Could crossed wires see the IT programme blow its fuse?

The surprise exit of a chair from the body set up to engage clinicians with the national programme for IT underlines what many have long suspected - that the scheme is still failing in its crucial task of engaging with grass-roots staff across the NHS.

Lyn Whitfield reports

How many professors do you need to engage staff in the national programme for IT?

Until a fortnight ago, the answer was two. Now It is one.

Chair of the Academy of Royal Medical Colleges Professor Peter Hutton quit as chair of the programme's national clinical advisory board on 21 April, barely six months after it was established to 'formalise and extend' consultation with healthcare professionals (news, pages 4-5, 29 April).

That leaves deputy chief medical officer Professor Aidan Halligan to engage doctors and other clinicians, a role he was given in March when he became joint sole responsible owner for the programme alongside director general of NHS IT Richard Granger.

Professor Hutton's resignation letter is understood to have expressed concerns about current arrangements for clinical input. In a separate report, he warned that the programme could be put in jeopardy by the lack of involvement of doctors and nurses.

As the news emerged last week, health minister John Hutton conceded that the programme had some unresolved issues. He said: 'We cannot have the kit starting to turn up and people not knowing what to do with it.'

On Friday, the Department of Health promised to review the formal arrangements for engaging staff and patients. It also announced that a new front-line 'support academy' to help NHS leaders with new technology will start taking students this month.

The academy will run simulations in which clinicians role play the new systems using actors.

But while the resignation of Professor Hutton has shone a light on some of the programme's challenges, some observers of the NHS IT scene question whether he was the right person to engage grassroots staff in the first place. One told HSJ that 'he's too immersed in conventional medical politics' and 'the royal colleges do not understand IT anyway'.

There is more optimism about Professor Halligan, who wowed March's Healthcare Computing conference in Harrogate with an emotional speech about his desire to see IT delivering benefits to staff and patients. 'The only risk is that we do not take the risk, ' he concluded, echoing (consciously or otherwise) Franklin D Roosevelt's words to the US in the throes of the Depression, that the only thing we have to fear is fear itself.

But Professor Halligan - who embarks on a tour of trusts this month - should have no illusions about the scale of the task ahead.

Most of the NHS's prominent staff groups have been polled on their views of the national programme and the findings are consistent.And while a large majority in each group thinks IT is exciting and that using it to modernise healthcare should be a priority for the NHS, few people actually know about the programme - and even fewer have been consulted by it.

The national IT programme was set up in 2002 when ministers lost patience with progress on the 1998 IT strategy Information for Health, which set national targets for IT, but left implementation to local organisations.

The idea was that it should deliver a new broadband infrastructure for the NHS and a set of applications to run over it, using a totally new, highly centralised system of procurement.

In January, BT won the contract to build the new infrastructure, known as N3. A few weeks earlier, it had also won two of the six contracts to create the most radical of the new applications, the NHS care records service, which will hold information on about 50 million patients.

As a national application service provider, BT will build a 'data spine' to hold basic demographics about patients and an outline medical history.

As one of five local service providers, it will also connect up existing local systems, plugging gaps and making sure they work together, and it will create NHS care records in London. Three other firms - Accenture, which won two LSP contracts, CSC and Fujitsu - will do the same job in other parts of the country.

The programme has also signed a national e-booking contract and is looking at national deals for prescribing, imaging and other systems. So on the procurement front, the past year has been, as Mr Granger told Healthcare Computing, 'a bad year for cynics'.

But it has also been a bad year for those who want to see the IT programme open up.

The companies that have won contracts have also signed tough confidentiality agreements and, even now, few details have entered the public domain.

In Harrogate, one speaker told his audience he had just taken a call to remind him of a confidentiality agreement he had signed, before symbolically ripping up his speech.

Yet Professor Halligan told the conference that the key to staff involvement was communication, 'the most important thing we do, alongside leadership'.

But professor of healthcare development at Sheffield University and chair of Nottinghamshire Healthcare trust Professor Brian Edwards asked another session in Harrogate, 'why do we worry about [staff involvement] so much?' After all, he pointed out: 'Nobody asks people who work in supermarkets about the tills they use; they use what is there.

'Clinicians walk into hospitals and use what is there. They want systems that are reliable, but That is it, is not it?'

The general consensus is that it is not. A supermarket can change tills without too much staff involvement because the basic task doesn't change that much.

The systems that the IT programme has procured have the potential to change working practices quite substantially.

The promise of electronic care records, for example, is that they will make information instantly available to any member of healthcare staff who needs it, anywhere in the country.

That should facilitate patient movement through the system and drive modernisation, by making many more choices available. But it implies a big change in working habits and relationships.

The lesson of other big public sector IT projects is that they tend to 'fail' when this is not taken into account.

In February, for example, the National Audit Office concluded that one of the fundamental errors in the calamitous attempt to introduce new systems to the Criminal Records Bureau was a failure to consult users 'at the earliest opportunity'.

As a result, executives and IT supplier Capita made assumptions about the design of systems and processes that turned out to be wrong, and 'failed to translate policy objectives into workable operational plans'.

This makes staff surveys about the programme worrying. A Medix survey of 1,000 doctors in February found that 75 per cent thought that IT-led modernisation of the NHS was a priority, but the same percentage had not been consulted by the national programme.

Almost 80 per cent supported the idea of electronic records.

But, worryingly, there was little enthusiasm for e-booking, which will begin later this summer.

An online survey of 2,000 nurses for the Royal College of Nursing last month found more than twothirds felt that 'spending billions' on IT was a good use of NHS resources and the same proportion thought electronic records were a priority.

But only 2 per cent felt they had adequate information about the programme's plans (and 26 per cent hadn't heard of it ).

'There are high expectations of what IT can do, but people are not getting information and there is a danger they could become disillusioned, ' says RCN informatics adviser Sharon Levy. 'People may switch off or not use the new systems in creative ways.'

British Computer Society health informatics committee chair Glyn Hayes issued warnings for a year about a lack of clinical engagement. He says he is more optimistic now Professor Halligan is on board.

'I think he is the best thing to happen to this programme because he understands the clinical environment and the political environment and is keen to learn about the technical stuff, ' he says.

But Professor Halligan will need those political skills. The term 'clinical engagement' is neat but it is often confused with talking to doctors - and even they have differing interests.

GPs, for example, generally have good IT systems - or, at least, systems into which they have put their own time and money, even if they do not connect up with the rest of the NHS. Their main concern is that the programme could force them to replace their systems with ones they have not chosen and may find inferior.

Hospital doctors, however, have generally had much less access to technology and have been less vocal about the programme.

And it has much catching up to do. The national programme says e-booking and records systems will be flexible, so if there is something a clinician really wants, they will be able to have it.

But British Medical Association IT committee chair Dr John Powell says engagement needed to start much earlier, with an analysis of what managerial and clinical problems such systems were meant to solve, and some baseline analysis against which progress can be measured.

'It is basic change management, ' he says. 'You have to involve the people affected by the change.'

Mr Hayes points out that the national IT programme is phased over a 10-year period, so there is still time for clinician buy-in.

But changing the professor in charge of clinical engagement will not do the trick. Professor Halligan must force the IT programme to open up and find clinicians who are not just seen as 'tokens' to champion change. It is going to be quite a challenge.