The private concerns of clinicians and IT professionals about
the national programme are not being addressed, despite the front
presented by the project's leaders.
Christopher Bland seemed determined to refute the impression given
by his name. At a private conference for health service
professionals last month he spoke with remarkable frankness about
the government's multibillion-pound modernisation of the NHS, the
national programme for IT in the NHS.
He appeared to portray the national programme as a worthwhile
gamble - the biggest IT gamble in the world.
It is unclear whether Bland was being candid because no journalists
had been invited to the NHS conference at The Pit, a basement
theatre in the Barbican Centre, London. It is more likely that he
has nothing to fear. He is chairman of BT and a successful
businessman of long standing.
He said that the Department of Health has awarded national
programme contracts to BT that, in aggregate, are the "biggest the
company has won in its history".
But he conceded that BT was concerned by the complexity and
enormity of the national programme.
"No other country has attempted what collectively we are about to
attempt," Bland said. "It is immensely exciting to us, and we are
somewhat frightened by the complexity and enormity of it - but it
is exciting and a real challenge to get it to work.
"And it will be an immense achievement for all of us if we can pull
it off," he added.
Bland described the view of BT's board on winning contracts worth
more than £2bn. "We felt slightly like a dog chasing a car - what
do we do if we catch it? Well, we caught it."
An enormous gamble
As if to reinforce the impression held by some people that the
national programme is an enormous gamble, the health minister John
Hutton told the conference that implementing the IT profession
would be embarking on a "journey of exploration and
discovery".
He said the benefits of new IT systems would be enormous, as are
the challenges. He added, "There are risks and it would be foolish
to ignore them."
Bland and Hutton's comments suggest that the national programme is
acquiring a dual personality: a smiling, inspired, self-confident
public face and a private one which perceives the project as a
collection of unknowns: a gamble.
The public face already speaks of the programme as an outstanding
success. It was launched about 18 months ago, and specifications to
replace thousands of diverse systems with new,
nationally-compatible technology have been published.
In record time, five local service providers have been appointed to
take over incompatible legacy systems and build new ones to a
standard design. Up to 50 million patients across England will
benefit.
The health secretary, John Reid, says the programme will
revolutionise healthcare: everyone will have an electronic health
record that they will be able to view from a home computer.
Everyone will be able to book an appointment electronically, at a
time to suit them, instead of waiting for a hospital letter.
This vision of the NHS is supported by ministerial statements and
press releases from the Department of Health which have nothing but
praise for the conduct of the national programme.
Only four weeks ago prime minister Tony Blair praised Richard
Granger, director general of NHS IT, who is running the programme.
And the health minister John Hutton said Granger has done a
"brilliant job" in overcoming scepticism about the programme.
Granger himself says the national programme is about three years
ahead of any comparable programme and he is quoted in the Financial
Times as saying there is "no other project of the same scale on the
planet", and in The Times as comparing the national programme with
great Victorian infrastructure projects, including the construction
of London's sewer system, by Joseph Bazalgette and the building of
the Great Western Railway, by Isambard Kingdom Brunel.
Biggest project on the planet
But there is also the hidden side of the national programme, in
which criticism is suppressed and IT professionals in the NHS
cannot get straight answers to direct questions.
So far the national programme has given no direct answers to many
questions posed by NHS staff, for instance:
- What will the national programme cost locally to
implement?
- What changes will it impose on working practices of doctors and
nurses?
- How will staff time and money be found to make data in the new
national systems accurate?
- Will clinicians and nurses take to using new systems when they
have not participated in purchasing them?
- Where will the money come from for training doctors and
covering for them while they are training?
- Will clinicians end up devoting less time to the care of
patients while they service the demands of the national
programme?
More questions
The big questions do not end there. General practitioners want to
know, given the national programme's stated aim of achieving
"ruthless standardisation", whether they will be able to continue
using their long-established existing systems even if they are not
among the selected technology adopted by the national
programme.
Seeking answers to these questions and more, IT professionals in
London went to The Pit last month to hear Bland, Hutton and other
speakers. Hutton gave reassuring but unspecific answers to the GPs'
questions, then left.
