It has been called the world's biggest civilian computer project. It has cost billions so far, has billions more to spend and is not even close to delivering the aims set for it in 2002. The national IT programme is, it would be fair to say, controversial.
The programme was set up in 2002 to bring modern computer systems to the NHS. Its main aim was to move the NHS in England towards an electronic care record for patients and to connect 30,000 general medical practices to 300 hospital trusts, providing secure and audited access to these records by authorised health professionals. Eventually, patients would have access to their own records via a service known as HealthSpace.
In 2003, the IT programme placed contracts worth£6.2bn to create a new broadband network for the health service in England; to deliver a suite of national services to run over the network; and to improve local administration, imaging and clinical systems.
The benefits were presented in terms of improved services for patients as well as improvements in efficiency and productivity.
There were concerns about the vast cost of the programme and, more fundamentally, about the wisdom and safety of a massive central database with the health records of every single person in the country.
In April 2005, the government disbanded the NHS Information Authority, which had, up to that point, run the IT programme, and replaced it with a new agency - NHS Connecting for Health.
In 1998, the NHS published its second IT strategy, Information for Health. It suggested creating electronic health records accessible by health professionals 24 hours a day and transferable between NHS organisations using an NHS 'information superhighway' - NHSNet.
Its catchphrase was 'national strategy, local implementation'. The idea was that new national bodies would set standards, deliver the NHS-wide elements of the strategy and run demonstration projects. This would leave health communities to procure and implement systems in line with national objectives.
The IT landscape in the NHS at this point was very undeveloped. GPs, as independent contractors, had led the way and invested heavily in computer technology. However, their systems rarely connected to the rest of the NHS.
The strategy never really got off the ground. NHS IT had no earmarked funds, so it slipped back in local delivery priorities. Procurement was slow and difficult and the project was challenged by the task of integrating new and old technologies.
By 2002, it was clear that the targets set in Information for Health would be missed. The Audit Commission published a scathing report on the dismal state of NHS IT, saying nearly half the hospitals in England and Wales were unable to collect enough data to know whether they were meeting government standards on waiting times.
This was the point at which everything changed. It stemmed not just from the failure of the 1998 policy but also from a seminar at 10 Downing Street in February 2002, at which major IT corporations, Microsoft among them, briefed prime minister Tony Blair.
The only way he would see the 2000 NHS plan delivered, they said, would be through wholesale computerisation of the NHS.
This was the vision they presented. Patients could be encouraged to look after themselves by giving them information via NHS Direct and access to their own health records. This would reduce demand for services and, with medication ordered electronically, they would not even need to visit their GPs for repeat prescriptions.
When they needed an appointment, they would book online in advance and their GP would have access to a full electronic record. The doctor could order tests and receive results online and use information from an 'expert system' to aid diagnosis.
If a hospital appointment were needed, it would be booked at a time to suit the patient.
At the hospital, 'workflow' software would co-ordinate procedures and create a discharge summary from the electronic patient record. The system would also notify social services and GPs if the patient needed follow-up care at home.
Last but not least, the system would create information for the NHS to tell the government - and its customers - how it is performing.
Mr Blair was persuaded and gave his blessing to a£12.4bn project to make the vision a reality.
It fell to Sir John Pattison, the Department of Health's civil servant responsible for NHS IT, to make the announcement at the Healthcare Computing 2002 conference in Harrogate in March. There would be a new, centralised 10-year NHS IT programme with central funding.
In return for more money from the Treasury, there was to be a ruthless standardisation and procurement from a slimmed-down list of major IT companies.
There were four major planks:
basic infrastructure in the form of a national broadband network, known as N3;
electronic health records, starting with a slimmed-down basic record accessible anywhere in the NHS. A full electronic record would be available in 2008;
electronic prescribing to cut waste and errors and guide doctors to generic prescribing;
electronic booking. By 2005, all patients and GPs would be able to book appointments at a time and a place convenient to the patient.
The general thrust and direction was set out in the April 2002 document, Delivering the NHS Plan. The detail was fleshed out in the third IT strategy Delivering 21st-Century IT Support for the NHS: a national strategic programme.
In October 2002, the national IT programme was formally established and Richard Granger, an IT consultant who had project managed the introduction of London's congestion charge, was made director general of NHS IT.
In April 2005, the government disbanded the NHS Information Authority, which had up to that point had overall responsibility for NHS IT, and created NHS Connecting for Health as a government agency to run the IT programme.
Implementing the programme
The overall plan was for a series of national projects - N3, clinical coding, interoperability standards, choose and book, NHSMail, electronic imaging systems and so on - and local projects to deliver products to NHS organisations.
These local projects were to be delivered through local service providers in five clusters across England. They were charged with delivering the national solutions to local organisations as well as developing and delivering new patient administration systems to NHS trusts and clinical systems to GPs.
The NHS would contract with a number of leading providers for the national contracts and the local ones. Mr Granger argued that this sort of block procurement would reduce costs, increase interoperability and offer more consistent development of NHS IT. It would also put some of the risk of failure back onto providers.
By December 2002, procurement was under way. The IT programme placed an advert in the Official Journal of the European Communities for 'prime service providers' to deliver different elements of the strategy.
May 2003 saw the publication of an output-based specification for an integrated care records service. It outlined the appointment of a national application service provider to deliver the national 'data spine' that would form the backbone of the electronic health record.
By December 2003, the contracts had been awarded and local service providers had appointed partners to develop the software that would run on their systems as they implemented them.
What the programme does
The IT programme has a number of roles and these have changed over the years. New services have been added since the original scope in 2002.
Nationally, it sets NHS computing standards and ensures that different computer systems are compatible with one another.
