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Improvements in the quality of care are com‐patible with resource saving — but to achieve these desirable aims, doctors' performance must change. More attention should be paid to this aspect of health care management. However, interest is far greater overseas than in the UK at regional or national level. The current UK lack of interest (at Government level) in the potential of information technology for clinical decision‐support is already prevent‐ing patient, physician and the public purse front benefiting from a concept originally promoted in the UK but now more widely adopted abroad. Unless some sensible means can be devised for coordinating clinical decision support systems with audit, resource management initiatives and HISS — and ensuring some structure which will offer both clinicians and managers some practical benefit — the present vast expenditure on IT in the National Health Service may merely repeat (at a hundred times the cost) the unfortunate 1960s experiments with computers and public money.

This presentation argues that improvements in the quality of care are perfectly compatible with resource saving — but, in order to achieve these desirable aims, doctors' performance must change. An example is cited relating to acute abdominal pain. In a recent multi‐centre study, doctors aided by a small desk‐top computer system appeared both to improve clinical care and save resources. It is argued that quite profound resource savings and improvements in care can be achieved by relatively simple changes in doctors' behaviour. More attention should be paid to this aspect of health care management.

Examines the ability of an expert computer system to evaluate uncertainty within a valuation context and thus emulate the professional skill of the valuer. Shows that because property valuation programs based on regression analysis require data input for each variable, they are unable to evaluate uncertainty and hence to apply the rational judgement which enables the human valuer to produce a valuation in the light of uncertain or incomplete information.

Considers the problems of a multi‐disciplinary team working together to understand and evaluate a healthcare information system, which itself is situated in a complex organisational and political environment. Provides general discussion of problems faced by evaluators of such systems. Describes this specific evaluation project (Electronic Patient Records in the UK National Health Service), gives an account of the evaluation process as it occurred, highlights some of the problems encountered, and discusses attempts to overcome these. Suggests that social, organisational and political factors are inherent in all such research enterprises, and that in order to facilitate a rich understanding of complex systems, these factors must also be considered as part of the research data.

Discusses the NHS Executive′s information management and technology (IM&T) strategy and its relationship to the 1991 reforms. Examines the recommendation for large acute hospitals to adopt integrated hospital information support systems (HISS). Reports that a recent census of these hospitals, undertaken by the authors, suggests that the implementation of the strategy′s recommendations has been slow at the local level. Attempts to diagnose the factors that are impeding implementation, using the evidence provided by the census. Identifies four main problem areas: the lack of success of past IM&T initiatives undermines confidence in the current strategy; the strategy is poorly aligned with other policy initiatives; the legacy of discrete, proprietary information systems within hospitals makes the creation of an integrative information environment difficult to accomplish without massive investment in new systems; and there are implicit contradictions between the following: the absence of a comprehensive post‐implementation evaluation of the economic, technological and cultural feasibility of HISS at any of the three HISS pilot sites; the strategy′s advocacy of HISS as the way forward for large acute hospitals; the requirement for a comprehensive business case to support any substantial investment in IM&T. Concludes that a massive rethink of policy is required, with a much greater emphasis on research, development and independent evaluation.

Today′s doctors require decision support aids to help them cope with the management of increasing amounts of medical information (records, research advances, new drugs), make appropriate choices and even to substitute in an expert′s absence. Such aids exist in the form of medical expert systems, which are complex computer programs that emulate clinical reasoning. Expert systems consist of a knowledge base in which doctors expertise is encoded and an “inference engine” which manipulates that knowledge. A number of successful diagnostic, management and combined systems are in use but these are a small fraction of the total available. Preventing wider usage are difficulties in evaluation as well as in response time. Significant improvements in resource management can be obtained by the deployment of medical expert systems, so they are predicted to influence profoundly the future of health care in general practice and hospitals alike.