Examination of Witnesses (Questions 200-219)
DEPARTMENT OF
HEALTH, PROFESSOR
PETER HUTTON
AND DR
ANTHONY NOWLAN
26 JUNE 2006
Q200 Mr Williams: On page 29 we are
told that from the outset this project went ahead with day-to-day
oversight provided by ministers. What did that consist of? What
did day-to-day oversight mean and who was calling the shots?
Mr Granger: In general, ministers
had regular meetings with key members of the leadership of the
programme and other interested parties every two weeks, four weeks
or so, initially with Lord Hunt of Kings Heath and then with John
Hutton and then with Lord Warner.
Q201 Mr Williams: Was it all harmonious
and free of confrontation? No-one was talking about seeking directions
or anything like that.
Mr Granger: Not in meetings I
have attended.
Q202 Mr Williams: I asked that because
the leadership seemed to be rather spasmodic in terms of continuity.
If you look at page 44, paragraph 4.6 says that at the inception
the director of research was the senior responsible owner. "In
March 2004 he gave up this role" and you end up with two
senior responsible owners with a further senior responsible owner
responsible for individual contracts. Then further down we have
another four sub-paragraphs of changes, all of which took place
in a very short time at the leadership level of this project.
Why on earth was so much mobility and lack of continuity permitted?
Sir Ian Carruthers: First of all,
there was continuity through Mr Granger and his team on the procurement;
that was there. You are well aware of the changes which have taken
place in the Department of Health over time.
Q203 Mr Williams: What changes are
you referring to?
Sir Ian Carruthers: Sir Nigel
Crisp has retired, John Bacon has also retired.
Q204 Mr Williams: Sir Nigel retired
relatively recently.
Sir Ian Carruthers: Yes. Changes
were made for reasons—
Q205 Mr Williams: Who at official
level was in charge?
Sir Ian Carruthers: At official
level obviously the Chief Executive of the NHS was in charge.
That function, as it says in the Report, was discharged at varying
times by the Deputy Chief Medical Officer and the Chief Executive
of Trent who was brought in as a director of service implementation.
Then Sir Nigel's assistant, John Bacon, who was director of health
and social care delivery. Those were the people in charge at that
time and since 7 April I am.
Q206 Mr Williams: This Committee
has had a whole series of reports to look at where things have
gone wrong. We do understand things going wrong; we do not expect
infallibility. I regard what you are trying to achieve as eminently
desirable. Let us start from that proposition. You had had RISP,
the regional scheme which wasted millions of pounds and then did
not deliver. Then you had HISP, which was the next major venture
into IT. You are not exactly unfamiliar with these matters and
indeed it says in the Report that a key lesson for many unsuccessful
IT projects is that success requires engagement of NHS managers
and clinicians in order to win their support for the overall vision
and purpose. In fact, what we have emphasised has been the need
to involve the users from the very outset in developing the vision.
Do you feel that is what you have done?
Sir Ian Carruthers: I should like
to say three things.
Q207 Mr Williams: No, I just asked
whether you think that is what you have done.
Sir Ian Carruthers: We have engaged
clinicians but, as the Report says, there is very much more to
do.
Q208 Mr Williams: But it is a bit
late for there to be "very much more to do", because
the "very much more to do" was to be done before you
placed the contracts, that is if you had learned the lesson.
Sir Ian Carruthers: No, that needs
to be dealt with in the implementation phase.
Q209 Mr Williams: No, no, no.
Sir Ian Carruthers: There was
engagement with clinicians in doing the specification.
Q210 Mr Williams: The specification
has to be drawn up very closely and with very intense input from
potential users.
Sir Ian Carruthers: Yes, but the
Report says that users were involved.
Q211 Mr Williams: It does not say
they were used intensively or to what extent.
Mr Jeavons: If I may, I think
I can help here. There was clinical involvement in the original
specification but the specification was for a ten-year programme.
It is utterly and totally realistic that, as the programme proceeds,
clinicians and other users get involved in much more detail. Let
me give you one example, e-prescribing, which is one of the most
important facets of the care record service because it is directly
related to the reduction in medication errors and adverse events,
470 clinicians have been involved in workshops over the last month
looking in detail at the national requirement to support e-prescribing
across the programme so that could be fed into design with our
suppliers and produce a coherent system. It is not a one-off,
one-stop shop.
