House of Commons - Public Accounts

Select Committee on Public Accounts Twentieth Report

2 Delivering the systems

7. The patient clinical record is to be delivered through a combination of a central system called the Spine and local systems delivered by Local Service Providers. The central and local systems work together to operate the National Care Records Service, which, in addition to the clinical record, holds non-clinical information on patients through the Personal Demographics Service, controls access to many of the Programme's service and handles the transmission of information between systems (Figure 2).[17]

Figure 2: NHS Care Records Service

Source: C&AG's Report, paras 5m, 1.8, 1.12; Figure 3

8. The Spine first went live in June 2004 as scheduled but the achievement of later milestones for increasing its functionality was delayed by up to ten months. By the time of our examination, the Personal Demographic Service held 72 million live records, 375,000 patient searches were being conducted every day and over 240,000 users had been registered, although this is only a small part of the overall scheme.[18]

9. The patient clinical record itself, however, had not yet been deployed at any location. It was due to be available in pilot form in late 2006, and in full form a year later, two years later than originally planned.[19] The Department told us that the decision to delay had been taken because some suppliers were having difficulty in meeting the timetable and because clinicians wanted to pilot the scheme. It hoped to have implemented most of the system by 2010, but the scale of the implementation and the risks associated with it needed to be recognised.[20]

10. At the time of our hearing in June 2006, some 13 acute Trusts had had their Patient Administration System (PAS) replaced, which itself provides no care record functionality beyond what they already had. In those regions where iSOFT is the main software supplier, the replacement has been an old iSOFT PAS which pre-dates the Programme because the PAS element of the new system, Lorenzo—which is being developed for the Programme and which the company stated was available from early 2004[21]—is not yet available. In those areas in which GE/IDX was originally contracted as the main software supplier but has now been replaced by Cerner, there are delays in anglicising the Cerner product. A considerable number of Primary Care Trusts and mental health Trusts who previously had no corporate patient administration system at all have been supplied with iSOFT's old PAS. No published plans exist for implementing shared electronic patient clinical records in line with the original vision for the Programme.

11. The other projects making up the Programme have made varying degrees of progress.[22] The New National Network (N3) was three months ahead of schedule.[23] Choose and Book, the electronic system to enable patients to book first outpatient appointments, had been deployed to over 7,600 locations by April 2006, but accounted for only 20% of referrals from GPs to first consultant outpatient appointments in the week preceding our examination.[24] The Department accepted that some GPs had not had a good experience of using the system, which it believed was often attributable to local implementation issues or to the hospital's patient administration system not being up to date.[25]

12. Deployment of the electronic prescription service and the computer accessible X-ray systems had been slower than anticipated, but the Department believed that later deployment targets would be met.[26] It reported that many other local systems had been deployed, including 13 acute hospital patient administration systems.[27] Two thirds of people had access to services that were dependent on services delivered by the Programme, and the Department said that would move to 100% over the next twelve months.[28] However, in June 2006 the Department told us that it would deliver at least 22 new Patient Administration Systems (PAS) to NHS Acute Trusts between June and October 2006. But even by the end of February 2007, only a further five had been deployed, suggesting that the Programme is still unable to meet short term targets.[29]

13. The experience of PAS systems that have been delivered has been patchy. Some Trusts have experienced problems including inability to report activity statistics,[30] missing patient records[31] and extended shut-down of some systems.[32] Clinical consequences have included waiting list breaches[33] and significant delays in providing inoculations to children.[34]

14. Plans published by NHS Connecting for Health in January 2005 indicated that by April 2007, 151 acute hospital Trusts would have implemented Patient Administration Systems of varying degrees of sophistication.[35] As of February 2007 only 18 had been deployed.[36] Such delays can cause considerable cost and disruption to Trusts, since they may have to replan expected live dates and spend money on preparing for expected dates that are not met. Mr Brooks told us in his submission that in his view there was no evidence that Local Service Providers have added any value to the National Programme and a cluster wide contract has not delivered any identifiable benefits.[37]

15. Total expenditure on the Programme to the end of March 2006 was £1,542 million.[38] This comprised £654 million on the contracts with suppliers against expected expenditure of £1,448 million; and a further £888 million on new projects added to the scope of the Programme, additional services, non-core projects, National Programme support for local NHS implementation, expenditure by local NHS organisations, and central administration.[39] The shortfall in expenditure on the contracts with suppliers reflected the slower than planned delivery of some systems and contractual provisions that suppliers would only be paid once services were delivered and working.[40] The Department told us that although it retained a timescale risk, it had transferred finance and completion risk for the most part to the suppliers.[41] However, the Department told us it also made advance payments to suppliers covered by a letter of credit from a bank or a charge on the company's assets of at least an equal value. By 31 March 2006 the Department had paid £443 million in forward payments to Local Service Providers and by December 2006 this figure had risen to £639 million.[42]

16. The Department told us that central expenditure on the Programme between the end of March 2006 and 31 December 2006 had risen by £532 million from £1,083 million to £1,615 million.[43] The Department had no information on expenditure by local NHS organisations after 31 March 2006, but even counting in local expenditure only to that date, total cumulative expenditure on the Programme to the end of December 2006 is not less than £2,074 million; and because of the unknown amount of local expenditure must in practice have substantially exceeded this amount.

17. The Department had brought in resources from abroad, though with poor results for some suppliers which were requiring close attention.[44] The Department regularly assessed the financial capacity and fitness of its prime suppliers in conjunction with Partnerships UK, whose most recent review had confirmed that all the key suppliers had sufficient financial capacity to fulfil their liabilities and continue to discharge their obligations under the contracts.[45]

18. However, continuing financial problems with key suppliers including iSOFT have been widely reported.[46] Shares in iSOFT lost more than 90% of their value after a series of profit warnings and the discovery of alleged accounting irregularities.[47] The company is now under investigation by the Financial Services Authority, while its former directors and former auditors are under investigation by the Financial Reporting Council's disciplinary body, the Accountancy Investigation and Discipline Board.[48] Although iSOFT has received loan support from its banks, there is a continuing risk to the National Programme if it is overly dependent on the future stability of a small number of suppliers.

19. In September 2006, the Department, Accenture and CSC announced that Accenture was to transfer its responsibility as local service provider for its two clusters to CSC by 8 January 2007, further reducing the supplier base, though Accenture would retain its responsibility for computer accessible X-ray systems in these clusters.[49] Commedica, the PACS supplier in the North West and West Midlands cluster, has also been replaced, and IDX has been replaced by Cerner as the main software supplier for the Southern and London clusters.[50]

17 C&AG's Report, paras 5m and 1.11-1.12; Figure 3 Back

18 Qq 6, 233; C&AG's Report, para 5m Back

19 On 19 July the Department announced that the first phases of the patient clinical record would be introduced in a small number of locations from early 2007, with wider roll out during 2008 (Department of Health Press Release 2006/0265, 19 July 2006). Back

20 Qq 1-7, 233; C&AG's Report, para 5m Back

21 iSOFT Group PLC 2005, Annual Report and Accounts, page 6 Back

22 C&AG's Report, Figure 3 Back

23 C&AG's Report, paras 3.17-3.19 Back

24 Q112; C&AG's Report, para 1.13 Back

25 Qq 112-113 Back

26 C&AG's Report, para 5m Back

27 Qq 226-228 Back

28 Q 118 Back