What officials promised Blair on NHS IT reform - release of secret papers

Among the Downing Street papers released by the Cabinet Office under the Freedom of Information Act was the Department of Health’s briefing to Tony Blair. The briefing was given to Blair four days before an NHS IT seminar at Downing Street on 18 February 2002 which spawned the National Programme for IT – NPfIT.

The Department of Health’s paper made it clear that the new programme to modernise the NHS using IT would be led by technology; it was not a project to change working practices with IT as a support tool. Indeed the paper to Blair was headed: “Strategy for modernising NHS Information Systems”.

The Department of Health’s briefing to Blair mentioned three private sector companies that officials had been “active in learning from” including Microsoft, BT and Cisco. Bill Gates had met Tony Blair in 2001 and had discussed an IT-based modernisation of the NHS.

BT much later won more than £1.5bn worth of contracts under the NPfIT. Microsoft has been briefing in secret the chief executives of NHS trusts on the benefits of the NPfIT.

The Department’s paper did not denigrate the state of NHS IT in 2002 to sell to Blair the need for a new national programme. Indeed the paper quoted statistics – much as NHS Connecting for Health does now to promote the NPfIT – to show that there had been a “step change following publication of Information for Health in 1998”.

The paper’s main objectives appeared to be to put the case for much more investment in NHS IT – with the promise of achieving a national summary care record by 2004/5 – and to caution the prime minister against going even faster. The paper listed the pros and cons of going faster.

This is a summary of the paper, quoting the words of the Department of Health:



“The NHS’s plan to improve care in the UK depends on a number of transformations in the quality, speed and capacity of the organisation. Information technology … practical examples of where IT can underpin the NHS are abundant – in patient record availability to citizen and clinician, quickly booking appointments and using prescriptions, scaling of scarce clinical expertise through telemedicine, knowledge capture and e learning through to the rapid transfer of critical documents like x-rays and MRI scans …

“Where we were

“In 1997 the NHS had a recent track record of IT disasters, e,g. Wessex, London Ambulance Service. It was focussed on administrative systems and the internal market. .. to overcome this Information for Health, the NHS strategy for information and IT, was published in 1998 and widely welcomed as a national strategy for local implementation.

“Where we are now

“There has been a step change following publication of Information for Health in 1998. .. the existing programmes are delivering significant benefits. For example in contrast to the position five years ago we can:

– ring NHS Direct Call Centres 24 hours a day

– get health information through digital TV

– keep and use electronic health records

– use decision support systems

– transmit test results electronically to GP surgeries

– transmit x-rays and other images electronically

– email anyone in the NHS

– run national projects successfully (Project Connect, software rationalisation, National Health Authority Information Service etc).

“The consequence of these developments is:

– 10,000 GP practices and 1,000 hospitals are connected to NHSnet

– NSHnet handles 1.5 million messages per day, usage rising by 8% every month

– There are over 300,000 addresses in the NHS address book

– Over 8 million traces in patients’ administrative details are made each month through the National Strategic Tracing Service

– 75 million datasets on NHS activity were processed by the NWCS [NHS-wide Clearing Service] over the last financial year

“We have also been very active in learning from other organisations – whether it is the Private sector (Cisco, Microsoft, BT), e-Government catalysts (Office of the e-Envoy, Office of Government Commerce) and other Departments (Education, Trade & Industry).

“However the interim report from Derek Wanless emphasised the relatively low investment in ICT in the NHS. Moreover the NHS Modernisation Board’s Annual report and a National Audit Office report on medicines management in NHS hospitals raised concerns over the NHS’s ability to implement information management and technology with particular doubts over implementing electronic patient records.

“Where we need to be

“From our own experience over the past four years and from interaction with Private and Public sector partners, we have learned that:

– the level and funding for IT in the NHS has not been sufficient – what resources have been available has not always been spent on IT

– the degree of standardisation of technologies and guidance from the centre to the NHS has not been robust enough. More central authority and funding control is necessary;

– we do not have to choose between massive, complex, national systems or local stand-alone choices of systems. By setting national standards and guidelines, encouraging the development of compliant local systems by vendors, and implementing a common national infrastructure connecting the NHS, we can have the best of both the traditional approaches, and avoid the worst;

– although the overall vision is generally understood, we can improve the communication and management of the delivery both Nationally and locally.