Q212 Mr Williams: I seem to remember
that in fact clinicians were confronted with a very large number
of very detailed documents and were given about two weeks to try
to absorb them. Professor Hutton or Dr Nowlan can clarify this.
What really happened?
Professor Hutton: I should like
to comment on the e-prescribing. The e-prescribing was a great
point of contention because in the original contracts it had been
put back to 2008, as I recall, and it has actually been brought
forward. That is an example of the fact that the contracts did
not actually meet the clinical need. I do repeat what I said earlier,
that the core of this programme is the NHS care record. Other
things are very helpful, but it is the care record which matters.
That is the picture we have on here: e-learning and the map of
medicine are add-ons. The thing which will actually enable this
White Paper (Our health, our care, our say, published January
2006) to take care back to the community is the NHS care record
and that has not moved forward.
Q213 Mr Williams: Is the Spine the
essence of it?
Professor Hutton: The Spine does
two things: it moves messages across and that is developing well.
The Spine is also used as a phrase for a repository of knowledge
about individual patients. That particular function, as far as
I know but I may be wrong, has not moved forward at all. The specification
for that, as to what should go on that record and the criteria
for that, was that the information put on that record is that
which is required when a healthcare worker sees a patient with
a new complaint or at follow-up or after referral from another
healthcare worker and what information they then need to pass
onto the next person who will see them. That was the novel concept
of the Spine. It was not developed until after—
Q214 Mr Williams: Leave it there
for the moment because I am limited on time. I want to come to
Dr Nowlan and what he has said. I have here a copy of the document
you provided. You say "At a meeting of the Ministerial Taskforce
in December 2002 several members of the Clinical Care Advisory
Group (CCAG) were asked to develop proposals for what they considered
the most important health care needs to address". You then
go on at the end of that paragraph to say "The principles
of the proposal were accepted in March 2003 by a meeting of the
CCAG, on the understanding of continuing close involvement in
the development of the proposals".
Dr Nowlan: Yes.
Q215 Mr Williams: How important was
that commitment which was required that they should have ongoing
involvement?
Dr Nowlan: It was essential. They
all recognised the enormous value if we could do this particular
piece of it, but that to carry it through would be challenging
and to implement it in particular would need full support.
Q216 Mr Williams: So it was essential.
Dr Nowlan: It was vital.
Q217 Mr Williams: Vital, essential,
critical, you cannot emphasise it too strongly. But, according
to your submission—and obviously I shall give you a chance
to come back on this in a moment—"Subsequent incorporation
of this work into contracts was... done without further involvement
of the CCAG". So it ended up forming only a relatively small
part of the overall specification, yet on the basis of that contracts
were placed. Is that what you are saying happened?
Dr Nowlan: Yes.
Q218 Mr Williams: That sounds unbelievable,
does it not? Would you like to clarify that Sir Ian? Is that wrong?
Sir Ian Carruthers: We would not
entirely agree with that.
Q219 Mr Williams: "Not entirely"
but you do agree with some of it.
Sir Ian Carruthers: Dr Braunold
is going to give a different version of what occurred and Mr Granger.
Mr Granger: I have to say that
when we supply you with the notes, one of the notes you will get
is a request from me to Dr Nowlan on three occasions that he supply
a structure to the clinicians that he was working with. It is
lamentable that his expertise ceased to be available when he left
the IA in December 2003, but his recollection of events is somewhat
different from that of the people who have been working on the
programme for the past four years and of Sir Muir Gray, who tells
me that over 6,000 clinicians have been involved in a programme
called, Do Once and Share.
Dr Gillian Braunold: In particular
the bit I really need to clarify is the fact that the content
of the shared care record on the Spine has moved forward a great
deal. We have been building a consensus on papers which have been
published on the CRDB website since last summer. We have had more
than 100 unique responses to our consensus-building document,
we have been through three iterations of that document and we
are now in a position to pilot with the approval of the colleges
and the BMA in slow incremental ways so that we can learn the
lessons of implementation and test those very access controls
and the legitimate relationships that people are concerned about,
to make sure that the information governance structures are secure.
We are ready to pilot that at the end of this year and that is
against specifications which have been agreed in consensus building
with clinicians. It is not true to say that we have not moved
at all.
| 
