Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH, PROFESSOR
PETER HUTTON
AND DR
ANTHONY NOWLAN
26 JUNE 2006
Q20 Chairman: May I just say Professor
Hutton, as the afternoon wears on, that it is better if you do
not read. Talk to us. Lift up your head and talk to me, do not
read from a long prepared script; it is not going to help your
case. Just talk to me. In your own words, was this imposed by
diktat from above or did it engage the medical community?
Professor Hutton: It did not adequately
engage the medical community and there is good evidence for that.
Q21 Chairman: Thank you. Mr Granger,
do you want to comment on that point before I pass on to my colleagues?
Mr Granger: Yes I do. I want to
supply you with a note[2]
which will include a copy of an e-mail from Peter Hutton to me,
marked confidential, 18 November 2003 at 11:27: "I am seriously
concerned that everyone who contacts you about clinical engagement
is made welcome by you. This will lead to chaos and undermine
those of us who are trying to prevent that. We will need meetings
with a plan, not a random selection". On 21 November at 9:09
I asked Professor Hutton to provide a plan. I am still waiting
for it.
Q22 Chairman: Right, well Professor Hutton,
you will have a chance later to come back on that because I know
that some people wish to ask you questions.
Sir Ian Carruthers: May I just
make one point? When you look at the National Audit Office Report,
there is a big debate about what is adequate and what is fair.
What is beyond doubt is that there was clinical engagement. If
I may look at this, I have been in the health service for 37 years
and I have never known the NHS go to so much trouble to identify
what clinicians would feel in any project as they have for the
output-based specification,
Chairman: Thank you for that. It is an
important point and we shall discuss it in the course of the afternoon.
Q23 Sarah McCarthy-Fry: My first
question is to Sir John Bourn. We only received this Report last
week; it has been very quick. Most of your Reports are externally
evaluated. Has this Report been externally evaluated?
Mr Shapcott: No, it has not. This
went into clearance before we started that as a routine process,
so it did not go through that.
Q24 Sarah McCarthy-Fry: I rather
guessed it had not. I am also concerned about the length of time
it has taken to get published. We have had all sorts of newspaper
articles; we have had briefings about the horse-trading that went
on. May I ask you whether you are happy that the Report you have
done fully reflects what you found that you have not been compromised
in any way?
Sir John Bourn: Yes, I am happy
with the Report. It is a complicated subject. It took a long time
to prepare. It was discussed in detail between ourselves, the
Department and the National Health Service. Although reference
was made in the media to delay, the only date to which we were
ever committed was today; that was the only date on which we ever
said we should produce a Report in time for the Committee's discussion.
It took some time to do, as you would expect for a professional
piece of work which is directed to produce a statement of the
facts which were agreed by the external auditor and by the auditee,
which is what the Report is.
Q25 Sarah McCarthy-Fry: May I ask
the same question of Sir Ian and Richard Granger? Are you happy
that the Report reflects adequately your reading of the situation?
Sir Ian Carruthers: From my perspective,
as Sir John said, there was a lot of discussion and it does reflect
our reading of the situation; we should not have agreed it otherwise.
Mr Granger: It is an agreed Report.
Q26 Sarah McCarthy-Fry: There is
nothing in the Report that you take issue with; you are perfectly
happy with the Report.
Sir Ian Carruthers: No, nothing.
Q27 Sarah McCarthy-Fry: Okay, having
got that one out of the way, I have the two written pieces from
Professor Hutton and from Dr Anthony Nowlan. Picking up the point
you made about engagement with clinical staff, what was the process
that you underwent?
Mr Granger: The process was that
in 1992 a strategy was produced which led to very little in the
way of implementation in the NHS. In 1998 another strategy was
produced. A number of pilots occurred after that known as ERDIP
pilots. In 2002 a further strategy was produced. Dr Nowlan and
other people have been interested in this for a number of years,
have been involved in extensive consultation and piloting. It
has been described to me by medical colleagues as a bad case of
"pilotitis". There has been extensive clinical engagement.
When I started this process, we took all the outputs from those
pilots and consultations, some of which were undertaken by Dr
Nowlan when he was employed by the Information Authority and we
put those into a structured requirements-evaluation process. This
was not perfect and I fully accept the criticism that is made
in the NAO Report that we failed to map input from every single
clinician who had input—there were thousands of them—into
a requirements document which, unusually for a government department,
we then published. Since the production of that requirements inventory,
further structures have been set up, one of which was chaired
by Professor Hutton and we have had a more stable and long-term
structure in place for about a year and a half now, a care record
development board with structured clinical and patient engagement.
