In a briefing paper for a meeting of his board on 3
August, IT director Mick Przystupa had only one
recommendation.
"The trust board is asked to note the progress of work to date
and the key risks associated with the introduction of NPfIT."
Przystupa, the director of information management and technology
at United Lincolnshire Hospitals NHS Trust, was referring to the
national programme for IT (NPfIT) in the NHS, the world’s largest
civil computer-based modernisation project.
His single, slightly euphemistic sentence put into words the
frenetic work being done at many trusts across England to prepare
for local implementations of new national systems and mitigate the
risks of failure.
"It is inevitable that a programme of this size and complexity
will carry risks and it is essential that robust programme
management arrangements are implemented to help to mitigate risks,"
his paper noted.
Among the key risks he cites is the need in 2005 to train more
than 4,000 staff which will present "significant funding and
backfill [paying for people to replace those who are training]
issues". His paper said the national programme requires a
"different specification of technology than that which has
traditionally been deployed within Lincolnshire" which "presents
both a financial and support risk".
Shared view
It is unfair to single out one briefing paper because it is
typical of others from IT directors to their boards across England.
The impression given by Przystupa’s paper, and many others by his
peers, is that they would like to be able to tell their boards:
"The benefits of the national programme are so great we should give
it our unqualified support." But some cannot.
Although the NPfIT has been running for two years, and all the
major contracts were awarded more than six months ago, trust IT
directors remain concerned about risks, uncertainties, complexities
and a lack of specific answers to direct questions.
Nobody doubts that the programme has already achieved much: the
potential benefits of technology for the NHS have a higher profile
than ever. Chief executives of all trusts in England have had their
minds focused, at some point, on their own important role in the
national programme. Nobody wants it to fail because the spend is
unprecedented, is unlikely to be repeated, and it could greatly
improve the care of patients.
But even some of the programme’s most enthusiastic supporters do
not believe it will succeed without officials going forward with
their eyes wide open to the risks and problems. This view is not
reflected in the literature published by the Department of Health,
which so far, has focussed on the benefits of the NPfIT with little
mention of the risks and uncertainties.
In March, at a national programme briefing to IT executives,
David Kwo, London head of the national programme for IT in the NHS,
said he wanted 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".
Some officials on the NPfIT believe with a visionary zeal that
the need to see the programme implemented successfully puts
concerns over uncertainties into a trivial perspective.
But, however much IT executives in the health service share the
vision of the national programme, they have also to contend with
financial realities.
Dealing with risk
A board meeting of North Somerset Primary Care Trust on 24 June
was told that the PCT "faces a challenging year to meet its
statutory duty to break even" and that the need to recover the
2003/04 deficit in addition to the already large recovery programme
will bring "significant risks to the PCT". It added that the
national programme will inevitably create risks. "Whilst the
hardware and software costs will be met centrally, costs for data
migration, training and ‘backfill’ will need to be met
locally."
There is £2.3bn definite funding for the NPfIT but contracts
worth more than £6bn have been signed with a handful of local and
national service providers. It is an assumption, not a certainty
that the difference will be fully funded. And the £6bn figure
excludes the currently unquantifiable costs of implementing the
national programme locally - costs that will have to be met largely
by trusts.
A briefing paper in May to the board of South East London
Strategic Health Authority from chief information officer Rob
Claridge, said on funding, "This remains an issue although there
will be some money for local implementation. This will not address
infrastructure development; nor will it enable Trusts to extend
their legacy IT or implement Pacs [picture archiving and
communications systems, the digitising of x-rays]."
Some trust IT directors have reported to their boards a large
gap between what they estimate it will cost to implement national
systems locally and the money they have been allocated centrally
and regionally, or in their budgets.
The most fortunate trusts are narrowing the gap. Stuart
Threlfall, director of ICT and service modernisation, in a board
paper to King’s Lynn and Wisbech Hospitals NHS Trust on 26 July
said that a business case to support the local delivery of phase
one release two of systems from supplier Accenture under the
national programme initially "left a significant and unacceptable
gap in funding" of about £1.2m.
Now, said Threlfall, the gap has been reduced but the remainder
will need to be addressed in part through "managed slippage and
savings from the original estimates". He recommended accepting the
business case with certain provisos, including this one: that the
local strategic health authority "accepts that local funding to
support NPfIT creates considerable cost pressure to an already
financially stretched local health system".
Similarly, the board of Medway NHS Trust was told in June that
there was an "urgent need to need to clarify timescales and
funding".
The board was told about some of the programme’s uncertainties,
that the trust’s local service provider Fujitsu Alliance and the
national care record service were "both still in the early stages"
and that "no set timescales, procedures or guidance had been
formulated".
Strategies get go-ahead
Most trusts have approved strategies to go ahead with their part
in the NPfIT while stipulating that there are risks and
uncertainties. But going ahead with implementations without
adequate funding and support could be disastrous.
John Bain, head of information management and technology at
Trafford Healthcare NHS Trust, in a board paper in May , referred
to the need to train and support care professionals and others to
enable them to make best use of the new systems. He warned that
underestimating the amount of such support was a cause of IT
project failures.
"It is important to note that evidence suggests that these
implementation costs may be as much as 70% of the overall costs of
introducing new systems. When new IT investment has failed to
provide the benefits expected, one major factor has often been the
underestimation and provision of implementation support," Bain
said.
Experts say that uncertainty is not all bad: it can add to the
excitement of project teams that are working at the frontiers of
business technology, doing things on an unprecedented scale; it may
also unleash the creative power of the local service providers BT,
Fujitsu, CSC and Accenture.
