In a briefing paper for a meeting of his board on 3 August, IT director Mick Przystupa had only one recommendation.
"The trust board is asked to note the progress of work to date and the key risks associated with the introduction of NPfIT."
Przystupa, the director of information management and technology at United Lincolnshire Hospitals NHS Trust, was referring to the national programme for IT (NPfIT) in the NHS, the world’s largest civil computer-based modernisation project.
His single, slightly euphemistic sentence put into words the frenetic work being done at many trusts across England to prepare for local implementations of new national systems and mitigate the risks of failure.
"It is inevitable that a programme of this size and complexity will carry risks and it is essential that robust programme management arrangements are implemented to help to mitigate risks," his paper noted.
Among the key risks he cites is the need in 2005 to train more than 4,000 staff which will present "significant funding and backfill [paying for people to replace those who are training] issues". His paper said the national programme requires a "different specification of technology than that which has traditionally been deployed within Lincolnshire" which "presents both a financial and support risk".
It is unfair to single out one briefing paper because it is typical of others from IT directors to their boards across England. The impression given by Przystupa’s paper, and many others by his peers, is that they would like to be able to tell their boards: "The benefits of the national programme are so great we should give it our unqualified support." But some cannot.
Although the NPfIT has been running for two years, and all the major contracts were awarded more than six months ago, trust IT directors remain concerned about risks, uncertainties, complexities and a lack of specific answers to direct questions.
Nobody doubts that the programme has already achieved much: the potential benefits of technology for the NHS have a higher profile than ever. Chief executives of all trusts in England have had their minds focused, at some point, on their own important role in the national programme. Nobody wants it to fail because the spend is unprecedented, is unlikely to be repeated, and it could greatly improve the care of patients.
But even some of the programme’s most enthusiastic supporters do not believe it will succeed without officials going forward with their eyes wide open to the risks and problems. This view is not reflected in the literature published by the Department of Health, which so far, has focussed on the benefits of the NPfIT with little mention of the risks and uncertainties.
In March, at a national programme briefing to IT executives, David Kwo, London head of the national programme for IT in the NHS, said he wanted 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".
Some officials on the NPfIT believe with a visionary zeal that the need to see the programme implemented successfully puts concerns over uncertainties into a trivial perspective.
But, however much IT executives in the health service share the vision of the national programme, they have also to contend with financial realities.
Dealing with risk
A board meeting of North Somerset Primary Care Trust on 24 June was told that the PCT "faces a challenging year to meet its statutory duty to break even" and that the need to recover the 2003/04 deficit in addition to the already large recovery programme will bring "significant risks to the PCT". It added that the national programme will inevitably create risks. "Whilst the hardware and software costs will be met centrally, costs for data migration, training and ‘backfill’ will need to be met locally."
There is £2.3bn definite funding for the NPfIT but contracts worth more than £6bn have been signed with a handful of local and national service providers. It is an assumption, not a certainty that the difference will be fully funded. And the £6bn figure excludes the currently unquantifiable costs of implementing the national programme locally - costs that will have to be met largely by trusts.
A briefing paper in May to the board of South East London Strategic Health Authority from chief information officer Rob Claridge, said on funding, "This remains an issue although there will be some money for local implementation. This will not address infrastructure development; nor will it enable Trusts to extend their legacy IT or implement Pacs [picture archiving and communications systems, the digitising of x-rays]."
Some trust IT directors have reported to their boards a large gap between what they estimate it will cost to implement national systems locally and the money they have been allocated centrally and regionally, or in their budgets.
The most fortunate trusts are narrowing the gap. Stuart Threlfall, director of ICT and service modernisation, in a board paper to King’s Lynn and Wisbech Hospitals NHS Trust on 26 July said that a business case to support the local delivery of phase one release two of systems from supplier Accenture under the national programme initially "left a significant and unacceptable gap in funding" of about £1.2m.
Now, said Threlfall, the gap has been reduced but the remainder will need to be addressed in part through "managed slippage and savings from the original estimates". He recommended accepting the business case with certain provisos, including this one: that the local strategic health authority "accepts that local funding to support NPfIT creates considerable cost pressure to an already financially stretched local health system".
Similarly, the board of Medway NHS Trust was told in June that there was an "urgent need to need to clarify timescales and funding".
The board was told about some of the programme’s uncertainties, that the trust’s local service provider Fujitsu Alliance and the national care record service were "both still in the early stages" and that "no set timescales, procedures or guidance had been formulated".
Strategies get go-ahead
Most trusts have approved strategies to go ahead with their part in the NPfIT while stipulating that there are risks and uncertainties. But going ahead with implementations without adequate funding and support could be disastrous.
John Bain, head of information management and technology at Trafford Healthcare NHS Trust, in a board paper in May , referred to the need to train and support care professionals and others to enable them to make best use of the new systems. He warned that underestimating the amount of such support was a cause of IT project failures.
"It is important to note that evidence suggests that these implementation costs may be as much as 70% of the overall costs of introducing new systems. When new IT investment has failed to provide the benefits expected, one major factor has often been the underestimation and provision of implementation support," Bain said.
Experts say that uncertainty is not all bad: it can add to the excitement of project teams that are working at the frontiers of business technology, doing things on an unprecedented scale; it may also unleash the creative power of the local service providers BT, Fujitsu, CSC and Accenture.
