Examination of Witnesses (Questions 100-119)
DEPARTMENT OF
HEALTH, PROFESSOR
PETER HUTTON
AND DR
ANTHONY NOWLAN
26 JUNE 2006
Q100 Mr Curry: I do not wish to push
the analogy too far Mr Granger.
Sir Ian Carruthers: There will
be people who will be working to their chief executive to deliver
this programme and this programme is important for the reasons
of patient safety, improving resource use, better operational
efficiency. I cannot imagine an NHS in the years to come where
we are not going to maximise the benefits of using IT.
Q101 Mr Curry: What would happen
if in just one of them though things were not... They are bound
to be different in their performances, are they not? We have seen
in the PCTs how different the performances are and in the NHS
trusts.
Sir Ian Carruthers: There are
two things. If something goes wrong, it will go wrong in a particular
implementation. One would expect that the strategic health authority
would intervene in that. If we felt the programme was going wrong
on too big a scale, we too would intervene.
Q102 Mr Curry: By what means would
you intervene? Who is your fire brigade?
Sir Ian Carruthers: Through the
performance management process. We would discuss with the strategic
health authority chief executives, if it went wrong in a place,
how we could support them, what we would need to do and that is
what we would actually do.
Q103 Mr Curry: How long would that
take? How long would it be between the perception that there was
a problem and the identification of the fix?
Sir Ian Carruthers: We do monitor
this regularly. At the moment it is on a quarterly basis, is it
not?
Mr Jeavons: We actually monitor
on a monthly basis already against performance targets.
Q104 Mr Curry: So you have a failsafe
mechanism. Somewhere a red light goes on in your office.
Sir Ian Carruthers: Not in my
office, but yes, a red light does go on.
Q105 Mr Curry: And he is immediately
on nuclear alert, is that right.
Sir Ian Carruthers: I should not
quite put it like that.
Q106 Mr Curry: It is important because
I must emphasise that an awful lot is changing locally in the
NHS at the moment, there is a great deal of turmoil, the financial
problems are causing severe problems and of course they are causing
disaffection amongst the GPs; there is no point pretending that
is not the case. I think you were here before when we were talking
about the Paddington Health Campus Scheme and what we discovered
there was that, after having conceived the project, they then
went and asked the users what they thought it ought to be doing
and they said that it ought to be doing something slightly different.
So when they reconfigured the project, they did not have any land
for it. There is a bit of a history here of conceiving projects
in abstract from the people who might have to use them. I am just
anxious to make sure that this disaffection by what one might
call the poor bloody infantry, which is how the GPs might see
themselves, would be important.
Sir Ian Carruthers: Two things.
First of all, it was not a discussion on Paddington Basin with
me, it was with my colleague Hugh Taylor, but the point that you
make is well made. In many local areas, and I can only speak for
mine, what we do have are local implementation systems where in
fact there are groups of managers, hospital clinicians and GPs
who are working together with clinical advice and support to avoid
some of those. Mr Jeavons can add to that and reassure you a bit
more.
Mr Jeavons: It is important to
recognise that that is the model that we are pursuing. A national
programme backed by a national policy that is the responsibility
locally to implement. Just to counter some of the suggestions
there, just as some are struggling, others are seizing these opportunities
and are taking them as part of moving their services forward very
positively and the role of the centre is to do two things: one
is to make sure that that which we know works is explained and
understood by everybody; secondly, where we can offer national
support, we do exactly that. Our job is not to go and do it all
for people locally. It is that clarity about local accountability
and the capability to do it which we really need to concentrate
on.
Q107 Mr Curry: In Skipton there is
a system called EMIS which is used by my GPs which they like and
say it works very well and is better than anything else that is
currently on offer. When I spoke to them a month ago, the only
problem was that the PCT had not actually paid the licence fees
for it, several months late, so that every time they switched
on their computer, they got a big thing on the screen telling
them that if the fees were not paid shortly, the whole thing would
go bust. That sort of thing is what might well undermine their
confidence in even more complex machines, is it not?
Mr Jeavons: It is very important
that primary care trusts are clear about their responsibilities
for supporting local information technology for general practitioners.
As it happens, I am actually aware of some of the issues in that
particular primary care trust and we have given them an absolutely
clear statement about what the primary care trust's responsibilities
are.
