The project to overhaul NHS IT is at a crossroads. With Lord Hunt back at the helm, the signs are that the programme will shift its focus to performance management. Lyn Whitfield looks at whether local accountability really is the next step

Lucky Lord Hunt. Not only has he found his way back to the Department of Health, but he has even returned to the IT brief he gave up when he resigned his government post in protest over the Iraq war.

Everybody interested in the subject can sense that the programme's role and the way it works are changing - but the intent and extent of those changes has yet to be spelled out.

It is quite possible they signal a new determination to performance-manage trusts and primary care trusts into deploying national systems.

But they could also signal the beginning of the end of the national programme as it was conceived, and the start of it becoming a national infrastructure and standards-setting body, with trusts left to procure IT in line with these.

If this is the intention, there will be some obstacles to overcome - including the programme's existing contracts and the low level of investment by local NHS bodies.

But one thing is absolutely certain: if that is the intention, nobody is going to admit it or provide the programme's critics with an end point to tally up its successes and failures.

Cause for pause

Martyn Thomas, visiting professor of software engineering at Oxford University, regrets this. 'If that is the case, it would be a good idea to pause for breath and learn lessons,' he says.

'But I suspect nobody will want to admit defeat in that way.'

Most observers of the NHS IT scene want more rather than less change, and are well aware that this involves going back to the future.

The 1998 IT strategy Information for Healthcreated the NHS Information Authority to develop national infrastructure and set targets. But it left trusts to purchase the systems to fit with them.

By 2002, it was obvious that most of its targets were going to be missed. Slow progress was blamed on problems in data cleansing and migration, lack of money and long procurements in a fragmented NHS IT market.

Later that year, the current national IT programme was created to continue with the development of national infrastructure, while replacing local procurement with contracts for a handful of ruthlessly standardised systems.

The national IT programme has had some successes. BT says it is on course to deliver all 18,000 connections to the new N3 broadband network by the target date of March this year.

And it has delivered some important building blocks for the NHS care records service 'spine', including a patient demographic service and a smartcard registration and authentication system.

Its contractors have made slow progress on the electronic prescriptions and choose and book, which is expected to miss its latest availability target in March. But both are expected to work eventually.

Where the national programme has really run into trouble is in delivering patient administration and clinical systems to trusts and other providers to form the local end of the care records service.

In an extraordinary interview with the Financial Timesin November, NHS IT director general Richard Granger admitted that trusts were 'increasingly reluctant' to accept systems from its suppliers, iSoft and Cerner.

Size matters

As a result, the programme's focus has shifted towards digital imaging and the deployment of smaller and more focused systems, many of them developed by the 'cottage industry' of small firms it once seemed intent on destroying.

The question, then, is whether a bigger shift is also under way, towards national standards and local procurement in all areas.

Or as Professor Thomas puts it: 'The question is whether it will give local areas control over specification and funding, or whether it is just handing down accountability for when things go wrong.'

That there would be changes to the programme was obvious as soon as new NHS chief executive David Nicholson arrived at the DoH.

He ordered a review that reported to the NHS management board; and subtly restated the shift in power in the NHS operating framework for 2007-08.

Intriguingly, its IT section opens by emphasising the DoH commitment not to the programme, but to the 'vision' of the IT strategies that preceded it.

Indeed, it says the department is committed to ' arather than the[our italics] national programme for IT in the NHS', and makes it clear that the 'vision' for NHS IT is now to be achieved by 'placing ownership' for it within the NHS.

The operating framework goes on to signal a major shift in the way the programme works, by making strategic health authorities rather than local service providers responsible for implementation.

And it says trusts and provider PCTs must develop a 'comprehensive and forward looking' IT plan.

These plans, along with projected spending on information management and technology, must be submitted to the DoH by March, and it is their content that will really indicate how much the national programme is changing.

Will they focus, as the operating framework says they should, on IT that is 'core to their business'? Or, as it also says they should, on 'exploiting the national programme opportunity' and 'migration to the NHS care records service'?

Ian Herbert, vice-chair of the British Computer Society's health informatics forum, feels the changes indicated in the operating framework are 'going in the right direction' but could go further.

First, he says NHS IT still needs to be more rigorously aligned with the NHS reform agenda. For example, he says systems to support the 18-week total waiting time target and payment by results have lagged behind the roll-out of these policies.

Second, he says more thought is still needed about where responsibility for NHS IT should lie.

In December, the BCS published The Way Forward for NHS Health Informatics, which put the case for a 'greater emphasis on standards to enable systems to interoperate effectively than on relatively few monolithic systems'.

Mr Herbert feels this could be accomplished without formally abolishing NHS Connecting for Health, the organisation responsible for running the programme. 'It does lots of things that will always need to be done,' he says.

The devil you know

'If you did not have CfH, you would just have to invent another body to [set standards, run infrastructure and develop national programmes] and it would only take more time to abolish it and start all over again.'

However, the BCS report not only urged the DoH to go further than it has towards a national standards and local procurement model, but recommended that the care records service also be rethought.

It suggested that instead of trying to build a hard records system, the focus should shift towards developing messaging standards that would allow records to be pulled out of different systems as and when they were required.

Specifically, it suggested that the summary element of the care records service should be abandoned and something akin to the Scottish emergency care record developed to support unscheduled care.

The government has not taken this advice. In his last press conference as the health minister in charge of both IT and modernisation, Lord Warner announced that the summary care record would go ahead, with pilots starting in about five primary care trusts this spring.

He made one concession to doctors and the privacy lobby by saying people will be able to refuse to have their summary record uploaded to the national data spine, as well as to have it shared.

But he insisted people would have to 'opt out' of the new system after publicity campaigns, and not 'opt in' as lobbyists had wanted.

National director for patients and the public Harry Cayton argued this was the most 'ethical' position, because the elderly and vulnerable people most likely to benefit from having their medical history available in an emergency were the least likely to opt in.

The concession has drawn the sting for the moment from a growing row over the creation of a centralised database of medical records that can be shared across the NHS with suitable legislation in place.

Consenting adults

But the row is likely to return. Mr Herbert says that while ministers are now associating the English summary record with the Scottish emergency care record, it is still a different beast.

'The Scottish record is explicitly for unscheduled care, and patients have to give their consent every time it is used,' he says.

'There has never been such a clear purpose attached to the English summary record, and there are not the same safeguards in place. Those are very big differences.'

Helen Wilkinson-Makey, from the Big Opt Out campaign, says it will continue to urge people to refuse to take part in the new system; and to opt out of electronic information-sharing more widely.

The announcement of the pilot sites for the summary care record will bring the national IT programme back into the public eye. So will the resumption of high-level investigations into its effectiveness.

The National Audit Office has said it will look at the programme again 'when we can add value by doing so'. And the Commons health select committee should announce the terms of an inquiry into 'aspects of NHS IT' this month.

Liberal Democrat member Sandra Gidley pushed hard for this inquiry because 'there are so many concerns coming through about the programme, from financial concerns, how well systems are working, and access and confidentiality.'

She would particularly like it 'to look at some of the barriers to getting systems implemented, and how best to move forward'.

Sinead Quinn, healthcare programme manager at the industry association Intellect, says the committee has a great opportunity to look at where the programme is really heading.

'It is evolving and we are pleased about that,' she says. 'There is a new interest in standards. And they seem to be looking to use existing suppliers a bit more. And there is a shift towards trust-level procurement.

'That is the impression we are getting, and if that is right, it should give more ownership of the programme to the NHS and make it more successful. But we don't know how big a shift there will be and we really need more clarity.'