Connecting for Health28th May 2007
Connecting for Health continuing to generate headlines of escalating
budgets, slow implementation, and faltering relationships with
contractors, we look at where recent developments leave the national
programme for IT.
What is Connecting for Health?
CfH is an agency of the Department of Health set up to deliver the national programme for information technology (NPfIT). It replaced the NHS Information Authority. The idea is that it should provide stronger central direction on IT, moving away from the piecemeal procurement of local systems that do not interface and share information between NHS organisations, and promoting greater use of IT to transfer information along the patient pathway. The Department of Health expects these changes to generate financial, patient safety and service benefits. CfH plans to connect 30,000 GPs and 300 hospitals serving the NHS’ 50m patients by 2014. The National Audit Office has described CfH’s programme as the most ambitious computer project in the world, and the single largest investment in IT in the UK.
The main elements of the programme are:
- NHS Care Records Service (NCRS), with a national database (‘spine’) of information about patients’ health and care at its core.
- On-line appointment booking, being rolled out through the Choose & Book programme.
- Electronic transmission of prescriptions.
- National Network for the NHS (N3) – predicted to be one of the largest virtual private networks in the world, N3 will provide the IT infrastructure and broadband connectivity to link NHS organisations across the country.
Other feathers of the programme include Picture Archiving and Communications Systems (PACS), a system to support data collection against the new GP contract (QMAS), and an NHS directory including email to help information sharing about services across the country (NHSmail).
Service Providers have been appointed to develop each element (eg N3 contract awarded to BT), and Local Service Providers (LSPs) have been appointed to lead implementation in five regional clusters, integrating new systems with existing, and training staff to get most use out of them. LSPs have sub-contracted with a range of specialist software development houses, most notably with iSoft and Cerner.
Figure 1: Regional delivery of CfH
|North West and West Midlands||Computer Science Corporation (CSC)|
|North East||CSC (previously Accenture)|
|East||CSC (previously Accenture)|
How much is it costing?
Original estimates of £6.2bn were made for the cost of commissioning various service providers to develop and implement the new systems. In its review of the programme published in June 2006, the National Audit Office suggested the figure would realistically be nearer £12.4bn, taking into account not only the cost of contracts with service providers, but also the cost of training, hardware, and interim spend on the existing infrastructure until new systems came on line. A figure of £20bn is also often quoted – put forward originally by the Health Minister Lord Warner as the estimated total cost of the NHS IT programme (of which CfH is one, albeit very significant, element) over the next 10 years.
Although estimates keep moving up as various considerations are taken into account and specifications are revised, the programme so far is actually under spent. This is due partly to delays putting costs back, but is also down to a tightly negotiated contracting round with service providers that has secured significant discounts for the NHS and placed delivery risk firmly with the contractor through fixed prices and payment only after full delivery. BT are reported as already having undertaken £200m worth of work in London, but have only been paid £1.3m so far. The NAO had particular praise for the way that CfH had managed the procurement process in which contracts were signed off within 10 months, compared to the usual 27 months in equivalent procurement exercises.
How is the programme progressing?
Many suggested that last June’s NAO report on CfH had been unduly influenced by the Department of Health. The report said that whilst the programme could provide value for money to the NHS (unlike many government IT schemes), tighter controls were required on contractors, and there were significant delays on key elements - the main obstacle being poor engagement at a local level with the staff expected to use the new systems.
Relationships with contractors
There have been a number of high profile difficulties with contractors. Early last year the share price of iSoft (the company working with LSPs on electronic patient records software, and responsible for 60% of the national programme) collapsed after announcing a £55m drop in expected profits due to delays in the CfH programme. It was already in dispute with the two LSPs it worked with. It has been under review by the Financial Services Authority for alleged accounting irregularities, and is now subject to a take over bid. Accenture announced a £238m provision for losses against its NHS contracts again citing delays in the programme. It has since pulled out of most of the national programme, with the North East and East clusters now working with CSC.
