I once wrote a book about the National Programme for IT in the NHS. It was called ‘The NHS IT Project: The Biggest Computer Programme in the World Ever!’
Despite the title, the book was not simply about NPfIT. It was also about the twenty years of NHS initiatives and developments in information technology that had led us all the point where it seemed necessary.
Record once and use many times
I wrote the book with a certain degree of hands-on knowledge, as I had been part of an earlier national intervention in NHS computing – the ‘Resource Management Initiative’ or RMI in the early 1990s.
One of the key conclusions of that programme was that any new initiative simply had to engage with clinicians. A further conclusion was that technology had to support the delivery of clinical care. Clinicians would not record clinical data just for the sake of it. The capture of the clinical data (for the casemix box in the case of the RMI) should happen as a by-product of that care.
I went on to become the NHS National EPR project manager. This piece of work fed conclusions into the Frank Burns “daffodil” information strategy of 1998 (so named because it was promised for spring and then delayed, leading to many out-of-season references to the flower).
Eventually, Burn’s strategy led to the government white paper, ‘Information for Health’. But the main conclusions of the EPR programme were not dissimilar to those of the RMI. Any project had to engage with clinicians, it had to have enthusiastic buy-in from senior managers, and the electronic record had to be a by-product of supporting the delivery of clinical care with technology.
Unfortunately, it soon became clear that the targets that IfH set for developing six ‘levels’ of EPR were going to be missed. The result was another strategy – ‘Delivering 21st Century IT’ – which decided this was down to technical problems, a fragmented supplier market, and a lack of commitment from trusts, which were spending ‘ringfenced’ money for IT on other priorities.
Political support – a two edged sword
The national programme was set up to solve all that, and initially I was supportive of it. At the very least, it seemed, we now had a health informatics project that had enthusiastic endorsement from the Prime Minister, the health secretary, and some very senior people at the Department of Health.
But time would show that this endorsement could be a two-edged sword. The programme got political buy-in, but the fundamental objective – “to use this technology to locally support the delivery of clinical care thus creating an electronic record as a by-product” – became lost to a more political objective: the need to be seen to modernise the NHS.
This new objective manifested itself with a desire to create a national electronic care records system, with a national electronic patient record. In my opinion this was wrong. The more pressing requirement was for local clinicians to have local clinical systems supporting them in “what they do.”
If this requirement had been delivered, then “what they have done” would have been captured automatically as “the electronic patient record.” This, in time, could have been shared nationally. But note those words, “in time.” The national record should not have been the prime objective.
NPfIT generated a lot of impressive activity building a ‘national data spine’ and other national services. But back in 1998, we had a very clear strategy that promoted the incremental development of integrated clinical systems, each one adding a layer (those ‘levels’) of increasing clinical complexity. The output from these active or “doing” systems would have generated, as an outcome, a passive record of care that clinicians could view.
I would have liked to have seen some serious focus on rigid supplier standardisation and at the very least, to have sought agreement on the outputs. Allocating new monies to support this new initiative would have resulted in huge advances in delivering these clinical systems. In time, there would have been opportunities to “standardise” these doing systems.
Instead, perhaps because the Treasury had asked a banker, Derek Wanless, to assess the future funding needs of the NHS shortly before NPfIT got going, there was a view in Whitehall that we should have one system for the NHS, in the way that Nat West had (at that time) a single system for its banking operations.
Today, it is interesting to see how recent advances in portal technologies have closed the gaps between the mixed-bag of clinical systems, without insisting that everyone has the same one. But back in 2002, in my mind, that is where the first wheel came off.
The big wheels come off
The second wheel came off when existing – and successful – IT suppliers were effectively disenfranchised. The computer suppliers who had delivered working clinical systems to the NHS for years were suddenly left out in the cold because they were not part of the nationally negotiated central contracts.
As it happens, and despite the contrary claims that were made at the time, these national contracts were subsequently let to suppliers who did not actually have the EPR systems that were needed. Or if they did, they were not “fit for purpose.”
Still, we had two wheels left. More of a motor bike than the four-wheeled drive super-car we were expecting. But let us not be completely negative about the programme. It did begin to address a number of contentious issues, like confidentiality, and technical interoperability, and these were desperately needed.
The objective of being able to book appointments on-line was a justifiable one – even if, sadly, the technology caused numerous implementation issues. The programme also began to address the need for some common look-and-feel, to get standardisation across the multi faceted NHS, through the Common User Interface standards led by Microsoft.
Back to tendering
So, the fact that there was a national programme for IT in the NHS was a good thing. The existing procurement process was both time-consuming and expensive. Something had to change.
The suppliers didn’t have the capacity to entertain this model indefinitely: each procurement cost the supplier a considerable amount of real money which had to be recouped eventually by winning a contract. The more the suppliers entered this procurement model, the more they had to recoup eventually. This was not sustainable.
But now, 14 years after IfH, we are not a lot further on. In fact, it’s worse than that. We are now seeing an increasing number of EPR procurements with all that expense for both the trusts and the suppliers.
Meanwhile, the clinicians we need to engage with to make this successful have become increasingly cynical about the use of IT, and the responsibility for this lies squarely with NPfIT. What doctors and nurses and allied health professionals were promised in the past was not delivered. Why should they believe us this time around?
They were told they would have a ‘state of the art’ four wheeled drive mega car and they ended up with a Lambretta.
The budget expectations of trusts have been punctured. Today, any trust that embarks on a new EPR procurement has a very difficult battle to justify the increase in spending they will need to deliver even part of their clinical vision. So expectations are scaled back.
Not even close to clinical engagement
In 2002, when the national programme started, we thought that in ten years every acute hospital would be have electronic ordering for tests, would have immediate access to patient results, would have implemented electronic prescribing, and would have introduced electronic care pathways to help roll out best practice care.
A decade later, less than half of all trusts have electronic orders and results, a mere handful are experimenting with e-prescribing, and care pathways remain an elusive dream. There are dozens of trusts in England for whom IT still means the patient administration system they installed in the 1990s, and for whom the future vision of technology is simply to upgrade this to a newer version.
For me that is the greatest failure of the national programme. It didn’t just fail to deliver. It took away the hope and tarnished that original vision of clinicians being supported by clinical IT.