NAO faces challenges in unprecedented investigation of national programme for IT
At the end of a long and articulate letter to GP-users of the Emis medical system last week, Manpreet Pujara suggested that public spending auditors investigate the national programme for IT in the NHS.
Pujara, who is head of the Emis User Group, is concerned that the government will spend millions of pounds unnecessarily replacing GPs’ systems.
He was not to know when he sent the letter last Friday that public spending watchdog the National Audit Office had just decided to launch a full value-for-money investigation into the £2.3bn NHS programme. It has taken the NAO a year to decide to investigate, having announced last August that it was considering holding an inquiry.
In his letter to Emis users – about 55% of England’s GPs use the system – Pujara expressed strong support for the principles underpinning the national programme. But he expressed concern over plans by the national programme to restrict the number of systems in use in GP practices to the two products offered by local service providers.
The local service providers comprise a small number of large companies including BT, Accenture, CSC and Fujitsu which have been chosen by the Department of Health to deliver new standardised systems throughout the NHS in England.
None of the local service providers is offering Emis. This is partly because they want to offer their own integrated systems and also because Emis refuses to sign contracts with the local service providers.
Sean Riddell, Emis’s deputy managing director, said his company cannot agree to clauses which, if signed, would lead to its professional indemnity insurers refusing to provide continued cover.
This leaves Pujara and other GPs concerned that Emis users will now face having to change from a tried and tested system, which has evolved over 16 years of use in a competitive market to one of as yet of unknown quality and features from a local service provider.
In his nine-page letter, Pujara said, "The government does not need to spend millions of pounds to replace GP systems that are working well for practices and will continue to do so for the foreseeable future."
The national programme for IT (NPfIT) wants the changeover as part of its strategy of "ruthless standardisation". But Riddell wants GPs to be able to choose any system that meets a much respected standard, known as HL7, for exchanging health data.
Pujara, a practising GP, said a switch from Emis to new systems supplied by local service providers could cause severe disruption to the running of GP surgeries. He counsels against the national plan adopting a "dogmatic approach, which cannot accommodate criticism from the primary care community".
He added, "It would seem opportune to have an independent view of the NPfIT before irreparable damage is done to primary care IT – a job for the National Audit Office, I would suggest."
The Emis controversy
Investigating the NPfIT will present especial difficulties, not merely because it is the biggest civil IT project in the world, according to the Department of Health’s literature; and not because of its high political profile: ministers are planning a series of announcements on the success of the project.
With such political sensitivities, the challenge for the NAO will be to distinguish the truth amid competing claims.
In contracts signed between the government and GPs, family doctors were told they would have a choice of systems.
Clause 4.34 of the GP contract stated, "From 1 April 2003 every practice in the UK will have the choice of RFA-accredited systems." RFA stands for requirements for accreditation, which is a core set of requirements, specified by the NHS Information Authority, which all GP systems should be capable of performing. Emis is an RFA-accredited system.
Clause 4.34 is backed by a joint statement from the British Medical Association and the national programme. It said, "Practices and their primary care trusts should not be financially or otherwise disadvantaged by choosing to remain with an existing [compliant] system…"
But the NPfIT has this month issued advice to healthcare suppliers which gives the impression that GPs will be expected to replace their non-local service provider systems – which would appear to include Emis – within two to five years.
The statement said the NPfIT’s plans are for two core clinical applications to "ultimately replace existing NHS clinical systems". It added, "As a general rule, it can be anticipated that the majority of existing systems will have been replaced or integrated within either a local service providers’ solution or management responsibility, at some point during the next two to five years."
To add to the confusion, Riddell said he is so concerned about incorrect statements that his company has written to some officials asking them to put right incorrect comments they are alleged to have made. For example, Riddell said that some of his customers have been told, wrongly, that Emis is running down its development of the product.
A spokesman for the national programme said, "All GP practices will be offered a choice of IT system to access the NHS Care Records Service. However, in the long term it is expected that the majority of the current plethora of existing systems will have to be replaced or integrated and it is likely that due to the large number of existing systems some will not be integrated."
Meanwhile the national programme will be working closely with Emis and other systems to ensure their systems are compliant for the roll-out of choose and book, the e-booking service, said the spokesman.
The NAO’s role
Without unravelling the Emis issue, the NAO may be unable to ascertain whether GPs are being forced to replace their systems unnecessarily and, if so, whether millions of pounds will be spent for little or no gain for patients.
But the Emis controversy is one of many examples within the NPfIT where there are disputed versions of the truth. For instance, a Computer Weekly reader said in a detailed e-mail that the national plan in London has had "huge problems recruiting the necessary numbers of NHS staff to fulfil key roles in their much publicised best practice groups for the London NHS Care Records Service [part of the national programme]".
The e-mail said the groups were set up initially to "advise on how we, the London NHS community, wanted our [new] solution to look and work". The author said he thought that work on developing systems for London would slow down "until such time as we had sufficient numbers to review all of the work to ensure that the system was adequately configured for London's needs". But he said he was told that the project "could not be delayed under any circumstances".
The e-mail claimed that "initial hype about involving the wider NHS community has fallen by the wayside to meet politically motivated deadlines".
Computer Weekly asked the national programme whether officials were sticking to a timetable rather than waiting until there are sufficient staff to adequately review the work of local service providers. The spokesman replied, "There is no shortfall in the numbers of NHS staff on best practice groups and they have been very well supported."
Doubtless NAO staff are expert in sorting fact from fiction, objective statements from those that contain material omissions and truth from a verisimilitude of it. Their report is due to be published next summer.
Key questions for the NAO
- Should the Department of Health have sought to modernise the NHS by allowing market forces to prevail – imposing rigorous standards which suppliers had to meet – or by restricting the market to selected companies?
- Should £6bn worth of contracts have been signed before it was known what the overall costs, including those of local implementations, would be; what changes in business process would be necessary; whether clinicians would use systems imposed centrally or regionally; how benefits would be measured; whether GPs would oppose any handover of control on the confidentiality of their patient records; and whether there were enough in-house skills to translate national plans into local action?
- Has the national programme understood the benefits of the projects better than the risks?