NAO faces challenges in unprecedented investigation of
national programme for IT
At the end of a long and articulate letter to GP-users of the
Emis medical system last week, Manpreet Pujara suggested that
public spending auditors investigate the national programme for IT
in the NHS.
Pujara, who is head of the Emis User Group, is concerned that
the government will spend millions of pounds unnecessarily
replacing GPs’ systems.
He was not to know when he sent the letter last Friday that
public spending watchdog the National Audit Office had just decided
to launch a full value-for-money investigation into the £2.3bn NHS
programme. It has taken the NAO a year to decide to investigate,
having announced last August that it was considering holding an
inquiry.
In his letter to Emis users – about 55% of England’s GPs use the
system – Pujara expressed strong support for the principles
underpinning the national programme. But he expressed concern over
plans by the national programme to restrict the number of systems
in use in GP practices to the two products offered by local service
providers.
The local service providers comprise a small number of large
companies including BT, Accenture, CSC and Fujitsu which have been
chosen by the Department of Health to deliver new standardised
systems throughout the NHS in England.
None of the local service providers is offering Emis. This is
partly because they want to offer their own integrated systems and
also because Emis refuses to sign contracts with the local service
providers.
"Ruthless standardisation"
Sean Riddell, Emis’s deputy managing director, said his company
cannot agree to clauses which, if signed, would lead to its
professional indemnity insurers refusing to provide continued
cover.
This leaves Pujara and other GPs concerned that Emis users will
now face having to change from a tried and tested system, which has
evolved over 16 years of use in a competitive market to one of as
yet of unknown quality and features from a local service
provider.
In his nine-page letter, Pujara said, "The government does not
need to spend millions of pounds to replace GP systems that are
working well for practices and will continue to do so for the
foreseeable future."
The national programme for IT (NPfIT) wants the changeover as
part of its strategy of "ruthless standardisation". But Riddell
wants GPs to be able to choose any system that meets a much
respected standard, known as HL7, for exchanging health data.
Pujara, a practising GP, said a switch from Emis to new systems
supplied by local service providers could cause severe disruption
to the running of GP surgeries. He counsels against the national
plan adopting a "dogmatic approach, which cannot accommodate
criticism from the primary care community".
He added, "It would seem opportune to have an independent view
of the NPfIT before irreparable damage is done to primary care IT –
a job for the National Audit Office, I would suggest."
The Emis controversy
Investigating the NPfIT will present especial difficulties, not
merely because it is the biggest civil IT project in the world,
according to the Department of Health’s literature; and not because
of its high political profile: ministers are planning a series of
announcements on the success of the project.
With such political sensitivities, the challenge for the NAO
will be to distinguish the truth amid competing claims.
In contracts signed between the government and GPs, family
doctors were told they would have a choice of systems.
Clause 4.34 of the GP contract stated, "From 1 April 2003 every
practice in the UK will have the choice of RFA-accredited systems."
RFA stands for requirements for accreditation, which is a core set
of requirements, specified by the NHS Information Authority, which
all GP systems should be capable of performing. Emis is an
RFA-accredited system.
Clause 4.34 is backed by a joint statement from the British
Medical Association and the national programme. It said, "Practices
and their primary care trusts should not be financially or
otherwise disadvantaged by choosing to remain with an existing
[compliant] system…"
But the NPfIT has this month issued advice to healthcare
suppliers which gives the impression that GPs will be expected to
replace their non-local service provider systems – which would
appear to include Emis – within two to five years.
The statement said the NPfIT’s plans are for two core clinical
applications to "ultimately replace existing NHS clinical
systems". It added, "As a general rule, it can be anticipated that
the majority of existing systems will have been replaced or
integrated within either a local service providers’ solution or
management responsibility, at some point during the next two to
five years."
To add to the confusion, Riddell said he is so concerned about
incorrect statements that his company has written to some officials
asking them to put right incorrect comments they are alleged to
have made. For example, Riddell said that some of his customers
have been told, wrongly, that Emis is running down its development
of the product.
A spokesman for the national programme said, "All GP practices
will be offered a choice of IT system to access the NHS Care
Records Service. However, in the long term it is expected that the
majority of the current plethora of existing systems will have to
be replaced or integrated and it is likely that due to the large
number of existing systems some will not be integrated."
Meanwhile the national programme will be working closely with
Emis and other systems to ensure their systems are compliant for
the roll-out of choose and book, the e-booking service, said the
spokesman.
The NAO’s role
Without unravelling the Emis issue, the NAO may be unable to
ascertain whether GPs are being forced to replace their systems
unnecessarily and, if so, whether millions of pounds will be spent
for little or no gain for patients.
But the Emis controversy is one of many examples within the
NPfIT where there are disputed versions of the truth. For instance,
a Computer Weekly reader said in a detailed e-mail that the
national plan in London has had "huge problems recruiting the
necessary numbers of NHS staff to fulfil key roles in their much
publicised best practice groups for the London NHS Care Records
Service [part of the national programme]".
The e-mail said the groups were set up initially to "advise on
how we, the London NHS community, wanted our [new] solution to look
and work". The author said he thought that work on developing
systems for London would slow down "until such time as we had
sufficient numbers to review all of the work to ensure that the
system was adequately configured for London's needs". But he said
he was told that the project "could not be delayed under any
circumstances".
The e-mail claimed that "initial hype about involving the wider
NHS community has fallen by the wayside to meet politically
motivated deadlines".
Computer Weekly asked the national programme whether officials
were sticking to a timetable rather than waiting until there are
sufficient staff to adequately review the work of local service
providers. The spokesman replied, "There is no shortfall in the
numbers of NHS staff on best practice groups and they have been
very well supported."
Doubtless NAO staff are expert in sorting fact from fiction,
objective statements from those that contain material omissions and
truth from a verisimilitude of it. Their report is due to be
published next summer.
Key questions for the NAO
- Should the Department of Health have sought to modernise the
NHS by allowing market forces to prevail – imposing rigorous
standards which suppliers had to meet – or by restricting the
market to selected companies?
- Should £6bn worth of contracts have been signed before it was
known what the overall costs, including those of local
implementations, would be; what changes in business process would
be necessary; whether clinicians would use systems imposed
centrally or regionally; how benefits would be measured; whether
GPs would oppose any handover of control on the confidentiality of
their patient records; and whether there were enough in-house
skills to translate national plans into local action?
- Has the national programme understood the benefits of the
projects better than the risks?
Inquiry is vital for NHS success>>