Health minister fails to address concerns as first contract is awarded in NHS IT plan

Experts question funding, timetables and whether NHS staff will use systems.

Experts question funding, timetables and whether NHS staff will use systems.

Somerset Maugham said that style is the art of omission. If so, a press conference given in Whitehall last week by health secretary John Reid, to announce an important IT contract, was quintessentially stylish.

Reid was announcing a five-year contract worth £64.5m for SchlumbergerSema to run an England-wide system that will allow GPs to book hospital appointments online.

It is the first major contract to be awarded in the £2.3bn national programme for IT (NPfIT) in the NHS which comprises four main projects:

  • Electronic bookings
  • Electronic prescriptions
  • An integrated care records service (ICRS) which will give every patient in England an electronic record by the end of 2005
  • A new technology infrastructure.

It was also the first time in recent memory that a secretary of state had been personally involved in chairing a press conference to announce the award of an IT contract - normally these events are left to junior ministers.

"This is an excellent example of how technology will transform the experience of patients," said Reid.

The National Electronic Booking System would be a revolutionary step in creating an NHS that was truly patient-centred, he said. By 2005 patients would no longer have to wait weeks to receive a notice of a consultation on a date that was inconvenient; appointments would be booked online at a time and location to suit the patient, he said.

Sitting beside Reid at the press conference was Richard Granger, director general of IT in the NHS, the £250,000-a-year civil servant appointed in 2002 to deliver the national programme's IT systems.

Granger declared that the contract for the booking systems had been part of the NPfIT's "ground-breaking schedule" - only 190 days elapsed between advertising the contract and awarding it. This was unprecedented for such a system, he said.

The specifications were "well-defined", the degree of clinician involvement in the process was high and the terms negotiated with the subcontractor, US supplier Cerner, were the "best" globally, Granger added.

Questioned about the NHS' record of national IT disasters (Read Codes 3, Hospital Information Support Systems and Administrative Register) Reid recognised that there had been fiascos. It would not happen this time, he said, citing the quality and experience of the team running the NPfIT's projects.

But there was much that Reid omitted to say, either because he did not know or chose not to mention. He did not mention how doctors and consultants would be coaxed into using a booking system that they may see no need for. Although some doctors like and use existing booking systems that have been introduced locally, with their support and involvement, a national system may have less support from consultants.

A survey in June by market research firm Medix into doctors' attitudes to the NPfIT found widespread scepticism about the need for a national booking system.

And although Reid spoke at length about how new technology would bring the health service in to the 21st century, his comments and Granger's converged on the equipment and what benefits it would bring patients. They did not discuss how, or whether, nurses, doctors and other healthcare workers would be persuaded to change their working practices to make use of new booking systems or electronic patient records.

No mention was made, either, of how or whether locums and other doctors who are struggling to cope with demands on their time would find the extra hours to train on the new systems, or whether doctors would want to use unfamiliar systems that they may feel had been imposed on them.

Historically there has been an under-use of national systems in the NHS. Separate reports from public spending watchdog the National Audit Office have identified costly national systems that were little-used by health workers and were abandoned with write-offs of tens of millions of pounds, or failed to deliver the anticipated benefits to taxpayers and patients.

In the 1990s, for example, the Department of Health introduced a national "Administrative Register" to store details of patients, such as name, address, date of birth, and GP. A report from the NAO identified multiple failures of Department of Health IT strategies in 1992 and 1998.

It said, "The NHS Executive strategy documents did not set out overall objectives for the strategy. Although they included milestones for most of the constituent projects, NHS bodies were not always clear about the purpose of the strategy's constituent projects. In the case of the NHS Administrative Register, the project was seen as having no clear purpose by 16 of the 20 NHS bodies visited by the National Audit Office."

So is there good reason to believe that clinicians will embrace the NPfIT's systems? Many specialists believe that this time it will different because the NPfIT has Richard Granger as its leader. Affable, but a tough negotiator and experienced in large-scale IT procurement, Granger is regarded as a born leader.

But his remit makes him mainly responsible for the IT in the NPfIT. He has only limited control over other elements which are critical and which could cause the systems to be under-used and disliked.

Mark Outhwaite, lead for the NPfIT at the Modernisation Agency, part of the Department of Health, said the IT capital and technological components were only about 25% of making the most of investment in computers. He cited organisational assets, including human capital, business processes and culture, as representing the other 75%.

Computer Weekly has highlighted some of the weaknesses in the programme which are not related directly to whether the systems work or not, such as the rushed procurement timetable and the lack of action to ensure that clinicians will use the systems. Department of Health officials have responded to some of the coverage by criticising Computer Weekly in articles published on the Department of Health's website.

But a new independent study into the NpfIT has raised profound concerns about the programme.

