Analysis of two national IT programmes facing major challenges
With his trademark straight-faced humour, Richard Granger, director general of NHS IT, lamented the delivery on time of a system to enable patients and doctors to book hospital appointments electronically.
He told the Procurement Solutions conference in London on 21 June, "It is unfortunate we delivered it to schedule because if we had delivered it a year or two late, I think the user input would have caught up with the system being delivered.
"It is going to be interesting to see, over the next few months, whether the potential of that working technology platform with very high levels of availability is taken up locally in the NHS."
He was referring, lightly, to one of the biggest risks facing the national programme for IT in the NHS, that clinicians might shun national systems which met the specifications and were delivered on time and to budget.
The danger is that Connecting for Health, an agency of the Department of Health set up to deliver the IT-led modernisation of the NHS, may help to deploy systems to hundreds of thousands of users, across thousands of sites. But clinicians may not use them.
Apart from Pacs x-ray systems, which have an obvious advantage to all, clinicians may access other nationally-bought systems to meet minimal administrative requirements, rather than use them in earnest for the good of patients.
This risk has already materialised with the Police Information Technology Organisation (Pito). Like Connecting for Health, Pito was created largely to deliver national systems locally, but some IT directors in the 43 police forces in England and Wales resented being pressurised to install technology bought by London-based officials.
Now a review of Pito's future, commissioned by the Home Office, has concluded that it has lost the trust of police forces. It found that the organisation cannot continue in its current form and questioned whether tens of millions of pounds has been wasted on national systems that are not used in earnest by most forces.
The review said the structure of police IT was "substantially dysfunctional", and its report increased concern about whether officials should have tried to impose national systems on independent police forces.
Similar questions are being asked in the NHS. What will be the implications of the Department of Health trying to thrust national systems on hundreds of hospital trusts and thousands of GP organisations, all of which are self-governing?
"Problems have arisen when what are judged to be national imperatives are imposed from above on a structure that sees itself as locally accountable and responsive - and to a significant degree operationally autonomous," said the report on Pito.
To a careful observer of IT-related project failures in government, the findings on Pito's future read like a potential post-implementation review of the NHS IT programme.
There are indeed some strong similarities between the IT strategies of the Home Office and the Department of Health. Both are, though agencies, trying to deliver national systems to end-users who have been used to buying their own technology. These end-users cannot always be forced to swap their preferred technologies for those favoured by Whitehall.
The review of Pito was led by Robert McFarland, a former chief executive of the BOC group. His report highlighted massive structural cracks in the foundations of police IT.
However, a comparison with Pito is not all bad news for the NHS programme. Pito is about six years into delivering its national systems. The NHS programme is only three years old, so this age gap could allow health officials to learn from the mistakes made in setting up Pito in 1998.
Most of the weaknesses in the structures of police IT, as disclosed in the Pito review, can be read across to the NHS national programme and Connecting for Health.
The review of Pito concluded that it has enjoyed some success but, in general, police forces oppose the delivery of its national applications. They perceive the national systems as "unreasonably delayed, expensive and technically backward". "Pito has not provided what its customers wanted when they wanted it," the report said.
Key systems within the national programme for IT in the NHS have also been delayed and are seen by some GPs and hospital doctors as expensive and technically backward. Many resent the one-size-fits-all approach.
McFarland's team found that police forces would prefer to adopt systems of their choice, built to standard specifications which followed a "data-centric" approach, rather than be instructed by the Home Office about what technology to use. But Pito has been committed to delivering national systems. "The fact is that Pito's overall credibility with the police is very low," said McFarland's review.
The same centralist approach has been adopted for the delivery of the NHS national programme.
Pito receives its funding directly from its parent department, the Home Office, not the businesses it is supposed to serve. So it has two masters which may have conflicting demands.
"If there is a conflict between Pito needing to deliver on a Home Office target and the police force wanting to trade delay for better functionality or improved business benefit, the Home Office target is bound to take precedence," said McFarland's review.
"This, objectively, may be right, but in such circumstances local police forces will see themselves as being dictated to, rather than receiving a service."
Connecting for Health is in same position as Pito. It receives its funding directly from the Department of Health, not from the businesses it is serving, which are run by GPs and NHS trusts. A common complaint about the national programme for IT in the NHS is that some trust IT directors and GPs believe they are being dictated to by the centre, rather than receiving a service.
The Home Office had hoped that forces would pay locally for national systems to be implemented. But many police forces refused. "Pito found itself developing systems that the majority of forces labelled as yesterday's technology tomorrow. Thus the funding model collapsed," said McFarland's review.
Many trust boards are expressing concern about the local costs of introducing national systems. Some may be unable or unwilling to drop other work to spend large sums on a national scheme for which they feel no ownership.
McFarland's team pointed to the lack of accountability for Pito's national systems.
"In practice accountability falls between the cracks. Those in a position to deliver, left outside the decision-making process, can and do deny ownership."
Similar systemic cracks have appeared in the structures of accountability within the NHS IT programme. Different organisations are in partial control of delivery, including the Department of Health, Connecting for Health, clusters, suppliers, primary care trusts, hospital trusts and GP organisations.
Responsibility for the NHS scheme has passed through a succession of owners and ministers, so there is much scope for buck-passing if it all goes wrong.
The potential losses from police's boycotting some national systems would run into tens of millions of pounds, perhaps £100m at the most. With the health service, the potential losses could run into billions.
The risk of losses of this size should have been debated fully when the programme was approved in concept at a meeting in Downing Street in February 2002. Did that debate take place? If it did not, this may be why Downing Street has refused Computer Weekly's request under the Freedom of Information Act to release details of the meeting.
The McFarland review came too late for Pito. It found that Pito's relationship with police has irretrievably broken down. But it is not too late for a McFarland-style review of Connecting for Health to save the national programme for IT in the NHS.