Examination of Witnesses (Questions 140-159)
20 MAY 2004
RT HON
JOHN HUTTON
MP, MR JOHN
BACON, MS
ANN STEPHENSON
AND MR
GORDON HEXTALL
CB
Q140 Mr Burstow: I just want to pick
that up because it was something which was coming out of the discussion.
You mentioned the interfaces between primary, secondary and tertiary
in your opening comments about IT. There is one other boundary
which is of interest, which is the boundary between social care
and the healthcare sector as a whole. I wondered whether you would
be able to tell us a little bit about where the work around the
roll-out of this IT programme is actually impacting upon, for
example, the development of the single assessment process and
the necessary IT systems shared between health and social care
to make that a reality. Is that part of this programme? If it
is not part of this programme, where is it being picked up?
Mr Hutton: It is part of the programme
and I think it is part of the subsequent releases on the national
care records service, is it not? Is the single assessment from
2005?
Mr Hextall: The single assessment
process is from 2005, wider social care 2008.
Mr Hutton: The single assessment
procedure for older people under the older persons will be built
into the care record system in the next year.
Q141 Mr Burstow: Will that be available
not just to the NHS, but would it be available in the same way
to social services departments?
Mr Hutton: I think that is the
idea.
Mr Hextall: Yes, except that the
linking up of the wider social services departments is really
in the planning stage now with a view to being implemented in
phase 3, which is the 2008 to 2010 period.
Q142 Mr Burstow: So the single assessment
process will be available to the NHS through this system in 2005,
but actually probably a very key player in making single assessment
a reality, the social services department, will not have access
until 2008.
Mr Hextall: They will be able
to have access. What they will not have is an integrated system.
Q143 Mr Burstow: That is what I meant.
I was obviously a bit sloppy in the framing of the question. That
is my question.
Mr Hutton: They will have access.
Mr Hextall: They will have access
but the integration into their own systems is further off.
Q144 Mr Burstow: Therefore they will
not have IT integration until 2008; they will not have that full
compatibility until then.
Mr Hextall: Yes. They might need
two terminals.
Q145 Jim Dowd: It is the security aspect
of it which strikes me, from the individual's point of view. You
mentioned a parallel with an internet banking account. Of course
generally there is only one person who seeks access to that bank
account and that is the individual who has it. Under this system,
particularly when you mention the emergency or accident, it could
be that you will have to give untold numbers of people within
the NHS access to patient records. How is that to be safeguarded?
Mr Hutton: In emergency cases,
where there is a need to make sure clinicians have the full, relevant
data, there will be an override for those clinicians; they will
be able to access the full record they need and rightly so. One
of the things which contributes to people dying unnecessarily
is the lack of proper information. The issue comes into focus
in a slightly different context in relation to carers for example
and how we can govern access to the information. The issues of
confidentiality are very, very important for us. It is not likely
that if you are admitted in Cornwall and you live in Tyneside
there are going to be hundreds of people perusing your care record.
That is not going to be appropriate and will not happen. In those
cases there will clearly need to be opportunities for nurses and
clinicians to gain access and they will be able to do that. It
will depend on who they are and their role in the team, but the
clinicians should have full access. If the patient is not able
to give it, because they are unconscious, I am not sure there
will be many people who say "Hang on. You have to wait for
the patient to come round". We are trying to be realistic
about this. We are trying to put some locks in there, so there
is proper scrutiny of access, but it is a classic dilemma for
all systems like this. The whole point about having information
is that people can use it, because it can save lives. However,
you do want to make sure that too many people do not see it. There
is one thing in particular which has been put to me and as a result
we built this into the system, which was what clinicians were
saying to us and patient advice groups: there are some sorts of
information in a person's healthcare record which are more confidential
and more private than others and there should be a subsequent
lock on some of that information. Genito-urinary medicine is the
most obvious. You are in A&E. Do you want everyone in A&E
having the fact that you have been to a specialist sexually transmitted
disease clinic up on their terminal? Almost certainly not. There
is a perfectly sensible case, within the care record, for having
lock-down around certain parts of the patient's record without
compromising the need for clinicians to get in and access it.