I should emphasise that last point: patient engagement. I should
just like my colleague Sir Muir to comment because he has been
involved in this for many years.
Sir Muir Gray: I shall answer
your question briefly. I have been involved since 1998. We started
with the National Clinical Advisory Board chaired by Professor
Hutton. That made very good progress across the whole piece, but
there were three things that it became apparent we wanted to strengthen.
One was patient involvement, so we set up the Care Record Development
Board. The second was to get some people giving significant amounts
of time, so we employed national clinical leads and that has been
very highly praised in the Report. The third key issue is that
when you get these big medical committees together, medicine is
a bit of a gerontocracy, there are older people like me. We want
to get people who are committed to 2015-20, so we now have some
younger people involved. That is what we have done.
Q28 Sarah McCarthy-Fry: A few more
points I want to raise. I want to come to Dr Nowlan and to Professor
Hutton. Do you believe in the principle, do you believe that there
is one standard UK system that can deliver what the project is
trying to deliver? Is it the principle of one standard UK system
you object to or the way that this particular system was procured?
Dr Nowlan: Certainly the way it
was procured. To answer the question, unless you test whether
it will fit, how do you actually know? The problem was that the
urgency to procure really trumped all other aspects of consideration.
Clearly there are parts of this that are very innovative and without
proper work to assess the need and the chance of success, it is
rather hasty to proceed on some of these matters. The focus of
the national clinical leadership in 2002-03 was to find something
which they believed was highly useful, but also achievable and
that is the one piece that was subject to reasonable scrutiny.
Q29 Sarah McCarthy-Fry: You mentioned
that you felt there was a danger about patient confidentiality.
Dr Nowlan: The danger is not a
system danger. The whole thing hinges on trust and governance
really and if you carry people with you and you have the right
oversight, then, like anything in healthcare, it can be made to
work. There are always risks and benefits and trade-offs. It is
not a technological system fix, it is about the arrangements for
governance and trust and people supporting and following it. If
that is not there, that is where the risks then come in of transparency
and what is happening really.
Q30 Sarah McCarthy-Fry: May I come
back to Mr Granger? Do you believe you do have a buy-in from clinicians?
Is that what you fundamentally disagree with?
Mr Granger: I shall just answer
in summary and then I should like a couple of the GPs who are
using these systems every day to comment on this. Dr Nowlan produced
a document on 16 December 2002 entitled, Confidentiality work
stream technical implementation project, which set out his
opinion, and I summarise for you Anthony, that opt-out was the
best model. We know that there are significant and legitimate
concerns from patients and the clinicians who serve them, which
is one of the reasons we have taken a more gradualist approach
to the introduction of summarisation, not just summarisation on
a read-only basis as exists in some parts of the UK, but summarisation
with people able to input things as well as just read them.
Q31 Sarah McCarthy-Fry: I only have
two minutes. I should love to hear from the GPs.
Dr Gillian Braunold: In answer
to why things have been delayed, one of the reasons is in order
to get that very consensus around some of the really complex issues
around exactly how the workforce changes will work which are implicit
in how we consult and how we jointly publish with patients information
to the Spine and to the other shared care bits of the record.
So although theoretically technically lots of very complex models
are possible, sometimes we as clinicians have had to pull back
and say yes, we know that you can create 1.3 million different
roles within the health service to access the security arrangements,
but when we have consulted with the colleagues within the BMA
and within the colleges, we have found that we do not really need
more than ten. Although the technology can do it and the provision
is there and all this stuff is being built, when you then work
with the colleagues, you find that that is going to be undermined
by human beings who are going to undermine the very information
governance structures that you are putting in place. As national
clinical leads we have been doing a lot of work, influencing and
bringing together colleagues in the national advisory groups that
are mentioned in here and consulting with them on some of the
technical issues and how they will work in implementation, to
make sure we do not build something so complex that it will be
undermined by the human beings trying to implement it.
Q32 Sarah McCarthy-Fry: May I come
to Mr Granger? If you believe you have the support of GPs, why
does the medics' survey on page 47 of the Report suggest that
support for the new system is falling and that over the space
of two years a 30% drop in enthusiasm has been recorded? Why do
you think that is?
Mr Granger: I will just say that
GPs are very, very shrewd consumers. They are very happy with
the QMAS system which is paying them more money and they are very
happy with the network connections. They find systems which are
more disruptive to their working practice more difficult to assimilate
to start with.