“Vision and strategy for modernising IT

“The strategic pillars required to delivery our vision are to:

– build connectivity so that all staff have the bandwidth and access devices they need

– develop core national services that can be used throughout the NHS (eg Electronic Health Record Service, Booking Service, Prescriptions Service)

– create a compliant choice of systems for critical local applications (eg electronic patient record) …

– manage funding to ensure IT receives the investment it requires

– work with industry to ensure we obtain the advantages offered by compliance with national data and systems standards

– work with the clinicians and Modernisation Agency [now defunct] to make sure the benefits offered by IT-supported working practices are delivered

“What will the NHS be liked if these investments are made? The table below includes some examples [edited by me]:


“Patients – I can use my digital TV to get advice. There are 500 NHS Direct Information Points for me to access.

“Doctors – I will be able to send clinical communications to other health care team members. I (some) will be able to see how my clinical practice compares with others via national clinical audit. I have best evidence and clinical guidelines through the National Knowledge Service.

“Delivery staff – My electronic staff record will be available. I will begin to access on-line learning materials through the NHS University [now defunct]. I know how to improve data quality.


“Patients – I can receive telecare at home, so I can leave hospital sooner. I can access my own Electronic Records. I know that if I have an emergency away from home that a summary of my health record will be available. I can book appointments where and when it’s convenient for me (and get reminders)

“Doctors – Electronic Patient Records will enable me to have clinical data online as well as reporting of results, and better communications. I can prescribe drugs more safely at less cost by using computer support. As a junior doctor I save 30 minutes a day in chasing results and getting ready for ward rounds. I will be able to use patient summaries (from their electronic Health Record), eg for emergency care. I will know that clinical terms in use are clearly defined and support analyses of practice

“Service delivery staff – I can really work as part of a multiprofessional team, and across organisational boundaries, providing seamless care to a patient wherever I see them. I can begin to use some video-based materials from the NHS University [now defunct]

“Implementation issues:

“Tackling the under investment in IT

– the USA spends 6% of healthcare budget on IT. Extrapolations from local investment plans suggest the NHS is currently spending up to £800m of its baselines revenue on IT. The interim Wanless report suggested that a baseline spend of about 1.5%% on ICT in the NHS was insufficient. To deliver a comprehensive ICT strategy it is suggested that investment in the order of £2.5bn pa is needed.

– “National standards for a National Health Service

– “Accelerate the programme of connectivity

– “Address three key issues at a national level:

“Consent and confidentiality. Patient consent and who can access confidential data are issues that constantly recur in NHS IT applications… A single national approach that can then be built into operating processes and systems must be developed

“Authentication of Users. .. Although this aspect may be managed locally a national approach is vital to ensure the same level of security and confidentiality can be delivered to clinicians and patients

“Encryption and Security. A single national approach is needed on the technical solution to encryption of messages and the security applied to information and access devices such as PCs …


“… Our strategy is focussed on delivering a balance of national and local systems, across high-speed, secure and standard infrastructure – with clinical care at its heart. To do so implies changes to the level of funding and the governance of IT in the NHS – and while there are options to accelerate delivery that have both pros and cons, some of the core decision are clear and can be actioned immediately, given the necessary funding and commitment.”


When this paper was discussed at the NHS IT seminar at Downing Street on 18 February 2002, Tony Blair asked repeatedly about speeding up the timescales – 2004/5 being too long a wait. There wasn’t a dissenting voice at the meeting, not to the plan or the compressed timescale.

Has there ever been a society which has died of dissent? Several have died of conformity in our lifetime, said the scientist Jacob Bronowski.

Less than four months after the Department of Health paper was written the NPfIT was announced.


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Secret Downing Street papers reveal Tony Blair rushed NHS IT – longer article

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