Q146 Dr Taylor: Going back to electronic
booking just for the moment, we understand that one of the reasons
that Professor Peter Hutton was bothered about things and resigned
was that he felt that e-booking could not really take place satisfactorily
until everybody had a unique identifying number. Is that the case
or can you do the pilots without the unique identifying number
and then add that in later?
Mr Hutton: Peter Hutton did not
resign for that reason. It was one of Peter's recommendations
to us that we use the NHS number as the unique identifier and
we have accepted that. That will be the key patient identifier
for e-booking and the care record service.
Q147 Dr Taylor: When will that come in?
Mr Hextall: Straightaway.
Mr Hutton: It will be built in
as we roll out.
Q148 Dr Taylor: Built in as you roll
out.
Mr Hutton: We all have a NHS number
now. I have no idea what mine is, but we all have them.
Q149 Dr Taylor: Are you talking to the
Home Secretary about getting that onto the identity card when
we get that?
Mr Hutton: No, the national identity
register will not contain any information which is relevant to
a person's health. That is outwith the scope of the legislation.
Q150 Dr Taylor: Going on with Professor
Hutton, it seems from the outside that his loss is pretty serious
as far as communicating with doctors and staff is concerned. Is
that so? Does that worry you? Are we allowed to know the reasons
for his departure?
Mr Hutton: I should like Peter
Hutton to be working for the department still, of course. He made
a very significant contribution to us. He is free to continue
to contribute and I know he will. He made his position clear in
his letter to the Financial Times as to why he was resigning
and that he was continuing to give full support to the national
programme for IT. Both of those were helpful. As I said earlier
in relation to my comments to the Chairman, we are in a different
phase now with the national programme for IT. We are through the
procurement phase largely, we are through the proof of solution
phase, we are through the technical phase. We are now into the
implementation phase. The key thing now is to have the maximum
possible engagement over the frontline staff. We have tried to
set out a very simple set of requirements for the programme. It
has to be usable, it has to be useful and it has to be compelling
in terms of its impact on frontline staff. They want to use it;
they are motivated and incentivised to use it and the quality
of the information on the database will be the key to its full
utilisation. If staff feel it is going to be helpful to them,
really going to transform the work they do and the quality of
care they provide, they will use it. If they do not, they will
not. The key thing for us now is this work that Aidan Halligan
is doing on clinical engagement across the NHS. I have mentioned
the frontline support academy in passing. We have just put £50
million into that to try to get that going. We have had a very
substantial level of involvement to date around clinical involvement,
something like 400 clinicians have been helping us with the design
and setting up of standards for the service. We have done 400
road shows around the country in the last few months, engaging
over 22,000 frontline staff and so on. This is ongoing work and
it needs to be right at the top of the list of priorities now.
With the best will in the world, you can have all the best kit,
plug it in and if no-one wants to use it, it is a complete waste
of everyone's time. We have to avoid that happening.
Q151 Dr Taylor: May I ask for some very
specific information? It may not be at your fingertips now, but
it is terribly important to know. The electronic transmission
of prescriptions relates largely to GP prescribing as I understand
it. Is it possible to know the number of NHS hospitals which are
already prescribing electronically? That is the first thing. The
second thing is: is it possible to know the number of NHS hospitals
which are already using the PACS, picture archiving and communication
system? That is an absolutely crucial advance.
Mr Hutton: We can certainly give
you numbers about PACS, but a very small number of trusts are
using PACS, a very small number. The deal we announced a couple
of weeks ago is a major breakthrough in getting PACS more widely
disseminated across the NHS. PACS has the potential to completely
change the way we go about things.
Q152 Dr Taylor: Totally. Can you give
us any idea about the speed of rollout of PACS across the country?
Mr Hutton: We are hoping to get
the programme going over the next three years; by the end of 2007
or thereabouts we will have that. We are putting in some additional
money, about £60 million this year to pump prime that extra
investment. Over the next three years we want every acute trust
to have PACS. Is it also possible to find out the state of electronic
ordering of pathology tests and X-rays in trusts at the moment?
