Insider view: Jon Hoeksma

The Public Accounts Committee has called for a new approach to delivering electronic records to secondary care within six months, if NHS Connecting for Health continues to falter.

Jon Hoeksma argues the committee is not alone in thinking that it is time to make some tough decisions about the programme. The question may be who will take them.

The verdict of the Public Accounts Committee’s second report on the National Programme for IT in the NHS will have made familiar reading for long-term followers of the project. It recites a long litany of delays and limited progress on electronic patient records.

According to the PAC, even a completion date of 2015 for the crucial care records systems now looks unlikely to be met: and 2015 is four years later than originally planned. Its report goes on to say that if significant progress has not been made within six months, the Department of Health should consider funding “alternative systems compatible with the objectives of the programme.”

That would mean financially supporting trusts to select systems that meet their local needs, an option dubbed ‘secondary care systems of choice.’ The PAC notes that at the moment the opposite holds true; trusts actually face financial penalties if they do not take nationally mandated NPfIT systems, even where those systems do not meet their needs.

Something must be done

The report’s call for something to be done echoes David Nicholson’s observation that the programme is at a “pivotal point.” The NHS chief executive told the Health Select Committee in December that “we can’t go on and on like this,” and that unless progress happened soon “we are really going to have to think it through again.”

The key question left unanswered is how long to wait. How long will it take to get working CRS software, coupled with a delivery model that enables local configuration, development and innovation? And what are NHS trusts meant to do in the meantime, with no certainty of final delivery?

“Six months” has been a pretty consistent answer to the question “when will NPfIT software will be ready” since about 2005. And given the scale of the challenges still ahead, it’s safe to say six months won’t be close to enough time now. Nor will 12 months and nor will two or three years. Big projects that start slipping tend to keep slipping, and there is no sign a final line has been drawn under this one.

In any case, the PAC warns that there are “considerable problems with existing deployments of Millennium and serious concerns about the future propsects for future deployments of Lorenzo.” Lorenzo is brand new software that is still only going into its first live test sites. No matter how good it is, it is bound to run into problems.

"There must be grounds for serious concern as to whether Lorenzo can be deployed in a reasonable timescale," says the report (which, incidentally, is highly critical of the confidentiality agreements the DH made with CSC on two reviews of the product). It recommends that before any new arrangements are signed in the Southern cluster “the Department should assess whether it is wise for trusts in the South to adopt these systems.”

Cerner’s Millennium, meanwhile, is a good, proven US clinical system, but even after years of work it is only partly Anglicised – and the stripped down, CfH version still doesn’t meet trust’s patient administration and reporting needs. Newham and Homerton have working with Millennium for five years and still remain a work in progress.

Compounding these problems are the deadening layers of bureacracy and paperwork that have built up around NHS Connecting for Health. In the name of engineering rigour, the development of software now crawls at a snail’s pace, lagging behind the policy and business imperatives of NHS organisations.

Still waiting

Out in the NHS, the CRS part of the programme has largely ground to a halt. In London and the South, there are no new CRS implementations scheduled. In the North, Midlands and East of England, even interim iSoft iPM installations seem to have all-but stopped.

In London, efforts are still focused on trying to fix problems at Barts and the London and the Royal Free Hampstead trusts, following their fraught Cerner Millennium implementations. This has blocked the pipeline of trusts that seemed to be getting to go-live as late as last summer. Even enthusiastic trusts have little against which to plan.

In the South, no deal has been concluded to provide long-term support to the “live eight” Cerner sites, leaving them in a limbo. The intention appears to be to offer other trusts in the South a choice of iSoft or Cerner; the PAC’s warnings notwithstanding.

In the rest of the country, contract renegotiations – called Change Control Notice three (CCN3) – with CSC remain unsigned; and similar negotiations with BT have still to be concluded.

One more heave?

If CfH has a plan to cut through these problems it is keeping its counsel. The DH’s chief information officer for health, Christine Connelly yet to provide the clear direction she promised by Christmas in her only public statement – a letter to the FT.

Even if all three deals were signed it is not clear that they would fix NPfIT’s problems, as CCN3 is understood to still be based on deploying the core LSP software, though with provisions for more local configuration. An approach best thought of as “one more heave.”

Faced with a task that grows more daunting by the day, Connelly and the head of CfH Martin Bellamy must surely privately agree with much of the PAC’s analysis of the problems they face. The £12.7 billion question is whether they have drawn similar conclusions and now have an answer for solving them.