The private concerns of clinicians and IT professionals about the national programme are not being addressed, despite the front presented by the project's leaders.
Christopher Bland seemed determined to refute the impression given by his name. At a private conference for health service professionals last month he spoke with remarkable frankness about the government's multibillion-pound modernisation of the NHS, the national programme for IT in the NHS.
He appeared to portray the national programme as a worthwhile gamble - the biggest IT gamble in the world.
It is unclear whether Bland was being candid because no journalists had been invited to the NHS conference at The Pit, a basement theatre in the Barbican Centre, London. It is more likely that he has nothing to fear. He is chairman of BT and a successful businessman of long standing.
He said that the Department of Health has awarded national programme contracts to BT that, in aggregate, are the "biggest the company has won in its history".
But he conceded that BT was concerned by the complexity and enormity of the national programme.
"No other country has attempted what collectively we are about to attempt," Bland said. "It is immensely exciting to us, and we are somewhat frightened by the complexity and enormity of it - but it is exciting and a real challenge to get it to work.
"And it will be an immense achievement for all of us if we can pull it off," he added.
Bland described the view of BT's board on winning contracts worth more than £2bn. "We felt slightly like a dog chasing a car - what do we do if we catch it? Well, we caught it."
An enormous gamble
As if to reinforce the impression held by some people that the national programme is an enormous gamble, the health minister John Hutton told the conference that implementing the IT profession would be embarking on a "journey of exploration and discovery".
He said the benefits of new IT systems would be enormous, as are the challenges. He added, "There are risks and it would be foolish to ignore them."
Bland and Hutton's comments suggest that the national programme is acquiring a dual personality: a smiling, inspired, self-confident public face and a private one which perceives the project as a collection of unknowns: a gamble.
The public face already speaks of the programme as an outstanding success. It was launched about 18 months ago, and specifications to replace thousands of diverse systems with new, nationally-compatible technology have been published.
In record time, five local service providers have been appointed to take over incompatible legacy systems and build new ones to a standard design. Up to 50 million patients across England will benefit.
The health secretary, John Reid, says the programme will revolutionise healthcare: everyone will have an electronic health record that they will be able to view from a home computer.
Everyone will be able to book an appointment electronically, at a time to suit them, instead of waiting for a hospital letter.
This vision of the NHS is supported by ministerial statements and press releases from the Department of Health which have nothing but praise for the conduct of the national programme.
Only four weeks ago prime minister Tony Blair praised Richard Granger, director general of NHS IT, who is running the programme. And the health minister John Hutton said Granger has done a "brilliant job" in overcoming scepticism about the programme.
Granger himself says the national programme is about three years ahead of any comparable programme and he is quoted in the Financial Times as saying there is "no other project of the same scale on the planet", and in The Times as comparing the national programme with great Victorian infrastructure projects, including the construction of London's sewer system, by Joseph Bazalgette and the building of the Great Western Railway, by Isambard Kingdom Brunel.
Biggest project on the planet
But there is also the hidden side of the national programme, in which criticism is suppressed and IT professionals in the NHS cannot get straight answers to direct questions.
So far the national programme has given no direct answers to many questions posed by NHS staff, for instance:
- What will the national programme cost locally to implement?
- What changes will it impose on working practices of doctors and nurses?
- How will staff time and money be found to make data in the new national systems accurate?
- Will clinicians and nurses take to using new systems when they have not participated in purchasing them?
- Where will the money come from for training doctors and covering for them while they are training?
- Will clinicians end up devoting less time to the care of patients while they service the demands of the national programme?
The big questions do not end there. General practitioners want to know, given the national programme's stated aim of achieving "ruthless standardisation", whether they will be able to continue using their long-established existing systems even if they are not among the selected technology adopted by the national programme.
Seeking answers to these questions and more, IT professionals in London went to The Pit last month to hear Bland, Hutton and other speakers. Hutton gave reassuring but unspecific answers to the GPs' questions, then left.
Other speakers, including David Kwo, who runs the national programme for London, sought to placate concerns raised by members of the audience. But, like Hutton, Kwo's answers were more reassuring than specific.
Two unknowns could floor the national programme. Some doctors wonder whether the national "data spine" of electronic health records will have so many gaps that it will become a good idea but an ineffectual entity, like a new hospital full of leading-edge technology which turns out to have too few staff.
The second unknown is whether the Department of Health will be able to change the practices of doctors through the introduction of new technology.
Best practice, say some experts, requires that working practices are agreed, planned and simplified before new technology is introduced. The board of a large private sector company may be able to impose changes on its staff, but the Department of Health cannot force doctors and nurses to change their working practices to use the new systems.
Challenge to win over doctors
Doctors may argue - some already have - that their first duty is to their patients, not the demands of a new system. Bland referred to this issue, suggesting that it would be a major challenge getting a single hospital group to adopt common systems, processes and procedures - yet the national programme aims to achieve this across thousands of healthcare organisations.
Bland said that he spent 14 years in the NHS, during which time he chaired a joint working party between groups of pathologists in London and tried to persuade them to adopt a common information system, common processes and procedures.
"My success there - I think what you would charitably give me would be about three out of ten, would you say?" he asked Kwo. Turning back to the audience, Bland said, " OK, two [out of ten]... it was a salutary experience about the complexities of getting common systems across organisations that had been used to working in silos."
Bland emphasised that the challenges were not technological but organisational. "If we all in this room can get our act together over the coming years there are no fundamental technical obstacles to making the vision become a reality.
"There will be problems, I think, particularly in the areas of integration and migration; problems with legacy systems and, for example, the role of Emis [a system already used by many GPs] which has been flagged today. But those are problems that I think can be overcome. The single biggest problem is in organisation and culture."
There will be disputes, Bland said. There would also be "what seem like almost insuperable problems," but he added, "If we succeed in implementing the totality of this project across the board it will be an immense achievement for all of us."
A senior representative of the National Health Service Information Authority raised knowing guffaws when he told the audience that "everything in the national programme changes daily".
He referred to internal deadlines that had been changed and said that bidders for contracts had submitted several "final best and final offers".
Kwo gets fired up
David Kwo, the London head of the national programme for IT in the NHS, told the conference at the Barbican that he wants chief executive officers and clinicians in the NHS to promote the programme with a "fire in their bellies".
Otherwise, he said, they will not be able to "hold the line when early resistance, which is natural in the beginning, emerges".
He added that they will need to be prepared for "noise and resistance" when new systems go online.
But he conceded that issues remained about funding of aspects of the national programme, the pricing of additional services by local service providers, how Emis, a system used by more than 50% of GPs, would fit in with the new strategy, and electronic transmission of prescriptions.
World's biggest gamble - the names and numbers
The national programme comprises four main projects:
- A £64.5m national system built by Atos Origin for the electronic booking of hospital appointments
- A care records service, supplied by BT under a £620m contract, which provides for everyone in England to have access to his or her own electronic health record. As part the service BT will build a national data spine with the help of Oracle, Sun Microsystems and Logica CMG
- An NHS broadband infrastructure, known as N3 and supplied by BT under a seven-year, £530m contract
- Electronic prescriptions.
- For London, BT, which was awarded a £996m 10-year contract
- For North East England, Accenture, which was awarded a £1.1bn contract that also includes BT, Microsoft and Isoft
- For North West England and the West Midlands, CSC, which was awarded a £973m contract
- For Eastern England, Accenture, which was awarded a £934m contract
- For the South, The Fujitsu Alliance, which was awarded a £896m contract, due to run until 2013. It is the largest of the five local service provider regions, covering almost a quarter of the country's population.