Government hampers progress by refusal to answer questions about NHS IT funds

The national programme for IT in the NHS has so far been promised £2.3bn. The government anticipates success, but clinicians are...

The national programme for IT in the NHS has so far been promised £2.3bn. The government anticipates success, but clinicians are questioning whether this is enough

IT manager Philip Jones compares himself to a mushroom. “I am fed mulch and am expected to grow,” he said.

Jones was referring to the way officials in the Department of Health expect him to prepare with enthusiasm for his trust to link into new systems that are being developed for the NHS’s £2.3bn national programme for IT, without giving him the information he needs.

Under the programme, local or national service providers will provide an integrated care records service, including electronic patient records, hospital appointments system, a new national infrastructure and e-prescriptions.

Jones needs, but cannot get, answers to his questions about how much his trust will receive to help make the national programme a success. He said that he and most other IT staff in the NHS are still waiting for answers to questions they have been asking for months. He wants to know:

  • How much he will receive to provide quality assurance on patient data for a new national data repository known as the spine?

  • How much will he receive to replace antiquated but working systems with standardised equipment from new local service providers?

  • How much will his chief executive make available from the Department of Health for interfaces to national systems?

Jones is the pseudonym of an IT manager in a London trust who believes his career would be damaged if he were named.
Last month, his strategic health authority arranged meetings to see how its trusts were preparing their IT systems to link to new national systems. But the meetings were cancelled at short notice. Officials at his strategic health authority realised that IT specialists could not give details of how prepared they were to provide data feeds into national systems, when there were no answers to their questions about the national programme.

Yet trusts still have to meet tight deadlines. By 2005 Tony Blair wants every patient in England to have an electronic record and to be able to book hospital appointments at their convenience.

One reason the systems have a high priority in the NHS and a short timetable for delivery is that, in the run-up to a general election, Blair wants to cite the successful introduction of the systems as evidence of the government’s commitment to modernise the health service and give patients a choice over where they are treated and when.

But, to the frustration of NHS IT managers, there is an absence of qualitative information about funding, which contrasts sharply with the quantity of information on the programme’s benefits.

As part of a communications programme to enlist the support of clinicians, officials at the Department of Health regularly brief newspaper and magazine journalists about how the national programme will transform the NHS, and the billions of pounds of extra money that the government is providing to fund an IT-led modernisation.

Indeed, various national newspapers over the past 10 days have given the impression that the NHS is flush with money for new IT.
“The health service’s IT spending is set to rise from about £850m a year – less in percentage terms than in almost any other modern Western health system – to more than £3bn annually by 2007,” said one broadsheet newspaper.

“Richard Granger, head of the project to modernise the NHS, is to ask the Treasury for a further £1.5bn to fund the scheme through its fourth and fifth years,” said another national broadsheet.

It went on to quote a Department of Health official as comparing the national programme to the historic engineering feats in the 19th century, which immortalised such men as Isambard Kingdom Brunel.

But for those faced with implementing the new IT systems at trust level, one of the basic issues is this: is the £1.5bn of extra money – on top of the £2.3bn allocated to the national programme for the three years from 2003 to 2006 – a hope or a guaranteed sum?

Believing this to be a straightforward question, Computer Weekly put it to a spokeswoman for the programme. The answer was not straightforward.

“The NHS received a five-year funding envelope and it is anticipated that in years four and five of that envelope, comparable funding to that allocated to the national programme for IT in year three will be achieved,” said the spokeswoman.

When asked if it were possible to establish whether the “anticipated” funding is definite, she tried but could not obtain any further authorised response.

Even if the national programme receives a further £1.5bn or £2bn on top of the £2.3bn, will this be enough? Richard Granger, director of IT for the NHS, has not been bashful about mentioning the size of the programme. He told the Financial Times there was “no other project of the same scale on the planet.”

With enormity of scale comes cost. A position paper, More Radical Steps, from the British Computer Society’s Health Informatics Committee, said that between four to eight times the £2.3bn may be needed for the non-IT elements that are critical to the programme’s success.

Jean Roberts, lead for the BCS health committee’s policy group, suggested last week that £10bn may be needed if doctors and nurses are to use new systems to their best advantage.

The money is needed, said the BCS, for “professional training, organisational systems redesign and realignment to support a successful national programme for IT”. It added, “Until any other figure is ratified, the potential for the national programme to have a substantial impact on care remains at serious risk”.

Mark Outhwaite, lead for the national programme at the Modernisation Agency, part of the Department of Health, was unable to give Computer Weekly any assurances that enough money would be made available for the business change that will accompany the IT systems. He did not deny that the costs could be of the order that Roberts mentioned.

Outhwaite said last week that doctors and nurses are changing their working practices as part of a successful change management exercise. But, he added, these improvements were planned before the national programme was conceived. These changes will  need to be “repositioned” to fit in with the programme’s requirements, said Outhwaite.

