Published: 25/08/2005, Volume II5, No. 5967 Page 15
Why am I writing about the national programme for IT now? Two reasons. First, the programme is approaching its third birthday and this autumn University Hospital Birmingham is implementing the first major release of the software.
Second, because implementation of the system is to become an integral part of the local delivery plan of every trust and strategic health authority. The Department of Health has told the NHS to set out requirements for integrated service improvement plans. These must describe 'the local health community's joint objectives for the next three years for its key enabling workforce, modernisation, finance and IT solutions, and the planned impact on performance'.
Now I understand why the Treasury underwrote the£6bn worth of contracts within the national programme. Or do I? Many would suggest that this directive from the DoH should have come at least three years ago. Now it looks like a piece of retro-fit management from a large bureaucracy that has not co-ordinated its departmental silos effectively enough.
This leads me to a set of questions that many ask. What are the benefits of the national programme? This has not been adequately explained, and we have not worked it out for ourselves.
That is what happens when you are told to implement a national system which is being paid for by somebody else. Or is it that I am just a typical trust chief executive who didn't understand the IT jargon when we were all instructed to embrace the national programme years ago? Or was the message not very clear?
Most would agree that the NHS has not done IT well. Many reasons are put forward; the most persuasive analysis was done by Treasury adviser Sir Derek Wanless, who said the NHS should be increasing its IT expenditure from around 1.5 per cent to 3-4 per cent of the total budget. The Wanless report also emphasised the importance of ringfenced IT budgets and stringent national standards. Those national budgets, and 'ruthless standardisation', are now largely in place thanks mainly to the determined, no-nonsense style of IT programme director general Richard Granger.
So the government has accepted the case for more IT investment, but has it arrived? Undoubtedly the placement of the national contracts has committed significant expenditure. But what about the costs to the NHS of implementation, training and support mechanisms?
Here the situation is not clear, and the picture is variable across the country.
To implement the national programme in the local health community of south Birmingham will cost£6.5m over three years.
This resource is now available from a variety of funding sources. But we hear of the new IT resources being diverted to meet more pressing requirements. You know, those to do with targets, star-ratings, and the like. Perhaps that is the purpose of linking IT investment to the local development plans. If one was being cynical, you might suggest it represents a forlorn hope that the new IT will deliver immediate, cashreleasing benefits.
As the national full business case for the programme is not a public document, the NHS does not know what benefits the government had in mind when it accepted the original case for investment. This is the key weakness as the national programme is now implemented locally. What will it deliver, and how do we achieve the 'benefit realisation?' At my trust, we have direct experience of implementing rulesbased prescribing systems that have demonstrably improved the safety of prescribing and administering medicines across the trust.
I believe investment in IT should support the development of safer and more efficient services, but not everyone will share my view.
So what is the current mood about the national programme? It varies from cautiously optimistic to sceptical. The reasons are complex.
Better communication is essential, but this can be a problem when there is a strong leader like Mr Granger who has been told to drive the programme from the centre. The real challenge is to obtain the understanding and engagement of the users, be they clinical or support staff.
Perhaps the main problem now is perception. Is the IT programme there to change the NHS, or just provide an IT infrastructure for the health service to use as it sees fit?
A new book by Sean Brennan, The NHS IT Project - the biggest computer programme in the world. . .
ever! , summarises the conundrum well. It claims that the cultural perception could be that we are about to implement a big patient administration system when the programme's real benefit is the ability to deliver transformed clinical processes, supported by modern IT.
Organisations will often take advantage of new software to change key business processes. But this approach is alien to the NHS. So how much standardisation of processes is appropriate?
The implementation of the national programme is being delivered through regional clusters which may be handling standardisation differently.
But whatever the approach, a degree of process standardisation may be achievable while PAS functionality is being deployed. But it will be harder for clinicians to agree protocols on ordering investigations and medicines management, or on how care pathways are to be constructed through organisations.
So the jury is out. There needs to be a managed debate with the NHS about the degree to which processes should be standardised.
There also needs to be a better model for engaging with the service so that users can influence how the new systems are delivered. Some successful early implementation would help to promote more positive opinions. .
Mark Britnell is the chief executive of University Hospitals Birmingham foundation trust.
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