Analysis of two national IT programmes facing major
challenges
With his trademark straight-faced humour, Richard Granger,
director general of NHS IT, lamented the delivery on time of a
system to enable patients and doctors to book hospital appointments
electronically.
He told the Procurement Solutions conference in London on 21
June, "It is unfortunate we delivered it to schedule because if we
had delivered it a year or two late, I think the user input would
have caught up with the system being delivered.
"It is going to be interesting to see, over the next few months,
whether the potential of that working technology platform with very
high levels of availability is taken up locally in the NHS."
He was referring, lightly, to one of the biggest risks facing
the national programme for IT in the NHS, that clinicians might
shun national systems which met the specifications and were
delivered on time and to budget.
The danger is that Connecting for Health, an agency of the
Department of Health set up to deliver the IT-led modernisation of
the NHS, may help to deploy systems to hundreds of thousands of
users, across thousands of sites. But clinicians may not use
them.
Apart from Pacs x-ray systems, which have an obvious advantage
to all, clinicians may access other nationally-bought systems to
meet minimal administrative requirements, rather than use them in
earnest for the good of patients.
This risk has already materialised with the Police Information
Technology Organisation (Pito). Like Connecting for Health, Pito
was created largely to deliver national systems locally, but some
IT directors in the 43 police forces in England and Wales resented
being pressurised to install technology bought by London-based
officials.
Now a review of Pito's future, commissioned by the Home Office,
has concluded that it has lost the trust of police forces. It found
that the organisation cannot continue in its current form and
questioned whether tens of millions of pounds has been wasted on
national systems that are not used in earnest by most forces.
The review said the structure of police IT was "substantially
dysfunctional", and its report increased concern about whether
officials should have tried to impose national systems on
independent police forces.
Similar questions are being asked in the NHS. What will be the
implications of the Department of Health trying to thrust national
systems on hundreds of hospital trusts and thousands of GP
organisations, all of which are self-governing?
"Problems have arisen when what are judged to be national
imperatives are imposed from above on a structure that sees itself
as locally accountable and responsive - and to a significant degree
operationally autonomous," said the report on Pito.
To a careful observer of IT-related project failures in
government, the findings on Pito's future read like a potential
post-implementation review of the NHS IT programme.
There are indeed some strong similarities between the IT
strategies of the Home Office and the Department of Health. Both
are, though agencies, trying to deliver national systems to
end-users who have been used to buying their own technology. These
end-users cannot always be forced to swap their preferred
technologies for those favoured by Whitehall.
The review of Pito was led by Robert McFarland, a former chief
executive of the BOC group. His report highlighted massive
structural cracks in the foundations of police IT.
However, a comparison with Pito is not all bad news for the NHS
programme. Pito is about six years into delivering its national
systems. The NHS programme is only three years old, so this age gap
could allow health officials to learn from the mistakes made in
setting up Pito in 1998.
Most of the weaknesses in the structures of police IT, as
disclosed in the Pito review, can be read across to the NHS
national programme and Connecting for Health.
User opposition
The review of Pito concluded that it has enjoyed some success
but, in general, police forces oppose the delivery of its national
applications. They perceive the national systems as "unreasonably
delayed, expensive and technically backward". "Pito has not
provided what its customers wanted when they wanted it," the report
said.
Key systems within the national programme for IT in the NHS have
also been delayed and are seen by some GPs and hospital doctors as
expensive and technically backward. Many resent the
one-size-fits-all approach.
Choice
McFarland's team found that police forces would prefer to adopt
systems of their choice, built to standard specifications which
followed a "data-centric" approach, rather than be instructed by
the Home Office about what technology to use. But Pito has been
committed to delivering national systems. "The fact is that Pito's
overall credibility with the police is very low," said McFarland's
review.
The same centralist approach has been adopted for the delivery
of the NHS national programme.
Centralisation
Pito receives its funding directly from its parent department,
the Home Office, not the businesses it is supposed to serve. So it
has two masters which may have conflicting demands.
"If there is a conflict between Pito needing to deliver on a
Home Office target and the police force wanting to trade delay for
better functionality or improved business benefit, the Home Office
target is bound to take precedence," said McFarland's review.
"This, objectively, may be right, but in such circumstances
local police forces will see themselves as being dictated to,
rather than receiving a service."
Connecting for Health is in same position as Pito. It receives
its funding directly from the Department of Health, not from the
businesses it is serving, which are run by GPs and NHS trusts. A
common complaint about the national programme for IT in the NHS is
that some trust IT directors and GPs believe they are being
dictated to by the centre, rather than receiving a service.
Funding
The Home Office had hoped that forces would pay locally for
national systems to be implemented. But many police forces refused.
"Pito found itself developing systems that the majority of forces
labelled as yesterday's technology tomorrow. Thus the funding model
collapsed," said McFarland's review.
Many trust boards are expressing concern about the local costs
of introducing national systems. Some may be unable or unwilling to
drop other work to spend large sums on a national scheme for which
they feel no ownership.
Accountability
McFarland's team pointed to the lack of accountability for
Pito's national systems.
"In practice accountability falls between the cracks. Those in a
position to deliver, left outside the decision-making process, can
and do deny ownership."
Similar systemic cracks have appeared in the structures of
accountability within the NHS IT programme. Different organisations
are in partial control of delivery, including the Department of
Health, Connecting for Health, clusters, suppliers, primary care
trusts, hospital trusts and GP organisations.
Responsibility for the NHS scheme has passed through a
succession of owners and ministers, so there is much scope for
buck-passing if it all goes wrong.
Potential losses
The potential losses from police's boycotting some national
systems would run into tens of millions of pounds, perhaps £100m at
the most. With the health service, the potential losses could run
into billions.
The risk of losses of this size should have been debated fully
when the programme was approved in concept at a meeting in Downing
Street in February 2002. Did that debate take place? If it did not,
this may be why Downing Street has refused Computer Weekly's
request under the Freedom of Information Act to release details of
the meeting.
The McFarland review came too late for Pito. It found that
Pito's relationship with police has irretrievably broken down. But
it is not too late for a McFarland-style review of Connecting for
Health to save the national programme for IT in the NHS.