The controversy over costs makes it easy to lose sight of what the government is aiming to achieve with its IT programme for the NHS. Lindsay Clark offers a guide to what is happening and why.
When an IT project inspires satirical sketches on TV, there is no doubt it has made the big time. Last month the Channel 4 programme Bremner, Bird and Fortune lampooned the NHS National Programme for IT as an example of government mismanagement of computer projects at the end of a difficult week for the NPfIT and its backers. Debate had raged about exactly how much public spending would have to be dedicated to make it fulfil its promise and ministers had sought to reassure the public and the Treasury that it was all under control.
Given the political sensitivities of the NPfIT, it is easy to lose sight of what the NHS is trying to achieve. The government argues that as things stand, far too much time is wasted in the health service trying to find patient notes and correcting information.
The strategy document, Delivering 21st Century IT, says the national programme aims to support the delivery of services for patient care quickly, conveniently and seamlessly. It should also support staff through effective electronic communications, better learning and knowledge management; reduce the time to find essential information, such as test results; and make specialised expertise more accessible. The management and delivery of services will be aided by providing good quality data to support clinical audit, governance and management information.
The programme focuses on the NHS but the government also intends to develop systems in social care IT so that the two services are integrated as local communities.
These aims are part of the government's broader political programme to modernise the NHS and offer patients greater choice. Other government departments and companies may have similar objectives, but what sets the NPfIT apart is the scale of the task. The government will spend about £6bn on IT systems and services and invest billions of pounds in training and management. Electronic health records accessible to all relevant medical staff wherever they are in the NHS will be created for 50 million people.
The programme also promises the electronic transfer of prescriptions (ETP) between doctors and pharmacists. More than 649 million prescription items were issued in 2003-2004 and this figure is growing at a rate of about 6% a year. The NPfIT anticipates that electronic transfer will support the increased volume of prescriptions and give prescribers, dispensers and patients greater choice and convenience. The system will be more efficient, will save costs and time, and will be delivered as a national application like the care records service. In addition GPs should be able to book hospital referrals online from their surgeries by the end of next year.
Such a massive undertaking has required the Department of Health to harness organisational structures that include centralised management, regional health bodies and private sector IT contractors. The national programme itself sits within the department as a executive agency. It has created the national strategy and managed the procurement contract for IT services.
Suppliers including the main contractors, called local service providers (LSPs), have signed up to deliver IT systems in five local clusters, and separate contracts were awarded for national applications such as the data spine that will store patient details, and the broadband infrastructure, N3, to allow communication between medical professionals via, for example, the Contact e-mail system.
The NPfIT says the systems that most need to be upgraded or replaced are the GP systems upon which national applications will run, and the hospital systems that will use and share patient and clinical records.
Although the local service providers will supply core services that will have these built in, existing system suppliers have an opportunity to upgrade existing systems and make these NPfIT-compliant. The national programme says the decision about when and how to introduce new or upgraded systems is managed at local trust level in discussion with the NPfIT and suppliers. The age, status and performance of existing systems and the contract renewal dates are factors taken into account at a local level.
The medical profession has welcomed the investment in new systems. John Powell, chairman of the British Medical Association's IT committee, says, "It is a massive job and something the NHS has needed. There has been under-investment in information generally without thinking about technology. Healthcare is an information-based business. In a way doctors are information managers, processing signs and symptoms, making diagnoses, instructing tests and prescribing drugs."
The argument for getting better quality information to doctors as a way of improving care is well established. To understand why this programme has been developed over the past couple of years and on such a grand scale it is important to examine the historical and political context.
The Labour government tried to improve NHS IT with the 1998 Information for Health white paper. It described an IT strategy with some of the same aims as the national programme - better electronic communication between doctors and hospitals and electronic health records. However, the department devolved implementation of the strategy to a health authority and NHS trust level. With Labour committed to the previous administration's spending targets for its first two years of office, NHS budgets were stretched and IT funding was often raided to support more urgent patient care.
In 2002 the government published a far-reaching review of the UK's health service called Securing our future health: taking a long-term view. Its author, Derek Wanless, former chief executive of NatWest bank, pointed out that NHS IT investment lagged far behind industry. He also said the lack of technological standards across the NHS and the inability to electronically share data between GPs, hospitals and community services created inefficiencies.
