Granger: bricks of the digital NHS coming together

 The pace of delivery of new IT systems to the hospital sector has been "disappointing", says NHS IT director general Richard Granger NHS IT director but he says the bricks that will build a digital NHS are slowly coming together.

In an interview given to E-Health Insider in the run-up to the publication of the NAO report into the delayed NHS National Programme for IT, he acknowledged that some things had gone well and others less well.

"We’ve got a lot of deployment done and we’ve got a lot of things that are troublesome out there." He added: "I’m not sure we’ve got to the bottom of some of the engineering challenges."

Granger says delivery to hospitals had been particularly difficult "The difficulties that independent software vendors have had in that sector are a work in progress".

These were not difficulties that had been anticipated at the outset, he said. "No, because when you get a market response which says ‘yes we will accept liability at these levels; these are the timetables we will sign up to.

Given such the industry’s positive response he says he had justifiable grounds for optimism: "You sort of think: well that’s everybody’s considered opinion about how this is going to be. Though there are some things that were always going to be specifically tricky such as the absence of the packaged solution that worked across care settings."

Revisionist positions were now being adopted, he said.

Another unanticipated stumbling block was the decision to disband the NHS Modernisation Agency, which was to have managed local implementations and change management. Further problems have been caused by "industrial relations" and the view taken by "trade unions" and the royal medical colleges.

Despite these travails Granger remains resolute that NPfIT has achieved much and still offers the only viable option to effectively digitise the NHS and achieve what he terms "information liquidity".

He added that while targets had been missed, much had been achieved. "If you have some very, very demanding targets and you miss some of them, that’s better than having some easily achievable targets and hitting them all."

Pushed on whether the 2010 target for every patient to have a national electronic patient record can still be hit, he told EHI that NHS CRS could be delivered, by: "About 2010, which is 3.5 years time."

Asked whether this would be too tough a target to meet he said: "Have you noticed any part of this programme that hasn’t been tough?"

"If we get agreement from stakeholders, the trade unions that are involved and the Royal Colleges and so on, and that’s the dependency. There is no reason why we cannot build the necessary system components," said Granger.

"So we will get not only a summary record, we will also get a patient view of that and we will get integration between that record and other care settings at which patients present themselves in."

Asked whether the NHS CRS remained deliverable Granger told EHI that the IT strategy he was brought in to procure against and implement had already been set by the time he came into post. Granger named individuals including Dr Anthony Nowlan of the old NHS Information Authority (NHSIA), Jeremy Thorp and Professor Peter Hutton as being parents of the strategy and specification procured against.

"Dr Anthony Nowlan spent the early part of this decade in the IA undertaking consultation about the EPR [electronic patient record] and feeding in details of the consent model and details of that record to 21st Century IT, and then to an output specification produced by Jeremy Thorp.

"So we got a view from IA and produced an OBS, which had significant input from Professor Peter Hutton, who had positional authority at the time," said Granger. "So that is a product we took and went and procured."

He said that currently there was a great deal of variation between what has actually been delivered by the four local service providers (LSPs) in the five different clusters of the national programme, particularly in relation to the strategic detailed local clinical solutions promised to hospitals.

Granger argues that in part is down to the different corporate cultures of the LSPs and NHS partners. "In some parts of the country the LSPs have favoured taking longer to get a richer product, so that’s the case with Accenture."

In the south he said the situation had been different: "Given what they were being offered by IDX, Fujitsu hit the restart button, in favour of getting a richer product later." Granger stressed this had been a decision taken by Fujitsu and the local NHS.

"In the North-west the NHS and the LSP decided they wanted to get on and take existing product with enhancements quickly, which is what they’ve done. There’s been extensive community roll out in the North-west, and are now getting into acute roll out…"

He said that the clinical independent software vendors shared several traits: "They are small by global standards and few of them are able to bear liability appropriate to the scale of the importance of what they do."

The NHS IT director told EHI of the difficulties with the clinical software available: "You’ve got companies reviewing software which was plausible through the technical design stage and through the proof of solution escapade, and you know it needs work doing to it.

"With the American software you know it needs substantial localisation. With the English software you know it has defects which need resolving, there were several thousand that CSC have commissioned iSoft to fix."

Granger added that getting end users to accept and use the currently available software was not easy. "One of the problems that I have is that the software which is available, which exists, is not going to wholly satisfy the latent expectations of people in many places. Because they can see individual components with great richness from their suppliers.

"It’s very hard to come along with a standard product which does not lead in some areas to functional degradation, combined with the undoubted disruption of putting these large systems in creates around data conversion and interfacing and so on."

He said that a balance needed to be found between providing NHS organisations with "substantial function enhancement" and them being ready to implement systems.

Granger highlighted the situation at Nuffield Orthopaedic Centre, Oxford, "We had to largely dismantle order physician entry at the Nuffield… yeah, well what was that about?

The answer, he says: "That’s about organisations that are very busy and their ability to accommodate disruptive change."

He stressed, though, that NHS CRS was only one aspect of NHS IT modernisation: "I don’t think it’s just about this text based record…

He said that huge benefits could be realised by progress in other areas as well: "I’d like to see us now push forward on things like GP2GP record transfer; we’ve had it working for over a year."

Granger says that much could be achieved if a more pragmatic view of benefits would be taken by the medical profession: "So rather than chasing the point of perfection, trying to do 100% of the record transferred, let’s just try doing 80-90%. Because 80-90% would be 3m patient transfers between practices every year."

The NHS IT director recited the litany of the programme’s successes he feels are not recognised: NHSmail, the N3 broadband network, QMAS, PACS in the south and London, and initial bits of the spine such as role-based access.

"On the basis that we’ve got the access control framework in place, we’ve got over 230,000 people using it, 14,000 places hooked up and we’ve got around 1,000 substantial system deployments, hooking into the spine and messaging through it."

"This programme to me increasingly looks like lots and lots of bricks in the wall which we’ve put in place and there’s going to be quite a lot of effort to put each one of them in place. And slowly but surely they start to join up."