But so many uncertainties two years into a programme raise the question of whether the promise of benefits to come are so great that they justify an experiment with billions of pounds of taxpayers’ money. Many in the NHS will say it is worth the gamble.
The key questions on implementation
- Have health officials underestimated the disruption to the work of clinicians and hospital staff, and the complexity of replacing computer systems in trusts and GP practices?
- If so, could IT services - and the care of patients - seriously deteriorate with the installation of new systems?
- Have the costs and implications of training and changing the working practices of tens of thousands of doctors and nurses been fully assessed?
- Will new national systems work and be trusted - and more importantly used - by clinicians and NHS staff?
- Will they be more useful than existing systems?
- Do trusts have sufficient skills and money to implement new national systems locally?
NPfIT: too early for full answers
The national programme for IT in the NHS was asked to comment on criticism that two years into its work there are still many uncertainties and that IT directors cannot always get specific answers to direct questions.
It replied, "The national programme seeks to answer questions as they arise as fully as possible at the time. However, it is a fact that it has not always been possible to provide answers to very specific and detailed questions. However, there will be greater clarity as the programme develops and as local plans are taken down to a lower level of detail.
"We are committed to dialogue within the clusters through the regional implementation directors and chief information officers and will continue to run local events and undertake visits and roadshows."
The four parts of the NHS’ NPfIT
NHS Care Records Service
Every medical and care record for 50 million patients in England will be held electronically and will eventually be available online. The idea is that health workers and patients will be able to access the records whenever and wherever needed. Health officials say the service went live on 30 June.
Choose and Book
GPs and other health staff will be able to book initial hospital appointments electronically, at a convenient date, time and place for patients, without sending referral letters to hospitals and waiting for a reply.
Electronic transmission of prescriptions
A new service making it easier and more convenient for GPs to issue prescriptions and for patients to collect medicines.
New national network
The aim is for a national network (known as N3) with sufficient connectivity and broadband capacity to meet current and future NHS needs.
The national programme for IT says its strategic direction includes the use of the Sun Java Virtual Machine. The programme said, "It is recognised that Microsoft VM is still in use and will take some time to migrate from. In the short term national applications are being tested to operate against both Sun and Microsoft applications."
NPfIT responses fail to answer direct questions
In an attempt to get some direct answers to specific concerns being raised by IT executives in the NHS, Computer Weekly put a series of questions to the national programme for IT, which will become an executive agency of the Department of Health next year.
As some IT directors are finding, the answers from the national programme were not always as specific as the questions.
We are told that every trust in England faces costs and risks regarding the linking of their legacy systems to new national systems: the data spine, Choose and Book and the care records service. These costs include security and technical compliance. This could amount to hundreds of thousands of pounds per trust. Is this true? If so, how will trusts fund this cost given that the money must be spent before the savings accrue from national systems? Does the national programme recognise that some trusts are already identifying funding gaps they are finding difficult to bridge, and are reporting this to their boards?
In response the national programme did not comment on where the extra money will come from. It accepted, however, that the costs of training and implementing upgrades to legacy systems to make them compliant with national systems may fall to the NHS.
"Legacy solutions are an integral part of the NHS Care Records Service particularly in the early years of the national programme… Some trusts will face additional costs in these areas, some will not and this forms part of the planning and preparation. These services will improve the overall standards of patient care in the trusts and any extraordinary costs will be dealt with on a case by case basis," said an NPfIT spokesman.
Not all existing suppliers may be able to afford, or be willing to pay for, compliance with national systems, and some are quitting the NHS. Will the national programme pay for work to make these systems compliant or support the migration of local systems to a local service provider’s services? If not, and the supplier does not pay for compliance, where does this leave system users?
The answer did not tell trusts what to do if they were left without support from companies that are quitting the NHS because of the NPfIT’s restriction on suppliers.
"Naturally," said an NPfIT spokesman, "over the course of a long project like the national programme the market changes. The national programme is in dialogue with all suppliers on the availability of upgrades to make solutions NHS Care Records Service compliant. Clusters [new regional groups which help to run the national programme] will be working with their local communities to assess the impact of market forces and, of course, the prevailing market conditions will influence their deployment plans."
Who will be responsible for the accuracy of data that goes into the spine record - a national database which will take in 50 million medical records, partly from GP systems?
The answer is not entirely clear. "Under the Data Protection Act (1995) the data controller is legally responsible for the accuracy of information. The controller cannot be named as the NHS or called the health service as these are not legal entities and, therefore, cannot be data controllers.
However, it is likely that in regard to online patient records the vast majority of the controllers will be the local area or regional NHS trust or a GP or other medical practice - in common with the secretary of state for health. Employees of the data controller (for example, a consultant within an acute trust) will then have a contractual responsibility to ensure that the information they enter into patient records is accurate and complete."
Progress so far
By 30 June, contractors were due to have programme-managed the upgrade of at least one acute trust patient administration system, or deployed national systems such as electronic booking? Has this happened and if so please say where?
"The plan, for summer 2004, was to implement electronic booking into the first early adopter sites. The first successful online patient appointments of the Choose and Book service have been made in the first early adopter sites.
"The initial elements of the NHS Care Records Service spine to support Choose and Book have also been delivered enabling GPs to book appointments into secondary care and produce electronic referral letters. The roll-out of the Choose and Book service is starting with a limited number of sites across England and we intend to allow these early adopter sites to undertake their work uninterrupted. It would be unfair to submit them to the attention of the media."