Published on an official NHS website earlier this month, it was written by IS manager Catherine Ebenezer. It briefed NHS managers on the NPfIT and what it meant to them. Her briefing sought to encourage NHS managers to participate in the NPfIT by maximising staff access to new systems and encouraging attendance at events relating to the programme.

She listed successes in NHS IT. However, a small section also listed the programme's "numerous significant problems and weaknesses".

These concerns echoed those raised by Computer Weekly over the past year, which have been strenuously denied by the leaders of the NHS IT programme.

After Computer Weekly made enquiries and quoted its criticisms to the NPfIT, it was withdrawn from the NHS website. Asked to comment on the paper, the NPfIT told Computer Weekly, "The national programme has made efforts to view the management briefing paper submitted to the NHS National Electronic Library for Health website that covers areas relating to the NPfIT. It understands that the report in question is currently unavailable as it is still in the process of review. In the absence of access to the full text of the paper and the context of the references to the national programme, it is unable comment at this time."

However, most of the points made in the paper reflect some of the major concerns being expressed privately about the NPfIT by IT managers in the NHS or by some prospective suppliers and doctors.

Suppliers have been barred contractually from talking to the media about the national programme, and IT professionals in the health service say they cannot express their views about the NPfIT openly without endangering their careers.

Points raised by the Ebenezer's paper include:

Change management challenge

"Insufficient attention has been paid to cultural, organisational and change management issues," the paper said.

This was a reference to doctors nurses and others having to change the way they work in hospitals if they are use and take advantage of, for example, the national data spine which, by the end of 2005, will hold a summary of medical and personal information on every patient in England. If clinicians avoid the systems, the records may not be updated regularly, so their usefulness to other clinicians will be lost and the national system could fall into disuse.

Insufficient user buy-in

"There has been insufficient clinician involvement in the ICRS [Integrated Care Records Service] specification", it said.

This referred to the specification for systems to present a summary of patient information being validated by what was described as a small working group in which "only a small number of clinical specialists are represented". A similar point has been made in an academic paper by Nick Booth, principal clinical research associate at the School of Population and Health Sciences, Centre for Health Services Research at the University of Newcastle.

Referring to the NPfIT's proposed health information spine, where patient summary information will be published for use by all NHS staff involved in the care of individuals, he said, "Few clinicians have played any part in planning the spine."

The paper also criticised the lack of representation of certain healthcare groups on the new National Clinical Advisory Board, which provides stakeholder input to the National Design Authority - an organisation that sets the specifications for national systems. The clinical board was set up only recently, late in the procurement cycle, as contracts are about to be awarded for national systems.

Independently of the paper, concerns have been raised with Computer Weekly that there are only two nurses on the 30-strong clinical advisory board, although tens of thousands of nurses will use the systems, some of them updating records regularly each working day.

Inadequate funding

The paper went on to mention the uncertainties about local funding, which is a major concern for NHStrusts. "There is a lack of clarity about local funding patterns and levels," it said.

Although this point was not expanded, evidence is emerging that the £2.3bn announced by ministers for the NPfIT will not be enough to deliver all three phases of ICRS, the project that will deliver electronic patient records.

NHStrusts' concerns about funding were summarised by Heather O'Brien, general manager of information systems at the Royal Free Hampstead NHS Trust board meeting last month.

Although expressing strong support for the NPfIT, O'Brien said in a briefing paper, "The first phase of [funding] the national programme is clear in that it will be drawn from the much-publicised NHS IT £2.3bn.

"However, it is obvious that the programme is so huge that in the future there needs to be local commitment (in the form of revenue monies) to continuing the programme through further phases. Clearly there will be some revenue savings for the trust that could be passed on if our existing systems are replaced by an ICRS but the extent of the trusts' commitment is unknown at this time."

The paper said tensions were apparent in systems development between those who want the new systems mainly for research and statistical purposes and those who want them to support patient care, and that there are concerns about the quality of data to be put on to the ICRS data spine.

Timetable too tight

"There is a very tight timetable for implementation, which is likely to lead to problems where systems have not been sufficiently tested," according to the paper.

Senior NHS executives recognise the risks posed by the tight timetable. Bill McCarthy, director of strategic development at West Yorkshire Strategic Health Authority, said in a briefing paper, "The NPfIT has the potential to transform the way that information is handled in the NHS.

"NPfIT represents a new, much quicker and more consistent approach to setting out requirements and procuring IT in the NHS. There is inevitably a risk involved in a project of this size and complexity being driven at unprecedented speed. We are managing this risk as best we can."

That the initiative is backed personally by the prime minister Tony Blair, who has regular meetings with officials to discuss the progress of the projects, puts pressure on officials to deliver a high-tech NHS before the general election in 2005 or 2006.

Officials are determined to sign contracts, worth potentially nearly £2bn, by Christmas, despite the many uncertainties and problems highlighted by Ebenezer's paper, Computer Weekly and some NHS trusts.