Q108 Mr Curry: In the past we have
had discussions in which we have agreed that when one is trying
to estimate the cost of things in an organisation as big as the
NHS, it is quite difficult to have sufficient data to be able
to come to proper costings. In the out-of-hours service we came
across you had uprated the tariffs to pay for this. How confident
are you that the up-rating, which is quite a precise sum, will
actually pay for it and what danger is there that that will not
go right? Again, quoting one of my Harrogate trusts, Harrogate
Hospital was delivering services for less than the tariff, so
it now gets paid more for doing the same. How confident are you
that that figure is right, whatever it was?
Mr Jeavons: Those figures were
based on data that were taken from typical hospitals for the costs
of those implementation, so inevitably, as you would with a national
tariff, they are average figures. The purpose of that was to ensure
that through the tariff system, trusts that needed to take on
the cost of implementation and new systems had the money channelled
to them through the tariff. It was an addition to the cost up-lift
and then it was of course netted down for productivity and so
forth in the final tariff calculation.
Q109 Mr Curry: You mentioned the
deadly word "average". Average is by definition something
which nobody performs, is it not?
Mr Jeavons: But that is the definition
of the tariff. It is a national tariff, so it has to be an average.
Q110 Mr Curry: Is there a danger
that this tariff may not be sufficient for certain areas or trusts?
Mr Jeavons: We are talking about
acute hospitals here because that is where the tariff applies.
Acute hospitals will all be starting in slightly different places
with their IT implementation. That is a fact and that is noted
in the NAO Report. Individual circumstances will differ. However,
over a period of time, they will all need to invest in information
technology, if nothing else to see the rise in expenditure that
we expect through Wanless and this programme, so we have to direct
money to trusts. The way to direct it now is through the tariff,
the tariff is a national calculation.
Q111 Mr Curry: So you are confident
that if there is a problem, let us say in North Yorkshire, they
will not say "My gosh, we are going to have to find some
extra money, so we shall close the remaining beds in the community
hospitals". You can give me the assurance that funding this
will never cut into other services.
Mr Jeavons: We are absolutely
clear that the evidence that was laid out in the business cases
gives you a very clear direction in terms of pursuing benefits
of these investments. Individual organisations put their own business
case together for investing in this technology and it is that
business case they sign off and they should sign it off on the
basis that it will deliver the benefits and will allow them to
meet their other responsibilities. That is the model.
Q112 Mr Curry: But if it did not,
they would have to find the money from somewhere else.
Mr Jeavons: They take the decisions
to do it and then they live with that.
Sir Ian Carruthers: The underlying
point which you are after is the cause of problems or deficits.
The Audit Commission have recently produced a report on the financial
management of the NHS and in that they say two things: one is
that there is no single reason in any organisation why the deficits
occur because it is a multiplicity of things and the real point
is that although they get average prices, people manage them differently.
It is a test as much of local management, of financial position
as it is of the allocations. The second thing is that it lists
in paragraph 8 of that report a number of things that may have
contributed, whilst saying that there is no single cause and Connecting
for Health is not listed in that list because they do not believe
that it is the cause of any of the financial problems in the NHS
at the present time.
Q113 Kitty Ussher: A lot of the questions
I had, have already been asked, so I just want to ask two additional
ones. The first concerns Choose and Book. I had a little delegation
of GPs come to see me on Friday in my constituency of Burnley
in Lancashire and they were actually coming to discuss some rather
worrying proposals locally to change the A&E configuration,
which I will not trouble you with at this point, although I am
happy to come back to you later. In the course of the conversation
they said, and I wrote it down "Choose and Book, why does
it not work?". They had an example. They are in their GP
surgery and then various options come up on the screen, all of
which seem quite far away. They try to choose one of them and
either the technology fails or there have been situations where
they have then rung the local hospital and said "Why do you
not have any places available for this outpatient appointment"
and they said "But we do, we have loads". Why does it
not work?
Dr Mark Davies: Speaking as a
GP who uses Choose and Book on a daily basis when I am not working
for Connecting for Health, I am telling you that it certainly
does work. In fact in the last working week, almost 20% of the
referrals that were from GPs to consultants went through Choose
and Book, which is evidence of that. It is interesting. There
are two groups of people who talk about Choose and Book who are
using it: those who are using it every day, whose patients love
it and have a positive experience of it; those perhaps who have
had one or two goes who are really struggling. It is undoubtedly
the case that there are some GPs who have had a go and, for whatever
reason, have not had a good experience of it. Often the reason
they have not had a good experience is down to the local implementation
issues that we were just discussing, for example how a local workstation
might be configured or indeed the availability of slots of appointments
at a hospital. It is certainly not the case that it does not work.
