Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 1-19)

DEPARTMENT OF HEALTH, PROFESSOR PETER HUTTON AND DR ANTHONY NOWLAN

26 JUNE 2006

  Q1 Chairman: Good afternoon. Today we are considering the Comptroller and Auditor General's Report The National Programme for IT in the NHS and I should like to welcome the following witnesses: Sir Ian Carruthers, who is the Acting Chief Executive of the NHS, Mr Richard Granger, who is the Director General of IT, Mr Richard Jeavons, who is the Director of IT Service Implementation, Professor Hutton and Dr Anthony Nowlan. You are all very welcome to our hearing. You will see that there are quite a few Members present today, so may I please appeal for short answers because otherwise it will be a very long hearing. If I feel that the answers given are unduly lengthy, the only result will be that the hearing itself will lengthen, so I appeal to you for crisp answers. Although I appreciate that you will want to get your entire answer out quickly, because you are obviously very heavily briefed on this, you will have the best part of two hours to get your case across, so you will have plenty of time to get it across. I shall address my remarks, if I may, to you Sir Ian because you are the Accounting Officer, but please feel free to bring any of your team in, either those sitting on either side of you or anybody indeed sitting behind you. This is not a point-scoring exercise: we are simply after the evidence here, so feel free to bring anybody in. Could you please start by looking at the Summary on page four where it says in point 5m: "...the advanced integrated IT systems that are central to the long-term vision for the Programme will now be later than originally planned. Deployment of the National Clinical Record is now planned in pilot form from late 2006, compared to the original plan of December 2004". I am sure you will agree that the National Care Records Service is the central part of this programme. Why is it running two years later than originally scheduled?

  Sir Ian Carruthers: Before answering that Chairman, may I introduce the colleagues with me because we shall call on them. On my far left is Dr Mark Davies, who is the Primary Care Medical Director for the Choose and Book programmes and a practising GP in Hebden Bridge. Next to him is Professor Sir Muir Gray, who is the Director of Clinical Safety for Connecting for Health and next to him is Dr Gillian Braunold, who is a national clinical lead and a practising GP. Your first question was about the delay in the National Clinical Record. It is important to recognise that the programme is amongst the largest in the world and it is extremely ambitious. The delay was actually a decision that was taken following two things: first of all some suppliers were having difficulty in meeting the timetable and clinicians wanted to pilot the scheme and see how it operated. It is for those reasons that the timetable was deferred until 2006 when we hope to pilot it and it will be operable in 2007. It is important to recognise that with a programme of this scale there is bound to be risk, there is bound to be some delay. However, as the National Audit Office Report says, what we have achieved is substantial progress in many, many other areas where targets have been exceeded and indeed in some cases accelerated. We need to see this in a wider context where much has been achieved with over 10,000 installations already in place.

  Q2  Chairman: It is not just delays, important as those are. There are about 170 acute hospitals, are there not? In terms of patient administration, the National Clinical Record system has been deployed into just 12 hospitals and no clinical systems have been deployed into any hospital. Is that right?

  Sir Ian Carruthers: No. PACS (Picture Archiving and Communications Systems), for example, have been employed across various parts of the country and large numbers of other programmes have been done. If I may, I shall ask Mr Granger to take that forward in detail.

  Q3  Chairman: May I just ask the National Audit Office? Are those figures right that I quoted of 170 acute hospitals and the system only being deployed into 12 of those hospitals in terms of patient administration alone?

  Mr Shapcott: I believe there are 172 hospital trusts; a number of those may be on more than one site. The clinical record element in the National Care Records Service is not in yet, but there are other types of systems.

  Q4  Chairman: Has not been deployed? Has it been deployed into any hospitals?

  Mr Shapcott: As I understand it, not at all.

  Q5  Chairman: Okay. Mr Granger, do you want to comment?

  Mr Granger: There is a highly selective marshalling of the data about the 10,000 or so deployments that have been achieved in the last 24 months. It is important to note that 33 acute trusts are now not using X-ray film. I think if you were having an X-ray, you would not draw the distinction between a system which required a clinician to type and one which required them to hold an X-ray film up to a light box.

  Q6  Chairman: I am not sure that is answering the question that I put. What is actually key about this, you will accept Mr Granger, is the National Clinical Record. My clinical record being able to be deployed into any hospital in the country is the key part of it, is it not? What I was told was that there are 170 hospitals and my clinical record, under the systems that you are developing, cannot be deployed into any hospital. Is that right or not?