He pointed out that IT investment in the NHS ran at £1.1bn a year and recommended that this be increased to reach a peak of £2.7bn in 2007-2008. This justified spending more on IT in the health service. Meanwhile, perhaps because of some frustration at the lack of progress on Information for Health, the Department of Health opted for a centrally managed IT overhaul and, in the summer of 2002, announced a procurement strategy that would lead to the creation of the NPfIT.
Paul Goss, director at health IT consultancy Silicon Bridge Research, says one of the problems for NHS IT has been a failure to attract a strong market of suppliers. "In 1990 there was greater capability to build bigger systems at a better price and a desire to say we need to look at health communities, not just organisational matters. But because of fragmented purchasing the market was small. The national programme has brought extra capability."
He argues that a relative reduction in the cost of computing power alongside the political will for expenditure has made a venture on the scale of the NPfIT possible.
Although the financing and IT suppliers are in place, the programme has yet to prove that it can deliver to NHS staff and patients. Powell says it does have the potential to improve efficiency. But he also has some concerns. "Yes, it can revolutionise patient care, but the problem is that too much time is spent saying it is about patients. It is also about changing working practices."
On this topic the programme has attracted most criticism. Last year the British Computer Society said training and a change management programme could cost five times more than the IT equipment and services. Although the government has given assurances the money will be available, some confusion remains about how much and who will pay for what.
Change management is a notoriously difficult aspect of any major IT programme and it requires the goodwill of the end-user community. Organisations such as the BMA have complained about lack of consultation, particularly at the grassroots level. GPs, most of whom are not directly employed by the NHS, also fear that they could be forced to stop using systems they are familiar with at a time when they are implementing their new contract with the NHS. Although the NPfIT says it has consulted hundreds of doctors, it could be years before its efforts at end-user consultation are fully tested.
For the government, a great deal is at stake. Its massive NHS investment programme is predicated on improved efficiency, which will come partly as a result of the national programme. And as more conditions become treatable and the proportion of older people in the population increases, the NHS must become more efficient. Otherwise health spending will grow to an unacceptable level or the NHS will stop being free at the point of delivery. As both of these options are politically off-limits, the NPfIT will remain in the spotlight for years to come.
New NHS technologies
The challenge faced by the national programme for IT in the NHS is the sheer scale and scope of what is being implemented; no one has ever tackled something this big before in healthcare. So most of the technical innovation lies in the underlying infrastructure rather than the front-line applications. Some examples include:
- The use of the Health XML level messaging standard (HL7 v3.0)
- The implementation of a service-oriented architecture
- The ability to move data seamlessly between known endpoints, such as a lab, a surgery and hospitals
- The gradual introduction of wireless technologies at the local area level, to ensure that mobile workers are in touch with centres, and at the facility level to recognise where a patient is in a hospital and relay vital signs.
Contact is a secure national e-mail and directory service. It was developed specifically to meet health service and British Medical Association requirements for clinical e-mail between NHS organisations
A group of strategic health authorities working together in a region to implement the new systems
Electronic transmission of prescriptions. This enables GPs or prescribers to send prescriptions electronically to pharmacies
Local service providers are responsible for making sure the new systems and services delivered through the NPfIT meet local requirements and are implemented efficiently
The New National Network. This is the new fast, broadband communication network for the NHS. N3 is delivered by BT and replaces the existing private NHS network, NHSnet
The spine is the name given to the national database of key information about a patient's health and care and forms the core of the NHS Care Records Service.
It will include patient information such as the NHS number, date of birth and name and address of a patient along with clinical information such as adverse drug reactions and major treatments.
Legal issues on data use
Like all collections of personal data, the national programme must comply with the Data Protection Act. This means that all data must be stable, accurate, secure, up to date and only held for the purpose which it is collected.
Suzanne Mercer, partner in IT in data protection and commerce at law firm Eversheds, says, "Given the scale of the project I would be surprised if there were no legal challenges. This is only to be expected.
"Initially the challenges are going to be around migration - getting the data in one place and in a form everyone can use. Then it will need to be secure, the right people must have access, and it has to be up to date.
"The difficulty is going to be in trying to work out who has the right to change data. You will need clear processes on how records can be changed. The key proposal is that people could access records online and point out errors. There is scope for greater patient involvement," Mercer says.
Although having accessible NHS data can make it more vulnerable, she says that as the nature of the data is no different to what is already stored, it could make it easier to manage.