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What is the future of the NHS IT programme now that its supremo has quit? Michael Cross reports
Five years ago, as the NHS considered the Wanless report's call for increases in national spending on health1, nearly everyone involved in trying to computerise health care agreed on two things: firstly, that information technology (IT) needed new investment, ringfenced so it could not be diverted to more urgent needs; secondly, that IT needed strong central leadership to coordinate developments and to ensure that money was wisely spent.
Remarkably, the government granted both wishes. The 2002 public spending round included £2.3bn (€3.4bn; $4.6bn) earmarked for healthcare IT in England. In June 2002 a Department of Health strategy announced that a “new national IT programme director” would be appointed to “improve the leadership and direction” given to IT and ensure “ruthless standardisation.”2
Five years on the 2002 consensus has evaporated. The constituency of individuals with opinions about IT in the NHS—vastly broader than in 2002—is divided over the technology, management, and ownership of electronic health information. The polarisation of debate, and the fact that it now involves clinicians, politicians, and civil liberties campaigners, as well as IT specialists, is a legacy of the man hired as IT programme director, Richard Granger.
Granger, who has announced that he plans to leave his post later this year (BMJ 2007;334:1290 doi: 10.1136/bmj.39251.605475.DB), was recruited in autumn 2002 after a career with management consultancies, where he specialised in installing IT for large companies and government departments. From the beginning he had a high personal profile, including the distinction of the highest salary on the civil service payroll. In 2004, when Tony Blair made a major speech on the future of the civil service, Granger was the only civil servant, apart from the cabinet secretary, mentioned by name. The announcement of his resignation—two weeks before Blair himself stepped down—made national newspaper headlines and was immediately portrayed by opposition politicians as an admission of failure.
The true verdict is more mixed. As director general of IT in the NHS in England, and later chief executive of the NHS agency Connecting for Health, Granger was tasked with turning into reality a 1998 strategy for nationally available electronic health records.3 The 2002 plan set out three separate strands of work: electronic booking of secondary care appointments, electronic transmission of prescriptions from doctor to pharmacy, and a lifelong electronic health record for each patient. The necessary systems would be deployed under national direction, rather than being left to the discretion of individual trusts and general practices, as had been the case previously.
Granger's true legacy must be judged by progress he made according to the 2002 plan.
During the course of 2003 he put his stamp on the programme by negotiating a series of 10 year contracts to develop and install national systems, most importantly a central information “spine,” and to replace organisations' IT in geographical areas. Apart from the scale and the unprecedented speed with which they were negotiated, the contracts were notable for insisting that contractors were paid only on delivery of working systems. In 2006 the National Audit Office commended this approach,4 although it has not been replicated elsewhere in the public sector.
Connecting for Health claims that substantial parts of the 2002 plan are now in place. All NHS organisations are now connected to the spine, which ensures that patients' demographic information (name, address, and NHS number) is correctly and consistently recorded. However, the main function of the spine, to carry a summary care record available everywhere and to transmit detailed health records between organisations, remains a far-off dream. One difficulty, which apparently came as a shock to Granger, is professional resistance to sharing information across a national system.
Another pillar that is substantially in place is electronic booking, the scope of which was extended to allow patients a choice of hospital under the government's Choose and Book programme. Although the NHS has failed to meet government targets for the proportion of bookings handled electronically, Granger says with some justification that the IT is not to blame.
Other projects now claimed as successes bear little relation to the 2002 plan. One is the national installation of software known as QMAS (the quality management and analysis system), hurriedly deployed in 2004 to support a new contract for GPs that involved payment by results. Another is picture archiving, communications, and storage (PACS) technology for handling digital x ray pictures and other diagnostic images. Although a proved technology, PACS was at the bottom of priorities in the 1998 vision of electronic health records, largely because of cost. A national procurement in 2004 moved PACS up the agenda, and Connecting for Health says that three quarters of hospital trusts in England are now using the technology.
By contrast, electronic prescribing, seen in the 2002 plan as a “quick win,” has been slow to roll out, partly because of the difficulty of dealing with community pharmacies. Connecting for Health says its electronic prescribing service is now being used for 11% of daily prescription messages, but in almost all cases these run alongside paper prescriptions.
The programme's biggest failure is over the installation of electronic patient records in secondary care. The 1998 strategy envisaged these being available across the NHS by 2005, procured trust by trust from at least a dozen suppliers. The national programme's “ruthless standardisation” replaced this market with two key software firms, the UK firm iSoft and the US's IDX, later replaced by Cerner. Both encountered problems developing systems to the specification required by the NHS; iSoft has relied on installing an “interim” system, while the roll-out of Cerner's systems began late and is only now getting under way.
In retrospect, the national IT programme as executed by Granger contained two big mistakes. One was in the contract structure, which did not reflect NHS loyalties on the ground and alienated the existing IT community. The second flaw—which Granger vehemently denies—was a failure to engage properly with clinicians at the outset of the design of the electronic health record. Granger's departure, and Gordon Brown's arrival as prime minister, create the conditions for face saving changes of policy. Despite the kneejerk political and media verdicts of failure, thanks to Granger the blocks of compatible technology are now becoming available to build the world's largest and most integrated e-health service—if the will to do so is there.