Could separation threaten the success of £6.2bn IT-led modernisation project?
Leaked e-mails written by officials leading plans for a technology-based modernisation of the NHS have exposed one of the congenital flaws in the scheme: a separation between the IT and business sides of the programme.
On the IT side is Connecting for Health, an agency of the Department of Health, which has responsibility for delivering new national systems as part of a programme costing between £2.3bn and £31bn once local implementations are taken into account.
The agency's chief executive is Richard Granger, the senior responsible owner (SRO) of programme delivery and systems within the national programme for IT in the NHS (NPfIT).
In his leaked e-mail Granger defended the programme's systems and expressed concern over late changes to the Choose and Book programme, which aims to give patients a choice of which hospitals to attend for appointments.
On the business side is the Department of Health, as represented by Margaret Edwards, director of access and patient choice, whose duties include helping to give patients a choice of hospitals to attend for appointments through the so called Choose and Book scheme, which is one of the government's top-10 priorities for the NHS.
The scheme is due to be complemented by a computer system which allows GPs and patients to book appointments online. This is due to replace the laborious process for arranging appointments in which a GP sends a "referral" letter to the hospital, which later posts an appointment letter to the patient.
The e-booking part of Choose and Book is considered by the government to be critical to the scheme, and so the software is a key component of the NPfIT.
In January 2005, the then health secretary John Reid said e-booking would be fully implemented by 2006, but the scheme is not now due to be fully rolled out until 2007 at the earliest, partly because hospitals and GPs do not have systems that talk to each other.
Edwards' internal e-mail in September 2005 expressed concern that the delivery of version 3.1 of Choose and Book software might be late. Version 3.1 aims to extend patients' choice of hospitals they can attend.
She said the Department of Health was committed to delivering extended choice from April 2006, but added that version 3.1 may not be ready in time. This version, she said, allows independent hospitals and Foundation Trusts to be added to the choice for patients.
"I have now been advised that 3.1 will not be available until 'summer' 2006, and that this date is not yet guaranteed. It might be later," said Edwards.
At worst, she said, extended choice would have to be delayed. This would "clearly cause major problems both in terms of our political masters' commitments, the reaction of FTs [Foundation Trusts] and I assume the IS [independent sector]".
In his response, Granger said changes with Choose and Book could affect the wider national programme. "We have already delivered major software upgrades, after they were belatedly requested, on schedule," he said. Connecting for Health will "of course do our best to accommodate" additional requirements but this will have implications.
"Strategic reprioritisation will need to be undertaken across the programme as a whole, for example deferral of electronic transmission of prescriptions, roll-out of payment by results upgrades [a new NHS financial regime], to focus on Choose and Book. This will need to be discussed with the other SROs at Thursday's programme board and thence with ministers. Adverse media coverage is unavoidable." He added, "Unfortunately, your consistently late requests will not enable us to rescue the missed opportunities and targets."
At one level the e-mails simply highlight a lack of harmony between the IT and business sides of the Choose and Book part of the NPfIT, a tension that is mitigated by officials such as Granger and Edwards, who are trying their best to help the NPfIT to be a success.
At another level the e-mails are a possible symptom of something more profound: a programme in trouble.
The e-mails draw attention to the lack of any one person or organisation that is responsible for the success or failure of the world's largest civil IT programme.
Connecting for Health does not have full responsibility for ensuring that new systems it commissions are used widely by clinicians for the benefit of patients.
John Bacon, overall SRO of the NPfIT, suggested to the House of Commons Public Accounts Committee on 31 October 2005 that Granger has never had full responsibility for the engagement of the wider community of clinicians.
The scheme was configured - long before Granger was appointed in September 2002 - for the IT professionals to achieve success in the delivery of systems, even if many clinicians remained sceptical and distrustful of the new technology, and few used it to good effect.
On the business side, the government had given responsibility for ensuring the support of clinicians to the Modernisation Agency of the Department of Health. The agency was disbanded in July this year.
To make matters worse for the programme, the people appointed by the government to run the business side have not stayed in post long enough to see the project through.
A project's SRO should remain in post from conception to delivery of benefits, according to the Office of Government Commerce, which advises departments on how to manage IT projects.
On the business side of the national programme, the government first appointed John Pattison, an experienced Whitehall research specialist. After helping to set up the national IT programme he retired.
Pattison was replaced by Aidan Halligan as SRO responsible for engaging clinicians. Halligan announced in September 2004 his intention to leave. In March 2005, Bacon was appointed overall SRO.
This is background to the leaked e-mails. The documents are mainly about the Choose and Book software but emphasise the implication of late changes on the NPfIT as a whole.
The exchange begins with an e-mail from Edwards.
