4 Securing the benefits of the Programme
25. One of the conclusions of our predecessors' examination
of the 1992 and 1998 Information Technology Strategies for the
NHS was that getting ownership of developments by clinicians,
general practitioners and other healthcare staff was essential.[67]
However, although there was support for what the Programme was
seeking to achieve among NHS staff, there were also significant
concerns, for example that the Programme was moving slower than
expected, and that deployment plans had been unreliable.[68]
Professor Hutton told us that the Department did not adequately
engage the medical community, and surveys of staff by Medix indicated
that support for the Programme had fallen between 2004 and 2006
(Figure 4).[69]
The Department's own Ipsos MORI surveys of NHS staff also showed
a decline between 2005 and 2006 in favourability towards the Programme
so far, with reasons given for unfavourable ratings including
not enough input or communication with the people that would be
using it, and poor organisation and planning.[70]
Figure 3: Support for the Programme has fallen
amongst GPs and other Doctors
Source: C&AG's Report, 4.13
26. In the case of the Programme, the Department
decided to conclude the bulk of procurement activities before
focusing on communicating with and engaging NHS staff.[71]
Wider consultation on the Programme with NHS staff did not commence
until the procurement phase had concluded at the end of 2003,
working initially through the clusters.[72]
Leadership in securing support from NHS staff and organisations
has changed several times over the life of the Programme: at the
time of our examination, responsibility for this task had passed
between six Senior Responsible Owners.[73]
27. The Department told us that some systems, such
as the new network connections, had been well received by clinicians,
but that clinicians found it more difficult to assimilate systems
that were more disruptive to their working practice.[74]
While it was necessary to recognise that a Programme of this scale
would cause a degree of controversy and dissent, the Department
said thousands of clinicians were already using the system and
quietly getting on with it.[75]
The Department had been working to establish further support for
the Programme through the Care Record Development Board, for example
in building a consensus over the last year on the content of the
clinical record.[76]
It said it had engaged clinicians, but recognised that there was
very much more to be done.[77]
28. One issue causing concern among GPs was the future
of their IT systems.[78]
Under the General Medical Services contract, Local Service Providers
were required to offer a choice of systems to GPs, but had only
been contracted to provide two and it very quickly became apparent
that one of these was not being delivered.[79]
The Department had now attempted to address this problem through
an initiative called GP Systems of Choice.[80]
The development and implementation of the scheme was subject
to discussions with suppliers.[81]
29. Another issue that has prompted concerns amongst
doctors and others is the protection of patients' confidentiality,
where Dr Nowlan told us that the most important issue was the
arrangements for governance and trust, and compliance with these
arrangements.[82] The
Department told us that the security systems in place will be
more secure than the Chip and PIN arrangements utilised by credit
and debit cards in the UK. It was also supporting the Information
Commissioner in his demands for higher penalties for information
abuse.[83]
30. When the main contracts for the Programme were
let in 2003 and 2004, the Department announced that they would
cost £6.2 billion.[84]
Subsequent estimates of the cost of the Programme reportedly attributed
to the Department have ranged up to £20 billion, but the
Department clarified that this figure relates to total IT expenditure
within the NHS during the life of the Programme and that it expected
the cost of the Programme itself to be £12.4 billion.[85]
Amongst other things, this higher figure includes, on top of the
cost of the original contracts, central expenditure; contracts
and projects added to the scope of the National Programme; additional
services to be purchased beyond the scope of the original national
core contracts; extrapolation of costs beyond the terms of the
existing contracts; and an estimated £3.4 billion local NHS
expenditure.[86]
31. The estimate of local expenditure on the Programme
of £3.4 billion dated from the time the contracts were let