As yet the specific changes in business practices that will enable doctors to take advantage of electronic booking and the data spine have yet to be costed. Trials will take place next year to assess what changes are needed and how much they will cost.

The level of uncertainty is of concern to NHS IT professionals who have a strong wish for modern, effective IT systems, but not if the national programme carries with it a high risk of failure.

Roberts said the Department of Health should question whether it should, even now, commit taxpayers to £2.3bn on the national programme when it does not know the whole cost.

Despite the uncertainties over funding, Sir John Pattison, senior responsible owner of the national programme, told Computer Weekly that there will be enough money for trusts to “do what they want to do in IT terms”. He added that the government is putting extra money into the NHS “in the most spectacular fashion – about £90bn by 2006/2007 or 2007/2008.”

So the success of the national programme rests on some financial certainty: that trusts will receive more money to support the modern equivalent of the 19th century’s Great Western Railway. But executives are still uncertain there will be enough money for the changes to business and technology.

Brunel was revered in his lifetime, but some may have forgotten another 19th century genius, Charles Babbage, who sought to build a difference engine, the forerunner to the computer. The project was so ambitious and dragged on for so long that government funds dried up. It was not completed until more than a century later.

Pattison: it is my belief that once trusts see the power of good IT they will invest

Sir John Pattison, senior responsible owner of the national programme for IT in the NHS, has sought to allay concerns over whether £2.3bn is enough to make the initiative a success.

In an impromptu interview with Computer Weekly, Pattison said the £2.3bn, together with other government money, would be enough to allow trusts to link into new national systems and replace a jumble of incompatible hardware and software with standardised equipment.

He said, however, that the £2.3bn allocated to the national programme over three years from 2003 to 2006 would not be sufficient without the existing £850m a year “baseline” spend by health organisations on IT systems and staff.

“The spending from the baseline continues,” he said, “We estimate this is approximately £850m a year and this has to be maintained. £2.3bn will not cover it [delivery of the national programme] if this is not maintained.”

Many IT managers doubt they will have enough money to fund their trust’s responsibilities under the national programme. So Computer Weekly asked Pattison how the £850m baseline spend could be diverted into part-funding new projects when most of it is already committed.

Much of the baseline money, according to trust IT managers, is spent on the salaries of technologists and other staff, for example, the specialists who code information that is entered into systems.

Pattison suggested in his replies that the costs of IT staff might become the responsibility of other health service managers or possibly new local and national service providers, as employees switch jobs or roles.

Pattison was asked in particular about a trust whose largest capital IT programme cost £300,000 a year. If, to meet the government’s plans for standardised systems, that trust had to replace its antiquated hardware and software with top-specification equipment costing £1m from a local service provider, how would the IT manager find the extra £700,000?

“People may have to do different things in the future,” replied Pattison. “You will have local service providers operating. You will have national contracts operating. Richard Granger, [director general of IT in the NHS], is very clear that he thinks we will need as many staff. They will not be doing the same things in the future as they have been doing in the past.

“IT staff may be taken over by local service providers or the requirement for the staff to do what they were doing will disappear. So there will be a change programme.”

When asked if the release of money allocated to salaries under existing IT budgets would pay for new systems to help meet the targets set by the national programme, Pattison said, “I do not want to give the impression it will free up staff costs. It might free up the staff. It is then a judgement for trusts on how best to deploy those staff.”

When pressed about how the IT manager, whose budget mainly comprises staff costs, would find the extra £700,000 to buy a
new system from a local service provider, Pattison said, “The Wanless report [an independent report to the government] said
that by about 2010 the NHS should be spending about 3% to 4% on IT”.

His reply appeared to suggest that the chief executives of trusts should at least double the IT spend from the existing 1% or 2% of the total budget to meet commitments.

When asked if the money would come from general hospital budgets, Pattison told Computer Weekly, “The NHS as a whole will have to find and will have to deploy a greater percentage of its expenditure on IT. It is the only sensible way to do things.”

He said the general level of funding available to hospitals was increasing substantially, “The pot is up in the most spectacular fashion," said Pattison, implying that trusts will have enough money for the extra IT spend.

“We cannot take every decision away from trusts," he added. "We will have to leave some decisions to them. But it is my belief that once they see the power of good IT they will invest in it. Once you have invested in it and your business is running with a dependency on IT you have got to keep investing in IT. You cannot stand still.”

When asked if the IT manager faced with finding an extra £700,000 should stop worrying because his trust chief executive will decide to more than double the IT budget, Pattison said, “You put it rather bluntly. It is not quite as simple as that but yes.”

It seems from Pattison’s replies that there will be enough money for trusts to finance their IT commitments under the national programme, but only if the boards of trusts allocate extra funds from the general hospital budgets.

The question is, therefore, will NHS trust boards allocate extra money to IT, rather than meeting other government targets on, for example, reducing waiting times for operations, or improving the care of patients who are being treated for cancer or heart disease.
This could be another uncertainty which compounds the risks to the success of the national programme.

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