The centralisation of Connecting for Health and a lack of local leadership are proving an important battleground for Conservative policy debate. Steve Mathieson looks at the detail

David Cameron's speech at the end of October's Conservative Party conference included many references to the health service, including an attack on Labour's frequent reorganisations. But it did not mention one of the most significant moves: the creation of the national IT programme run by NHS Connecting for Health.

Although he described the programme as 'delayed, disorganised; a£20bn shambles' in a speech at the start of the conference, it did escape Mr Cameron's ire in the 'no more pointless reorganisations' rallying cry of his second conference speech. So it seems he can see the point of reorganising this.

But what might that involve? 'We've said very little on what we would do in government,' says Stephen O'Brien, shadow minister for health responsible for IT, although he says CfH would be subject to a review.

'The point of a review is it's only as good as its information,' he adds, while also claiming that the government hides behind commercial confidence to avoid providing full data on the project, although he has used parliamentary questions to extract some. 'It's noticeable that the National Audit Office found it very difficult to get in behind all the issues that needed to be examined,' he says.

Mr O'Brien's main criticisms of CfH provide some idea of what might be changed in England under a Conservative government. 'First, there was inadequate consultation with user groups at the outset of the programme,' he says. When consultations took place, those questioned could not then see how their views had any impact. Since then, little user feedback has been sought.

Conservative MP Richard Bacon, a member of the Commons public accounts committee, has written a paper on how CfH could be reorganised. This is not an official document from the party: Mr Bacon says party allegiance should not be a factor on IT projects.

'It's hard to think of anything less party political than a computer system - it either works, or it doesn't,' he says. The paper was jointly written with Liberal Democrat MP John Pugh (see box) and Mr Bacon had hoped to involve a Labour MP as well, but the person chosen was unavailable.

He and Mr Pugh suggest decentralising many IT purchasing decisions to managers at local trusts and involving practitioners, an argument which fits with Mr Cameron's rhetoric and Mr O'Brien's criticisms.

Mr Bacon says the main problem lies with the local service providers (LSPs), which are falling far behind in implementing systems at local trusts. In June, NHS IT director general Richard Granger passed on information from LSPs which suggested patient administration systems (PASs) would have been implemented in 22 acute trusts by the end of October. In reality, only two trusts had implemented the systems and just two more partially (news, page 9, 2 November).

Mr Bacon says that although the LSP contracts are secret, he understands that the penalties were 'absolutely excruciating' - about half the total contract value - for any companies pulling out.

But Accenture, when it abandoned most of its CfH work in late September, was not held to these penalties, which Mr Bacon estimates should have cost the US firm about£1bn. 'The fact that they were able to walk away without paying a huge penalty is, at best, a vague sign of realism from CfH,' he says.

Powerful guy, big wallet

Mr Bacon believes LSPs would probably jump at the chance to leave CfH, given the losses they appear to be suffering. Instead, health trusts would choose their own systems, within standards set by a smaller CfH.

Trust chief executives would be made personally responsible for introducing modern IT by 2010 - which Mr Bacon says was part of the previous NHS strategy.

He says this would reduce the central programme's complexity and reduce reliance on a small number of suppliers, including the troubled software firm iSoft. Mr Bacon also believes it would be cheaper, largely dismissing the argument that CfH has saved money by buying in bulk.

In the case of picture archiving and communication systems, a late addition to CfH, Mr Bacon says he has been told each hospital trust is paying£600,000-£1m more a year than they would have done if they had bought systems independently. However, he says Mr Granger likes centralisation: 'That makes him a powerful guy with a big wallet. I'm not sure that's a good use of taxpayers' money.'

The spine of patient data, available throughout the health service, would be slimmed to purely demographic and emergency medical information, and its accuracy improved.

Other centrally provided systems, such as the N3 broadband network, would also be reviewed.

Mr Bacon insists he is no Luddite. 'There are clinicians who will tell you that electronic prescription of drugs makes such a difference that it is unethical not to use it,' he says. 'I don't want to be seen as an opponent of IT - I am an opponent of wasting taxpayers' money on things that don't work.'

The Conservative Technology Forum, a party think tank, is also considering CfH's future. In April 2005, it published Computerising the Chinese Army, a report which characterised CfH as a 'top-down transformation programme [which] is not only being imposed on users who have not been well consulted, but is being done at a speed which compounds the risks'.

Author Ellie Hopkins is working on a revised version. 'I still think the system is fundamentally flawed but there are some potential strengths if they can be made to work,' she says. These include choose and book, if changes such as offering more information on the clinical quality of each option were brought in.

But other areas of CfH's work seem to be in serious trouble, Ms Hopkins adds, such as the system's basic infrastructure - which she compares to tourism developments in the former eastern bloc ('you build all the hotels but don't put in the transport infrastructure').

The large, central database model, and its use within CfH, is criticised by some experts in information security. Ross Anderson, professor of security engineering at Cambridge University and chair of think tank the Foundation for Information Policy Research, told a conference fringe meeting held by the Conservative technology forum: 'As a general principle in systems, you can have any two of functionality, scale or security, but not all three.'

Margin for error

Security of personal information is the one element he believes the current government would sacrifice.

'I may be happy about trusting my GP, but I'm sure as hell not happy about trusting the permanent secretary of the Department of Health,' Professor Anderson told the meeting.

Professor Anderson said the move to centralised databases also puts new and unexpected stresses on technology infrastructure. This would mean the health service could be crippled by the failure of data centres and network connections: 'If you are going to re-engineer the UK like this, people will die,' he said.

MP Charles Hendy, president of the forum, said the Conservatives' health passports policy, since dropped, included issuing cards holding medical data, which would put responsibility into patients' own hands. Placing records on a smartcard is used by the New York borough of Queens, allowing patients to move between hospitals while maintaining a health record.

Mr O'Brien says there is a major difference between Conservative criticisms of the national programme and those of the identity card scheme: the Conservatives do not want to abolish the national programme. 'There's a world of difference between information which is to identify people as a citizen, and information which is part of the medical history and prognosis of patients,' he says. 'We all agree that if you could get electronic patient records, easy exchange of information and the other objectives of CfH easily and efficiently, that is a desirable goal.

'Our criticism is the design and implementation and the absence of full accountability.'