For those who’d rather not read the 250 pages of the latest Wanless report the following paragraphs are excerpts that relate directly or indirectly to the NHS’s National Programme for IT [NPfIT] They are in the order they appear in the report. There is some repetition in the paragraphs.
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“Actual spending on modernisation of the NHS ICT infrastructure has followed neither the solid progress nor the fully engaged spending trajectories. And it has not been without its difficulties, with most progress tending to relate to systems that were not originally part of the modernisation plan. The well-documented problems and delays that have beset the NPfIT have the potential to undermine seriously the productivity gains envisaged by the 2002 review.
“Future commitment not only to implementing core ICT systems but also to realising patient benefits and productivity gains is vital. The programme needs to be audited comprehensively to ensure that benefits will outweigh costs and to assess the precise impact on future productivity. Overall, in terms of resources this places the NHS much closer to the solid progress scenario.
“Implementation of the ICT programme has been slow, with its main anticipated benefits not yet achieved. And, although clinical governance now comprises a wide range of policies at individual, service and organisational levels, their specific impact on performance is hard to detect.
“The NHS is now in better shape than in 2002 to deliver improved quality and increased productivity, although huge challenges remain around commissioning and choice, competition between providers, the balance between targets, standards and incentives and between central direction and local discretion, and the shift towards local provision of care.
“However, the new policy framework deserves only conditional approval at this stage as it will be some time before a clear view can emerge about its effectiveness. And, even if the general direction is right, there can be no guarantee that sufficiently improved performance, in terms of outcomes or productivity, will be achieved at the levels required by the solid progress or fully engaged scenarios of the 2002 review.
“ICT deliverables are critical to many future productivity and service enhancements. However, despite some positive developments, there have been serious criticisms about the implementation of the Connecting for Health programme. Connecting for Health should be subject to detailed external scrutiny and reporting so that forecasts of long-term costs and benefits can be made with more confidence.
“The five years since the 2002 Wanless review have witnessed unprecedented levels of government investment in the NHS …The funding increase has helped to deliver some clear and notable improvements – more staff and equipment; improved infrastructure; significantly reduced waiting times and better access to care; and improved care in coronary heart disease, cancer, stroke and mental health. Although difficult to attribute directly to the NHS, life expectancy has also continued to improve… However, what is clear is that thus far the additional funding has not produced the improvements in productivity assumed in the 2002 review – costs of providing health services have increased and there is patchy and conflicting evidence on the impact on productivity overall, including little information about community-based care. … without significant improvements in NHS productivity, and efforts to tackle key determinants of ill health …even higher levels of funding will be needed over the next two decades to deliver the high quality services envisaged by the 2002 Wanless review. Such an expensive service could undermine the current widespread political support for the NHS and raise questions about its long-term future.
“The 2002 review identified better use of information and communications technologies (ICT) as key to productivity in terms of both reduced costs and better quality; it argued that there was a strong case for rapid investment – but only if this was sure to deliver cost-effective solutions.
“The National Programme for IT in the NHS (NPfIT – now Connecting for Health) – is responsible for implementing an integrated ICT infrastructure into all NHS organisations in England by 2014. The programme originally had four key deliverables:
– integrated care records service
– electronic prescribing system
– electronic appointment booking system
– the IT infrastructure to support these systems.
“The programme has since assumed responsibility for other services, including Picture Archiving and Communications Systems (PACS), the Quality Management and Analysis
System (QMAS) and NHSmail.
“The total cost of NPfIT is estimated at £12.4 billion (at 2005/6 prices) over the 10 years to 2013/4 (NAO 2006) , and the ICT resources recommended by the 2002 review should be sufficient to cover this cost. Given the well-documented delays that have beset the programme, it is not surprising that actual spending on ICT in England has followed neither the solid progress nor the fully engaged spending trajectories; in fact it is estimated to have increased from £1 billion in 2002/3 to £2.3 billion in 2005/6 (NHS Connecting for Health 2007a). However, planned spending of just under £2.9 billion in 2006/7 would overshoot both those spending trajectories and so come closer to that assumed in the solid progress scenario.
“There is as yet no convincing evidence that the benefits will outweigh the costs of this substantial investment. Two factors likely to impact on the 2002 review’s productivity assumptions are:
– an apparent reluctance to audit and evaluate the programme
– a structure for NPfIT contracts that risks creating monopolies in various areas of the programme.