This in itself presents difficulties for the programme with responsibility for delivery now in the hands of only three LSPs (including CSC covering 60% of the country). Market analysts are predicting further supplier market consolidation with these few large national players forcing many small specialist developers out of the market or into sub-contractual arrangements with the big three. This would leave the NHS with very few potential partners and would reduce the degree of contestability that helped it to negotiate such a good deal in the first round of procurement.
Delays and local engagement
The most worrying delays are with Choose & Book and the National Care Records Service. Both delays can be put down largely to poor engagement and take-up at local level, with CfH finding it hard to move roll-out beyond the ‘techno-friendly’ early adopters. Richard Granger, the national head of CfH, acknowledged in an interview he gave to the Financial Times in November 2006 reluctance by local staff to work with iSoft and Cerner. Surveys have suggested that 30% of staff have little or no knowledge of CfH, and that it is not popular with those that have, even though they broadly support the aims of the programme. The local end of the care records system requires a number of new Patient Administration Systems to be put in place at Trusts, but only 19 have been out of the 43 that should have been up and running from last November. Financial incentives were offered to GP practices to hit the March target to get 50% of referrals made through Choose and Book, with maximum financial awards being available to those practices that hit 90% up-take. Despite this, no SHA or PCT has yet hit the 90% target, with most performing between 30% and 40% take up.
At the same time, BT hit their milestone of delivering 18,000 connections to N3 two months ahead of schedule. The QMAS system has been fully rolled out, and digital imaging has replaced film across half of the country, with PACS due to be deployed in most locations by March 2007, followed by full implementation on schedule for December.
Concerns about patient confidentiality across the new IT infrastructure have been championed by patient representatives and the BMA. They have asked that every patient have a chance to ‘opt-in’ to having their data shared on the national data spine – something that would incur significant delays. In response, the government has put forward plans to allow patients to ‘opt-out’ if they wish, with only minimal data around allergies and prescriptions being nationally available from the spine, at least to start with.
What does the future hold?
NHS Chief Executive David Nicholson announced a full review of the scope and operation of CfH late in 2006. CfH has already become a slimmed down executive agency, with many of its staff redeployed locally to work on implementation at SHA level. To get over the problems with local engagement, and to guard against another massive government IT programme failure, many leading opinion formers (including the British Computer Society reporting in December) are speculating about a shift from the current strategy of national control and procurement, to local procurement within a national framework of standards. The NHS would face considerable difficulty managing tensions between existing national contracts and new local arrangements if this were to happen.
- Devolution of many CfH functions to SHAs has been delayed. Full transfer of responsibilities is now not expected until late summer or beyond. The April deadline was missed whilst financial arrangements and policies and procedures were finalised. CfH will be left with responsibility for the overall commercial strategy for NPfIT and managing supplier contracts.
- The Commons Public Accounts Committee has found that urgent remedial action is required to bring NPfIT back on track in terms of timing and cost. Its review concluded that significant clinical benefits were unlikely to be delivered by the end of the contract, and that the Department of Health needed to ‘get a grip’ on spend. It said that whilst suppliers struggled, the Electronic Patient Record (EPR) element was now two years late, and Trusts should be allowed to look for local alternatives. The government rebuffed the PAC’s findings, saying that it was based on the NAO report of last June, and was therefore out of date. It said that significant progress had been made against the NAO’s recommendations since last summer, and costs were not escalating. The PAC has now called for a second full review by the NAO ‘in the next year’ to ‘call the government’s bluff’ on whether progress really has been made since last June’s report.
- Richard Granger, the head of CfH, speaking at the
Health Select Committee after the recent PAC report, said that delays
in the EPR were due to the length of time consultation with users had
taken. He confirmed that the majority of the NPfIT would be
delivered on time by 2010. However, interest groups have
dismissed Granger’s comments and are still calling for an independent
hearing on NPfIT.
For more information about CfH, go to:
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Title: Connecting for Health
Author: Sue Knights
Article Id: 1953
Date Added: 28th May 2007