This article describes some of the findings of an informal study of access to the Internet for information professionals working within the UK public funded health sector e.g. hospital libraries, NHS trusts, and other public funded medical libraries.
The OMNI service  receives a steady number of inquiries from a large and diverse number of people. Many of these inquiries are from members of the public requiring medical and health information; in these cases, as we are not medically qualified or legally covered, we have to politely point out that services such as OMNI are meant to complement their General Practitioner, not to replace him or her. We also point people in the direction of the large amount of patient or public information resources that we catalogue.
However, an increasing number of enquiries are from people who work in hospitals, hospital libraries, general practices and NHS trusts. These people frequently want details of where to find health and medical information, for their own work-related purposes, or how to find such information. What we have found interesting is how these people, within the UK public funded health sector, have contacted us. Some use email - either their work email system, or email through an Internet Service Provider, usually from home. Many people within this sector either telephone OMNI, or even send a fax. In some cases, queries come to us through the University of Nottingham or the Queens Medical Centre, as people do not have Internet access and therefore find it difficult to get precise contact details. We have also had two letters addressed simply to OMNI, University of Nottingham.
What we found interesting was - why do so many people working in the UK public funded health sector not use email, the quickest mechanism, in order to contact us? Our interest deepened as we spoke to some of the people who had used non-Internet methods of communication, about why they had used the post, telephone or fax. Some of the reasons given were:
- we cannot send uninitiated email; we can only reply to email
- if we want Internet access, then we have to use the cybercafe across the street
- only managers are allowed to have Internet access in order to send email - people who deal with users are apparently a security risk
- we are on the NHSnet, I think, and email is a nightmare. I cannot even send email to the person sitting next to me, let alone to Nottingham University
Out of these comments was born the idea of writing a short article for a publication on access to the Internet. With our obligatory article for Ariadne needing to be done, we thought that we would kill several birds with one stone. In addition, perhaps we could come up with some ammunition for people who were having difficulty in getting Internet access to use.
Surveying the unsurveyable
Our main problem was identifying and contacting people who, by the nature of the problem, were difficult to identify and contact! This was done by putting various emails on lists, in the hope of locating either people who were forced to access the Internet from home, or friends or colleagues of people who had problems with access. In addition, colleagues and collaborators sent out mini-postal surveys of people who they thought may have a problem. It was made clear that confidentiality would be strictly respected. In total, we received some 140 pieces of correspondence from around 100 different people.
Ten recurring themes
Ten themes emerged from the responses that we received. By theme, we mean that at least two people (in most cases, many more) gave the same answer or part answer as someone else.
1. Computers and IT are prohibitively expensive
This was mentioned by several people as the official reason that they were given. In terms of kitting out a full room full of multimedia PCs, all with Internet access, the cost can indeed be great, even with the price of PCs falling all of the time.
However, three people pointed out that their direct or indirect managers had state of the art PCs, with full Internet access; two of the three indicated, upon further contact, that their managers had little or no contact with end- users. In one case:
‘My line manager never sees a user, and has expressed a strong desire to never see one. However, we have users who ask about things they have found on the Internet, or how to find things about the Internet. As I do not have access, I cannot answer their query, which often annoys the user and demoralises me.’
2. The security excuse
An oft-repeated reason for not allowing Internet access is that ‘the security of patient records will be compromised’. However, several people noted that they worked in units, or institutions, that did not keep patient records!
In one particular case, a correspondent told us that:
’…if we are given access, then we will hack into the Department of Health and cause problems. I cannot even use Word because the hospital refuses to fund IT training, yet they reckon that we are all super-hackers.’
3. Productivity will slump
Several people quoted people higher up in their institution who had devised internal policy blocking Internet access. In two cases, this was due to isolated incidents involving single members of staff or students ‘…for which we are all seemingly punished’ (unquote).
Two other anecdotes under this theme, both from hospital libraries, are as follows:
‘Our manager has told us, quite seriously, that the Internet is proven to corrupt and that instead of handling inquiries, we will be drawn into looking at pornography all day.’
“People will spend all day looking at sports scores’ - this was from a manager who promptly left to watch cricket for the rest of the day.’
4. No standards or deadlines for access
Several people, often using the word inertia, commented on the lack of any deadlines for access within their own institution or organisation. All of these people commented that without a firm deadline, preferably from some source of funding, it was unlikely that there would be any change to the status quo.
‘No-one seems to be giving the Trusts deadlines and decent standard to meet… and they will certainly drag their feet if they are allowed to.’
5. Access good. Support bad.
Some places did have some level of access, but the staff were left on their own in terms of support and working out how to use the Internet to the best of their advantages:
‘We have had access to the Internet for some time, but didn’t really know what to do with it. We used these search thingies, and couldn’t find anything useful… eventually, the 7 year old daughter of the head librarian showed us how to find useful stuff. We have never looked back.’
6. Problems with email
A variety of problems, both technical and political, were quoted that prevented people from being able to use email effectively and with confidence:
‘I cannot send an email to someone off my own back; I can only reply to an email’
(this point was quite common)
‘We are sent an email, every week, informing us that the IT department has the right to monitor emails that it deems to be of a suspicious nature; it is somewhat intimidating.’
7. Climate of fear
It may seem an odd, or paranoid, statement to make, but in some areas of the public funded health sector, there is often a noticeable fear of ‘whistle- blowing’ or ‘kicking up a fuss’, as it is felt that this may have a negative effect on your career prospects.
