Annex 1—Evidence Submitted to the
PAC in June 2006
Evidence for the Public Accounts Committee
(PAC) Hearing on 28 June 2006 Regarding the National Programme
for IT (NPfIT)
1. Evidence that the PAC should note, for
its Hearing on the NPfIT on 28 June:
(a) Evidence demonstrating that the most
important areas of functionality contained in the LSP contracts
are unlikely to be delivered by the National Programme (Exhibit
A)
(b) Evidence demonstrating that the benefits
required by the NHS to justify the business case in the LSP contracts
are unlikely to be delivered (Exhibit B)
(c) Evidence demonstrating that the National
Programme mis-managed the implementation of the Local CRS solution
at the first Southern Cluster site and caused preventable local
disruptions (Exhibit C)
(d) Evidence demonstrating that the National
Programme is operating without proper accountability (Exhibit
D).
2. The PAC should note that the delays to
the delivery of software by the LSPs have largely been due to
Connecting for Health (CfH) management decisions, not the suppliers.
This is because the Spine message definitions were delayed in
being published by the NPfIT staff in 2004 and 2005.
(a) The PAC should pose the question to the
NP leadership: what delays were caused to the LSP deliveries as
a result of the NP's delay in publishing its Spine Message definitions?
(b) The PAC should also realise that the
LSPs are afraid to reveal this fact for fear of damaging their
relationship with the NP. In effect, they are afraid of placing
blame on their customer, despite the fact that the customer is
to blame for their own non-performance.
3. The PAC should note that the NAO report
is a travesty because it simply published what the NPfIT claims
is their deployment statistics. This is useless without target
data as to what was supposed to be deployed and when.
(a) The PAC should take the NAO to task.
There ARE target figures in the LSP contract schedules for what
modules of Local CRS were due to be deployed, where and by when.
Unless these targets are used to compare the ACTUAL implementations
(the only figures published in the NAO report) made by NPfIT,
the "Audit" element of the NAO's role has been woefully
neglected.
(b) It is akin to an Annual Report of a large
publicly-quoted company reporting that it earned £2m in revenues
last year, but not reporting what it was supposed to earn that
year. Without the target figure, the annual report is useless
and its shareholders would not stand for it.
EXHIBIT A
Evidence demonstrating that the most important
areas of functionality contained in the LSP contracts are unlikely
to be delivered by NPfIT
Background: The National Programme intends
to deliver a Care Records Service (CRS) which is made up of (a)
the National Care Records Service (National CRS), or patient summary
record, also known as the "Spine CRS", and (b) the Local
Care Record Service (Local CRS), also known as the "electronic
patient record (EPR)" or "core EPR", which contains
the full patient details and full "electronic patient record"
functionality.
NPfIT admit that the National "Spine"
CRS is going to be at least 2.5 years late in being delivered.
However, in reality, this delay does not matter and is merely
a (perhaps deliberate) distraction that is drawing attention away
from the real problem, which is that the National CRS is a flawed
and unproven concept. What is much more important to patients
and the NHS, but not reported by the media, is the Local CRS (core
EPR) because this is a proven and crucial set of computer tools
that doctors and nurses need to treat patients on a day to day
basis.
There is extensive published evidence[32]
to demonstrate that, for instance, doctors using the electronic
prescribing functionality in the Local CRS (but not a part of
the National CRS), will certainly reduce medical errors and patient
deaths due to improper drugs prescribing practices.
This is in contrast to there being no published
evidence to show that the National CRS patient summary record,
or Spine CRS, will have any significant clinical benefits. In
fact, the Scottish experience with using their equivalent of the
patient summary record is that it rarely used by clinicians. This
is largely due to the fact that the summary record is "unintelligent"
with no direct interaction with the clinical system, containing
the patient's detailed local electronic record, which clinicians
use on a day to day basis.
Furthermore, the limitations of the Spine CRS
underscore the need to have a local CRS (EPR) deployed across
care settings which provides embedded clinical knowledge to support
the efficacy and efficiency of the provision of health care to
patients. For example if a patient develops an allergy to a drug
in the acute care setting, the "alert" for this will
be immediately applied in primary care. Thus preventing that drug
from being prescribed without a warning whatever setting the patient
is in.
The Evidence: Appendix 1 shows the list
of the 59 Local CRS functions (labelled as "modules")
that the Eastern Cluster LSP, as an example of all 5 LSP contracts
which are virtually identical in their scope of functionality,
was contracted to deliver for the Eastern Cluster and the contracted
delivery "phase" in which they are to be delivered.
The timescales for these phases are listed as follows in the Eastern
Cluster contract (page 23 of the Approval to Proceed 2 document):
"The ICRS programme is intended to be
implemented in three phases. These phases have now been subdivided
into five elements whilst still retaining the three overall phases:
— Phase 1 Release 1 (roll-out complete
31 December 2004)
— Phase 1 Release 2 (roll-out complete
30 June 2005)
— Phase 2 Release 1 (roll-out complete
30 June 2006)
— Phase 2 Release 2 (roll-out complete
31 December 2008)
— Phase 3 (roll-out complete 31 December
2010)."
Source: This data is extracted from the
Eastern Cluster "Approval to Proceed" document ("AtP
Eastern cluster v0.20 (no finance case).doc") which is
available on the Norfolk, Suffolk and Cambridge Strategic Health
Authority website.
This table shows that the LSP contracts were
full and extensive in the "depth" of Local CRS functionality
to be delivered to NHS organisations. In fact, every function
that was considered possible and useful for local CRS systems
to support clinicians was included.
The Problem: The reality now however
is that, due to the massive delays to the delivery of the early
phases, only the rudimentary elements of Local CRS functionality
(only elements of Phase 1 and Phase 2, such as patient administration)
are likely to be delivered by the National Programme which only
replicates what the NHS have already and adds no new value to
the NHS. At the current rate of implementation, where only the
early and less clinically important modules are beginning to be
implemented, the latter, more clinically important and difficult
to develop modules will not be available and implemented prior
to the end of the contract.
The conclusion here is that the NHS would most
likely have been better off without the National Programme in
terms of what is likely to be delivered and when. The National
Programme has not advanced the NHS IT implementation trajectory
at all; in fact, it has put it back from where it was going. For
example, local initiatives to deliver more seamless care through
common systems across care settings have been stopped for several
years although the National Programme promised to deliver such
a solution.
GP's having not seen anything developed to address
their needs have lobbied to retain the right to choice for their
systems, thus fragmenting the National Programme further. In fact,
what is currently happening (largely due to the delays and the
emphasis on the National Spine CRS), is that LSP's are being forced
by the Programme to deliver out-dated legacy systems, which the
Programme was established to replace, with no cross-care setting
functionality, but instead all on a "standalone" or
"silo" basis. This step backwards has been taken simply
to try and demonstrate to the Government and general public that
the Programme is "delivering something" against the
£6.2b funding provided.
32 Effects of computerized physician order entry and
clinical decision support systems on medication safety: a systematic
review. Kaushal R et al Arch Intern Med. 2003 Jun 23; 163(12):
1409-16. Back
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