An NHS accident waiting to happen

Government plans for a national patient booking system have kept NHS IT managers in the dark and left them fearful of another...

Government plans for a national patient booking system have kept NHS IT managers in the dark and left them fearful of another costly national IT disaster. This week Tony Collins reports their views

When IT directors across the NHS woke up to find out the Department of Health was likely to implement another risky national IT project, largely without their input, they were damning of the proposals. One even went as far as suggesting that ministerial ambition may be at the heart of the problem.

"Unfortunately, ministerial priority is to get something done quickly before they move to other jobs," a West Midlands NHS IT director told Computer Weekly. "That must be the only reason they are trying to rush this through and with a certain amount of secrecy."

This reaction came after Computer Weekly revealed that the Department of Health is planning a national computerised patient booking system, without full consultations of the health service's most experienced IT professionals.

The department has already made it clear that it wants to own the publicity for NHS IT projects. In a letter to regional heads of information it said there should be no unplanned local announcements. "We would not wish to see local publicity about the details of a new investment in information management and technology pendingaministerial announcement," it said.

The department has also been keen to publicise patient booking systems and since 1998 has made at least 12 separate announcements on plans for the systems. Two were written for the prime minister Tony Blair.

Two weeks ago the health secretary, Alan Milburn, promised that there would be a national booking system by 2005.

To meet this target, the Department of Health's National Patient Access Team has written a consultative paper which sets out a timetable for electronic booking systems. Although it gives a list of options for consideration, it favours a national system or service supplied by a large IT company or a consortium. It sets out proposals for a tender, evaluation and contract to be awarded by the end of 2002.

NHS IT managers declined to criticise publicly new government plans for a national booking system, but several spoke anonymously to Computer Weekly of their concerns about a consultative NHS paper on systems.

NHS IT directors said that the proposals were being rushed and that a national system would become disastrously entangled in its own complexity. It could also waste up to £40m already spent on local booking systems, while a national system or service could lose between £75m and £140m in abortive costs.

At present, most NHS hospitals arrange appointments without asking patients which dates are most convenient, leading to more than 10% of patients failing to turn up for an appointment, which in turn wastes NHS funds. With a pre-booking scheme, the patient is offered a list of available dates and chooses when to have an operation or consultation.

Many trusts are now at an advanced stage of implementing, or preparing to implement, electronic local booking systems. They were encouraged by Blair's announcement in 1999 of an extra £40m for the systems. But if a national system or service is now approved, these local patient booking projects could be scrapped or sidelined.

"We have invested large sums on our booking systems - well in excess of six figures," said an IT manager in the north-west of England. "Is the NHS now saying we have to put all that development in the bin?"

Another said, "A centralist approach will stop a lot of very good projects going on around the country."

The NHS claims that the consultative paper, which sets out a strategic outline case (SOC) for electronic booking systems, is an early draft and shows that nothing has been decided on whether to set national standards for local implementation or adopt a national system.

However, some IT directors believe that the department has already made up its mind, and that the SOC consultation is largely a perfunctory exercise.

"We are a hospital pretty much at the forefront of electronic booking systems and I have not been asked for my views on the paper," said one IT director. "I do not know whether others have been asked, but I am the most senior IT person at the trust."

Another senior trust IT executive said, "I suspect that had I not received my copy of the document [the consultation paper] from an external source, I would not have received a copy at all. That is quite worrying."

One of the chief criticisms of the paper is that, although it acknowledges that electronic booking systems are "high risk" and require "major organisational and cultural change", it does not say how this will be achieved before 2005.

IT directors also claim that the paper underestimates the technical complexities of an electronic booking system. The paper suggests that appointments could be held on a national database with two-way transfers to local booking systems via a series of interfaces. But IT specialists have said it would prove impossible to synchronise a national database with diverse local booking systems and hospital patient administration systems.

"Can you imagine the scale of this [national system]?" said an IT director at one trust. "A typical district hospital has about 800 to 1,000 consultant streams: rooms are allocated in a morning, and patients queue up to see a registrar or a consultant. The scheduling of all those clinics involves appointments that are being changed and the situation is shifting, sometimes every few seconds. Bookings are being cancelled and extra ones are laid on. That is life in terms of managing a resource in a trust. If you have to create that again outside the trust [for a central system with its own database] you are doubling up on the amount of work to recreate that booking system and keep it up to date."

The Department of Health told Computer Weekly, "To speak of a national system being imposed at this stage is premature and demonstrates a lack of understanding of the purpose of a strategic outline case."

This is despite Milburn's commitment to a "national appointment booking system by 2005".

Reaction to NHS national booking system plans

Computer Weekly spoke to a range of IT professionals across the NHS. This is how they have reacted to the Government's plans for a national booking system:

  • "If I was gambling man, I would look at previous form. I would have to say that on previous form the NHS has not managed to deliver a successful project on a national scale. I would therefore say that it [a centrally-run booking system or service] is a disaster waiting to happen."

  • "The most worrying thing is the spectre of centralisation of procurement. It has never worked. We can all point to many central initiatives that have failed: the hospital information support systems strategy [which lost up to £103m] and casemix, which cost millions but which have nearly all been switched off now. The point is that I cannot think of any really big national project that has succeeded."

  • "People think of the health service as a national health service, but when it comes to technology the sheer size of the NHS works against centralisation. It is such a monolithic thing that grinds so slowly that by the time the centre thinks something is a good idea, things have moved on two or three years."

  • "They are suggesting having a central system so that there is compatibility of booking systems outside a particular area. But how often do you need to book an appointment outside of your area? The amount of sophistication required to deliver such compatibility is out of proportion with the need for it. You could spend £100m to solve a £10 problem. It is quite easy to pick up a telephone and achieve the same outcome."

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