Long a focus of controversy, the NHS’s flagship programme for renewing its information technology has been radically scaled down and ‘re-focused’ by the new coalition government. Jerry Fishenden welcomes the change, but worries that letting diversity bloom again without learning the lessons of both NPfIT and its predecessor policies will not break the mould of past failures.
The news from the Department of Health that the National Programme for IT (NPfIT) in the health service is taking a new direction will hardly provoke loud gasps of surprise. The programme’s centralised, national approach always sat uneasily with an organisation that is largely locally run and organised, and locally accountable, in nature.
The NPfIT programme was designed from the start to be an imposed central IT solution for the NHS The seeds of its failure were there to see from its birth. When talking early on with one of the key architects and movers of the whole idea, I was surprised to be told that no stakeholders (ie actual doctors, nurses etc) were at that time involved with the plan. Apparently their views were not needed. ‘They’ll use what they’re given’, was this leading figure’s robust response.
The Department of Health (DoH) now claims that it is changing the whole information technology approach within the NHS to one that is more local and needs-led. This is an encouraging sign that finally IT will have to meet business needs rather than being imposed for its own sake. Yet nagging doubts remain. There needs to be absolute clarity about what IT is trying to achieve, how it will help both NHS staff and patients alike. And this also means a recognition that technology is not the answer to every problem. For too long technology seems to have been the enthusiastic and expensive tail wagging a rather confused and emaciated dog.
The Health Service approach to IT oscillates regularly between highly centralised initiatives and local autonomy. As a Director of IT in the NHS during the 1980s I remember being educated early on about the relative importance of modern communication technology to many of its key users. The context was that Edwina Curry MP, then serving as Minister for Health, made her infamous, if honest, comments about most British eggs being contaminated with salmonella. This surprise outbreak of ministerial honesty took everyone by surprise, and so the Department urgently needed to communicate with every District Medical Officer (DMO) across the country, to instruct them on how to handle this announcement so as to alleviate the upwellling of public concerns. First class letters were dispatched alongside urgent emails, sent out over the private NHS email system provided by BT (known as ‘Merlin’ if memory serves me right).
After the salmonella panic died down, a post-incident review was conducted into how effective the two communication channels had been. The overwhelming feedback was that the DMOs had received, opened and acted upon the letters the following day. ‘But what about the emails?’, I asked, keen to prove how essential IT had become to the NHS. Well, most DMOs got around to reading their email a week or more later. Some did not even bother, not seeing why email was needed in their busy lives when first class post was perfectly adequate and cheaper.
Roll forward some 20 plus years, and what has changed? Well, some aspects of what has been delivered recently by NPfIT do seem to be working and delivering value. Notable here are the picture archiving and communications system for digital X-rays(called PACS), the national NHS network (called N3) and the transfer of records between from one GP surgery to another (called GP2GP). But these elements account for a tiny fraction of what the overall programme has spent.
The remaining expenditure appears to have delivered little. Major elements of NPfIT, such as ‘choose and book’ services for patients, and aspects of electronic prescriptions, remain uncertain in terms of their future viability, at least in their current form. Worse still, the whole central approach has stifled the ground-up innovation which always inspired me when I was in the NHS – designed by users for users, but with modern IT ideas and tools.
A return to locally determined IT needs, based on clear health service requirements, developed within the context of common standards, is a healthy step, if long overdue. But the NHS has been here before of course. At one time the NHS Information Authority had around 1,000 staff all trying to agree the IT standards that NHS bodies should be working to at local level. That was an equally ineffective model and it got nowhere, in part creating the political impatience amongst Labour ministers that resulted in the imposition of the centralised approach.
The real concern for public and government alike is the fact that the estimated £6 billion spent so far on NPfIT is just a fraction of the total amount of public money thrown at IT within the NHS over the last 20 or so years. The failure to transform health service IT over such an extended period suggests a deeper, more systemic failure of governance. It is not unreasonable for any NHS professional, citizen or indeed government minister to ask why this has happened – and also to assess what such expenditure could have achieved had it gone directly into improving NHS services, rather than on IT-led initiatives.
So, where do we go from here? My prescription is twofold:
- First: conduct a rigorous, rapid audit of what went wrong, covering governance, architecture and procurement. The focus here should be not just narrowly around NPfIT, but also covering the longer-term and systemic failures of IT in the NHS. This review should also examine claims that NPfIT has set back IT across the health service by ten or more years. And it must hold those responsible to account for the scale and cost of NPfIT. This audit should not aim to produce a long esoteric report but to provide a practical fixlist for improving implementation.
- Second: the NHS should apply the lessons learned both from its own experience and elsewhere about how to integrate and manage IT better. The NHS should implement professional, rigorous, effective and accountable IT governance that is suited to the way it works. It must stop making the same mistakes time and time again.
The coalition government has the perfect opportunity to commission an independent, authoritative review to help fix the way that IT in the NHS is planned and delivered. Unless this is done now, my worry is that in another 20 years we will still be wondering why IT has not delivered for our most critical public service.
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