  Mr Granger: What is correct is that every day 375,000 patients have their details searched on the demographic database which is a core part of the National Clinical Record and there are over 240,000 people registered in the NHS to use that system already and that covers all the major acute hospitals. They are all now connected up to a secure national network as well.

  Q7  Chairman: Right. Well I cannot pursue this point but other Members can come in on it. Sir Ian, how are you going to make up for the lost time in implementing the National Care Records Service? What is your plan? When will it be delivered? You are two years behind already, although there is some argument about the basis of the discussion. My essential point is that it has not been delivered in essence to any hospitals yet. How are you going to make up for lost time?

  Sir Ian Carruthers: We have to see the piloting, we have then to move on to implementation and the overall part of the programme is that we would hope, as the National Audit Office Report says, to have implemented most of the compliant system by 2010. However, the scale of implementation and the risks associated with it, because we are trying to do something here that has not been done on this scale before, do need to be recognised because what we want is a system that works rather than a system which is put in quickly for its own sake. The overall benefits that we shall achieve, clinically and in terms of patient safety as well as value for money, will be significant.

  Q8  Chairman: That is precisely the point I want to take you to, because it is important that you answer this essential criticism of what you are trying to do. This is dealt with on page 29 of the Comptroller and Auditor General's Report "Taking account of earlier experiences, the Department decided to procure and manage the Programme centrally". Why are you seeking to impose such a massive system from above on the NHS instead of building on local initiatives?

  Sir Ian Carruthers: First of all, it is important to say that there are two parts to the programme: one is the national procurement and the second is the implementation. The national procurement is being undertaken nationally, but actually implementation is locally driven. The reason why we are undertaking it nationally is because we want to overcome past poor track record, we want to get value for money, we want to deliver integrated systems which we can upgrade and change in future at reduced costs. There is a whole series of benefits such as standardising practice and allowing people to move between employers without re-training. It is the procurement that is being driven nationally and in fact that has paid off, because the National Audit Office have been very clear in saying that the procurement has brought with it great benefit in terms of value for money, it has brought with it a lot of good practice that others can learn from. Of course within that we have tried to adopt the advice of this Committee itself which is about saying "Can we be contestable? Can we pay only on delivery?" and, firstly, "Can we actually not rely on any single supplier?". So good practice elements have been built in. The delivery locally is through each NHS organisation and we have established a system where the chief executives of each of the new strategic health authorities which come into being on 1 July 2006 will be accountable for overseeing the actual delivery in their local NHS. In any hospital or in any PCT, the implementation will take place locally with national support, so it is not centralised in that way at all.

  Q9  Chairman: On the other hand, if we read the key paragraph in this Report which you can find on page 11, paragraph 1.8: "The scope, vision, scale and complexity of the Programme is wider and more extensive than any ongoing or planned healthcare IT development programme in the world. Whilst other countries are seeking to adopt elements of the services within the National Programme, such as electronic patient records, these are not being introduced on a country-wide basis". So you are doing something that no other country apparently is attempting. Is this not unwise?

  Sir Ian Carruthers: It is true that we are doing it; we think it is the right way, but I shall hand over to Mr Granger.

  Q10  Chairman: May I just add a rider to that? The NHS itself is very diverse. You are attempting to impose centrally-imposed procurement from above on what is a very diverse organisation in the biggest IT health project in the world. Is this not a very dangerous undertaking you are engaged on Mr Granger?

  Sir Ian Carruthers: If I may, there are risks, we have said that. I have also said that nationally we are only procuring and the benefits of that have come through. Implementation will be local and in fact, elsewhere in the Report, it says that every local implementation has its own characteristics and needs to be locally tailored. Yes, it is diverse but we need to handle that in a local sense.

  Mr Granger: The statement that no other countries are implementing systems such as this is only partially accurate.

  Q11  Chairman: It is in the Report which you spent a whole year arguing with the NAO to get right. I have just read to you from the Report and one of the reasons why you apparently had to "fight, street by street, block by block with the NAO"—their own phrase to me—was that you wanted to agree on this. I have just read it to you, so please do not come back to me and say it is only partially true. Why has this NAO Report been delayed a whole year then, if it is not right?

