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A Doctor's View of the NPfIT

Can the National Programme for IT (NPfIT) deliver on the Health Secretary’s promise of better healthcare, a "service designed around the patient?"

A recent Westminster meeting of The Conservative Technology Forum heard from Parliamentarians and physicians that a radical centralisation of systems and processes is in danger of failing to recognise the needs of clinicians.

Malcolm Harbour, Michael Fabricant and Glyn Hayes

Sharing the platform with Shadow Health Secretary Andrew Lansley MP and Shadow Industry and Technology spokesman Michael Fabricant MP, Dr Glyn Hayes, chair of the BCS Informatics Committee and president of the UK Council for Health Informatics Professionals, warned the meeting that a programme of such ambition and scale that refused to consult properly with health professionals. “It has”, Says Dr Hayes, “killed an innovative UK software industry for health, by squeezing out smaller expert companies and has instead given the market to a small number of large suppliers... many of whom have been given contracts for things we don't know how to do".

The National Programme is composed of four main projects: a £64.5m national system built by Atos Origin for the electronic booking of hospital appointments; a care records service, supplied by BT under a £620m contract, which provides for everyone in England to have access to his or her own electronic health record; an NHS broadband infrastructure, known as N3 and supplied by BT under a seven-year, £530m contract; and the roll-out of a full electronic prescriptions service.

Dr Hayes believes such a rapid and radical change in technology cannot be imposed upon the medical profession without agreement upon the nature of risks and benefits to the general public. He points out that for most hospital managers, it was "A career catastrophe to become involved in IT”, and that a general culture of IT avoidance exists in hospital management inside the NHS".

"Hospital IT systems," Hayes continued, "are not relevant to the needs of hospital staff as clinicians." He explained these are weighted towards management collection systems and while most general practitioners find IT useful, and many have considerable IT experience, “Doctors have not been consulted over the NPfIT, are not informed about NPfIT and steps are only now being taken to involve them".

The fundamental thrust of the argument that is now levied at the National Programme by its critics, is that it replaces one unwieldy and frequently inefficient system, that delivers care, in spite of rather than because of management, with a centralised IT procurement system that fails to recognise how doctors actually work. This may be illustrated in the lack of professional enthusiasm for the flagship system of electronic booking of hospital appointments, which Health Secretary John Reid has said will "Revolutionise way patients access the NHS".

A former GP and an authority on medical technology, Dr Hayes told the meeting that electronic booking only tends to increase patient/GP consultation times, placing more workload on an already overstretched and critical part of the health sector. He added that the NPfIT only reflects the cycle of public sector bad practice and that here has been widespread neglect of the people and disciplines necessary for success, beginning with clarity of objectives, priorities and responsibilities.

From an observer’s perspective, NPfIT may look like an example of the 'tail wagging the dog' and Shadow Health Secretary Andrew Lansley remarked at last week's meeting: "To be fair to Richard Granger, it is the job of the programme to tackle procurement and not user involvement." The NHS, Lansley said, "is superficially responsive to central direction, as in the case of the fight against MRSA in our hospitals" but the results aren't always as intended.

The NPfIT is regarded by both doctors and politicians as a plan which should be supported but it appears to say more about the Health Service's need for business change than the case for information technology as a solution to a much bigger problem. "The NHS," said Dr Hayes, "is a complex, adaptive system which does not respond well to a top-down approach. It makes assumptions over data accuracy and compatibility and the Data Spine - which will share patient information between clinicians - holds horrendous implications for the security and ownership of data."

Andrew Lansley added that introducing "special safeguards for some, in the security of their data, means concerns for everyone else".

Veiled in an atmosphere of secrecy, the closed nature of agreements between the government and companies involved in the programme gives rise to concern. Delays in fulfilling NPfIT contracts are now starting to trigger non-compliance penalties for some of the partners and this now presents an opportunity to re-negotiate contracts. A health programme manager for one of the larger NPfIT partners, responding to criticism of contractual secrecy and project delivery, pointed out that he hadn't actually seen the contract between his company and the NHS and asked why anyone might expect his company or any other to bid for a project they weren't absolutely sure of being able to deliver.

I answered that not being able to properly deliver any large public sector IT project has never prevented a list of well-known companies from bidding in the past, accepting hundreds of millions of pounds of taxpayers money and then walking away, so why should the NPfIT be any different?

Dr Hayes presented a number of recommendations and among these was a call for the NPfIT to be made "more bottom-up, owned, understood and made affordable locally".

He added that consideration should be given to distributed solutions and not one "fat data spine" and that rigorous confidentiality constraints must not interfere with patient care. Shadow Health Minister Lansley remarked that an incoming Conservative government would be able to change the direction of travel of some elements of the NPfIT but others would have to remain on a "fixed path".

Summing up his sense of progress to date with an analogy, Dr Hayes said: "You can predict reasonably well the direction and distance a brick is going to travel if you throw it. However, if you release a pigeon you can't be so sure but placing a little bird seed on the ground might persuade it to land on the spot you want. Government has however mandated that the pigeon, the health professionals, should be tied to the brick, the NPfIT and thrown out of the window, which gives predictable direction and distance but no guarantee that the results will be as expected.”

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