Conclusions and Recommendations
1. The delivery of the patient clinical record,
which is central to obtaining the benefits of the programme, is
already two years behind schedule and no firm implementation dates
exist. By now almost
all acute hospital Trusts should have new NPfIT patient administration
systems (PAS) as the essential first step in the introduction
of the local Care Record Service. As of June 2006 the actual number
was 13 hospitals. In June 2006 the Department wrote to us stating
that by October 2006 there would be a further twenty-two. So far
as we are aware, up to the end of February 2007 the number has
increased by only five acute hospitals. The introduction of clinical
as opposed to administrative software has scarcely begun; indeed,
essential clinical software development has not been completed.
The Department should develop with its suppliers a robust timetable
which they are capable of delivering, and communicate it to local
NHS organisations who may then have greater confidence as to when
systems will be delivered.
2. The Department has not sought to maintain
a detailed record of overall expenditure on the Programme and
estimates of its total cost have ranged from £6.2 billion
up to £20 billion. Total expenditure
on the Programme so far is over £2 billion. The Department
should publish an annual statement outlining the costs and benefits
of the Programme. The statement should include at both a national
and local level original and current estimates of total costs
and benefits, costs and benefits to date, including both cash
savings and service improvements, and any advances made to suppliers.
3. The Department's investment appraisal of
the Programme did not seek to demonstrate that its financial benefits
outweighed its cost. The main justification
for the Programme is to improve patient services, and the Department
put a financial value on benefits where it could. The Department
should also quantify non-financial benefits, even if they are
not valued, to better inform decision making and to provide a
baseline for work after implementation to ensure that the intended
benefits are being fully realised. The Department should commission
and publish an independent assessment of the business case for
the Programme in the light of the progress and experience to date.
4. The Department is maintaining pressure
on suppliers but there is a shortage of appropriate and skilled
capacity to deliver the systems required by the Programme, and
the withdrawal of Accenture has increased the burden on other
suppliers, especially CSC. The Department
should review with suppliers their capacity to deliver, and use
the results of this review to engage, or to get suppliers to engage,
additional capacity where required. It should also regularly review
suppliers' performance for any signs of financial difficulties
potentially affecting their ability or willingness to discharge
their obligations. In view of the slippage in the deployment of
local systems, the Department should also commission an urgent
independent review of the performance of Local Service Providers
against their contractual obligations.
5. The Department needs to improve the way
it communicates with NHS staff, especially clinicians. The
Department has failed to carry an important body of clinical opinion
with it. In addition, it is likely that serious problems with
systems that have been deployed will be contributing to resistance
from clinicians. It should ask the heads of the clinical professions
within the Department, such as the Chief Medical Officer, to review
the extent of clinical involvement in the specification of the
systems, and to report on whether they are satisfied that the
systems have been adequately specified to meet the needs of clinicians.
6. We are concerned that leadership of the
Programme has focused too narrowly on the delivery of the IT systems,
at the expense of proper consideration of how best to use IT within
a broader process of business change.
The frequent changes in the leadership of the Department's work
to engage NHS organisations and staff have damaged the Programme
and convey that the Department attaches a low priority to this
task. The Department should avoid further changes in the leadership
of this work, beyond those necessary to improve its links with
clinicians, and strengthen the links between the Programme and
the improvement of NHS services that the Programme is intended
to support.
7. The Department should clarify responsibility
and accountability for the local implementation of the Programme.
At a time when many changes are taking place in the configuration
of the local NHS and a range of other initiatives require implementation,
it is essential that Chief Executives and senior managers in the
NHS understand the role they need to play in the implementation
of the Programme. The Department should make clear to Chief Executives
and senior managers their objectives and responsibilities for
local implementation, and give them the authority and resources
to allow local implementation to take place without adversely
affecting patient services.
8. The use of only two major software suppliers
may have the effect of inhibiting innovation, progress and competition.
In addition, the fact that the Programme
has lost Accenture, Commedica and IDX, three key suppliers, is
running late and is having difficulty in meeting its objectives
raises doubts over whether the contracts will deliver what is
required. The Department should seek to modify the procurement
process under the Programme so that secondary care trusts and
others can if they wish select from a wider range of patient administration
systems and clinical systems than are currently available, provided
that these conform to national standards. This approach could
have the benefit of speeding up the deployment of new systems
and of making it easier to secure the support of clinicians and
managers. We are concerned in particular that iSOFT's flagship
software product, 'Lorenzo'—on which three fifths of the
Programme depends—is not yet available despite statements
by the company in its 2005 Annual report that the product was
available from early 2004.
9. At the present rate of progress it is unlikely
that significant clinical benefits will be delivered by the end
of the contract period. As a matter of
urgency the Department must define precisely which elements of
functionality originally contracted for from the Local Service
Providers will be available for implementation by the end of the
contract period and in how many NHS organisations it will be possible
to have this functionality fully operational. The Department should
then give priority to the development and deployment of those
systems of the greatest business benefit to the NHS, such as local
administration and clinical systems.
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