‘We would like Internet access, and we know that the network services are lying through their teeth with the excuses they give, but to complain around here would make you a marked person when it comes to the annual budget review - i.e. cost cutting exercise’
There were comments about the problems of communication between departments who needed Internet access, and departments (such as IT departments) who were supposed to supply it:
’…IT department doesn’t answer our queries, as they have publicly stated that the library and librarians are not a serious or professional activity or people’
‘IT matters are poorly communicated within Trusts’
Personal problems with communication can also impede access to the Internet:
‘My manager has a problem with speaking to women. As all bar two of the staff that he manages are women, you can imagine the problems that this causes’
9. The ‘you are not important enough’ excuse
Overlapping with several of the other themes, some people noted how their status counted against them:
’…within our organisation, there are no links to the NHSnet unless you are a senior manager.’
’…our manager doesn’t deal with any users. And he has Internet access. Users come to us after hearing about how great the Internet is. And we don’t have access. I have had enough; I’m leaving to work in a University.’
10. Who defines the policy of what information you can have access to?
Several variations on this statement were provided:
‘Our IT department determines information policy. This doesn’t make sense - surely the library, which deals with the information needs of the users, should have a say in what information is needed. It is surely up to the IT department to provide the electronic access to that information.’
Why help the unconnected…
So - we have a problem. There are a number of people who do not have a reasonable degree of Internet access - but how do we help them? And should we bother?
From the purely selfish point of view of OMNI, one reason would be to help people get on line, which in turn would boost the number of users that we have and give us more leverage with funders and sponsors! On a less capitalistic basis, users are good for OMNI, not just to bump up our access statistics, but to submit resources of use to fellow users.
Taking a wider perspective, it is important to get everyone on board, with regard to full Internet access, sooner rather than later. If we do not, then when major initiatives such as the National Electronic Library for Health , or the Resource Discovery Network , take off, then there will be a class-like system, with people either in the ‘well connected’ class or the ‘information [access] poor’ class. Those in the former class will be able to develop, in terms of skills, knowledge and contacts, at a more rapid pace than those in the latter class. This could lead people without Internet access, or the means of getting it, to effectively become ‘de-skilled’, with reduced opportunities for IT development, job prospects, and becoming part of a larger, UK health Informatics community.
Helping the unconnected…
So - how do we help these people? A combination of top-down and bottom-up approaches have been suggested; we haven’t thought of one solution to the whole problem yet, and welcome suggestions.
Approach 1: Top down (1)
The NHS could send out a questionnaire to all NHS Trusts, Hospital Libraries, and other organisations, asking:
- do your information services (e.g. library) staff have reasonable access to the Internet?
- if the answer to the previous question is No, then when will they be provided with reasonable access?
Approach 2: Top down (2)
The NHS could get in touch with people on the ground - i.e. the actual library staff, and ask them about what access they have. Ways in which they can help themselves to obtain better Internet access could be formulated and passed directly to the staff. An official NHS support unit, with senior backing, could assist people in getting better access at their place of work.
Approach 3: Top down (3)
The NHS could send out a policy statement, requiring that all units that it funds:
- provide reasonable (and free) access to email for their staff
- provide reasonable (and free) access to the Web for their staff
- resource and awareness literature (even if it is just a few Internet introductory books)
- provide access from the desktop (in other words, not from a building on the other side of the campus or site)
- provide the above by a fixed, unmovable date, or come up with a reasonable reason why such access and facilities cannot be provided
As one correspondent noted:
‘Maybe a model Internet [NelH] access policy for IT managers would be helpful’
Approach 4: Bottom-up attack
Do you have friends or colleagues on other sites who are having access problems? Then give them a hand!
- give them literature to help their cause i.e. details and information on access policy at your place of work, or some other public-funded UK health service
- show them useful stuff on the Internet, either at your own place of work, or at home, a cybercafe, or some other point of access. Inspire them and inform them
- get them to find out which of their work colleagues has access from home. Encourage that colleague to monitor relevant mailing lists, bring in printouts of relevant information, and locate other Internet access points nearby
Though the survey described in this article has been very informal, and somewhat anecdotal in data, this does not mean that it has no merit. It is clear that a number of people within the UK public health sector do indeed have problems in getting reasonable access to the Internet, for work related reasons. However, what is unclear is just how many of these people there are, and therefore what is the best method of helping them.
We have therefore decided to carry on with this work, and have proposed a more formal investigation, involving e.g. the Regional Librarians group, in order to quantify how bad the problem is. The work of the Regional Librarians Group to date has, from some of the comments received, obviously assisted with the problems connected with accessing the Internet within this sector; without their work to date, then the problem would be much more serious. It is hoped that we can determine the extent of the problem, and any clusters of people (either geographically, or with the same underlying problem that is hindering reasonable Internet access). This will assist us (OMNI, the Department of Health) in alleviating their problem, so that they can enjoy the full benefits offered by Internet access, and services such as OMNI and the National Electronic Library for Health.
I wish to thank all the people who sent in comments, queries, stories, anecdotes and other material that helped in this article. I also wish to thank Veronica Fraser, Library Advisor from the Department of Health, for invaluable support and advice.
 OMNI: Organising Medical Networked Information. Available from: URL http://omni.ac.uk/
Last checked 07/06/99
 NelH: National Electronic Library for Health. Available from: URL http://www.nelh.nhs.uk/
Last checked 07/06/99
 The Resource Discovery Network Centre’s approach (Dan Greenstein). Available as a set of powerpoint slides from: URL http://www.ukoln.ac.uk/services/elib/events/information- ecologies/ppt/greenstein.ppt
Last checked 07/06/99
Author DetailsJohn Kirriemuir
Greenfield Medical Library,
Queens Medical Centre,
web site at: http://www.omni.ac.uk