The report was strongly supportive of the scheme and replete
with praise for the Department of Health and NHS Connecting for
Health, its agency which runs the NPfIT. But earlier drafts seen by
Computer Weekly tell a different story to the final NAO report.
Comparing the earlier drafts against the final version of the
NAO's report shows that there has been a cover-up, with passages
critical of the programme removed or substantially altered. Among
the key changes are:
It is common practice for NAO reports to pass through several
drafts to correct and update facts, but in this case the changes
between the drafting and publication of the final NAO report do
something more. The draft reports on the NPfIT have been reshaped
to tell a different, and much more positive, story.
The final report is so complimentary about the Department of
Health, Connecting for Health, and the NPfIT that MP Greg Clarke, a
member of the House of Commons Public Accounts Committee, commented
on its tone at a hearing on 26 June.
"In a year on the committee I have read 62 NAO reports. This is
easily the most gushing," he said.
MP Richard Bacon, a member of the Public Accounts Committee who
has followed the NPfIT closely and refers to it regularly in
Commons speeches, says the report on the scheme is not up to the
NAO's usual high standards. He has sent dozens of written questions
to the NAO and the Department of Health. He hopes the answers will
help inform the committee before it publishes its report.
Now that three draft reports on the NPfIT are available -
released to Computer Weekly under the Freedom of Information Act -
it is possible to analyse what has changed, the extent of the
changes, and their effect on the final report. This is the first
time a series of draft NAO reports have been released.
What jumps out from the final report, in comparison with the
drafts, is the aggregation of changes that are seemingly minor when
considered singly, but which have changed the tone and tenor of the
NAO's findings.
The first draft in January 2006 notes that the NPfIT - the UK's
largest IT investment, costing £2bn more than the Channel Tunnel -
has strong support from ministers and senior management in the
medical professions, and there is some praise for the work of
Connecting for Health. But the draft also shows that the NPfIT has
deep-rooted weaknesses that put the programme's success in
jeopardy.
The January draft refers to concerns among NHS trusts about the
affordability of the programme it quotes surveys as suggesting that
there is considerable distrust and cynicism about the scheme, which
the Department of Health and Connecting for Health are a long way
from overcoming it also reveals that trainers in trusts are already
working to capacity, and that hospitals and the programme's
suppliers are trying to recruit from the same scarce pool, which is
driving up salaries. By the final report, all these points have
been omitted.
The final version is longer than the first draft, despite the
deletion of lengthy passages of criticisms. The extra space is
given over largely to comment, explanation, clarification, and
speculative statements in praise of the programme or Connecting for
Health.
In comparison with the unembellished January draft, much of the
final report published six months later reads as if it were a
defence of the programme composed by the Department of Health.
This is not normal.
The NAO has a reputation for producing factual reports that keep
comment and speculation to a minimum. It audits the annual accounts
of major government departments such as the Department of Health,
the Department for Work and Pensions and HM Revenue and Customs. It
also publishes value-for-money reports on particular projects, of
which the NPfIT is one.
The NAO has a special place among publicly-funded organisations:
a protected independence from government. It is accountable to
parliament's Public Accounts Committee, and has its budget set by
the Public Accounts Commission of the House of Commons. In this way
it is set up to be immune to pressure from government or from
permanent secretaries who run Whitehall departments.
Its special role reflects the pivotal position it holds in the
democratic process: its job is to report objectively to parliament
on the £800bn government spends and receives each year.
But the changes made to this report on the NPfIT prompt
questions about whether the NAO's independence has been
undermined.
Before NAO reports are published, convention requires that the
NAO agree the factual content of its reports with the departmental
heads before publication. This process was particularly lengthy -
six months - in the case of the NPfIT report.
As the delay in publication dragged on, the NAO came under
pressure to agree its report with the Department of Health - but
Whitehall officials did not have to sign off an NAO report they
were not content to be published.
The resulting document defends the adoption of a centralised
programme and depicts Connecting for Health as an exemplary manager
of the UK's largest IT investment.
It is also an official vindication of the programme in the face
of criticisms of some key facets of the NPfIT from within the NHS,
academia and members of organisations such as the British Computer
Society.
But the final publication does not represent the concerns
expressed by doctors and IT executives in the NHS - or the NAO's
auditors in their draft reports.
In the first draft, there are 19 section headings, of which five
are critical, including concerns about possible structural
weaknesses in the programme. One, for example, says that "not all
contractual arrangements have worked".
By the final report there are 21 section headings and the
negative ones have disappeared, except one which is only mildly
critical: it says that national leadership of parts of the
programme has changed a number of times. The words "not all
contractual arrangements have worked" have gone.
Some of the praise in the final version - not included in the
first draft - introduces discrepancies into the final report
figures for savings have been revised upwards by billions of
pounds, words and construction of sentences have been changed to
remove negative connotations, and some changes go further by
turning a neutral or critical statement into a positive one.
The January 2006 draft, for example, has a neutral
recommendation advising Connecting for Health to "continue to
closely monitor suppliers' performance". The same recommendation in
the final report praises Connecting for Health. It recommends that
the agency "continue its strong management of suppliers'
performance".
And between the draft and final reports, a negative comment
about Cable & Wireless is turned into a positive one.
The comment refers to the company's contract with Connecting for
Health to provide a secure e-mail service for the NHS. The draft
says plainly that Cable & Wireless did not achieve go-live and
availability targets between October 2004 and March 2005.
The final version of the NAO report wraps this sentence in a
longer one that ends on a positive note. It says that although
Cable & Wireless did not achieve go-live and availability
targets between October 2004 and March 2005, these were not
termination grade failures and the number of registered users of
the service increased to 167,946 and the number of active users
increased to 80,183.
