Wanless warns NPfIT risking NHS modernisation

In a review of NHS modernisation efforts Sir Derek Wanless has criticised the slow progress of the National Programme for IT (NPfIT) and called for an audit of the programme to ensure it supports wider health service modernisation.

The report warns that considerable challenges lie ahead in modernising NHS IT systems and says there is "continuing debate over the feasibility of some current NPfIT plans".

With limited progress on its core objectives, and the lack of a clear measurable business case against which savings can be measured it says that Connecting for Health, the agency responsible for NPfIT, appears to be being allowed to follow "a high-cost, high-risk strategy that cannot be supported by a business case". Concerns are also expressed about the future impact of the monopolistic contracts awarded by the agency.

The report analyses the progress of NPfIT within the wider context of NHS modernisation and investments made and finds the programme wanting in key areas, particularly enabling productivity gains within the service. It observes that NPfIT has largely occurred in the absence of any published or measurable business case.

Despite receiving very significant investment since 2002 Wanless says the programme has so far largely failed to deliver. "The extent to which the NHS will benefit from these investments remains unclear."

In the King’s Fund commissioned report Sir Derek provides a progress report on the government’s progress on NHS modernisation. In 2002 he carried out a strategic review of the health service, for the then chancellor Gordon Brown, which was instrumental in making the case for a 50% increase in NHS spending.

The 2002 review identified better use of information and communication technology (ICT) as key to potential productivity and health gains. In his progress report Sir Derek says these productivity improvements have not been achieved.

This is despite actual ICT spending in England increasing from an estimated £1bn in 2002/3 to £2.3bn in 2005/6 and now projected to rise in 2006/7 by a further 25% to just under £2.9bn – a level that actually exceeds the 2002 review’s projected peak in spending of £2.7bn in 2007/8. In effect the money has been spent but the delivery on ICT has been decidedly patchy.

On the main areas of ICT investment under NPfIT the report says that there has been good progress on the N3 network and, notes that additional work has been added on PACS, QMAS and NHSmail. However, on the core strategic programme of implementing an integrated care records service progress has been very limited.

The report says the NHs Care Records Service (NCRS), originally due to be substantially delivered by 2004 under the NHS Plan has been a significant failure. "However, controversy has seriously undermined this aspect of the NPfIT, partly due to the absence of any published plans for the design and implementation of NCRS."

Commenting on the first pilots of the NCRS summary care record it notes: "National roll-out is expected to begin in 2008, but it will be several years before coverage is complete. A date has not been specified for the system to be fully operational."

On the electronic prescriptions service it says that after a slow start the system is now being used by 1,700 GP practices (about 20% of the total) "although only for a minority of their prescribing". The 2007 target for the system to be available to all GP surgeries, community pharmacies and other dispensers "will almost certainly be missed."

On Choose and Book the report again notes progress is being made but also that both the original 2005 target for electronic booking of appointments to be in use across the NHS and the later March 2007 target for 90% of practices to be using Choose and Book have been missed.

Commenting on the slow progress and lack of detailed published plans the report concludes: "the continuing uncertainty and delays have the potential to undermine the productivity gains envisaged by the 2002 review", a key part of the business justification for additional investment.

At the strategic level the report identifies three factors that is says have had an impact on the 2002 review’s original productivity assumptions. "The first is the failure to develop and ICT strategy whose benefits are likely to outweigh costs". It says the failure to produce a business case which shows benefits outweighing costs is a serious criticism, "implying either the absence of an original business case for investment or investment made in spite of a business case that did not justify the spending".

The report goes on to highlight the lack of evidence provided for the ICT investments made by CfH in particular technologies, quoting BCS concerns about poor value for money from the project.

It concludes: "It is difficult to understand why Connecting for Health is being allowed to pursue a high-cost, high-risk strategy that cannot be supported by a business case."

The second major criticism made focuses on the failure to audit and evaluate the benefits provided by the investments made through the programme, noting "it does not seem possible to obtain reliable data on NHS resources committed to NPfIT". CfH, it says, has so far committed "negligible investments of £0.5m in evaluation" out of a total of £12.4bn.

"There seems a real risk that the costs and benefits of NPfIT will never be accurately assessed."

The third criticism made, which the report says may turn out to be the most important, "is that the NPfIT contracts risk creating monopolies in various areas of the programme". Noting the award of contracts to a handful of exclusive consortia, and the heavy reliance on just two clinical software suppliers, the report warns CfH looks to have sacrificed future market competition and choice.

"Connecting for Health chose to award a small number of large contracts to consortia charged with designing and implementing the technologies. But they could instead have set out to create a competitive market for IT goods and services."

The report makes clear its preferred alternative with the question: "Is it possible that a robust business case could be created, even now, with a focus on strategies for encouraging a healthy market?"

The former chief executive of NatWest says the £12bn IT programme run by the NHS IT agency Connecting for Health should undergo "detailed external scrutiny to ensure the benefits will outweigh the costs".

Sir Derek’s call for a review will be difficult to ignore and will come as an embarrassment to the government which has repeatedly rejected calls for an independent review of the NHS IT programme. Such a review was one of the main recommendations made by the Commons Public Accounts Committee in April this year.

Overall, Sir Derek’s progress report paints a mixed picture identifying solid progress, but criticising the government for introducing policies without adequate preparation and seeking quick results.

In response to questions from EHI about the report the DH said in a statement: "The Programme is no stranger to independent scrutiny. From day one it has been subject to the Office of Government Commerce (OGC)’s Gateway process, and more recently the subject of NAO and PAC reports, and the report of a review by the Health Select Committee is imminent. 

"We do not consider there are grounds for another independent review of the National Programme at this time. The costs of the Programme remain under control and, although there have been delays to the delivery of some items, much has either been delivered early or remains on target.

"Although we do not agree the need for an independent review it will, in accordance with normal practice, develop a programme to ensure the relevant business cases are reviewed and refreshed."

Link

King’s Fund: Our Future Health Secured? (PDF)