Memorandum submitted by Dr Anthony Nowlan
I am writing regarding the National Audit Office
Report on The National Programme for IT in the NHS (NPfIT),
published 16 June 2006, which you are due to consider on 26 June
2006.
From December 1999 to December 2003 I was an
Executive Director of the NHS Information Authority (NHSIA). From
early 2002 I was closely involved in the start of what became
the National Programme for IT. At the request of the then Director
of Research and Information at the Department of Health I took
forward national work on privacy and confidentiality and began
to establish health professional leadership for the upcoming developments.
From early 2003 I was seconded to work with the Director General
for IT in the NHS. That secondment was terminated in the middle
of 2003 and I was made redundant at the end of the year.
Since then I have reserved public comment on
the National Programme for IT. Now that the NAO Report has been
published I wish to raise with you what I believe are important
aspects of the early part of the Programme. I encourage you to
look further into matters that are central to whether or not the
Programme as formulated can deliver benefits for people's health
and care commensurate with eh scale of the effort and public expenditure.
The NAO Report focuses on the commercial procurement
of 2003, the resulting commercial contracts, and the subsequent
management of those contracts. It says much less however about
how the health care content of those contracts and the National
Programme as a whole were determined. The quality of that work
is crucial to current and future success.
QUALITY OF
THE SPECIFICATION
WORK
The section, NHS Connecting for Health has
sought to ensure the systems meet users' needs (paras 2.10
to 2.13) gives an account of some events but it does not make
an assessment of the adequacy of the specification work that has
shaped all subsequent developments.
For clarification, the NHS Information Authority
did not produce the first Output-Based Specification (OBS) for
an Integrated Care Record Service in July 2002. That was published
by the Department of Health. I was a Director of the NHSIA at
the time and on the eve of its publication I strongly recommended
in telephone calls to senior staff at the DH that it not be released
as it was unfit for purpose.
Section 2.12 goes on to then state that this
OBS was revised and finally released in May 2003. It should be
clarified that this occurred after the Director General for IT
had taken up the post and was therefore under his control. The
Director General had initiated the procurement and the OBS had
to be produced to a timetable determined by that procurement process.
Section 2.12 states that the final specification
was produced with further input from 400 clinicians and others.
In my opinion, the involvement of clinicians was by any credible
measure inadequate for such an enormous scope with such far reaching
consequences. Irrespective of numbers, it was implausible that
any valid, sustainable conclusions could be drawn by asking some
clinicians to comment on hundred of pages of text in systems-speak
in the space of a few weeks. This was particularly the case for
what became Part II of the Output Based Specification covering
the huge array of hospital, general practice, and other systems
to be delivered by a Local Service Providers. These systems account
for the majority of the work and expenditure.
There was an awareness of the risks involved
in producing a specification under such circumstances. I was personally
told to provide a list of "hundreds" of names of clinicians
who had been involved in the specification work in order to provide
evidence to reviewers that the work was valid. This was in my
view not proper and would not give a fair reflection of the validity
of the work. I refused. Section 2.13 states an explanation for
the lack of documented validation which to me is not credible.
ENGAGEMENT OF
HEALTH PROFESSIONAL
LEADERSHIP
In the spring and summer of 2002 I embarked
upon work to marshal clinician leadership as a pre-requisite to
meaningful health professional involvement and the translation
of health care requirements into information systems requirements.
In this I was greatly assisted by the President of the Royal College
of Physicians and other senior figures. During the summer Professor
Peter Hutton, then President of the Royal College of Anaesthetist
and Chairman of the Academy of Medical Royal Colleges increasingly
gave his support. In the autumn a meeting a meeting of senior
leadership agreed to work together to help set priorities and
address wider clinical issues. This agreement finally resulted
in the formation of a Clinical Care Advisory Group (CCAG) under
the chairmanship of Professor Peter Hutton, and linked to the
Ministerial Taskforce that had been formed to oversee the National
Programme.
At a meeting of the Ministerial Taskforce in
December 2002 several members of the CCAG were asked to develop
proposals for what they considered the most important health care
needs to address. This resulted in the proposal for a common integrated
basic record for each person. In some regards the objectives were
modest but to the clinicians it represented high health care value
and was achievable if designed and implemented with the full involvement
of health professionals and patients. Similar work was done with
several groups representing patients. 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.
Copies are available if required.
This work was fed in to the start f the specification
of the contracts. Subsequent incorporation of this work into contracts
was however to the best of my knowledge done without further involvement
of the CCAG. Furthermore it ended up forming only a relatively
small part of the overall specification, The large majority of
the Output Based Specification, and in particular Part II which
included for example the major hospital systems, was developed
without even this level of involvement and scrutiny by the leadership
of the health professionals It was at this time that it became
increasingly clear to me that efforts to communicate with health
professionals and bring them more into the leadership of the programme
were effectively obstructed.
WIDER IMPLEMENTATION
PROGRAMME
The design of information services should follow
from the design of health care. The commercial procurement of
technology, if required, is only part of what must be done and
should come at the appropriate stage of a wider programme. In
this context the engagement of clinicians and managers is not
just about telling them what is going to happen. The NAO Report
recognises this at the start of section 4. And yet the Report
goes on to describe that this is not what was done for reasons
of timing. In fact it could never have been achieved given the
determination to complete commercial contracting. As a consequence
all the issues of complexity had to be faced after the letting
of contracts. The most serious consequence is that the majority
of the development of electronic records has stalled. Connecting
for Health claims much of this is due to unforeseen complexities.
This is not the case. Those with experience and in particular
clinicians were well aware of the complexities at the outset but
their contributions went unheeded. Furthermore it is not acceptable
to claim that the transfer of "completion risk" to the
suppliers manages the intrinsic risks of failure to implement.
Financial penalties may be in place, but the real risk of non-completion
always remain with health services that both need the solutions
to care for people and will have invested far more in direct and
indirect costs than any commercial penalty. Tax payers also get
sick.
ISSUES TO
CONSIDER
There are several basic issues affecting the
success of the Programme that you may wish to consider:
— What was the quality of the decisions
that determined the basic structure and clinical content of the
procurement?
— What effort was made to engage the
wider NHS and understand the feasibility and costs of implementation
prior to contracting?
— Who was and is responsible for the
wider implementation programme and, if as the Report suggests,
it is not Connecting for Health then how does that fit with the
obvious far-reaching control over all health information matters
exercised at the time by the Director General for IT in the NHS?
— Who is responsible for the consequences
of the procurement for health care in England?
FINAL COMMENTS
I remain fully committed to the use of information
science and technology in health care. Redesigning the ways care
is organised and conducted and supporting those new ways with
information science is more important to people's health overall
than any new drug we could develop in the next decade. It is therefore
personally saddening to be in this position.
I must make clear I am not raising a personal
issue, but you need to understand the circumstances in order to
make a judgement on my comments.
Dr Anthony Nowlan BA MBBS
MRCP MFPH PhD
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