“Although there has been some progress in modernising the NHS ICT infrastructure, this has generally been in areas (such as PACS) that do not relate to the original four key deliverables.
“On the timetable for implementing NPfIT, the House of Commons Public Accounts Committee (2007a) stated that ‘The Department is unlikely to complete the Programme anywhere near its original schedule’, and that ‘At the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period’.
…”While the NHS collects large amounts of data about most of its activities and outputs, there is none about the impact it has on the health status of the patients it treats. This remains a glaring omission that hampers any proper assessment of NHS performance. Second-best information comes from routine data sources recording aspects of the health of the population as a whole, such as life expectancy, rates of cancer survival, and so on. But changes in, say, mortality rates, cannot necessarily be attributed to interventions by the NHS because a wide variety of factors contribute to mortality, often over many decades.
“Both the NHS Plan and the 2002 review envisaged that IT would facilitate major improvements in service delivery. But, as seen in Chapter 2, implementation of the ICT programme has been slow, with substantial benefits yet to be realised. Although the IT programme has contributed to the introduction of Choose and Book (albeit behind schedule) and to improvements in diagnostic performance, its main anticipated benefits have not been achieved.
“There is little evidence of a systematic process for learning from past experience.
“The balance between central direction and local discretion has yet to be determined.
“Review of the implementation of Connecting for Health
“The weaknesses of ICT in the health service have long been evident and the programmes of recent years have represented a determined attempt to improve. The deliverables are critical to many future productivity and service enhancements but, as indicated in chapter there have been serious criticisms made about the current situation and implementation of Connecting for Health, despite some positive developments. Future productivity and quality gains envisaged in the plans for the NHS and reflected in the future forecasts of costs require the effective use of ICT budgets. There is much money still to be spent. There is a need for an audit of the technical aspects of the Connecting for Health programme and the financial costs and benefits before deciding whether or not to continue with the implementation of current plans. Unless there is greater clarity about the costs and benefits of the programme, it will be difficult to make assessments of the longterm costs and investment needs of the NHS.
“It is recommended that Connecting for Health is subject to detailed external scrutiny and reporting so that forecasting of long-term costs and benefits can be made with more confidence.
“NPFIT PROGRESS TO APRIL 2007
“Integrated care records service
“The NHS Care Records Service (NCRS) aims to provide an electronic health care record for every patient in England. The NHS Plan noted that this could become a reality by 2004, when 75 per cent of hospitals and 50 per cent of primary and community trusts would have implemented electronic patient record systems. However, controversy has seriously undermined this aspect of the NPfIT, partly due to the absence of any published plans for the design and implementation of NCRS. It is also unclear what information will be held on individual electronic health care records. Doctors and patient groups remain anxious about who will have access to electronic patient records and the associated risk to patient confidentiality. The government has now agreed to allow patients to ‘opt out’ of having their records held by CRS, although the details of the opt-out procedures have not been settled. Consequently, real progress is only just beginning. In the spring of 2007, a number of early adopters began reating ‘summary care records’ as a prelude to the national roll-out. These records are expected to include significant elements of a patient’s care, including major diagnoses, procedures, current and regular prescriptions, allergies, adverse reactions, drug interactions and recent investigation results. However, this will be a challenge. National roll-out is expected to begin early in 2008, but it will be several years before coverage is complete. A date has not yet been specified for the system to be fully operational.
“The Electronic Prescription Service (EPS) allows prescriptions to be sent electronically from prescribers to pharmacies. Implementation began in early 2005 (NHS Connecting for Health 2005a), slightly after the 2004 start time envisaged by the NHS Plan. As of April 2007, nearly 16.5 million prescription messages have been issued electronically, with the service being used for around 8 per cent of daily prescription messages. The system is being actively used by 1,700 GP practices in England (around 20 per cent), although only for a minority of their prescribing (NHS Connecting for Health 2007a). Every GP surgery, along with community pharmacies and other dispensers, was expected to have access to the service by 2007, although this target will almost certainly be missed due to slower-than-expected uptake. In time, prescribers operating from other locations, such as walk-in centres and dental practices, will be included in the scheme, and there are also plans to include hospitals issuing prescriptions for dispensing in the community.