  Mr Granger: Let us clear that point up. The Department of Health had possession of the Report for review for 59 days[1] out of the last year and a half. Aside from that, if we look at what other countries are doing, many of them are now looking at implementing a central infrastructure that will move patient information around. It is already present in Holland, it is already present in Denmark, it is being implemented in Sweden, Canada has a scheme to do the same thing which is rolling out across several provinces at the moment, Australia are procuring a system to do that as well. Some of these are procurements which are ongoing or schemes which have been partially implemented to date. Many countries are looking carefully at what the NHS is doing; it is at times uncomfortable being in a leadership position. As the NHS is a diverse organisation, one of the things that binds it together and moves millions of messages between trusts and between GP practices right now today is the Spine infrastructure which is live; that provides a coherent backbone to the NHS to move clinical messages around in a secure and reliable manner.

  Q12 Chairman: Let us go on as quickly as possible. Can we look at some of these contractors, some of whom are showing signs of strain? Is it right that Accenture has made provision for £450 million losses on this contract?

  Mr Granger: No, it is not.

  Q13  Chairman: $450 million sorry, dollars not pounds.

  Mr Granger: They have made a provision against potential future losses which have not crystallised.

  Q14  Chairman: Are some of your suppliers showing signs of strain on this?

  Mr Granger: They are and better they are than the taxpayer.

  Q15  Chairman: Can you be sure that they have the strength to handle these risks?

  Mr Granger: Yes. We regularly, in conjunction with Partnerships UK, the Treasury agency, assess the financial fitness and capacity of our prime contractors. At the last report from Adrian Kamellard of Partnerships UK, a body of the Treasury, he confirmed that all the key contractors have sufficient financial capacity to fulfil their liabilities and continue to discharge their obligations under the contracts.

  Q16  Chairman: Page 27, paragraph 1.33 on the cost of this. Why do you not know how much the NHS is spending on implementing the programme? "NHS Connecting for Health has not sought to monitor systematically the actual impact the Programme is having on local IT spending." Is that not a fairly key point?

  Sir Ian Carruthers: First of all, as you have just said, we want to do this as locally as possible. On that page, if we go back to the earlier paragraphs, what people are saying is that £3.4 billion is based on forecasts which have come from business cases, £770 million of that, or thereabouts, is from PACS and the other is £2.6 billion. Individual business cases are actually being prepared and have formed the basis of that and we shall not know the true savings until they are implemented. If I might ask Mr Jeavons, he could give you one or two examples because significant savings are being made.

  Mr Jeavons: On PACS, for example, where we projected £682 million worth of cash savings against the contracts, we are already seeing clear evidence from both business cases and post-implementation reviews that the scale of those cash releasing savings are there. That is not surprising because they are extremely clear and very predictable.

  Q17  Chairman: Are you worried at all about patient confidentiality? My records are potentially going to be driven around the countryside, if this works. Am I really happy with that idea? I know some doctors have expressed concern about this.

  Sir Ian Carruthers: What we should say is that obviously we recognise the importance and Mr Jeavons, who is leading that part of the programme, will comment.

  Q18  Chairman: Can you give me an absolute reassurance that your systems are sufficiently robust that there is no way in which my clinical records can leak out?

  Mr Jeavons: The position is that the policy has always been implied consent, the programme is implementing the highest levels of security and access ever seen in any public project and so is setting standards which have never been surpassed.

  Q19  Chairman: Lastly, there has been a lot of criticism from the doctors, that this is being imposed by diktat from above rather than getting the consent of the medical community. Do you have any comment to make on this Professor Hutton?

  Professor Hutton: I do feel that the clinical community was disadvantaged in the early stages of the programme and that this has led to some of the problems we now see. I am pleased that you have concentrated on the issue of the healthcare record because it is absolutely central and does not really get very much mileage in the Report. The Report fails to emphasise that key decisions were taken in the early period without proper clinical input and that the resulting consequences are still having a major impact on the viability of the core programme. Nowhere does it mention that the recommendations on the care record were actually only developed towards the end of the contracting process, so one can ask what was actually being contracted for. It fails to state that there is no good audit trail for clinical input into the production of the output-based specification, which was the basis of the contracts and the placing millions of pounds of public money.


1   Clarification of matters of fact (by witness): The NAO provided the Department with a draft accompanied by supporting evidence on 17 March 2006. It was some 59 working days later that the final Report was agreed. In this time, the NAO was waiting for responses from NHS Connecting for Health during two distinct periods between 17 March and 7 April and between 12 May and 22 May. Back


 
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