Q114 Kitty Ussher: That has not quite
answered the question. Could you explain specifically what has
gone wrong, when on the screen it says there are no appointments
available, but if you pick up the phone to speak to the hospital,
they say there are lots of appointments available?
Mr Granger: That is very simple.
The patient administration system in the hospital they are trying
to book into is not up to date. It would be very, very similar
and you might have seen only today EasyJet finally announcing
they are going to offer something about 1% as complicated as Choose
and Book and you will be able to book all slots on-line. You have
had a situation where an airline has been trading as an internet
airline that has not had most of its inventory available on the
internet. We have NHS trusts that have been putting up appointment
availability which has not been updated.
Q115 Kitty Ussher: So East Lancashire
Hospital Trust, which owns and manages the hospital in my constituency
simply does not have their software in place and has not sorted
it out.
Mr Granger: And they are due for
their system to be replaced in October of this year.
Q116 Kitty Ussher: That is an extremely
useful clarification. I shall feed that back to the GPs. My other
question was about the procurement process generally. We have
seen quite a lot of these processes in front of this Committee,
as you probably gathered, and I am intrigued by how successful
on paper the process appears to have been compared to the traps
that various government departments have fallen into in the past.
The NAO says, for example, that you have managed to get the lowest
prices in the world for Microsoft products. My understanding seems
to be that you have managed to push all the risk onto the supplier
companies to protect the taxpayer and obviously this Committee
will be delighted by that. Could you say perhaps what are the
key elements that have been learned from problems in the past
and can we spread these out across the Whitehall machine? Where
is it working?
Sir Ian Carruthers: There are
some in the back of the document, but I shall ask Mr Granger to
comment because he led most of this.
Q117 Kitty Ussher: What was it that
made it work? What was new?
Mr Granger: We put a team together,
not without difficulty, at the same time as starting the procurement
process. We got work packages, the LSP contracts, each around
£1 billion, of sufficient magnitude to attract high quality,
large suppliers to bid and the NHS had not had that supplier base
for the preceding decade. We were very clear and before we put
the procurement advertisements in we published a procurement strategy
which we have endeavoured to adhere to. We were transparent about
the nature of the terms and conditions and in fact the terms and
conditions owe their provenance to contracts I put in place for
congestion charging. Clearly, for those of us who use the roads
in London, you can see that they worked. Capita did deliver to
schedule. We undertook financial analysis as to the capacity of
the suppliers and their delivery capacity. Some things have gone
wrong. We also undertook a prima facie evaluation of their
ability to work together and to get different components to work
together as part of a technical design study. As much as possible
we tried to stick to a timetable, recognising that some other
public sector procurements take 27 months; the NAO referred to
standard PFI transactions. That is generous for some large-scale
IT procurements and that carries significant risks around technology
obsolescence, cost over-run and the taxpayer ends up paying for
that process through inflated costs because the suppliers have
to recover the costs somehow. We have been very clear about what
we wanted to buy, very clear about the basis we wanted to buy
it on and very clear about the consequences of delivery or non-delivery.
I tried to apply some of the principles that you would want if
you were buying consumer goods to the more complex world of IT
procurement.
Q118 Kitty Ussher: Am I right in
thinking therefore that the risk is in the timescale rather than
the costs? Is that right?
Mr Granger: Yes. Because we have
transferred finance and completion risk for the most part to the
suppliers, the primary risk that we continue to bear is a timescale
risk.
Q119 Kitty Ussher: Is that built
into your deadline for the completion of the roll-out of the entire
project? Are you on track still?
Mr Granger: We are on track for
the deadline of the programme. Nothing is ever totally certain,
but if you look at the rate of progress we are achieving now in
terms of volumes of users picking up every week, we shall be in
a place where, for most of the MPs here, at least two thirds of
your constituents now have access to a number of NHS services
which are dependent on things that my organisation delivers. We
shall move to 100% position on that over the next 12 months. Already
the NHS cannot function without the things we have delivered:
passing messages, pathology results, e-mail, a number of GP systems
and, as Dr Davies said, 20% of appointments now into secondary
care. There is a large volume of core NHS services now being delivered
by electronic means under these contracts.
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