Some negative findings by the NAO are not disputed by even the
NPfIT's most ardent supporters, but still they are omitted from the
final report.
For example, the draft says, "The programme represents the
largest single IT investment in the UK and it is important for
taxpayers and patients that it pays off. However, the programme has
attracted criticism from many sources, which, whatever the basis of
this criticism, emphasises the need for the programme to be well
managed and open to public scrutiny."
The final version leaves out any reference to the sentence about
the programme's attracting criticism. It says that it is "important
for taxpayers and patients that the investment pays off, and for
the programme to be well managed and open to public scrutiny".
In the summary of the final report, the change of a single word
from the draft makes the NAO complicit in the controversial view
that the quick signing of £6.2bn worth of contracts with local
service providers was good news. In the draft, the NAO says that
procurement of the contracts was completed "very quickly". By the
final version, the procurement was described as having been
completed "commendably quickly".
Other changes between the drafts and the final report are more
obvious, and all have the effect of showing the NPfIT in a better
light. According to the draft report, deals negotiated by
Connecting for Health with Microsoft and other suppliers are
expected to save about £470m. By the final report, the estimated
savings have risen to £860m.
Other figures have been revised upwards. The draft in May 2006
says that Connecting for Health commissioned a report from analyst
firm Ovum. The report compared the prices achieved by Connecting
for Health with estimates of the prices that could have been
achieved by individual organisations buying the same services
separately. "On this basis it estimated a saving of some £3.8bn
from central procurement by NHS Connecting for Health."
By the final NAO report, the saving had increased. "On this
basis it estimated a saving of some £4.5bn from central procurement
by Connecting for Health."
Similarly, the draft says that Connecting for Health "achieved
significant price reductions from the eight prime contractors, the
difference between their initial and final bids totalling
£4.5bn".
This figure of £4.5bn remained in the drafts dated May and 6
June, two weeks before the final report was published. By the final
report the saving had increased by more than £2bn. The final report
said Connecting for Health had achieved "significant price
reductions from the eight prime contractors, the difference between
their initial and final bids totalling £6.8bn".
The final report's praise is not always accurate. It says the
programme is the "only major public sector IT project in the UK
where the responsible body has a dedicated website to provide
information on the progress of the project". This is not correct.
There is a dedicated website on the progress of billions of pounds
worth of criminal justice information systems.
But the most obvious changes between drafts and the final
version are the omissions.
The June draft, for example, has a reference to a failed
implementation of an x-ray Picture Archiving and Communications
system (Pacs) supplied by CSC, one of four local service providers
appointed by Connecting for Health to deliver centrally-specified
systems.
The June draft says, "The Royal Liverpool University Hospitals
NHS Trust rejected CSC's Pacs solution for its Broadgreen Hospital
after an abortive three-month implementation effort." This is not
mentioned in the final report.
The June draft also refers to Norfolk and Norwich University
Hospitals Trust. It said it had "decided that it could no longer
continue with delays in the delivery of the implementation of the
new local service provider solution and it suspended the
implementation of iSoft's Patient Administration System to be
supplied by Accenture as it was not confident that it would be
delivered to the timescale it needed". Again, this does not make
the final report.
A draft also expresses uncertainty over whether trusts will set
aside enough money to implement national systems locally. "Money
will only be available if trusts give IT spending priority over
other demands on their budgets," says the January draft. This
concern is omitted from the final version.
An entire research paper published in August 2005 by the London
School of Hygiene and Tropical Medicine is excluded from the final
report. An NAO draft says the survey "reported that uncertainty and
poor communication were leading to a lowering of morale amongst NHS
staff responsible for implementation". The researchers had looked
at the processes and outcomes of implementing an electronic care
record in four acute hospital trusts.
Another omission in the final report is an NAO criticism about
the output-based specification for the NPfIT. "We encountered a
widespread view that there had been a lack of consultation about
the development of the output-based specification."
There are too many significant changes and omissions to list
here. Had the January draft been published, with allowances for
minor corrections, it would given the impression that the NPfIT had
much right with it, and much wrong. As it is, the final report
gives the impression that the programme is one of the most
outstanding successes in government IT.
The most satisfactory explanation for the differences between
the draft reports and the final publication is that the NAO has
been self-censoring: that it saw its January draft as too plain
speaking, too unembroidered, too hard on the programme. So it
decided to change the wording, the tone, and the impression created
by the draft, not forgetting to add more pages of amplification,
clarification and praise for the programme and its managers.
But it is more likely that every sentence, every phrase, was
fought over in the effort to get sign-off, with the NAO losing
every skirmish. Next week Computer Weekly will publish evidence
that Connecting for Health put the NAO on the defensive more than a
year before the final report was published, and that the NAO ended
up writing a long deferential letter to the agency.
The NAO says that the changes between the drafts and final
report on the NHS IT programme represent nothing more than the
normal process of clearance that precedes every major report it
publishes. But it is not normal practice for the NAO to delay a
report for a year and spend six months agreeing its drafts.
The NAO also says in response to accusations of a cover-up that
the conclusions and recommendations of the drafts have not changed.
This is not true either, as in the main text there are subtle but
important differences.
Given the apparent enfeeblement of the final report, questions
may now be asked about a process which means the NAO has to obtain
clearance from the departments it studies. And some may also
question whether the NAO can always be relied on by parliament to
conduct objective studies on major IT projects within central
government.
Some of the most serious criticisms of the National Programme
for IT in the NHS were removed between the draft and final reports
of the National Audit Office. These are some examples:
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