Dr Gillian Braunold: The most
important thing to remember is that GPs thrive on being able to
consult in a ten-minute window which is very, very concise and
they have their current systems smoothly flying to be able to
deliver that. Anything that they need to take on board to deliver
something else has to be accommodated and they are very resistant
to that. They were very resistant to the negotiators within the
General Practitioner Committee over-delivering them a 30% pay
rise because the way they had to do it was to put in more data
and that was resisted fiercely and still is frankly. Nevertheless,
as patients benefit, then the GPs stopped complaining. We have
now started to ask GPs whether they would like us to take Choose
and Book away and there is resistance amongst those who are actively
delivering patient benefit and clinician benefit with Choose and
Book. They are actually saying that they are going home for the
smartcards they have forgotten. The medics' survey, if you look
at when it was done on the Choose and Book curve, was very early
in the curve against the number of deployments of Choose and Book
and 54% of GPs are using it now.
Q33 Greg Clark: May I start my questions
to Sir John? Sir John, we have a conundrum here. In a year on
the Committee I have read 62 NAO Reports. This is easily the most
gushing and yet we know that the Report was published on the very
last day that it could have been to be in time for this Committee
because it had been, we assume, haggled over. How can you square
these two things? Is it that Mr Granger was bashful at the extent
of the praise that was being lavished on him? What were the concerns?
Sir John Bourn: What we needed
to do was get it right, to catalogue those things which had gone
well and to underline those things where improvements could have
been made. The Report does that. Although, as I said a few moments
ago, it took a long time to take it forward, it did reach an agreement,
as it were, warts and all. Therefore I was glad to be able to
present it to the Committee in the form that they asked: facts
agreed.
Q34 Greg Clark: What were the areas
that you had trouble agreeing for so long?
Sir John Bourn: I personally had
no trouble at all. I do not want to say "trouble", because
that suggests an antithetical relationship, which is not right.
We should probe and we should press and we should get out the
facts and that is what we did. It is a very long subject with
many, many aspects to it, the biggest programme in the world,
so it is not surprising that it took a long time to do it. Yes,
of course, as we came towards 26 June, there was concern. As I
have told the Committee, I was very keen that you should have
it in time to have two clear weekends, which is your rule and
so I pressed forward to get it to you at that time. From my point
of view, it is a Report on an important subject, perhaps the biggest
subject we have ever done since you were on the Committee, Mr
Clark and it covers the waterfront, pluses and minuses.
Q35 Greg Clark: Nick Timmins of the
FT says that the NAO's Report was the outcome of one of the fiercest
Whitehall battles in recent years. Can you explain the background
to that?
Sir John Bourn: I am not responsible
for what appears in the newspapers and I do not see it as a battle
between us; I see it as an important subject in which both sides
were anxious to get at the truth. Of course there was proper debate
and of course one side argued with the other. I do not regard
it in any way as an illegitimate series of discussions which led
up to that.
Q36 Greg Clark: Sir John, I am keen
on getting to the areas of contention. As you know, this is the
world's biggest civilian IT project, funding up to £12 billion
and IT projects are notorious for going wrong. We rely on you
to alert us to the areas of major concern and I was struck by
the very positive, almost universally positive tone of this Report.
Could we perhaps turn to your conclusions, page 50 of the Report,
appendix one, "Methodology". This was the methodology
you applied to answer the Committee's questions. The first aspect
of the methodology raised the question of whether the programme's
vision is soundly based. What is your conclusion on that? Is the
programme's vision soundly based?
Sir John Bourn: My conclusion
is that for a system of the kind it is, it is soundly based.
Q37 Greg Clark: That is helpful.
The second aspect is whether the contracts are likely to deliver
value for money. In your view are the contracts likely to deliver
value for money?
Sir John Bourn: I think they are
because, unlike most contracts in this field, they do involve
payment for results which often has not been the case with IT
contracts.
Q38 Greg Clark: Part four of your
methodology is whether you consider the project management is
fit for purpose.
Sir John Bourn: Yes, I do. The
point that I would make about that is the one that has been implicit
in discussions and that Sir Ian and Mr Granger have said. Of course
in a project of this kind there is the question, as the General
Practitioner herself said, in which you are developing a system
and you want, as it were, to take the customers with you. That
is a very difficult thing to do; it has not been done with 100%
success but, given its size, scale and nature, I do regard the
project itself as well conceived.
Q39 Greg Clark: That is extremely
helpful because it is an ambitious project and it is helpful to
be able to assess it. We know that it is risky and that it is
innovative. From where we are sitting today, are you confident
that this programme will deliver on schedule its core objective
of transforming patient care by providing an integrated healthcare
record?
Sir John Bourn: If the recommendations
I have made are followed out, then it will.
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