matthew_Hancock

(and many, many more sources if you really need them...)

I agree with everything you say, but GPs have always been private companies operating under NHS GP contracts, and Babylon Health isn't at all unusual in that regard.

They are a very large provider, and that's causing problems for their hosting CCG.

None of this detracts from your point: the NHS has been deliberately under-funded for years, and the Conservatives are pushing for non-NHS providers to provide services.

The overall context is a government that has been openly antagonistic to the NHS for at least a decade, pushed for disastrously expensive "privatisation by stealth" efforts [0][1][2], and is now effectively trying to outsource the digital side of NHS operations to private companies [3]. Strategically starving certain departments is par for the course.

If the goal is to "starve the beast" NHSX isn't having trouble with retention then are they?

> plugging in the computers to the wired network is a good free first step

Plugging into wired ethernet is only free if you have a wired port near the computer and it connects (properly) to an available port on a network switch and you have patch cables onsite and free labor to connect them (including labor that can access the network closet if needed) and free labor to configure the computer to prefer the wired over the wireless, if necessary.

Ideally, it's not a lot of labor, and there's likely to be some switch ports available and some patch cables available, but there's also probably a reason the computers are using wifi if they are.

You can argue this is probably part of someone's job already, but if they aren't doing it because they have too much other stuff to do, you'll need to pay someone else to do it.

What you're describing sounds most like a) badly-written login scripts, or b) misconfigured DNS confounding the client's domain controller locator, or c) both. IME the folks who tinker with login scripts don't tend to think about execution time or failure modes, and it's tough to get a good developer assigned to that kind of work--and the MIS folks are unlikely to invite that kind of attention to their works.

Or "the systems don't talk to each other so I need 5 different log ins": https://twitter.com/katesmjenkins/status/1213419794361470976... https://twitter.com/KWebbNurse/status/1213544538960285702?s=...

Or computer can't cope with twin birth either side of midnight on NYE: https://twitter.com/VoicesHeard3/status/1213482121513390080?...

The replies to this (labour, left wing) politician (who many HCPs will tend to support) are illustrative of some of the problems faced: https://twitter.com/AngelaRayner/status/1213469393692299264

And the replies to this post give a bit more idea about what's going on: https://twitter.com/NHSCCIO/status/1213390407784161281?s=20

The hell? What is wrong with those computers? Atom CPUs, mechanical drive and 2GB of ram?

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