National Programme for IT

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The National Programme for IT (NPfIT), is an initiative by the Department of Health in England to move the National Health Service towards a single, centrally-mandated electronic care record for patients and to connect 30,000 General practitioners to 300 hospitals, providing secure and audited access to these records by authorised health professionals. The Department of Health agency NHS Connecting for Health (NHS CFH) is responsible for delivering this programme. In due course it is planned that patients will also have access to their records online through a service called HealthSpace. NPfIT is said by the NHS CFH agency to be "the world's biggest civil information technology programme".[1]

The cost and scope of the programme, together with its ongoing problems of management and the withdrawal or sacking of two of the four IT providers, have placed it at the centre of ongoing controversy, and the Commons Public Accounts Committee has expressed serious concerns over its scope, planning, budgeting, and practical value to patients.[2][3]

Contents

[edit] Structure and scope of the programme

The programme was established in October 2002 following several Department of Health reports on IT Strategies for the NHS.[4], and on April 1, 2005 a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced. CfH is based in Leeds, West Yorkshire.

[edit] Reviews

The refusal of the DoH to make "concrete, objective information about NPfIT's progress [...]available to external observers", nor even to MPs, has attracted significant criticism, and was one of the issues which in April 2006 prompted 23 academics[5] in computer-related fields to raise concerns about the programme in an open letter to the Health Select Committee.[6][7] 2006-10-06 the same signatories wrote a second open letter[8]

Reports by the King's Fund have also criticised the government's "apparent reluctance to audit and evaluate the programme"[9].

The initial reports into the feasibility of the scheme, known to have been conducted by McKinsey, and subsequent reports by IT industry analyst Ovum among others[10] have never been published nor made available to MPs[11].

[edit] Costs

Originally expected to cost £2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be £12.4bn over 10 years [12]. However, officials involved in the programme have been quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of 440% to 770%[13].

In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."[2]

The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not £1bn, as the contract permitted, but just £63m[14]. Granger's first job was with Andersen Consulting[15], which later became Accenture.

[edit] Deliverables

The programme is divided into a number of key deliverables. These are:

[edit] The Spine (including PDS & PSIS)

The Spine is a set of national services used by the NHS Care Record Service. These include:

  • The Personal Demographics Service (PDS), which stores basic demographic information about each patient and their NHS Number. Patients cannot opt-out from this component of the spine.
  • The Personal Spine Information Service (PSIS). This is a summary of patient's clinical information, such as allergies and adverse reactions to medicine.
  • The Secondary Uses Service (SUS), which uses data from patient records to provide anonymised and pseudonymised business reports and statistics for research, planning and public health delivery.

The Spine also provides a set of security services, to ensure access to information stored on the Spine is appropriately controlled. There are, however, already suggestions these security measures are inadequate, with leaked internal memos seen by the Sunday Times mentioning "fundamental" design flaws[18]. In addition, government spokeswoman Caroline Flint failed to dispel concerns regarding access to patient's data by persons not involved in their care when she commented in March 2007 that access would be granted to "in general only those staff who are working as part of a team that is providing a patient with care, that is, those having a legitimate relationship with the patient, will be able to see a patient's health record."[11]

[edit] Exceptions

The NHS in Wales is also running a national programme for service improvement and development via the use of Information Technology - this project is called Informing Healthcare. A challenge facing both NHS CFH and Informing Healthcare is that the use of national systems previously developed by the NHS Information Authority are shared by the both these organisations and the Isle of Man. Separate provision needs to be made for devolution, while maintaining links for patients' travelling across national borders.

NPfIT is currently focussed on delivering the NHS Care Record Service to GPs, Acute and Primary Hospitals, medical clinics and local hospitals and surgeries. Whilst there are no immediate plans to include opticians or dentists in the electronic care record, services are delivered to these areas of the NHS.

[edit] Clusters and Local Service Providers

The programme originally divided England into five areas known as "clusters": Southern, London, East & East Midlands, North West & West Midlands, and North East. For each cluster, a different Local Service Provider (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered. However, in July 2007 Accenture withdrew from the project, and in May 2008 Fujitsu had their contract terminated, meaning that half the original contractors had dropped out of the project. As of May 2008, two IT providers were LSPs for the main body of the programme:

  • CSC Alliance - North, Midlands & Eastern (NME) cluster
  • BT Health London (formerly BT Capital Care Alliance) - London cluster
  • Accenture had full responsibility for the North East and East/East Midlands clusters until January 2007, when it handed over the bulk of its responsibilities to the CSC Alliance, retaining responsibility for Picture archiving and communication system (PACS) rollout only.
  • The Fujitsu Alliance - had responsibility for the Southern cluster until May 2008, when their contract was terminated. Ownership of this cluster from that date remains uncertain[19].

