It is a pity Richard Granger, director general of NHS
IT, is to leave as head of
Connecting for
Health, the agency that is running the National Programme for
IT (NPfIT). The decision was his - he was not asked to leave.
Indeed, officials at the Department of Health may soon recognise
that they are losing the NPfIT's most valuable asset.
Without Granger the
NPfIT is at risk of falling apart, for he has given the
programme a credibility it would not otherwise have had.
Long before he joined the Department of Health as director
general of NHS IT, the future of the NPfIT was to a large extent
sealed.
By then a key lesson from the failures of three separate
IT-related programmes - Wessex Regional Health Authority's Regional
Information Systems Plan (1992), the Read Codes version three
(1998), and the Hospital Information Support Systems initiative
(1996) - should have been learned. And that was that large,
centralised IT schemes imposed on semi-autonomous NHS sites rarely
work. They engender a scepticism among doctors that becomes
impossible to overcome.
Instead of avoiding this mistake, officials at the Department of
Health and Downing Street made it the central ingredient of a new
scheme of unprecedented scale and boundless complexity. Ministers
further deepened scepticism among clinicians by conceiving the
national programme in secret and announcing it as a fait
accompli.
Need for an electronic system
Later, when Granger joined the programme in autumn 2002, he gave
it a credibility based on a conviction that it was needed. And he
was right. Reliable electronic health records are needed urgently.
Paper notes go missing, and are not generally available after
hours.
So there is no disagreement on the need for easily accessible
electronic medical records. But local patient record systems were
already being installed successfully before the NPfIT was born. It
was just happening slowly. So it is understandable that ministers
wanted progress to be accelerated.
The answer was for national standards to be set, money put aside
for modernisation, teams from successful sites deployed as
troubleshooters within the NHS, and incentives paid to GPs, IT
specialists and chief executives for successful implementations in
which benefits for patients were measurable.
Instead, the Department of Health wanted in early 2002 to put
itself at the centre of everything that happened. Bureaucracies
love complexity. And so an amorphous national programme without a
simple, clear objective grew around the sound idea of electronic
records for everyone in England.
Later, Granger joined the programme. And he and his team have
achieved much. IT is now a high priority for NHS trust boards and
he has broken new ground in his firm dealings with suppliers. The
NPfIT has also done much to force trusts into identifying duplicate
and inaccurate patient records, and some trusts have had antiquated
IT replaced with more modern systems.
Connecting for Health has also delivered a number of useful
systems that most people have never heard of, including the
Secondary Uses Service (a healthcare planning, clinical audit and
research tool), the Personal Demographics Service (a database of
names, addresses, dates of birth and NHS numbers), and the Quality
Management and Analysis System (a means of assessing the work of
GPs).
Though successful, these systems may, for the NPfIT as a
programme, represent "scope creep" in that they were not among the
original four main NPfIT systems. These four were an electronic
system to book hospital appointments, national electronic health
records, a new broadband infrastructure and e-prescriptions.
Our verdict on the NPfIT systems
BT has successfully delivered the broadband infrastructure,
though critics attack the cost of making changes to bandwidth. The
electronic system to make hospital bookings is working, and though
a significant number of GPs refuse to use it for a variety of
mostly understandable reasons, they may support it when it is
quicker and they are used to its idiosyncrasies.
E-prescriptions have been hit by delays, but may in time prove a
useful system. A national electronic health record is the main
reason for the NPfIT and it looks to be years away. Many experts
now question whether it is needed. An accurate, comprehensive and
secure locally-available electronic health record may be a better
idea.
Since some of the NPfIT's main systems have yet to materialise
fully, ministers have sought to direct positive publicity towards
x-ray systems, known as Picture Archiving and Communications
Systems (Pacs). But these were being installed before the advent of
the NPfIT.
Pacs is a technology that has unanimous support in the NHS - it
replaces x-ray film, which can easily go missing, with digital
images that can be viewed on high resolution monitors - if
necessary by consultants who are miles away from the patient.
But Pacs was not one of the four main NPfIT systems, so its
success does not make the NPfIT a success, though ministers in
their statements treat the two as the same.
And this is arguably the biggest weakness in the NPfIT:
ministers have politicised it.
Too political
In the private sector the project would have been reviewed
independently. If there were parts that did not work, and it was
thought unlikely they would ever work, they would be scrapped.
Money and people would instead have been directed into installing
systems that yielded measurable patient benefits at an affordable
price.
But in politics, changing direction can be seen as a weakness,
or even, dare we say it, a mistake. So changes must be made below
the radar, without anyone really noticing, while transient
ministers declare that all is well.
Unannounced changes are indeed being made to the NPfIT. Local
NHS trusts are installing standalone systems that are being adapted
to national standards. These may be integrated in years to come
when, for example, there is agreement among clinicians on how
records can be shared.
But with Granger's departure, the programme is losing a rock.
About a dozen ministers with overall responsibility for the
programme have come and gone, and the health minister Lord Hunt has
gone and come back again. But Granger has for years remained as
senior responsible owner for the IT parts of the scheme.
So we are disappointed that he is leaving. And it is surprising
the Department of Health is not doing more to keep him. A figure as
charismatic and demanding will prove difficult to replace. We are
by no means sure the programme can be held together without
him.
Computer Weekly's
National Programme for IT site >>
Tony Collins'
blog >>
NAO report on The
Hospital Information Support Systems Initiative - 11 April 1996
>>
NAO report on
Read Codes - 12 March 1998 >>
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