Letter from Professor Peter Hutton to
Chairman, Committee of Public Accounts
I was previously the clinical lead with the
National Programme for IT in the NHS (NPfIT) and am writing to
you following the publication of the National Audit Office (NAO)
Report on The NPfIT in the NHS. I remain concerned of the
possibility that decisions taken in the early part of the programme
had, and continue to have an adverse effect on system development
and clinical engagement. I gave evidence to the NAO during their
enquiries in November 2004.
When the Director General for the NPfIT (Mr
Richard Granger) was appointed in 2002, although several previous
attempts had been made, there was no clinically accepted agreement
on what should comprise the core of a nationally available electronic
health care record (eHCR). It was the production of this eHCR
(sometimes called the Spine) which had the potential to transform
how health care was practised and managed. The Spine was the vital
component that would deliver benefits realisation for the public.
I was appointed by the Department of Health as the clinical lead
to obtain a professionally agreed consensus around what was the
most valuable information to store and what was achievable in
practice. I did so through the creation and Chairmanship of two
committees:
— The Clinical Care Advisory Group
[CCAG] (December 2002-Spring 2003).
— The National Clinical Advisory Board
[NCAB] (Summer 2003-April 2004).
Because of the difficulties described below
I offered my resignation to the Department of Health (to which
I was seconded) on 19 April 2004. Since then I have remained silent
about the NPfIT but now I feel it proper to comment on the NAO
Report.
Prior to my resignation I wrote a report for
internal use within the Department of Health on the work of the
CCAG and NCAB. Neither of these bodies is referred to in the NAO
Report. I think that you would find this internal report a useful
information source and could supply a copy if requested. It consisted
of a 13 page review and over 80 pages of appendices including
minutes of meetings, letters and references to other bodies and
details of working groups. A copy of this was given to the NAO.
The report described the functional development of the eHCR and
raised a number of questions.
I am anxious that the NAO Report does not sufficiently
examine the impact of decisions taken in the early part of the
programme which formed the basis for long-term contracts in relationship
to the eHCR. The quality of information available at that time
was critical and has shaped all subsequent developments. The NAO
Report describes the mechanics of contracting well but does not
really ask the question: "what was it that was trying to
be achieved and was it achievable?" Points you may wish to
consider are:
— Although the way forward was agreed
in principle by the CCAG in March 2003, NCAB's recommendations
to the National Programme Board concerning "Consent and
the Content of the Electronic NHS Care Record" were not
agreed until November 2003, well after contracting was well advanced
with implementation planned for early 2004. The Secretary of State
announced the adoption of an electronic NHS Care Record on 8 December
2993. As the lead clinician in the programme responsible for the
development of the functionality of the Spine and the content
of the eHCR, I was not allowed to be involved in the contracting
or to see the contracts.
— There was repeated concern from NCAB
over aspects of the detail in the contract. Particular concerns
were how the work was to be divided between the national and local
service providers, the time scheduling of activities and the sustainable
pace of change in the clinical environment. NCAB was never given
an explanation or diagram that indicated how all the elements
would work together: it was therefore not possible for its clinical
representative to offer a view on the feasibility of the programme.
— Both the CCAG and NCAB were seriously
concerned about the lack of engagement with clinicians and other
NHS staff and the instructions from the management of the programme
not to undertake such activities. Example of this are that:
— In May 2003 documentation was prepared
(together with FAQs) to inform the service of what was happening
and what it meant for them: this initiative was stopped.
— Plans for NCAB to make "10 road
shows" across the country to inform the NHS of progress before
Easter 2004 were stopped.
Without requesting permission, I gave an interview
to a professional magazine called Hospital Doctor (published 18
March 2004) describing the work of the national programme and
what it meant for clinicians and patients. On 31 March 2004 I
wrote to (the then) Sir Nigel Crisp with a copy of the NCAB internal
report expressing my concerns. A sentence from that letter reads:
"I remain concerned that the current
arrangements within the programme are `unsafe' from a variety
of angles and, in particular, that the constraints of the contracting
process, with its absence of clinical input in the last stages,
may have resulted in the purchase of a product that will potentially
not fulfil our goals."
Soon afterward I was asked to consider my position
and tendered my resignation. The Department of Health subsequently
dissolved NCAB. I remain convinced that an electronic care record
is vital to the development of quality, cost effective health
care and regret that I am no longer involved. The NAO Report correctly
praises the high-speed contracting process that obtained the best
price for the NHS and the strict penalty clauses for failure of
delivery. However, fundamental questions remain that the Report
does not address:
— How could detailed contracts be placed
for the eHCR before its content had been approved by the National
Programme Board?
— Was there appropriate detail given,
and was the programme confident, that suppliers had understood
what was required in a particular contract so they could make
a valid assessment of its feasibility?
— Is the content of the contracts fit
for purpose and will they deliver what the NHS needs?
— Why was communication and engagement
with clinical and other staff, and the public, consistently inhibited
rather than encouraged?
For a complete account of events, reported in
the public domain, it is, in my view, essential that the NAO Report
addresses these issues. I note that there is no intention at present
to call any clinicians but would attend your Committee if request.
If you do wish to see me, some notice of attendance and the likely
questions would be helpful so that I can assemble any documentation
I have into a sensible order for submission to you. If you think
my worries have no basis, I would be grateful to know the reasons
why, so I can feel comfortable that the public's interests have
been satisfied.
Professor Peter Hutton
19 June 2006
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