But so many uncertainties two years into a programme raise the
question of whether the promise of benefits to come are so great
that they justify an experiment with billions of pounds of
taxpayers’ money. Many in the NHS will say it is worth the
gamble.
The key questions on implementation
- Have health officials underestimated the disruption to the work
of clinicians and hospital staff, and the complexity of replacing
computer systems in trusts and GP practices?
- If so, could IT services - and the care of patients - seriously
deteriorate with the installation of new systems?
- Have the costs and implications of training and changing the
working practices of tens of thousands of doctors and nurses been
fully assessed?
- Will new national systems work and be trusted - and more
importantly used - by clinicians and NHS staff?
- Will they be more useful than existing systems?
- Do trusts have sufficient skills and money to implement new
national systems locally?
NPfIT: too early for full answers
The national programme for IT in the NHS was asked to comment on
criticism that two years into its work there are still many
uncertainties and that IT directors cannot always get specific
answers to direct questions.
It replied, "The national programme seeks to answer questions as
they arise as fully as possible at the time. However, it is a fact
that it has not always been possible to provide answers to very
specific and detailed questions. However, there will be greater
clarity as the programme develops and as local plans are taken down
to a lower level of detail.
"We are committed to dialogue within the clusters through the
regional implementation directors and chief information officers
and will continue to run local events and undertake visits and
roadshows."
The four parts of the NHS’ NPfIT
NHS Care Records Service
Every medical and care record for 50 million patients in England
will be held electronically and will eventually be available
online. The idea is that health workers and patients will be able
to access the records whenever and wherever needed. Health
officials say the service went live on 30 June.
Choose and Book
GPs and other health staff will be able to book initial hospital
appointments electronically, at a convenient date, time and place
for patients, without sending referral letters to hospitals and
waiting for a reply.
Electronic transmission of prescriptions
A new service making it easier and more convenient for GPs to issue
prescriptions and for patients to collect medicines.
New national network
The aim is for a national network (known as N3) with sufficient
connectivity and broadband capacity to meet current and future NHS
needs.
Technical specification
The national programme for IT says its strategic direction includes
the use of the Sun Java Virtual Machine. The programme said, "It is
recognised that Microsoft VM is still in use and will take some
time to migrate from. In the short term national applications are
being tested to operate against both Sun and Microsoft
applications."
NPfIT responses fail to answer direct
questions
In an attempt to get some direct answers to specific concerns
being raised by IT executives in the NHS, Computer Weekly put a
series of questions to the national programme for IT, which will
become an executive agency of the Department of Health next
year.
As some IT directors are finding, the answers from the national
programme were not always as specific as the questions.
Cost implications
We are told that every trust in England faces costs and risks
regarding the linking of their legacy systems to new national
systems: the data spine, Choose and Book and the care records
service. These costs include security and technical compliance.
This could amount to hundreds of thousands of pounds per trust. Is
this true? If so, how will trusts fund this cost given that the
money must be spent before the savings accrue from national
systems? Does the national programme recognise that some trusts are
already identifying funding gaps they are finding difficult to
bridge, and are reporting this to their boards?
In response the national programme did not comment on where the
extra money will come from. It accepted, however, that the costs of
training and implementing upgrades to legacy systems to make them
compliant with national systems may fall to the NHS.
"Legacy solutions are an integral part of the NHS Care Records
Service particularly in the early years of the national programme…
Some trusts will face additional costs in these areas, some will
not and this forms part of the planning and preparation. These
services will improve the overall standards of patient care in the
trusts and any extraordinary costs will be dealt with on a case by
case basis," said an NPfIT spokesman.
Compliance issues
Not all existing suppliers may be able to afford, or be willing
to pay for, compliance with national systems, and some are quitting
the NHS. Will the national programme pay for work to make these
systems compliant or support the migration of local systems to a
local service provider’s services? If not, and the supplier does
not pay for compliance, where does this leave system
users?
The answer did not tell trusts what to do if they were left
without support from companies that are quitting the NHS because of
the NPfIT’s restriction on suppliers.
"Naturally," said an NPfIT spokesman, "over the course of a long
project like the national programme the market changes. The
national programme is in dialogue with all suppliers on the
availability of upgrades to make solutions NHS Care Records Service
compliant. Clusters [new regional groups which help to run the
national programme] will be working with their local communities to
assess the impact of market forces and, of course, the prevailing
market conditions will influence their deployment plans."
Data accuracy
Who will be responsible for the accuracy of data that goes into
the spine record - a national database which will take in 50
million medical records, partly from GP systems?
The answer is not entirely clear. "Under the Data Protection Act
(1995) the data controller is legally responsible for the accuracy
of information. The controller cannot be named as the NHS or called
the health service as these are not legal entities and, therefore,
cannot be data controllers.
However, it is likely that in regard to online patient records
the vast majority of the controllers will be the local area or
regional NHS trust or a GP or other medical practice - in common
with the secretary of state for health. Employees of the data
controller (for example, a consultant within an acute trust) will
then have a contractual responsibility to ensure that the
information they enter into patient records is accurate and
complete."
Progress so far
By 30 June, contractors were due to have programme-managed the
upgrade of at least one acute trust patient administration system,
or deployed national systems such as electronic booking? Has this
happened and if so please say where?
"The plan, for summer 2004, was to implement electronic booking
into the first early adopter sites. The first successful online
patient appointments of the Choose and Book service have been made
in the first early adopter sites.
"The initial elements of the NHS Care Records Service spine to
support Choose and Book have also been delivered enabling GPs to
book appointments into secondary care and produce electronic
referral letters. The roll-out of the Choose and Book service is
starting with a limited number of sites across England and we
intend to allow these early adopter sites to undertake their work
uninterrupted. It would be unfair to submit them to the attention
of the media."