Independent audit could be key to success

Officially the NHS's national IT programme, the largest civil IT scheme in the world, is a success.

Officially the NHS's national IT programme, the largest civil IT scheme in the world, is a success.

In February, the health minister Liam Byrne - a former employee of Andersen Consulting, now Accenture, one of the programme's main IT suppliers - made a statement to the House of Commons on the scheme.

He said that more than 1.5 million patients have benefited from the national programme for IT (NPfIT) in the NHS. "Progress is within budget, ahead of schedule in some areas and, in the context of a 10-year programme, broadly on track in others." 

But the glowing tenor of his statement conflicts with the facts. Drafted by civil servants in the Department of Health, his statement made no mention of delays of at least a year in the delivery of core integrated software, or the hardships facing IT staff in the NHS who are trying to sell the benefits of the programme's systems to an increasingly sceptical medical fraternity.

Nor did Byrne mention the fraught introduction in December 2005 of a Care Records Service - including an electronic patient record - at the Nuffield Orthopaedic Centre in Oxford.

Nuffield was the first NHS trust in Southern England to go live with the service, but its introduction led to patients having their operations delayed, and some hospital records were lost. As a result of problems with the new system, the trust issued an alert to the National Patient Safety Agency. 

The good news is that clinicians have generally welcomed the objectives of the NPfIT. They especially want electronic medical records to replace paper ones.

But surveys of doctors - by Mori and online researcher Medix - also show that many clinicians lament what has happened since the programme began in 2002. Some see the NPfIT as characterised by secrecy, conflicting information over whether the NHS's technology is moving forward or regressing, and uncertainties about the potential costs, timetable for delivery of software and the achievements so far.

The uncertainty is exemplified by the comments of the audit committee of the Birmingham and the Black Country Strategic Health Authority.

On 21 March 2006, the committee discussed the NPfIT at length and concluded there had been considerable progress. Despite this, the committee "remained concerned over the limited control on slippage and additional cost, lack of clarity around the system, what it was able to deliver" and "how [interim and legacy] systems will migrate following reconfigurations of organisations". 

Meanwhile, the share price of iSoft, one of the main software suppliers to the NPfIT, has more than halved since it announced lower than forecast profits from the NHS contract. Accenture, the NPfIT's local service provider in two of the programme's five regions, has announced a predicted write-off of £260m on the contract.

BT, the local service provider for London, has been fined more than once for poor performance. And US clinical software specialist IDX has been dropped as the main software supplier for Southern England, though it remains BT's main software subcontractor in London.

These developments could be simply the settlement cracks that beset otherwise sound new buildings. They are easily pasted over. Or they could be early warning signs of a calamity. It would not be the first time suppliers had signed contracts for integrated systems that proved unworkable in practice.

When the London Ambulance Service sought to computerise the sending of ambulances to emergencies in the 1990s, it set specifications and a timetable that proved too ambitious, according to an official report written after the project failed.

Some ambulance staff said the introduction of the system delayed the dispatch of ambulances and caused unnecessary deaths.

Critics of the NPfIT's plans point out that the technology to share medical records nationally on the scale proposed in England remains unproven. And Nuffield hit serious problems after installing only a basic system - not one that was fully integrated and allowed the sharing of medical records with trusts across the country.

This leaves unanswered the question of whether installing new integrated national systems that are more advanced than Nuffield's will cause serious disruption in NHS trusts, leading routinely to surgical operations being delayed or cancelled, and medical records being corrupted or lost.

This concern may be compounded by the recent comments of Kenneth Robertson, clinical lead for information management and technology, Scottish Executive Health Department. He told the Healthcare Computing conference at Harrogate in March that IT suppliers are not yet capable of delivering fully integrated health records.

"I do not think suppliers are yet in a position to meet our needs in terms of our full vision of a single electronic health record accessible wherever."

Yet the NPfIT is largely predicated on the notion that a single electronic health record is accessible across England. 

On the other hand, Connecting for Health, which is managing the NPfIT, is deploying many new systems which are working well. Trust IT executives report that these are "tactical" systems which mostly pre-date the NPfIT and are not fully integrated. They do not, for example, share electronic medical records nationally.

This raises questions about whether the total spending on the NPfIT so far represents value for money. Byrne told the House of Commons on 20 March 2006 that the total cost of the NPfIT from its inception in 2002 to 31 January 2006 was £1.02bn.

It is against this mixed picture  of progress in some areas mingled with deep concerns over whether the programme's complexity will cause it to fail that leading academics have called for an independent audit.

Their open letter echoes a campaign begun by Computer Weekly a year ago for an independent audit. This publication has argued that an audit would complement an investigation of the programme by spending watchdog the National Audit Office.

The NAO's report has been delayed by nearly a year. When it is finally published, it will look at the progress of the programme and whether it represents value for money, but it is unlikely to answer the big question: will the NPfIT work? 

A further limitation of the audit office's report is that it is likely to be criticised as being out of date by the time it is published. In comparison, independent technical auditors, if they have the power and terms of reference to make far-reaching and measurable recommendations, could see their findings making the difference between success and failure.

An independent audit in 1999 by consultancy Arthur D Little of a long-delayed air traffic control system destined for use at Swanwick in Hampshire made many tough and specific recommendations - including a suggested change in the culture of secrecy - which arguably helped to prevent the project from turning into a complete disaster.

National Air Traffic Services opposed the audits, which were ordered by the government, and few will be surprised if Connecting for Heath resists calls by academics for an independent audit of the NPfIT.

But some managers at National Air Traffic Services, though they disliked the idea of the audits, found them trenchant and perceptive, which made the cost of the investigations seem trivial. And one of the audits confirmed that, subject to recommendations being acted on, the systems would eventually work.


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