In february the prime minister chaired a seminar on IT in the NHS at Number 10 in the presence of the Chief Secretary of the Treasury, the e-Envoy, representatives of the Wanless Review Team on modernising the NHS, Alan Milburn, Lord Hunt, Sir John Pattison of the NHS Information Policy Unit and others of the great and the good. Such a high-level seminar was necessary because IT in the NHS - particularly the project to implement an Electronic Health Record (EHR) nationally - was off the rails. Something drastic had to be done to get it back on. Otherwise much of the lovely lolly, which kind Gordon Brown was shelling out to the NHS, would disappear down a computerised black hole.

What had gone wrong? Although many GPs had replaced their paper carousels by records on their PCs, they had encountered a glass ceiling. Their local hospitals were not interested in sending paths reports or consultants' letters to them by email. They were wasting money in re-keying patient data from print-outs from other NHS computer systems. The NHS had failed to imposed standards centrally.

At a meeting of the Parliamentary Information Technology Committee in April, Dr Richard Gibbs, chair of the NHS Chief Executives' Forum, admitted that the hospitals had fallen behind the GPs in implementing Electronic Patient Records internally and externally. He blamed the underfunding of hospital IT: that as much as 80 per cent of money ring-fenced for IT would be diverted to reduce waiting times. He also blamed a "balkanised" approach to the programme management of IT, resulting in the purchase of incompatible computer systems. Finally he regretted that IT was still not considered a mainstream activity in the NHS - rather the haunt of anoraks and nerds.

Perhaps, the main failure came from the centre of the NHS. Over the last few years several departments have been created to push the management of information in the NHS: the Information Policy Unit, the National Health Service information Authority, the National Accreditation and Procurement Process Service and the Primary Care Information Modernisation Programme. These have spent months debating the form and content of an EHR, but their functions overlap, and they seem to vie for position in a bureaucratic turf war. What has been lacking is the sense that anyone is driving the initiative, or setting milestones to reach along the way.

Four long months after the meeting at 10 Downing Street, on June 12, the trumpet finally sounded to march the raggle-taggle NHS army of stroppy GPs and cash-strapped Hospital Trust anoraks into battle. Health minister, Lord Hunt, announced the publication of Delivering 21st Century IT support across the NHS. This calls for:

This is good news but it is really all elementary project management stuff. Why is it that nobody had the wit to put it all in place two or three years ago, when people started thinking seriously about Electronic Health Records? They'll take months to appoint a tsar, and then he or she will have to get their feet under the table. That's another six months down the drain. The new tsar will have to be a Stalin - with a velvet glove. I cannot see any current NHS executive being up to the job. I am told that soundings are already being made across the pond. This seems to me curious. America may be a master of technology, but not of national health systems. What about a Sven or even an Arsene? Their countries have health systems that work.

Even if they find the right tsar, he or she will have a battle against the tendency of all parts of the NHS to resent any direction from the centre. Already, GPs' leaders and health experts are moaning that the Wanless Report was too top-down. They will roar with pain at the idea of a tsar and stringent national standards. They have a point. Previous attempts to impose standards, like X400 messaging, were a disaster. But reliance on bottom-up has not worked either. The NHS is strewn with the corpses of innovative pilot schemes, which have not been designed to be replicable in other parts of the NHS.

The trick for the new tsar is to set the technical standards, the content of the records, the project deadlines and training schedules for the national EHR quickly, and make sure that the GPs and hospitals develop their EPRs to link to the EHR. Then the clinicians can then do what they like with the data, to assert their precious professional independence. With EHR, top-down and bottom-up must co-exist. You don't really need a meeting at 10 Downing Street to tell you that.

In 1998, the NHS Plan defined Electronic Health Records (EHR) and Electronic Patient Records (EPR) as follows. An EPR is the record of what happens in an individual setting, like a hospital treatment or a GP's surgery. Each is separate. A patient's EHR brings those records together. "Information for Health" envisaged a "cradle to grave" record of all the significant medical events in a lifetime.