Mr Hextall: We will try to get
any information we have on that to you, if that would be helpful.
In relation to hospital prescribing, as I understand it, that
would be a system within the hospital and I would have thought
a very large number are doing that electronically. What is completely
missing at the moment is the link between the person who is diagnosing,
the prescriber, and the person who is going to be dispensing,
the community pharmacist, where the vast majority of the prescriptions
are issued. We do not have an automated system and that is increasingly
anomalous and something which the ETP component of the national
programme will address.
Q153 Mr Bradley: With such a huge project
the government has not always had a good track record of delivery
on such projects and three main issues have normally arisen: huge
slippage in timescale; belatedly building into the systems chimneys
which you cannot easily get out of, so you do not have the flexibility
for further development of the service; and, crucially, coming
in on budget. Are you confident on all three points that this
one will actually achieve those objectives?
Mr Hutton: We have driven through
a very good set of agreements for the taxpayer and for the NHS.
No delivery no payment. We have a good risk-sharing agreement
there. If there is delivery, there is going to be a reasonable
amount of profit and that is right too, because it is going to
benefit the NHS and the patients. I think we have led an outstandingly
good procurement exercise around the national programme. I am
very, very confident about the products we have purchased and
the process we have followed. I can say generally on that score
that I am confident we have a good product for the NHS and we
have met all of the milestones around the procurement of the national
programme. People said we could not do it, but we have. As I keep
saying, and this is going to sound very, very boring, we are into
a different period now with the programme. We have agreements
with the suppliers of the kit and the manufacturers and the systems
people and everything else. It is going to start rolling out this
year. There is going to be a major amount of visible activity
across the NHS over the next 18 months or so with all of this,
with the broadband connectivity happening, the software and the
systems going in place around e-booking and the care records over
the next 18 months. The really crucial thing now is the governance
arrangement around the programme, the effective performance management
of it and, crucially, the frontline clinical engagement. I would
be a fool to say that we do not have more to do in relation to
clinical engagement. We have. We have 1.2 million people out there
who need to know about this system in the NHS. We have patients
who need to know what it means for them too. We are at the beginning
of that process and although we are well into it, we have a lot
of work to do.
Q154 Dr Taylor: Continuing on that theme,
most people are very sceptical about the ability of any organisation
to succeed with something as huge as this. We think of the IT
system for tax credits; all of us as MPs receive innumerable letters
about the Child Support Agency and their new computer system.
Have measures been taken to make sure that the system is robust
enough to stand up, actually to roll out on time and not crash
immediately?
Mr Hutton: We have had a quite
vigorous proof of solution phase as part of the procurement exercise
and we have a very clear phasing in of the new technology across
the system, so we can learn from problems.
Mr Hextall: There are some significant
differences to the systems you just mentioned there. For a start,
the procurement has been conducted much more rapidly than it has
ever been done in public sector terms before; it is not unusual
for procurements to take two to three years, by which time the
design is getting out of date and being amended by all sorts of
new things which are coming in. So there is a difference in terms
of the speed with which this is being done. The nature of the
IT application development for the Child Support Agency was a
two-year phase before they got to the first release. We are talking
about releases in much more bite-sized chunks so that we get to
see things much faster. We are not waiting until the end, we will
have a release this summer and then a release in another six months'
time. That will be the pattern of releases we are looking for
and building up gradually. Similarly, the minister has mentioned
this proof of solution stage, we have that built in now. The actual
stage that electronic booking is in, is that it has been through
its unit testing, its module testing. It is now into integration
testing. BT, who are developing the NHS care record bit of this,
are integrating that with Atos Origin, who developed the electronic
booking, and the legacy suppliers who have the GP systems out
there are all now, this week, actually testing their own software
in the integration test-bed that we call the sandpit and we are
monitoring that on a daily basis. There is a great deal of close
attention and the stages are much more closely managed and the
releases are occurring in bite-sized chunks rather than this huge
monolithic release like tax credits.
