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.