Horrible history part one: here comes the 21st century

It is June and the government has set out a ten-year “vision” for information in the NHS. As the result of a new strategy, the patients of the future will “see that their health records are always available to staff” and be able to “help to maintain the quality of those records” by getting access to them.

The time that healthcare staff spend with patients will be “spent more effectively” because of the information at their fingertips. Data will also be opened up to healthcare managers and researchers and to new services such as telemedicine, which will become “commonplace.”

Of course, it is not June 2012 and the strategy is not ‘The Power of Information: putting us all in control of the health and care information we need.’ Instead, it is June 2002, and the strategy is ‘Delivering 21st century IT support for the NHS:  national strategic programme.’

Ruthless standardisation

‘Delivering 21st century IT’ is the document that paved the way for the National Programme for IT in the NHS. Its big innovation was not its vision – which it shared with earlier NHS IT strategies, as well as later ones – but the mechanisms it put in place for delivering that vision.

As it said upfront in its opening paragraphs: “The core of our strategy is to take greater control over the specification, procurement, resource management, performance management and delivery of the information and IT agenda.

“We will improve the leadership and direction given to IT and combine it with national and local implementation based on ruthless standardisation.”

Specifically, a ministerial taskforce was to be established under the chairmanship of Lord Hunt, a former head of the NHS Confederation, who had been made a Labour peer after the 1997 general election and was health minister in the Lords.

A new NHS IT programme director was to be appointed to lead on what Lord Hunt himself described as “the IT challenge of the decade.”

Standards for data and data interchange and system specifications for a new, National Health Record Service were to be set at a national level. And there was to be a big shake-up of procurement arrangements, with “consortia of suppliers” bidding for the work.

Finally, strategic health authorities were to appoint chief information officers to make sure that primary care trusts and providers “implement and use the core IT solutions determined at a national level.”

A product of its time

‘Delivering 21st century IT’ did not come out of nowhere. In 1998, the NHS had published ‘Information for Health’, a well-received strategy written by NHS IT pioneer Frank Burns, that proposed a rather different set of delivery mechanisms.

An NHS Information Authority was set up to create a national IT infrastructure, to run electronic patient record ‘beacon’ projects, to set standards for increasingly sophisticated ‘levels’ of EPR functionality, and to measure progress against targets for deploying that functionality to hospitals.

However, it left trusts to procure their own systems to meet these targets. And by the start of 2002 it was obvious that they were going to be missed.

IfH’s failure was blamed on technical issues, on trusts spending money that was supposedly ring-fenced for IT on other pressures, including a fledgling reform programme, and on the sheer difficulty of procuring systems from a “cottage industry” of suppliers.

But while the strategy had faltered, the pressure on the NHS to make better use of IT had grown. IfH was launched against a background of Tory “cuts” in the health service and Labour promises to restrain growth during its first term in office.

The strategy itself was to be funded from a £5 billion modernisation fund that had other calls upon it.

Yet in January 2000, Prime Minister Tony Blair was bounced into promising a massive increase in NHS funding in response to media stories about the NHS failing to cope with winter pressures.

The Department of Health quickly insisted that more money would have to be accompanied by "reform" and launched ‘The NHS Plan’.

This included some ideas for getting the NHS to adopt the kind of consumer-facing technology that had been adopted by other industries – such as ‘airline-style booking.’

Meanwhile, a furious Treasury had asked a former banker, Derek Wanless, to investigate the demands that the health service would need to make on it in the future.

At the start of 2002, Wanless (who died recently) reported that if spending was going to be kept under control, the population would need to become healthier and the NHS would need to become more efficient.

He saw a big uptick in IT adoption as part of the second half of the equation, and proposed that NHS spending on IT should rise to £2.7 billion a year over a three-year period to deliver big gains in productivity.

The final part of the jigsaw was that Downing Street was keen on NHS IT, thanks to a seminar at Downing Street at which Microsoft chief executive Bill Gates, in the UK to promote Windows XP, persuaded Blair and his advisors of replacing a local approach to NHS IT with a national one.

From enthusiasts to professionalism   

‘Delivering 21st century IT’ reflected its genesis by saying that it wanted to address a long-standing problem: that “historically, the NHS has not used or developed IT as a strategic asset in delivering and managing healthcare.”

It acknowledged what IfH had achieved, but said that “while there are good, usually local IT initiatives sponsored by enthusiastic visionaries, these [have been] outweighed by the overall lack of funding and development priority given to IT at all levels.”

Moving forward, it said patients should not only expect that NHS staff should have good access to electronic records, but that IT systems should support best practice, and allow for a new kind of interaction with the NHS.

“Patients will be able to obtain information over the phone or via the internet 24 hours a day… to make appointment bookings online… to [receive] telecare and monitoring services [in] the convenience of their own home.”

At the same time, it said healthcare professionals would not only have access to records, but be able to schedule care plans, prescribe drugs, commission tests, and access new professional support services online.

Eventually, IT would support integration with GP and social care services. And “all of the above aim to ensure that the benefits offers by IT-supported working practices are delivered across the NHS and in support of patient-centred services.”

A problem then, a problem now

The results of ‘Delivering 21st century IT’ were initially spectacular. By September 2002, a new director general of NHS IT, the famously abrasive Richard Granger, had been appointed.

By January 2004, a contract for a national NHS network (N3) had been let to BT and national projects for e-booking, e-prescribing, and summary care records were underway.

England had been split into five ‘clusters’, for which local service providers had been given billion pound-plus deals to contract for EPRs and deploy them to health communities.

Yet the strategy itself admitted that it would be a “challenge” to “balance rapid progress at a national level with user acceptance and implementation capacity in the NHS and IT industry at a local level.”

And after 2004, NPfIT started to slip behind schedule when it came to getting national projects delivered and adopted – and spectacularly behind schedule when it came to getting new IT systems into trusts.

The scale of the failure of ‘Delivering 21st century IT’ is shown by ‘The Power of Information’ since it effectively restates the earlier stratgy’s vision and retreads some of its specific proposals.

The latest deadline for giving patients online access to their records – just their GP records – is still three years away. Telemedicine is not only not "commonplace" but the subject of a 3millionlives campaign to kick-start the market.

Most trusts have still to implement what became known as ‘Clinical 5’ functionality. The Treasury has stepped in to order new information services to promote the life sciences industry.

Even more shockingly, the failure of ‘Delivering 21st century IT’ is shown by the scale of the financial crisis that Wanless was so keen to avert, but which now looks set to engulf the NHS.  

The difference between Wanless’ best case scenario and the money the NHS now has to deal with a less healthy population, without having increased its own productivity, is the ‘Nicholson challenge’ – £20 billion.