3 Managing implementation and ensuring
that the systems meet the needs of the NHS
20. The Programme is a combination of national and
local projects, with local implementation organised in five regional
clusters (Figure 3). Each cluster has a Local Service Provider
which is responsible for delivering services within the cluster,
working in conjunction with the Strategic Health Authorities and
local NHS organisations within the cluster.[51]
Figure 3: The five regional clusters and their
current local service providers
Source: National Audit Office
21. The scale, specialisms and fragmentation of existing
IT systems has made the delivery and implementation at each NHS
site more complex than other IT implementations, and the Programme
is being implemented against a background of change in the configuration
of the NHS.[52] The Department
told us that although procurement had been carried out centrally,
implementation was local through each NHS organisation. Every
local implementation had its own characteristics and needed to
be locally tailored.[53]
It had established a system where the chief executives of the
new strategic health authorities that came into operation on 1
July 2006 were accountable for overseeing implementation in their
local NHS.[54] Within
each organisation, the chief executive was responsible, and at
both levels, chief executives should be supported by a chief information
officer.[55] If anything
went wrong in a particular implementation, the strategic health
authority would intervene, and NHS Connecting for Health would
intervene if the programme was going wrong on too big a scale.[56]
It is unclear how much the localising of responsibility will help
unless local Trusts are also given flexibility in the choice of
systems so that local needs can be taken into account.
22. The procurement of the systems was based on an
"Output Based Specification", a statement of the functions
that the system was intended to perform. Development of the specification
began in February 2002, and drew on information from various sources,
including specifications developed by NHS bodies for their own
patient record services and consultation with NHS staff. The specification
was initially published for consultation in July 2002. Following
further revisions, it was issued to potential suppliers in May
2003. After contracts had been placed, clusters also established
clinical advisory groups to obtain clinical input as specific
systems were developed.[57]
23. An appraisal commissioned by the National Audit
Office of the development of the specification found that it was
developed after engagement with a broad spectrum of NHS stakeholders
but that there was no recorded link between the detailed items
in the specification and the person or group making that contribution.[58]
The Department's explanation was that NHS Connecting for Health
had not had the resources to record the attributions individually.[59]
Dr Nowlan told us that in his view this explanation for the lack
of documented validation was not credible.[60]
Professor Hutton also told us that there was no good audit trail
for clinical input into the production of the specification, and
that key decisions were taken in the early period of the Programme
without proper clinical input.[61]
He and Dr Nowlan also both told us that they felt that clinicians
and the local NHS were not taken into account and did not have
sufficient say.[62] The
Comptroller and Auditor General told us that "the approach
from the top down had not permitted the full degree of consultation".[63]
24. The Department commented that hundreds of people
had input to the design process. Not only had there been clinical
input in the original specification, but as the Programme had
proceeded clinicians and other users had been involved in much
more detail. For example 470 clinicians had recently been involved
in looking at the national requirement to support e-prescribing,
although this appears a very late point at which to do so, since
the specification of the solution and the terms of the contract
had been set before it began.[64]
Other action had included establishing the Care Record Development
Board to strengthen patient involvement, and the appointment of
national clinical leads.[65]
In their examination of NHS information technology our predecessors
stressed the need to involve end users, noting that getting the
commitment of everyone is crucial to successful implementation
of complex IT projects.[66]
51 C&AG's Report, para 3 Back
52
Q 94; C&AG's Report, para 1.8 Back
53
Q 10 Back
54
Q 8 Back
55
Qq 96-97 Back
56
Qq 100-101 Back
57
C&AG's Report, paras 2.10-2.13, 4.3 Back
58
Q 26; C&AG's Report, paras 2.11-2.13 Back
59
C&AG's Report, para 2.13 Back
60
Ev 29 Back
61
Q 18 Back
62
Q 59 Back
63
Q 218 Back
64
Qq 63, 205, 209 Back
65
Q 26 Back
66
Committee of Public Accounts, The 1992 and 1998 Information
Management and Technology Strategies of the NHS Executive,
HC (1999-2000) 406, para 33 Back
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