“Electronic appointment booking (‘choose and book’)
“The ‘choose and book’ system allows patients at the point of referral to book online appointments from a GP surgery, at a date and time of their choosing. From January 2006, the system also enabled them to choose a provider from a limited list of around four organisations, which will expand over time. The NHS Plan promised to achieve electronic booking of appointments by 2005. Choose and book began (albeit on a limited scale) within this time frame, with the first booking made in July 2004 (NHS Connecting for Health 2005b).
“Subsequent take-up appears to have been slow. The system currently relies on relatively outdated technology, which has led to dissatisfaction among GPs (Medix 2006). The Department of Health has not achieved its target for 90 per cent of all patient referrals to use choose and book by March 2007.
According to NHS Connecting for Health, as of April 2007, more than three million bookings have been made using the system, accounting for around a third of NHS referral activity, from GP surgery to first outpatient appointment (NHS Connecting for Health 2007a). This includes some appointments made by telephone, using choose and book. Around a quarter of GP referrals through the choose and book system are made in the surgery at the point of referral.
“New National Network (N3) project
“The NHS Plan aimed to have all GP practices connected to NHSnet by March 2002, achieving 95 per cent connection prior to the deadline. Since then, NHSnet has been superseded by a wew national network for the NHS known as N3. This aims to link all NHS organisations, providing secure networking services and the broadband capacity to meet all the current and future IT needs of the NHS. Connections to the N3 network started in April 2004, with full implementation expected to take three years. Progress as of April 2007 appears on schedule, with 18,989 connections to N3 and 98 per cent of GP practices connected to the network (NHS Connecting for Health 2007a).
Spending on the NPfIT is projected to be £12.4 billion (at 2005/6 prices) over the 10 years to 2013/4 (NAO 2006). Up to the end of March 2006, actual expenditure on the contracts let in 2003 and 2004 was lower than planned: £654 million (estimated outturn) compared with expected expenditure of £1,448 million, reflecting the slow delivery of some systems. Our analysis suggests that the ICT resources set out in the 2002 review should be sufficient to cover the National Audit Office (NAO)’s estimated cost of £12.4 billion for the 10-year programme.
“The extent to which the NHS will benefit from these substantial investments remains unclear. A detailed review of NPfIT is beyond the scope of this report, but three factors seem likely to have an impact on the 2002 review’s productivity assumptions.
“The first is the failure to develop an ICT strategy whose benefits are likely to outweigh costs. The NAO (2006) noted that ‘…it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme’. This is a serious criticism, implying either the absence of an original business case for investment or investment made in spite of a business case that did not justify the spending. In similar vein, a report by the British Computer Society (2006) concluded that ‘… the central costs incurred by NHS [Connecting for Health] are such that, so far, the value for money from services deployed is poor’.
“Surprisingly, systematic reviews of ICTs show that evidence for key technologies, such as NCRS and PACS, is lacking (Delpierre C et al 2004; Poissant L et al 2005). It is difficult to understand why Connecting for Health is being allowed to pursue a high-cost, high-risk strategy that cannot be supported by a business case.
“Second, while the 2002 review assumed that investments would be audited and evaluated, apart from the NAO report the necessary work is not being undertaken and it does not seem possible to obtain reliable data on NHS resources being committed to NPfIT. Connecting for Health has so far made negligible investments of less than £0.5 million in evaluation (a fraction of the projected £12.4 billion costs). There seems a real risk that the costs and benefits of NPfIT will never be accurately assessed.
“The third factor, which may turn out to be the most important, is that the NPfIT contracts risk creating monopolies in various areas of the programme. The House of Commons Public Accounts Committee (2007a) has noted that ‘The use of only two major software suppliers may have the effect of inhibiting innovation, progress and competition’. Connecting for Health chose to award a small number of large contracts to consortia charged with designing and implementing the technologies. But they could instead have set out to create a competitive market for IT goods and services. Is it possible that a robust business case could be created, even now, with a focus on strategies for encouraging a healthy market?
“It is clear that there are considerable challenges ahead in modernising NHS IT systems, and continuing debate over the feasibility of some current NPfIT plans. The continuing uncertainty and delays have the potential to undermine the productivity gains envisaged by the 2002 review.
The extent to which the NHS will benefit from these substantial investments remains unclear. Three factors likely to have an impact on the 2002 review’s productivity assumptions are: failure to develop an ICT strategy whose benefits are likely to outweigh costs; failure to audit and evaluate investments; and the risk of monopolies in parts of the programme. These factors, together with delays to the programme, have the potential to seriously undermine the productivity gains envisaged by the 2002 review.