NHS IT project still on critical list

“If you live in Birmingham,” declared Tony Bliar when he was UK prime minister, “and you have an accident while you are, for example, in Bradford, it should be possible for your records to be instantly available to the doctors treating you.” Not any more.

Or not, at least, if the Conservatives win the next general election. For the Tories have pledged to scrap the countrywide version of the National Health Service’s electronic patient record.

Back in 2002, the idea of a full patient record, available anywhere in an emergency, was the principal political selling point for what was billed as “the biggest civilian computer project in the world”: the drive to give all 50m or so patients in England (the rest of the UK has its own arrangements) an all-singing, all-dancing electronic record. 

Roll-out was meant to start in 2005 and be completed by 2010.

Under a Conservative government, development of the local record – exchangeable between primary care physicians and their local hospitals – would continue. Nationally, clinicians would still be able to seek access to it when needed from the doctors who would hold it locally. But the idea of a national database of patients’ records, instantly available in an emergency from anywhere in the country, would disappear.

This may or may not matter, depending on your point of view. For many clinicians, the idea of an instantly available national record was always something of a diversion. It is access to a comprehensive record locally that is crucial for day-to-day care.

Nonetheless, the Conservatives’ decision to scrap the central database is a symbolic moment for a £12bn ($20bn, €14bn) programme that has struggled to deliver from day one. 

It is currently running at least four years late – and there looks to be no chance in the foreseeable future of its delivering quite what was promised.

So what went wrong? Too much ambition, too much speed, too much centralisation, too little local ownership and not enough choice have been just some of the problems. 

‘It is more difficult than people think. But I do think that by now, seven years on, we would have been further forward’ Glyn Hayes, former chairman of the British Computer Society’s health section

In hindsight, it is easy to see why the programme was set up the way it was – with big central contracts and a one-size-fits-all central offering. For a start, while there had been some local successes, the health service had also had its share of IT disasters when things were run locally.

“The arguments for centralisation were first that all these systems had to be able to talk to each other,” says someone who was closely involved in the government’s original decision to launch the programme. “Second, there were powerful arguments for economies of scale if the system was bought centrally. And, third, the NHS had a long history at local level of taking ringfenced money, whether for IT or other projects, and finding ways of spending it on something else.

“Looking back, it was the wrong thing to do. It was right to centralise standards for communication and for what should be in the record. It was right to use centralised purchasing power. But the next step, that the whole programme had to be centralised, did not have to flow from that. It proved to be a mistake.”

With a staggeringly ambitious goal to get the first electronic records running just three years down the line – when what was to be in them had yet to be fully defined – Richard Granger, the then director, decided that the fragmented and small providers of IT still in the NHS hospital market did not have the scale or industrial muscle to deliver.

So he brought in some of the big boys of IT – Fujitsu, CSC, BT and Accenture – to install the systems. They, however, were not health IT specialists. And, according to Mr Granger, the two providers of the electronic record software ended up with mirror-image problems.

The US company Cerner had good clinical systems. But software designed for hospital billing systems in the US needed a big rewrite to run all the administration and reporting functions of the NHS. By contrast, iSoft, which at the time was a British company, knew how to run the administrative side of the health service but lacked a clinical record. It has taken years for the often troubled company to come up with one. The first deployments of early versions of it are only just under way.

For all the difficulties in getting early versions of an electronic patient record into the NHS, the IT programme has had some success. England is one of the first countries to have fully digital imaging – replacing film X-rays and scans with manipulable digital images that largely put an end to lost films and unnecessary repeat examinations.

In spite of the delays, suppliers insist they will get there in the end. Gary Cohen, CEO of iSoft, one of the record suppliers, says: “It is a bit like swimming the English Channel. If you are 80 per cent of the way there and tired, what you don’t do is say ‘Well, we’ll swim back and start again’.”

On top of that, while there was a £6bn budget for the 10-year central contracts, no money was earmarked for training, in spite of the lesson, from the relatively few successful installations of electronic records in US hospitals, that at least as much has to be spent on changing the way staff work as is spent on the systems themselves.

Furthermore, there was no local ownership of the programme. Local developments of electronic records that were under way were halted. The national programme became something that was delivered from on high to hospitals and clinicians, not something that they chose or voted for. They also had to fund their own training and other costs. On top of that, all the installations of early versions of the software into big hospitals have caused serious disruption.

So where does the programme go now? BT and CSC, the two remaining systems installers, have been given deadlines of November 2009 and March 2010 respectively to achieve a smooth implementation in a big acute hospital. Failing that, the department of health says it will “look at alternative approaches”.

Quite what plan B is, however, remains a mystery. Any decision to cancel the contracts is likely to result in mighty litigation. The for hundreds of millions of pounds set aside to achieve an electronic record could go up in smoke in claim and counter-claim as each side blames the other.

It has been a sorry tale to date- and one that still continues.

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