[edit] Local ownership

In the first half of 2007, David Nicholson announced the "National Programme, Local Ownership programme" (known as "NLOP") which dissolved the 5 clusters and devolved responsibility for the delivery of the programme to the ten English Strategic Health Authorities (SHAs)[20]. Connecting for Health retains responsibility for the contracts with the LSPs[21].

Under NLOP, staff employed by CfH in the Clusters had their employment transferred to the SHAs, with some being recruited to revised national CfH posts.

[edit] National Application Service Providers

In addition to these LSPs the programme has appointed National Application Service Providers (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are:

[edit] Changes to service providers

In March 2004, EDS had their 10-year contract to supply the NHSMail service terminated.[22][23] On 1st July 2004, Cable and Wireless were contracted to provide this service, which was initially renamed Contact.[24]

IDX Systems Corporation was removed from the Southern Cluster Fujitsu Alliance in August 2005 following repeated failure to meet deadlines[19]. They were replaced in September 2005 by Cerner Corporation.

In early 2006, ComMedica's contract for supply of PACS to the North-West/West-Midlands cluster was terminated, and they were replaced by GE Healthcare.

In July 2006, the London region started the contractual replacement of IDX (which had been bought out by GE Healthcare in January 2006) as its supplier. Systems for secondary care, primary care and community and mental health services are proposed by BT to be provided by Cerner, INPS (formerly In Practice Systems) and CSE Servelecrespectively.[25]. This is subject to contractual negotiation known as 'CCN2'.

In September 2006, the CSC Alliance, Accenture and Connecting for Health signed a tripartite agreement that as of January 2007, the CSC Alliance would take over the responsibility for the majority of care systems the North East and Eastern clusters from Accenture, with the exception of PACS. As part of the handover process, around 300 Accenture personnel transferred under a TUPE process to CSC, and CSC took over the leases for some of Accenture's premises in Leeds. Accenture now retains only a small presence in the city for the delivery of its PACS responsibilities.

In May 2008 it was announced that following the failure to conclude renegotiation of the contract for the Southern Cluster, CfH terminated the contract with Fujitsu.[26]

[edit] Criticisms of the programme

[edit] Data security risks

NPfIT has been criticised for inadequate attention to security and patient privacy. In 2000, the NHS Executive won the "Most Heinous Government Organisation" Big Brother Award from Privacy International for its plans to implement what would become the NPfIT.[27] In 2004 the NPfIT won the "Most Appalling Project" Big Brother Award because of its plans to computerise patient records without putting in place adequate privacy safeguards.[28]

Advocates of the NPfIT note that these concerns must be set alongside the necessity of care professionals having access to personal medical data if they are to deliver safe, high quality care[citation needed]. The balance between the right to privacy and the right to the best quality care is a sensitive one. Also there are sanctions against those who access data inappropriately, specifically instant dismissal and loss of professional registration. This means that not only will the perpetrator lose their job, but any chance of getting another[citation needed]. Although, proving whether this information has been forwarded to other interested third parties would be hard, if not impossible to prove, in many instances : in that people involved in using these systems with a good comprehension of IT systems would be highly unlikely to be deterred from abusing it thorough fear or favour even if the consequences involved custodial sentences of many years. This would also be true with the ID Card scheme. More worryingly, a January 2005 survey among doctors indicates that support for the initiative as an 'important NHS priority' has dropped to 41%, from 70% the previous year.[29] There have been concerns raised by clinicians that clinician engagement has not been addressed as much as might be expected for such a large project.

Concerns over confidentiality, and the security of medical data uploaded to the Spine have also led to opposition from civil liberties campaigners such as NO2ID the anti-database state pressure group and The Big Opt Out who provide patients with a letter to send to their doctor so that their records are withheld from the database.

[edit] Reservations of medical staff

As of August 5 2005, research carried out across the NHS in England suggested that clinical staff felt that the programme was failing to engage the clinicians fully, and was in risk of becoming a white elephant.

Surveys suggest that two-thirds of doctors will refuse to have their own medical records on the system[30].

