Agile in the NHS: 10 years, £5bn and still not finished

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When the Department for Health signed £5bn of contracts for care records systems in 2003, Oxfordshire and Buckinghamshire Mental Health Trust (OBMH) already had one.

But OBMH was forced to swallow the system under the extortionate National Programme for IT (NHSIT) anyway, even though it would cost way in excess of twelve times what OBMH already paid for a perfectly functional patient system, and even though, seven years since NHSIT was conceived, the software still wasn’t up to the job.

This must be what passes for agile development in the NHS: £5bn, 10 years and still not finished.

If you want to know why the Public Accounts Committee thinks NHSIT is an expensive failure, this is a prime example. OBMH bought the NHSIT software because that was the only way to avoid a £9m fine being levied on Trusts that didn’t get with the programme.

The numbers are unbelievable, even without the extortion. OBMH had been paying an IT SME called Maracis £60,000 for ongoing support and development of its “enviable” PCIS care records system, which OBMH already owned under a perpetual licence that only cost £250,000. In comparison, NHSIT had arranged to pay BT £9m for each Trust it supplied under the programme.

The Trust expects the RiO system to cost in excess of £350,000-a-year when the NHSIT contract runs out in 2010 – and that’s just for starters. Development costs will go on top. Then there’s the cost OBMH expects to incur from buying in other systems to fill in the gaps left by RiO’s poor functionality.

It sounds like too much for any cash-strapped NHS trust to swallow, and it’s a wonder BT managed to persuade anyone to use its care records system. But lets not forget the extortion. OBMH’s Business Case for using BT RiO said the chief reason was indeed the £8.8m fine it would be forced to pay if it tried to use an alternative – even if that alternative was the Maracis system it was already using when BT RiO and NHSIT were but a twinkle in some bozo’s eye.


In the 12 years OBMH used PCIS, the system “served the Trust well”, said the report. It put OBMH in the “enviable position” of already having a comprehensive records system. The Trust was nevertheless forced to conclude (after using it for 12 years) that PCIS wouldn’t meet its strategic objectives in the long term because there was no longer a market for non-NHSIT records systems in the NHS.

No matter that Maracis had already “significantly” developed the system over the years since it first installed it at OBMH in 1998, four years before NHSIT even got started.

And what a farce it turned out to be. After NHSIT got started in 2002, OBMH was told to ditch a regional care records system it had already been working on with other Trusts. Just as well the Trust had carried on with PCIS because it had meanwhile supported new implementations of implemented document management, an integrated electronic health record and clinical management information – all while NHSIT was still trying to get started.

NHSIT originally planned to force Trusts in the Southern Cluster to accept the IDX CareCast records system on subcontract from Fujitsu, which then held the calamitous Local Service Provider Contract for the South. But IDX was shown the door in 2004, leaving NHSIT up the creek without a paddle. OBMH was meanwhile getting on just dandy with PCIS on mobile devices – being possibly the first trust to have electronic care records available to its community workers.

NHSIT meanwhile tried to clear up the mess it had created with IDX. It tried replacing it with Cerner Millennium, a system so so poorly suited for Mental Health Trusts that OBMH had to muck in on a programme to get it fit for purpose. But it was so rubbish they had to ditch that too. PCIS was meanwhile still going strong.

OBMH’s ongoing use of PCIS was making a mockery of NHSIT. It not only had a working care records system, but it was being continuously developed as well – and for mere tens of thousands of pounds. It implemented support for the Care Programme Approach to mental health, an outpatient project, a patient transfer project, an outreach data project, and a Child and Adolescent Mental Health data project.

In the wake of Fujitsu resigning from the programme, Some Mental Health Trusts had meanwhile taken a look at the iSoft Lorenzo application. But Lorenzo’s delays and financial problems scared them off. Then in 2009 BT bought up the remnants of Fujitsu’s contract and trusts were lumped with RiO.

OBMH was still making great strides with PCIS. It automated document loading, implemented another child and maternity records system, a notes system and an archive project.

And then came crunch time. The Trust was told that if didn’t ditch its trusty PCIS and install RiO the South Cental Strategic Health Authority would extract an £8.8m fine. Suddenly, the £90,000 a year it was paying for ongoing development of a system that was already and ever being made fit for purpose was nearly a £1m a year over 10 years. Who clocked the bonus for that one?

Thought experiment

To appreciate how absurd this situation is, contemplate spending £5bn on a patient administration system.

Remember that industry analysts used to justify the high cost of these systems by saying BT ought to be paid a decent rate for a decent job. Now try this thought experiment. Imagine installing Maracis everywhere (disregarding for now that this would be as absurd as installing RiO everywhere). The first time costs of Maracis are, according to the firm, £250,000 for a single Trust and £60,000-a-year for ongoing support and development. (£70,000-a-year if you throw in bespoke development).

Lets say for the sake of argument the 392 Acute, Mental, Community and Ambulance Trusts originally set to be supplied under NHSIT all bought Maracis and were all charged the same rate. Lets also assume (for the sake of argument because Maracis doesn’t do a GP version) the 5,643 GP practices originally set to be supplied under the £5bn NHSIT programme all bought Maracis as well, and they paid an average (across practices from 1 to 10s of GPs in size) £40,000 for install and then £8,000-a-year. The total cost of the Maracis NHSIT contract would be £1bn. That’s one-fifth of the cost. Even if you add £100m for large-scale extras and throw in another £100m for fat cat salaries and wide boy pensions, that’s still only £1.2bn.

A more realistic comparison can be made if we were to imagine either BT or Maracis getting a contract to supply all 80 UK Mental Health Trusts. At the rate each of them established at OBMH, it would cost £720m under BT and £76m under Maracis.

This is clearly absurd. Just where has all the money been going?