Other speakers, including David Kwo, who runs the national
programme for London, sought to placate concerns raised by members
of the audience. But, like Hutton, Kwo's answers were more
reassuring than specific.
Two unknowns could floor the national programme. Some doctors
wonder whether the national "data spine" of electronic health
records will have so many gaps that it will become a good idea but
an ineffectual entity, like a new hospital full of leading-edge
technology which turns out to have too few staff.
The second unknown is whether the Department of Health will be able
to change the practices of doctors through the introduction of new
technology.
Best practice, say some experts, requires that working practices
are agreed, planned and simplified before new technology is
introduced. The board of a large private sector company may be able
to impose changes on its staff, but the Department of Health cannot
force doctors and nurses to change their working practices to use
the new systems.
Challenge to win over doctors
Doctors may argue - some already have - that their first duty is to
their patients, not the demands of a new system. Bland referred to
this issue, suggesting that it would be a major challenge getting a
single hospital group to adopt common systems, processes and
procedures - yet the national programme aims to achieve this across
thousands of healthcare organisations.
Bland said that he spent 14 years in the NHS, during which time he
chaired a joint working party between groups of pathologists in
London and tried to persuade them to adopt a common information
system, common processes and procedures.
"My success there - I think what you would charitably give me would
be about three out of ten, would you say?" he asked Kwo. Turning
back to the audience, Bland said, " OK, two [out of ten]... it was
a salutary experience about the complexities of getting common
systems across organisations that had been used to working in
silos."
Bland emphasised that the challenges were not technological but
organisational. "If we all in this room can get our act together
over the coming years there are no fundamental technical obstacles
to making the vision become a reality.
"There will be problems, I think, particularly in the areas of
integration and migration; problems with legacy systems and, for
example, the role of Emis [a system already used by many GPs] which
has been flagged today. But those are problems that I think can be
overcome. The single biggest problem is in organisation and
culture."
There will be disputes, Bland said. There would also be "what seem
like almost insuperable problems," but he added, "If we succeed in
implementing the totality of this project across the board it will
be an immense achievement for all of us."
Daily changes
A senior representative of the National Health Service Information
Authority raised knowing guffaws when he told the audience that
"everything in the national programme changes daily".
He referred to internal deadlines that had been changed and said
that bidders for contracts had submitted several "final best and
final offers".
Kwo gets fired up
David Kwo, the London head of the national programme for IT in the
NHS, told the conference at the Barbican that he wants chief
executive officers and clinicians in the NHS to promote the
programme with a "fire in their bellies".
Otherwise, he said, they will not be able to "hold the line when
early resistance, which is natural in the beginning,
emerges".
He added that they will need to be prepared for "noise and
resistance" when new systems go online.
But he conceded that issues remained about funding of aspects of
the national programme, the pricing of additional services by local
service providers, how Emis, a system used by more than 50% of GPs,
would fit in with the new strategy, and electronic transmission of
prescriptions.
World's biggest gamble - the names and
numbers
The national programme comprises four main projects:
- A £64.5m national system built by Atos Origin for the
electronic booking of hospital appointments
- A care records service, supplied by BT under a £620m contract,
which provides for everyone in England to have access to his or her
own electronic health record. As part the service BT will build a
national data spine with the help of Oracle, Sun Microsystems and
Logica CMG
- An NHS broadband infrastructure, known as N3 and supplied by BT
under a seven-year, £530m contract
- Electronic prescriptions.
To help feed information to the national systems and replace
incompatible legacy equipment locally, the Department of Health has
appointed five local service providers across England. They are:
- For London, BT, which was awarded a £996m 10-year contract
- For North East England, Accenture, which was awarded a £1.1bn
contract that also includes BT, Microsoft and Isoft
- For North West England and the West Midlands, CSC, which was
awarded a £973m contract
- For Eastern England, Accenture, which was awarded a £934m
contract
- For the South, The Fujitsu Alliance, which was awarded a £896m
contract, due to run until 2013. It is the largest of the five
local service provider regions, covering almost a quarter of the
country's population.
The public and private faces of the programme >>
Data spine to be tested this month >>