"We have a problem. As you know, we are committed to implementing the Extended Choice Network from 1 April 2006. This will enable all IS [independent sector] providers and FTs [foundation trusts] to be added to the Choice menu. This is an important part of the agenda to roll out more choice and demonstrate we are serious about plurality to the IS," said Edwards.
She continued, "The plan was to make an enhancement to the Choose and Book software to enable FTs and IS providers to be added to the list of providers. This enhancement is part of release 3.1 of the Choose and Book software. I have now been advised that 3.1 will not be available until 'summer' 2006 and that this date is not yet guaranteed."
She said a colleague was working to see if there is an alternative way of booking appointments with foundation trusts and independent hospitals but "my personal view is that this will not prove possible".
Edwards continued, "We have not yet told ministers that there is a problem or even John [Bacon] yet. But as we are due to give them an update on where we are with the Extended Choice NetworkÉ we need to decide how we are going to handle this urgently.
"Similarly, I feel concerned that I have not mentioned it in any of the Choose and Book updates, but did not want to do so until we had an agreed line." Edwards asked if everybody was happy with the "following holding line", which implies that a software delay may turn out to be the cause of any late delivery of extended choice.
In his response to Edwards, Gordon Hextall, chief operating officer at Connecting for Health, said, "There is no governance agreement for Release 3.1 of Choose and Book. Clare Mitchell [group programme director, Choose and Book] is in negotiation with Atos [Atos Origin, the supplier of Choose and Book software] for a price and confirmation of a development timescale and, subject to this, we will need a full impact analysis on the spine [national data spine that will hold a summary of patient records] and local service provider programmes."
Hextall said a contract change notice had been signed with BT over the spine.
"We need a separate discussion about the governance processes for agreeing future releases of all components of the national programme including Choose and BookÉ because of the huge potential costs of change to either the spine or the local service provider programmes."
Granger, in his reply to Edwards, said, "You have presumed that the relevant extended choice network documentation has been made available from your SRO office to your IT colleagues; I was not aware that this was the case until your recent e-mail."
Granger said he raised with Edwards the acceleration of provision of interfaces to the independent sector in November 2004 but there was active discouragement from pursuing this "policy/opportunity".
"The original request from your predecessor and yourself was for an electronic booking system. The change of this to Choose and Book occurred in the second quarter of 2003. This was the first of what are now recurrent major changes in your requirements."
He added, "Deployment disruption to PAS [patient administration systems], N3 [BT broad- band network for the NHS], and GP system upgrades have been accommodated by local health communities to prioritise Choose and Book. Choose and Book's £20m IT build contract is now in grave danger of derailing, not just destabilising, a £6.2bn programme."
Granger said there was no contract in place for version 3.1. "We will do our best to accommodate these requirements," but, "Strategic reprioritisation will need to be undertaken across the programme as a whole.
"Adverse media coverage is unavoidable."
The leaked e-mail exchange and points made by Granger in interviews have been picked up by MPs. At a debate in the House of Commons on NHS finances on 15 November, Liberal-Democrat MP Sandra Gidley, a qualified pharmacist, put her interpretation on the disclosures. She said progress on the NHS IT project "seems to be dragging on somewhat, so far with little apparent benefit for patients".
Gidley added, "Richard Granger, the man in charge of the scheme, has said that is not his fault and claims that responsibility for the late delivery lies with the policy people at the Department of Health. If the secretary of state is able to elaborate on the problems at the department, I am sure that we would all be very interested."
Secretary of state Patricia Hewitt did not elaborate; and a spokesman for Connecting for Health declined to comment on the e-mails. "We do not comment on leaked correspondence, but there is no question of the programme being derailed," he said.
Choose and Book software: risk factors and time delays
Changes in the requirements demanded by the Department of Health were seen as a major risk to the success of the Choose and Book software in the scheme's business case drawn up in September 2003.
To mitigate the risks, the department simply noted that there existed as part of the contract "strict change control mechanisms".
The business case added, "The cost of changes will be borne by the national application service provider [Atos Origin] up to a maximum limit."
In an interview with the BBC in January 2005, John Reid, the then health secretary, was adamant that "all" patients would be able to book hospital appointments online by 2006.
"All of the patients by next year will be able to book if they want to online. All of that is on schedule," said Reid, responding to a report by the National Audit Office which contained criticisms of the Choose and Book scheme, and the e-booking support programme.
By the end of last year, Whitehall's plans to have 205,000 appointments booked online had led to only 63 electronic bookings. But by 26 October this year, use of the Choose and Book service had increased to only 20,297 bookings: against a potential of 10 million appointments each year.
Computer Weekly has learned that many of the 20,297 were made by patients on the phone, with the Choose and Book software performing only a truncated role.
During his January interview Reid said the Choose and Book computer system was "running weeks late, not months or years late".
He described the national programme as the biggest IT scheme in Western Europe and said the government had become Microsoft's third biggest customer.