Mr Hutton: It is true to say that
this is a major, major programme. It is the biggest IT programme
in the world today and it would be stupid to imagine there will
not be problems on the way. There are going to be problems on
the way. All I can say to the Committee is that we tried to put
in place at the right time and in the right place the sorts of
measures to enable us to deal with those problems and to minimise
them. There will be problems; of course there are going to be
problems. We have a very good set of arrangements in place and
we have to maximise now the work we are doing with clinicians.
The potential for the NHS here, although there will be teething
problems, is absolutely huge. Of all the issues we are dealing
with in the department at the moment, this is top of my list of
priorities, because it has the potential to change our own individual
experiences of the National Health Service completely and what
it can do for us. This is going to help save more lives. It is
going to improve the quality of the care we provide and it is
going to make the service more convenient and flexible for the
patients. It is really, really important to get this right.
Q155 Dr Taylor: Thank you; that is very
encouraging. Just one final quick point. Implementing this at
service level in trusts, PCTs, hospitals is going to cause a vast
amount of extra work. People go away for training, there has to
be cover, but actually inputting the stuff into the new system
can be a tremendous load. Is there going to be any sort of financial
help for PCTs and SHAs for the actual implementation?
Mr Hutton: Part of it is covered
by the national programme investment which we are putting in.
It is also worth bearing in mind that primary care trusts and
hospitals are spending about £850 million a year on precisely
that sort of thing now, which will be expenditure which we can
use to sustain the national programme as activity migrates from
our current systems into the new programme. There is a significant
amount of resource available for the NHS.
Q156 Dr Taylor: So part of the huge investment
is going into that as well for staff costs.
Mr Hutton: Oh, yes. The local
service providers, our five local contractors, have also got responsibilities
around the preparation of training material and e-learning for
staff as well. That will be supplemented by the work of local
trusts.
Q157 Mr Burstow: A very quick question
about the bite-sized pieces and the way they are being released
and so on. One of the criticisms which was made of the CRB project
was that there had been a whole series of releases of the system
and that the people responsible for writing the code and documenting
the code had not kept up to speed with that. Are you satisfied
that at each release the documentation for that release will be
absolutely up to scratch so that as subsequent releases come along,
those who are constructing those, writing those, will have the
full information to do so?
Mr Hextall: Yes, in two respects.
The first, as far as the messaging standards are concerned, the
messaging standards the system will be developed to meet are under
very strict change control and being developed to SNOMED standards,
which will be well known and well recognised. The code control
and configuration management is getting a lot of attention now
across all our suppliers to ensure that the process is in place
for those subsequent releases because there will be individual
test cycles. That code needs careful control to make sure that
as it goes through, regression testing and everything else, unlike
the CRB system, quality application code is being released. Those
processes are being put in place now and are common across all
the suppliers.
Q158 Dr Taylor: And documentation.
Mr Hextall: With documentation
to accompany them.
Q159 Dr Naysmith: Quite a few people
have raised worries and concerns about the size and complexity
of the national programme. Sir Christopher Bland, Chairman of
BT, one of the suppliers, said he is "somewhat frightened
by the complexity and enormity" of this project. Peter Gershon
of the Treasury said to the Committee of Public Accounts that
the programme is "inherently risky and ambitious". I
wonder why you think people who know that much about computer
systems are saying things like that?
Mr Hutton: It is what I have said
today as well. I have acknowledged that there are risks around
this programme; there are bound to be. You cannot introduce this
sort of systems change in an organisation without there being
some risk. To be fair though, it has also the view of the Office
of Government Commerce that the procurement stage of the national
programme really has set a remarkably high standard for the rest
of the public sector. What we have done around the national procurement
for IT has really moved our understanding of how we should go
about procuring very much further forward. The procurement exercise
has been a model of its kind. Yes, there are risks, but with BT
and our other partners, the importance of the arrangements we
have struck with them is that we both have a responsibility to
manage them. There are responsibilities on both sides of the line
here. No delivery: no payment. That is a pretty good deal to have
struck.
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