Healthcare IT in Britain is today symbolised, rather starkly, by the troubled NHS National Programme for IT (NPfIT). This ambitious initiative was meant to catapult Britain into pole position in the global e-health readiness league. It sought to link more than 30,000 GPs to nearly 300 hospitals, provide comprehensive e-prescribing and develop a centralised medical records system for 50 million patients. The NPfIT’s initial budget of GBP 2.3 billion over three years was officially revised to GBP 12.4 billion over 10 years. Some sources claim that spending will eventually pass GBP 20 billion. As a result, it has also been billed as the world’s largest civilian IT programme.
Volleys of Criticism
The NPfIT programme was launched in 2002 and originally scheduled for completion by 2010. It has since been postponed to 2015.
It has, meanwhile, also been subject to sustained volleys of political and public criticism, along with attacks on its alleged over-ambitiousness by respected physicians. 2008 saw the departure of its Chief Executive. This followed the sacking by the government of one of its key contractors Fujitsu, which was installing the programme in the south of England. Previously, in 2006, Accenture, which was delivering the system in the north, had walked away.
A Taste of Things to Come – Beyond
Overall, the NPfIT may provide a foretaste of developments in the US and elsewhere in Europe. Fragmented healthcare IT systems are universally accepted to be a barrier to improving the quality of healthcare services. However, users face the classic IT systems modernisation challenge of unravelling the back-office spaghetti, while continuing to deliver ready-to-eat meals up front.
Benefits “Still Theoretical”
In January 2009, the House of Commons Public Accounts Committee (PAC) published a scathing report on NPfIT, and on Connecting for Health – the agency charged with running the programme. Other than cost-overruns, the PAC also raised concerns about the about data security and confidentiality of patient records, and noted that for many staff, the benefits of the Programme were “still theoretical.”.
As a political watchdog, one of the PAC’s most telling comments was the “little or no consultation” which NPfIT had with physicians – a topic covered in depth in a previous issue of Healthcare IT Management. Finally, the PAC cast doubts about whether the 2015 deadline would – or could – be met.
No Real Yardsticks
NPfIT proponents, on their part, point out that the PAC had little to say about technical issues, most crucially about performance parameters of the NHS’s modernised IT infrastructure, measured against realistic benchmarks for similar endeavours elsewhere, or roughly similar ones given the sheer scale of the NPfIT project.
Indeed, the PAC only briefly overviewed the tension between vendors and system integrators responsible for security, and NHS staff who are ultimately responsible for the security of data which they access are briefly explored.
It also briefly passed over one of the most crucial ethico-legal issues and technical challenges with respect to electronic records, about the change-over to a “consent to view” approach.
IT Managers Dismiss “Idle Chatter”
One senior IT executive associated with the NPfIT was especially dismissive about what he called the PAC’s idle chatter on such issues. Access to records, according to the PAC, “are not yet in use in all Trusts because early releases of the care records software in London and the South do not support them.” What did the PAC expect, he asked HITM: “that millions of access cards are rolled out of a newspaper kiosk on a Saturday morning ?” It is clear that the NPfIT project has become a hot potato.
The PAC report noted that the (new) completion target of 2014-15 (as mentioned itself delayed by four years) “must now be in doubt.” It injected a further dose of politics by noting that the project cost taxpayers GBP 12.7 billion, “although this figure remains uncertain.”
Party Politics and Muddleheadedness
A growingly partisan undercurrent to the debate is underscored in comments by Edward Leigh, the PAC chairman (and Member of the opposition Tory Party). Leigh said that if there was no improvement to the situation within six months, “then the Department (of Health) should consider allowing Trusts to apply for funding for alternative systems."
Richard Bacon, another Tory member of the PAC, said the NPfIT programme was now “in deep trouble from which it is un- likely to recover.” In a stark example of the difficulty faced by politicians in understanding the complexities of IT in general (and healthcare IT in particular), Bacon concluded that “hospital trusts should now be free to buy the systems they want, subject to common standards…”. His advisers had obviously failed to point out that (the lack of) common standards in healthcare IT are exactly at the root of the problems faced by NPfIT and likely to remain so for some years.
In August, the Tories left no room for any more doubt about the politics of the NPfIT problem.
In an official statement by Party leader David Cameron, the Tories said that, if elected, they would “dismantle Labour's central NHS IT infrastructure” and instead use local systems for local areas. Worse was the announcement that contracts signed under NPfIT would be halted and renegotiated.
Such a stance raises the chance of an incoming Tory government becoming embroiled in legal disputes with BT and CSC, the two IT firms with local service provider (LSP) contracts for NPfIT. The UK government has been locked in legal dispute with Fujitsu since terminating its LSP contract in April 2008.
Echoing Bacon’s muddle-headedness, the statement reiterated the Party’s commitment to open standards, and insisted that local systems should be “rigidly interoperable”.
Microsoft, Google and the Tory Party
More telling was an NHS IT review, commissioned by the Tory shadow health minister Stephen O'Brien, whose authors compared Microsoft's HealthVault with Google Health for potential use in the UK health system. Neither application is currently available for British citizens.
The report endorsed HealthVault, which has greater privacy and security safeguards than Google Health’s “relatively simplistic” design, which they observed, was primarily deployed for personalised advertising in the US, a claim immediately rebutted by Google.
Needless to say, the Tory statement was enthusiastically endorsed by Microsoft. “We are pleased,” said Mark Treleaven, healthcare strategic marketing manager for Microsoft UK, “that this area is being looked at seriously in the UK, as we believe strongly in patient empowerment…. We have seen huge benefits in the US and, while the healthcare system is different, patient needs are the same.”
No Big Bang, nor Chorus of Little Bangs
While the politics of healthcare IT is never far beneath the surface, the UK is showing just how far it can interfere with serious technology decision-making and roll-over into the realms of Big Business, above all from the US.
And yet, the inability to implement technical modernisation (and in some cases, muster adequate staff) to perform a Big Bang rollout, or achieve a planned but functional phasing-in of new systems (a chorus of Little Bangs ?), has meant that the NHS currently runs on a patchwork of IT systems, and will continue to do so for a few more years.
Painful Transition, Slowdown
As a result, not a few British hospitals have been forced to bring in their own bespoke electronic software to replace existing ageing systems which cannot connect to modernised systems elsewhere. For some critics, such a transition is more painful than having an older system, but one which worked.
Worse still is a slowdown in the pace of implementation, almost entirely due to the exit from the project by major vendors such as Accenture and Fujitsu.
Illustrating this is the fact that the new care records system was installed in only six NHS trusts in the first five months of 2008-09, taking the total number of installations to 133 out of 380.
Users Sanguine, but See Tough Decisions Ahead
Major user groups, meanwhile, remain sanguine. According to Nigel Edwards, policy director of the NHS Confederation: “NHS organisations have already had to work around the delays by putting alternative IT systems in place. Everyone recognises the potential of the programme and is frustrated at the delays, however, we are getting to the point where, having spent so much money both in funding the system and keeping it running, the time is quickly approaching to make tough decisions on what the future of the project should be.”
Dr Vivienne Nathanson, Head of Science and Ethics at the British Medical Association, concurs: “Despite the problems we must not lose sight of the potential benefits that could be delivered in terms of patient safety, by the National Programme for IT."