In rude health

Published: 20/03/2003, Volume II3, No. 5847 Page 20 21

After heading the London congestion charge team, Richard Granger is turning his blunt approach to another seemingly intractable problem - the lamentable state of IT in the NHS. But after so many false starts, and such a patchy implementation record, is a centralised approach the right one?

In the 100 days since Richard Granger took up his job as director general of NHS IT, he has acquired a reputation as one Britain's least civil civil servants.

His first meeting with suppliers last year caused shock waves, not least because he reportedly summed up his opinion of some of their products in four letters.

(He was 'misquoted', he says, not expecting to be believed).

He doesn't like or trust journalists and has given only three interviews, including this one, since his appointment.His last interviewer described him as 'short, blunt and assertive' and said 'the overwhelming impression is one of controlled aggression'.

It is hard to argue with that. Mr Granger's probably had some media training recently, because he tried really hard for HSJ.He'd even prepared a couple of little stories and remembered to smile after telling them.

But watching him trying to get through a 45-minute interview without swearing or exploding was rather like watching a child trying to be good at a wedding.

A quarter of an hour in, the tension is so much that he has to get up and prowl around his office at Richmond House. In doing so, he fiddles with a lamp, knocks it over and fills the air with the smell of singed wire.

Still, Mr Granger is not being paid£250,000 a year to make a good impression in interviews.

He is being paid to meet what NHS chief executive Sir Nigel Crisp has called 'the IT challenge of the decade' - delivering the national programme for NHS IT.

Announcing Mr Granger's appointment last October, Sir Nigel also said he was 'confident that Richard's skills and experience put him in a unique position to [do this]'.

He has delivered IT programmes for most of his professional life. He worked on the computerisation of Britain's benefits system and national projects in the former eastern bloc before joining Deloitte Consulting as a partner in 1998.

In 2000, he was appointed by Transport for London to lead a Deloitte team to project-manage the capital's congestion charge.

He took a large pay cut to join the NHS, but says he was attracted by the work challenge presented by the national programme and its potential impact.

Also, the job 'met with the approval of my wife, who is a speech therapist' and chimed with his personal values. 'It was not a difficult choice.'

Mr Granger is understandably proud of the congestion charge. 'I dare say You have noticed how much easier it is to get around central London, ' he says at one point.

The congestion charge was delivered by a new co-ordinating body, Transport for London, using private sector expertise.

It generated luke-warm public support and slightly hysterical media coverage - London media quoted residents and shopkeepers willing to predict everything from parking chaos to the collapse of the capital's economy.

Yet in the end, the congestion charge was introduced smoothly and delivered most of what was promised for it.

There are obvious parallels with NHS IT.Although national strategies have existed since 1998, NHS IT has been a mess for years. Some trusts and GP practices have installed excellent systems, but many more have not.

Even the enthusiasts have been working with a cottage industry of small suppliers, who have gone out and won one contract at a time, tailoring their wares and prices to local circumstances.

This started to change last March when Sir John Pattison, the Department of Health's director of research, told an NHS IT conference that major programmes would be delivered nationally and procured differently.

This eventually led to the creation of the national programme, which should deliver fast voice, data and video links and three big functions to run over them - electronic prescriptions, electronic booking and the new integrated health records services.

It also led to a new system of procurement, based on the creation of consortia led by major firms. Some of these will deliver national infrastructure and applications while others - the local service providers - will work with strategic health authorities to get local systems up to scratch and talking to each other.

In his first 100 days, Mr Granger has created his own Transport for London - the national programme office - and is about to announce which of five major consultancies will project manage the programme.

Meanwhile, the official notice calling for firms to express an interest in leading or being part of the new consortia has opened and closed on time - which is impressive in itself.

However, the programme has generated little enthusiasm and not a few negative headlines.

There are still people who feel that the NHS should not be trying to centralise IT at all; and that it is courting disaster if it tries. They argue the NHS should be setting standards and leaving trusts, GPs and others to create locally owned systems, with specialist providers, that meet the standards instead.

Mr Granger does not accept this.

'Things were done differently in the past, ' he says. 'There was a long definitional phase, a process of getting functional fit and then a long implementation phase because the systems were so complex.

'One of the things I find perplexing, and a bit annoying, is that [NHS IT] has this model... and frankly you just do not get IT delivered like that anywhere else.

'My starting point is to have good electronic records that support other applications and put in systems where they do not exist.

My challenge to anyone who wants to do it differently is 'bring me a business plan and show me we can do it'.'

Mr Granger believes the scare stories are coming from those with a vested interest in the status quo - smaller suppliers, and clinicians and managers who have become too close to them. He has repeatedly warned suppliers not to talk to the media, while tackling restrictive practices head on.

For example, he wants to link existing systems - 'to get away from islands of good IT in a sea of no data interchange'. This sounds simple, but it has involved getting firms to release details of their application interfaces - how their products can be made to work with others.

This has not been done before.

Mr Granger has done it 'by setting up an environment in which it is clear that there is a place for suppliers to supply what clinicians and patients want and no place for suppliers who maintain proprietary models.'

Not everybody is unhappy. Mr Granger says some of the larger suppliers have been trying to get letters of support into the IT press (which he particularly dislikes) because they want a large and stable market. He says they want this even though they will have to price keenly, while smaller firms are 'very upset' about seeing their margins eroded.

It is too early to say whether the national programme, like the congestion charge, will be introduced smoothly in the end.

But if it is, it will still have to persuade people to use the technology it delivers.

Mr Granger seems puzzled when this issue is raised: 'There would be no point in delivering a beautiful, shiny gizmo if nobody used it and I have never done that.'

However, Mr Granger sees usage as a technical issue. He wants systems that are easier to use, with a 'common user interface' so all NHS computers look and feel familiar.He would like to exploit new mobile technologies.

His assumption is that if these things are delivered, people will use them. London drivers have adapted to the congestion charge.

It remains to be seen whether NHS staff will do the same.

Clinicians, in particular, are used to being consulted and considered; it will be interesting to see if they simply change their working patterns in response to what the national programme gives them.

Another potential problem is privacy. Mr Granger says it is 'essential to deliver an IT system that protects people's privacy; it is a mandatory requirement'. But he also wants a system that 'will allow you to do things'.

'I would like my blood group details to be available if I was knocked down by an ambulance, ' he says. 'Am I alone in that? I expect not.' Undoubtedly not.

But people might worry if any member of NHS staff could get hold of any medical detail about them; or if the information was passed on to other government departments.

Privacy groups argue that the Home Office's entitlement card proposals would allow that. But Mr Granger points out there are 'no implementation plans' for this - and similar proposals have been turned down in the past.

Mr Granger sees the big issues as technical challenges - how to convert data from one format to another, how to get it to travel across different systems - the sheer scale of the deployment and how to overcome the ongoing negative coverage.

'There is a tendency to only want to write bad news, to write the 'IT going wrong' story, ' he says. 'We should be writing about 'how quickly' not 'what if '.'

He accepts that the long delay between Sir John's speech to HC2002 last year and the launch of the national programme has caused uncertainty and frustration, with IT staff unsure of their role and other stakeholders impatient to know when they will see results.

'I am not a massively patient person myself, and people can be reassured by that, ' he says. 'But I need a bit of patience. We will deliver to the timetable set out and we will get a bloody good deal for the NHS.'

He fell at the last. However, as if to make up for the swear word, Mr Granger finishes the interview with a little story. His litmus test for success, he says, is 'whether IT supports a speech therapist in Derbyshire'. Then he smiles.