Some health officials believe it is worth taking risks to raise the quality of patient care. Others say the potential patient benefits are so great that they outweigh the risks. Some take the view that if officials and politicians want to gamble with billions of pounds, without fully acknowledging the the risks, they should use the toy notes from a board game rather than the public purse.



The NHS national programme for IT: key dates

2002

Details of the £2.3bn national programme for IT announced. The Department of Health concedes there are "significant risks".

Summer 2003

Eleven companies shortlisted for national and local contracts. After months of work on thousands of documents and producing demonstration systems, one of the three main bidders, Lockheed Martin, withdraws inexplicably.

October 2003

The first major contract under the national programme is awarded to SchlumbergerSema for a national electronic booking system. It is worth £64.5m over five years.

November 2003

Contracts are due to be awarded to local service providers to run systems in London and the North East, Yorkshire and Humberside. Three remaining contracts are to be signed by the end of 2003. Each contract could be worth nearly £900m over seven years.

2004

The first phase of Integrated Care Records Service (electronic patient records) is due to go live by the end of 2004. A national data spine containing a summary health record is due to be introduced.

2006

Phase two of Integrated Care Records Service is due to be completed. It is due to include more detailed electronic patient records.

2006-2010

Various further phases of the programme.

Measuring success: what if GPs do not use the system?     

Health secretary John Reid has fuelled concerns that his department will measure the success of the £2.3bn national programme for IT by the number of doctors and nurses who have access to new systems, not by how many use them. 

At a press conference to announce the award of a contract for a national electronic booking system - one of four main projects in the national programme - he said that 30,000 GPs would have access to new booking software. But he did not say how many would use it.  

In a speech to the Harrogate healthcare conference earlier this year, Frank Burns, chief executive of Wirral Hospital NHS Trust and formerly the most senior IT executive in the Department of Health, expressed concerns about how officials would measure the success of the national programme.

He said that installing systems and implementing them were entirely different processes.   

"Successful implementation requires a full-scale local change management project. Getting this bit right at local level is absolutely critical and I am not sure how the new strategy is going to address that. In my view, success for 21st century IT should not be measured by how many clinicians have desktop access to a clinical system, but by what percentage of clinicians is using [them] on a daily basis." 

In the past ministers and officials at the Department of Health have proclaimed the success of projects such as NHSNet, a national NHS network, and Read Codes version 3, an electronic thesaurus of medical terms, citing the large numbers of clinicians who have access to the systems. But public spending watchdog the National Audit Office has pointed to their under-use.     BOXTEXT: How much will the national programme cost?   

Computer Weekly asked a spokesman for the national programme for IT whether the total estimated costs of the project over the life of the contracts with local and national providers was known and, if so, what the costs would be.  

He said, "We have estimates of the overall cost of the national programme for IT plans. However, as we are currently in the middle of several large procurements, these estimates are commercially sensitive. Once negotiations are complete and contracts are agreed with successful bidders we will, as is normal and as we did with the award of the electronic booking procurement, announce the value of the contract.   

"The commercial sensitivity during the procurement process is to ensure that the market prices competitively, thus providing value for money for the NHS and therefore the taxpayer."  

Computer Weekly also asked how much had been allocated to changing working practices, which could cost at least as much as the £2.3bn IT contracts programme.  

The spokesman said, "The national programme funding will cover the cost of suppliers developing training material, including e-training services and for training the trainers in the use of new IT services.  

 "The cost of delivering training to NHS staff is part of the normal funding provision, which is anticipated and planned for by the NHS, including the Modernisation Agency.  

"The regional implementation directors in each of the five clusters are currently planning the change activities at local level and their teams are funded by the national programme."

How much will the national programme cost?

Computer Weekly asked a spokesman for the national programme for IT whether the total estimated costs of the project over the life of the contracts with local and national providers was known and, if so, what the costs would be.

He said, "We have estimates of the overall cost of the national programme for IT plans. However, as we are currently in the middle of several large procurements, these estimates are commercially sensitive. Once negotiations are complete and contracts are agreed with successful bidders we will, as is normal and as we did with the award of the electronic booking procurement, announce the value of the contract.

"The commercial sensitivity during the procurement process is to ensure that the market prices competitively, thus providing value for money for the NHS and therefore the taxpayer."

Computer Weekly also asked how much had been allocated to changing working practices, which could cost at least as much as the £2.3bn IT contracts programme.

The spokesman said, "The national programme funding will cover the cost of suppliers developing training material, including e-training services and for training the trainers in the use of new IT services.

"The cost of delivering training to NHS staff is part of the normal funding provision, which is anticipated and planned for by the NHS, including the Modernisation Agency.

"The regional implementation directors in each of the five clusters are currently planning the change activities at local level and their teams are funded by the national programme."

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