Briefing papers written for NHS trust boards have revealed the risks, benefits, challenges and uncertainties faced by local IT executives as they plan to implement the NHS's multibillion-pound national programme for IT (NPfIT).
The papers highlight a gap between the day-to-day realities confronting trusts and the reassuring comments about the costs of the programme by health minister John Hutton on the BBC Radio 4 Today programme last week.
The briefing documents have also revealed the size of communications gap between those driving forward national projects and those charged with implementing them locally.
Without exception the authors of the papers seen by Computer Weekly expressed strong enthusiasm for the NPfIT - although they were equally frank about the risks to the success of the initiative, especially over the perceived shortages of funding.
In particular, the papers drew attention to a depth of uncertainty that is rarely, if ever, publicly acknowledged by ministers or Whitehall officials.
This gap between the perception of the programme by ministers and IT managers on the front line could add to the problems inherent in managing such a large programme.
This issue was previously highlighted in an independent report by management auditors Arthur D Little into the causes of a failing, large-scale IT project at National Air Traffic Services (Nats).
The report criticised an organisational culture at Nats which inhibited the flow of bad news up the chain of command. It also found that the unwillingness of the organisation to face up to setbacks contributed to the project's serious problems.
Now Computer Weekly has studied dozens of briefing papers on the NPfIT presented to trust boards across England. A paper to the Board of Bristol North Primary Care Trust for its meeting on 7 October 2004 is typical in setting out the specific challenges faced by hospital IT and business managers.
The paper is by Yvonne Preece, acting director of IM&T for the Weston Area Health Trust.
After listing the many benefits of the national programme she warned about the risks.
"The enormous scale of the project, bigger than any other healthcare IT implementation in the world, means it is at high risk of failing to deliver - either in terms of the timescale or applicability of the finished product to healthcare delivery in this country."
In her area the local service provider (LSP) appointed by the national programme is Fujitsu, which won a contract worth £896m. The subcontractors are IDX for software applications, Tata Consulting for technical support and Pricewaterhouse-Coopers for change management consultancy.
She said that although there are five LSPs covering England, only two main software products are being offered - IDX in the South and London, and iSoft across the rest of the country.
The National Care Records Service, which will include a national database of patient records for 50 million people, will be implemented as a single database for the whole of England.
Exactly what the care records service will comprise has "not yet been agreed between the London and southern clusters," said Preece.
Fujitsu's contract with the national programme will cover the cost of software and central hardware to run the core system, but Preece said, "we have to pay local costs of implementation, which include PCs, printers and local area networking, with a specification of infrastructure required for the system to work as fast and securely as the standard set in the contract" - the so-called "warranted environment".
Preece said there is a risk that, "Central costs may be inherited by local organisations once the nationally funded phase comes to an end" - perhaps after five years.
Meanwhile the "local costs to be borne are likely to be high, at least in the short-term, especially in terms of infrastructure and staffing."
Specific local costs include:
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- The cleansing of data before migration to new systems to ensure it is in the right format and has no duplicated files
- Change management
- First-line helpdesk support
- Non-core "bundles", such as radiology and pharmacy stock control.
A further uncertainty is that although trusts will face local costs, they will have little control over the main supplier. This is because the contract is between the secretary of state and the LSP.
One result of this is that trusts are not being asked to sign off their own part of the region-wide implementation plan on a formal basis "as had originally been envisaged".
This uncertainty was mentioned again later in Preece's paper, where she said that as the contract with Fujitsu had been signed by the Department of Health "in that sense its consequences will be visited on local organisations, whether as willing participants or not".
She noted that "we still cannot be certain" of the financial implications of the implementation timetable, as the trust does not yet know:
- "Whether we will need to replace a lot of the existing PC stock to comply with the need for secure, smartcard access."
- "The price of non-core systems such as radiology and pharmacy stock control, which we would have to pay for ourselves, prices for which have not yet been published."
- "The work to be done in moving from our current systems onto the new ones." As this is far from clear "it is hard to know whether we need additional staff, and of what type, to support the change. As an example, even for the sites such as Bath which are early implementers, the data to be migrated has not been agreed."
There are other uncertainties. How the contract will be managed across the South of England is the "subject of an implementation planning exercise which is complete for 2004/05 but not for subsequent years".
Planning for the local implementations has had to address demand for new systems exceeding the contracted supply "both in absolute terms and especially in the first two years".
Preece asked her board to note the report, but her recommendation could equally apply to ministers. Their comments on the costs and challenges faced by the national programme will be more realistic the better they are briefed on the risks and uncertainties.
Many trust IT executives believe that their fears and uncertainties could be assuaged by open, frank and diligent communications between ministers, Whitehall officials and those on the front line in trusts.
IT staff have been trying to convey this message for more than two years, but they seem to have encountered a blockage in the communications pipes.
Benefits and risks of local implementation of the national plan for IT
Yvonne Preece's paper for the North Bristol Primary Care Trust lists a series of benefits and risks of implementing locally the national programme for IT in the NHS:
- Reduced IT costs, with local savings from hardware and software that are funded centrally.
- Avoiding protracted procurement processes. l Commonality of systems, enabling significant changes in working practices.
- Delivery of care in a wider range of settings through providing on-line access to patients' records, x-rays and diagnostic results.
- Faster access to treatment and reduced clinical risk.
- Direct booking of diagnostic tests, appointments and procedures in primary and secondary care.
- More proactive management of patients through better sharing of information between different professionals involved in an individual's care.
- Changes in the types and skill mix of healthcare professionals.
- Reduced length of stay for patients because of the rapid availability of results and standardisation of patient care. However, Preece said, "None of this will happen simply through the implementation of IT solutions. Clinicians, managers, planners and HR specialists all need to be involved in driving through these types of change. Implementing the national programme is essentially an organisational development project supported by IT, rather than an IT project."
- Being reliant on the delivery of the national care records service. "An example of problem of scale is already apparent in the time taken to make decisions."
- "Capacity problems in NHS IM&T as demand rises", for example, the demand for information analysts to support data migration onto the new systems. This may result in increased costs as we are forced to buy in support from Fujitsu to complete implementations to which we are committed."
- "Reduced data quality at the time of migration onto new systems", which may affect the government strategy of "payment by results".
- Problems with changing the working practices of professional groups, including GPs and consultants, who may "find the new systems change the way they are able to practice".
- Failure to handle the ending of the (existing) EDS contract could effectively "place operational services at risk and /or significantly increase the costs of existing contracts".
- Providing staff with sufficient training at a time of capacity constraints may prove difficult, thus compromising the ability to derive benefits from the project.