However by July 2006, over 75 trusts were live in the NWWM cluster alone[citation needed]. Supporters of the scheme suggest the only other choice was to do nothing and this was unacceptable[citation needed].

[edit] Impact on IT providers

The size of the programme means that it has become a substantial element in the UK activities of many IT providers[citation needed]. The onerous contract terms which have been an element in the process have therefore placed significant organisational and financial strain on some providers[citation needed]. According to the Daily Telegraph, the head of NPfIT, Richard Granger, 'shifted a vast amount of the risk associated with the project to service providers, which have to demonstrate that their systems work before being paid.' The contracts meant that withdrawing from the project would leave the providers liable for 50% of the value of the contract; however, as previously mentioned, when Accenture withdrew in September 2006, Granger chose not to use these clauses, saving Accenture more than £930m[14].

The programme's largest software provider iSOFT has been seriously affected by this process and is under investigation by the UK Financial Services Authority for irregular accounting.[31] On 28th September 2006, the consultancy Accenture announced its intention to withdraw from £2bn of 10 year contracts with NPfIT, which were taken over in January 2007 by the CSC Alliance - both Accenture and CSC laid blame with iSOFT, although CSC has said it will be retaining iSOFT as its software provider for all its clusters.[32] Earlier in the year Accenture had written off $450m from its accounts because of 'significant delays' in the programme.

[edit] Management team

The NHS appointed a management team, responsible for the delivery of the system:[33]

  • Richard Granger - is the former Director General of IT for the NHS. He took up his post in October 2002, before which he was a partner at Deloitte Consulting, responsible for procurement and delivery of a number of large scale IT programmes, including the Congestion Charging Scheme for London. In October 2006, he was suggested by The Sunday Times to be the highest paid Civil Servant, on a basic of £280,000pa - £100,000pa more than former Prime Minister Tony Blair[34]. Granger announced on 16/06/2007 that he would leave the agency "during the latter part" of 2007[35]. Granger finally left the programme in February 2008[36]. Granger's credentials were questioned by his own mother, a campaigner for the preservation of local health services in her area, who expressed her amazement at his appointment, critcising the whole scheme as "a gross waste of money"[15].
  • Gordon Hextall - Chief operating officer for NHS Connecting for Health. A career civil servant. On Richard Granger's departure, Hextall assumed overall responsibility for the programme.
  • Richard Jeavons - Senior responsible owner for service implementation. Previous posts include being CEO of the West Yorkshire Strategic Health Authority.
  • Harry Cayton - Chair of the Care Record Development Board.