It develops software to support national policies (such as the quality management and analysis system that supports payments to GPs) and negotiates 'enterprise-wide agreements' for commercial products such as Microsoft's Office suite.
The core of the programme is to oversee the creation of a new IT infrastructure for the NHS based on the N3 broadband connection, a suite of national services and improved local systems.
The national services were to be delivered by national application system providers who bid for contracts throughout 2003. Over the years, the providers have chopped and changed in response to commercial pressures and their ability to deliver. This is the progress on the main projects so far:
N3: a new broadband network for the NHS to replace NHSNet and provide fast, secure data, voice and video links for the NHS in England. Although the rollout suffered early delays, by November 2007, N3 connections were in place in 20,917 NHS locations supporting more than 1.2 million staff. The contractor on this was BT.
NHSMail: the NHS directory and e-mail service that provides NHS staff with an e-mail address for life and secure e-mail facilities from the internet or NHSNet. By November 2007, more than 300,000 NHS staff were registered to use it. The contractor was Cable and Wireless.
NHS care records service: another BT contract. Initially meant to roll out in 2008, then in 2010 and now delayed further. It now has two components: a detailed record of information recorded by health professionals and held in their own organisations and a summary record, holding basic information about the patient and their medication, including allergies, to be held on the national spine. It has been beset with problems (see criticisms). By November 2007, a handful of 'early adopter' site were operating using summary care records.
Choose and Book: Atos Origin and Cerner won the contract for the online service that would allow patients to choose their secondary care provider and make an appointment online. It has been beset by delays and objections but by November 2007 over 6 million bookings had been made using the system.
Electronic transmission of prescriptions: this got off to a mixed start, with GPs still issuing paper prescriptions with a bar code that dispensers could use to retrieve an electronic copy. In the second release, GPs will issue an electronic message with a digital signature to a nominated pharmacy. By November 2007, more than 50 million prescription messages had been sent using the ETP system.
Picture archiving and communications systems: one of the early wins for the IT programme. PACS offer electronic images in diagnostic applications, allowing hospitals to do away with x-ray films, for example. Images can be transmitted to where they are needed. By November 2007, 121 PACS were installed and more than 437 million images had been created and stored.
GP2GP: a system for transferring patient records between GP practices. Now up and running.
Secondary uses services: the reporting part of the spine, where anonymised patient data can be analysed for financial information and used for research. Governance of this information has proved controversial.
Snomed: a common clinical language being developed by NHS Connecting for Health is still in development.
Local service providers: these have been beset by difficulties and delays. Some have been fined for late delivery; some have withdrawn and had to be replaced. Both the major software providers have withdrawn. The rate of PAS installation is painfully slow.
Criticisms of the programme
These fall into several categories:
local versus national approach;
confidentiality and the opt in/opt out model;
The most fundamental objection to the national programme - and one that was made at the outset - was that the whole idea of centralising NHS IT was flawed because healthcare is too complicated and local organisations too diverse for this to work effectively.
Critics have argued that the principles behind Information for Health should have been retained with trusts and GPs left to work with suppliers to create systems that comply with national standards.
Mr Granger has never accepted this argument, insisting that no other industry works in this way and that the problems the NHS experienced before the programme proved it did not work anyway.
In fact, there has been some devolution. GPs were furious that new systems were to be imposed on them and they have negotiated a GP systems of choice deal with Connecting for Health that should, in theory, see some discretion. It has yet to be finalised.
More broadly, in 2007 Connecting for Health launched the local ownership programme, which saw strategic health authorities taking a strategic lead for delivery in their areas. Meanwhile, in London, BT set about negotiating a contract reset that would see a move towards 'best of breed' that would allow trusts some choice in new PAS providers.
In the summer of 2007, the health select committee called for a further decentralisation of power, arguing for a move down to trust or PCT level. The Department of Health rejected the idea.
Another major and long-standing criticism is over patient confidentiality. Critics, including academics, the BMA and civil liberties groups, argued that the very act of putting all patient data onto one single spine is a recipe for disaster. They accused Connecting for Health of paying insufficient heed to protecting privacy and safeguarding data.
Connecting for Health has responded to these concerns by setting up a variety of mechanisms designed to ensure data is protected. For example, in September 2007 it issued the NHS Care Record Guarantee, which sets out the rules that will govern information held in the NHS care records service.
However, much to the chagrin of the BMA, Connecting for Health has not conceded ground on the opt in/opt out model. The BMA wants to see patients opt in to the system by signing up; Connecting for Health is pressing ahead with an opt-out model that requires individuals who object to their data being held making their wishes known.
Clinical engagement was another of the big complaints, with doctors and nurses saying their experience, perspective and energies were being ignored. In autumn 2004, Connecting for Health set up a clinical engagement programme and employed clinical leads to address this.
The cost of the programme continues to be controversial, with questions raised not just about how much has been paid to whom and what far but also about what the total bill will be at the end of the implementation.
In June 2006, the National Audit Office published a report that apparently gave the IT programme a clean bill of health. Connecting for Health summarised it by saying: 'The National Audit Office's report in June 2006 confirmed that the National Programme for IT in the NHS is much needed, well managed and on budget. The overall cost of the National Programme for IT is£12.4bn over 10 years.'
A leaked earlier draft later emerged, indicating that the report may have been watered down.
In April 2007, the public accounts committee published another report on the programme which said: 'Four years after the start of the programme, there is still much uncertainty about the costs of the programme for the local NHS and the value of the benefits it should achieve.'
In June 2007, Mr Granger, for so long the face of the IT programme, announced he was going to quit at the end of the year. By the last day in November, there was still no announcement about his successor.
There is no credible suggestion that the IT programme should be abandoned, but with contracts now being 'reset' in London and other clusters likely to follow suit, the future direction of travel - like much of the detail of the programme - is not entirely clear.