and the actual level of ongoing local NHS expenditure on the Programme
was not systematically monitored.[87]
Further costs have arisen for the local NHS Trusts where they
have been required to pay suppliers a total of £24 million
in order to be released from contractual obligations to provide
staff to help suppliers develop the systems.[88]
Delivery delays have also had an impact on local NHS expenditure,
with a number of Trusts having had to renew their own patient
administration systems, for example because they were time expired,
or upgrade them to make them compliant with the National Data
Spine. Deploying such interim systems would affect both costs
and benefits.[89] The
Department was providing some financial support to Trusts for
upgrading, and where new systems came in, Trusts did not have
to pay for the old system anymore.[90]
32. In the business cases for the various elements
of the Programme, the Department sought to put a financial value
on the benefits of the Programme where it could.[91]
Its main aim with the Programme, however, was to improve services
to patients rather than reduce costs, and there was a gap between
the estimated financial value of the benefit of the Programme
and its costs.[92] The
Department was unable to give a full statement on the extent of
this gap but said that the business case for the computer accessible
X-rays contract had identified cash savings of £682 million
against a contract cost of £1.3 billion.[93]
33. The Department believes that the patient safety
benefits achieved through the Programme's successful implementation
could be worth many billions over ten years, for example from
reductions in preventable fatalities arising from medication errors;
the number of patients requiring treatment as a result of medication
errors; and in the amount paid by the NHS each year to settle
clinical negligence claims. No detailed analysis had been carried
out in order to substantiate these estimates.[94]
The Department also predicts that the Programme will result in
further savings by improving staff efficiency, by for example
reducing the amount of time spent repeatedly taking patients'
medical histories and demographic details.[95]
The Programme would also help standardise practice and allow people
to move between employers without re-training, improve information
available when patients were referred to hospitals, and improve
resource use and efficiency.[96]
34. The Local Service Providers were contracted to
deliver Local CRS systems to NHS organisations in three phases.
Phases 2 and 3 are the key to the delivery of clinical benefits
and were the core of the business case for the high cost LSP contracts.
Phases 2 and 3 provide the NHS with functionality that would enable
organisations to support integrated clinical care processes (scheduling,
investigating, prescribing, treating, assessing, etc.) by healthcare
staff no matter in what organisation (hospital site or GP practice)
or in what care setting (primary, mental health, community, tertiary).
Phase 1, the least important from a clinical point of view because
it contains mainly administrative functionality, is already late
with no published dates for its completion. The implementation
of Phases 2 and 3, may, therefore, scarcely have begun by the
time the Local Service Providers were originally contracted to
have implemented completely all three Phases to all hospitals
and Trusts in England.
67 Committee of Public Accounts, The 1992 and 1998
Information Management and Technology Strategies of the NHS Executive,
HC (1999-2000) 406, para 9 (v) Back
68
C&AG's Report, paras 5k, 4.14 Back
69
Qq 19, 31; C&AG's Report, para 4.13 Back
70
A Baseline Study on the National Programme for IT, MORI, 9 September
2005; Wave 2 Study on the National Programme for IT, Ipsos MORI,
20 July 2006. Back
71
C&AG's Report, para 4.2 Back
72
C&AG's Report, para 4.3 Back
73
Qq 168-175, 200 Back
74
Q 31 Back
75
Q 62 Back
76
Q 217 Back
77
Q 205 Back
78
C&AG's Report, paras 3.27-3.28 Back
79
Q 64 ; C&AG's Report, para 3.28 Back
80
Q 64-65 Back
81
C&AG's Report, paras 3.27-3.28 Back
82
Q 28; C&AG's Report, paras 2.17-2.18; Appendix 3 Back
83
Q 89 Back
84
C&AG's Report, para 1.20 Back
85
Qq 47-48 Back
86
C&AG's Report, paras 1.20-1.28 Back
87
Qq 15, 47, 123-124, 130; C&AG's Report, paras 5r, 1.26, 1.33 Back
88
Qq 234-247; DoH note on Qq 242, 247 Back
89
Ev 97 Back
90
Q 128-129 Back
91
C&AG's Report, para 1.29 Back
92
Q 153; C&AG's Report, para 1.29 Back
93
Qq 15, 153-159 Back
94
C&AG's Report, paras 1.29-1.32 Back
95
C&AG's Report, para 1.4 Back
96
Qq 8, 66-70, 99 Back
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