[edit] References

  1. ^ NHS Connecting for Health — Service Implementation.
  2. ^ a b Patients 'won't benefit from £12bn IT project' - Telegraph (2007-04-17). Retrieved on 2008-05-29.
  3. ^ DoH: The NPfIT in the NHS - twentieth report of session 2006-2007. Retrieved on 2008-05-31.
  4. ^ NHS Connecting for Health — History of our organisation.
  5. ^ Signatories of the open letter to the Health Select Committee: Ross Anderson, Professor of Security Engineering, Cambridge University ; James Backhouse, Director, Information System Integrity Group, London School of Economics ; David Bustard, Professor and Head of Computing and Information Engineering, University of Ulster ; Ewart Carson, Professor of Systems Science, Centre for Health Informatics, City University; Patrik O’Brian Holt, Professor, School of Computing, The Robert Gordon University ; Roland Ibbett, Professor, School of Informatics, University of Edinburgh ; Ray Ison, Professor of Systems, The Open University ; Achim Jung, Professor, School of Computer Science, University of Birmingham ; Frank Land, Emeritus Professor, Information Systems Department, London School of Economics ; Bev Littlewood, Professor of Software Engineering, City University ; John A McDermid, Professor of Software Engineering, University of York ; Julian Newman, Professor of Computing, Glasgow Caledonian University ; Brian Randell, Professor, School of Computing Science, University of Newcastle ; Uday Reddy, Professor, School of Computer Science, University of Birmingham ; Peter Ryan, Professor of Computing Science, University of Newcastle ; Geoffrey Sampson, Professor, Department of Informatics, University of Sussex ; Martin Shepperd, Professor of Software Technologies, Brunel University ; Michael Smith, Visiting Professor, Department of Computer Science, University College London ; Tony Solomonides, Reader in Computer Science and Medical Informatics, University of the West of England ; Ian Sommerville, Professor, Computing Department, Lancaster University ; Harold Thimbleby, Professor of Computer Science, Swansea University ; Martyn Thomas, Visiting Professor of Software Engineering, Computing Laboratory, Oxford University ; Colin Tully, Professor of Software Practice, School of Computing Science, Middlesex University
  6. ^ Collins, Tony. "NHS Focus: Open Letter: Questions that need to be answered", ComputerWeekly.com, Reed Business Information Limited, 2006-04-12. Retrieved on 2006-11-01. 
  7. ^ Collins, Tony. "Signatories to health committee letter", ComputerWeekly.com, Reed Business Information Limited, 2006-04-11. Retrieved on 2006-11-01. 
  8. ^ Collins, Tony. "Experts strike new NHS warning note", ComputerWeekly.com, Reed Business Information Limited, 2006-10-10. Retrieved on 2006-11-01. 
  9. ^ King's Fund - Our Future Health Secured? A review of NHS funding and performance. Retrieved on 2008-05-29.
  10. ^ House of Commons - Public Accounts - Minutes of Evidence. Retrieved on 2008-05-29.
  11. ^ a b Another ministerial spokesperson for the NHS IT programme moves on (Tony Collins's IT Projects Blog). Computer Weekly. Retrieved on 2008-05-29.
  12. ^ NHS Connecting for Health — Mythbusters: The Cost of the National Programme for IT is spiralling.
  13. ^ Bill for hi-tech NHS soars to £20 billion. The Daily Telegraph (2004-10-12). Retrieved on 2008-05-31.
  14. ^ a b Kablenet. Accenture escapes £1bn penalty for NHS walk-out. The Register. Retrieved on 2008-02-28.
  15. ^ a b Health service IT boss 'failed computer studies'. The Observer (2006-11-12). Retrieved on 2008-05-29.
  16. ^ Contact lost as NHS e-mail relaunch misfires. E-Health Insider. Retrieved on 2008-05-31.
  17. ^ Connecting for Health fails to lead on Contact. E-Health Insider. Retrieved on 2008-05-31.
  18. ^ Jonathan Carr-Brown. Computer loophole hits hi-tech NHS trial. The Sunday Times.
  19. ^ a b Second contractor drops out of £12bn NHS computer upgrade. The Guardian (2008-05-29). Retrieved on 2008-05-29.
  20. ^ Hunt spells out local ownership moves. E-Health Insider. Retrieved on 2008-05-31.
  21. ^ NPfIT to go local by August. ZDNet.co.uk (2007-06-15). Retrieved on 2008-05-31.
  22. ^ Granger terminates EDS's NHSmail contract. E-Health Insider. Retrieved on 2008-05-31.
  23. ^ National programme says NHSmail was 'unacceptable'. E-Health Insider. Retrieved on 2008-05-31.
  24. ^ Press release:NHSMail Service To Transition Onto Microsoft Exchange Platform. Cable & Wireless. Retrieved on 2008-05-31.
  25. ^ NHS officially told of London Cerner switch. E-Health Insider. Retrieved on 2008-05-31.
  26. ^ E-Health Insider :: Fujitsu's £896m NHS IT contract to be terminated. Retrieved on 2008-05-31.
  27. ^ The 2000 UK Big Brother Awards. Retrieved on 2008-05-31.
  28. ^ Privacy foes named and shamed. BBC NEWS. Retrieved on 2008-05-31.
  29. ^ Doctor's support of NHS National Programme for IT declines, says new survey. PublicTechnology.net. Retrieved on 2008-05-31.
  30. ^ Daily Mail Comment: The NHS and its great white elephant. The Daily Mail (2008-05-30). Retrieved on 2008-05-31.
  31. ^ Daily Telegraph, 28 September 2006, 'IT providers left in the debris of NHS's 'Big Bang'
  32. ^ Daily Telegraph, 29 September 2006, 'Accenture pulls out of NHS deal'
  33. ^ Top Team — NHS Connecting for Health. Retrieved on 2008-05-31.
  34. ^ Fat cats of the public sector take top pay. The Times Online. Retrieved on 2008-05-31.
  35. ^ E-Health Insider :: Granger to leave in transition by end of 2007
  36. ^ Granger era ends as DG leaves CfH. E-Health Insider. Retrieved on 2008-05-31.

[edit] See also

[edit] External links