Under pressure

Major IT implementations tend to run late and go wildly over budget. And the national IT programme is no exception.

Earlier this year, health minister Lord Warner was forced to admit that the original£6.8bn cost estimate was now likely to be around£12.4bn. Industry observers consider that the actual figure may end up as high as£15-18bn - well over double the original budget.

The national emergency care records service, linking all parts of the programme, is two years behind schedule. The local care records services are also late, although three patient administration systems are now in place.

High-profile technical problems at the launch of choose and book last year, and more recently the 48-hour crash of booking systems in the Midlands and the North-West, have not helped the programme's image.

But all the criticism may be a little unfair. The NHS programme is the biggest ever civilian IT project in the world, and the health service's record on standardising and modernising IT is not exactly the finest. All IT systems have down time and glitches and are prone to failure at launch.

Warm reception

Anecdotal evidence strongly suggests that where aspects like choose and book are embedded and running, they are well liked and considered user friendly. There have now been 16,540 connections to the national network for the NHS (N3), and 97 per cent of GP practices are connected. When completed, N3 will be one of the largest virtual private networks in the world.

The health service badly needs the programme, delivered by NHS Connecting for Health, to work. Many of the financial assumptions made about productivity and savings depend on IT systems being on time and consistent. It is clearly a big job, with a lot of room for problems.

One of those is around uptake. It appears that the scheme has got stuck beyond early adopters and the tech-friendly section of the user community. The programme is currently preparing a raft of regional events to address and engage the GP community.

One of the carrots to the GP community effectively began at the beginning of September, with the start of the measurement period for the choose and book payment incentive. Practices will be rewarded if they make at least 50 per cent of referrals though choose and book by the end of February 2007. To qualify for the maximum payment, they must get to 90 per cent.

National primary care director Dr David Colin-Thomé ¡nnounced this summer that over a million referrals have now been made through choose and book - although he was candid enough to point out that this meant 80 per cent of referrals are not done online.

More bad news was unearthed in a recent survey of acute trusts by E-Health Insider, which found that only seven of the 22 acute trusts due to have installed electronic patient administration systems to book consultant appointments by the end of October will meet the deadline. Without these in place, delivery of other parts of the programme are of little use.

The more recent high-profile problems have been with the suppliers. iSoft, the programme's largest software supplier, is now under investigation by the Financial Services Authority for possible accounting irregularities. One of the company's co-founders has been suspended and accountant Deloitte has refused to sign off its accounts for the past financial year.

The FSA is also investigating allegations of irregularity in the company's accounting procedures in recent years. The firm announced pre-tax losses for the 12 months to the end of April this year of£344m (news, page 6, 31 August).

iSoft has also said it is in dispute with both Accenture and Computer Sciences Corporation (CSC), which are installing its products as part of their NHS contracts. The Guardian found in July that iSoft's Lorenzo software, which was to be installed in 60 per cent of England's GP practices and hospitals, was regarded by Accenture and CSC as having 'no believable plan' for release.

Accenture itself announced a£238m provision against future losses from NHS revenues, before it pulled out of its local service provider contracts for the North East and Eastern clusters. In theory the contracts are worth almost£2bn over 10 years.

In a statement on its Q2 financial figures, Accenture chief executive William Green said: 'Several issues increased the risks and uncertainties associated with the NHS contracts and affected our estimates of expected contract revenues and costs.' He added that the company had 'devoted additional management resources at the highest level to resolve the NHS matter as quickly as possible.'

BT has been paid just£1.3m for its work in the past two years in London, having spent over£200m. The company recently dropped its original software partner IDX in favour of Cerner: a change of sub-contractor likely to have set BT's plans and timetable back.

But BT's public comments about medium- to long-term financial consequences have been bullish, and it predicts there will be no need for a rethink on current forecasts.

BT's London implementation attracted adverse publicity when a system relating to children's health and immunisation records created significant problems in the data: attributable, according to BT, to problems with the original paper records.

The health IT industry is awash with rumours about plans for a wave of supplier consolidation. This was reflected in the number of organisations unwilling to comment on the record for this article. Some commentators feel market consolidation is the only way to get delivery back towards schedule.

Others point out the irony that the 'contestable' supplier market envisaged in the programme's design, aiming to ensure lean-and-mean market conditions for suppliers to the advantage of the programme, will be out of the picture should this happen.

Another dispute has arisen over payment. Ministers have insisted payment is conditional on delivery, and only follows successful sign-off. However, a letter seen by The Observer, sent from the national IT programme's chief financial officer Gordon Hextall to all NHS trust executives in May 2005, reportedly said the Department of Health 'agreed to make annual payments to iSoft in respect of predicted charges payable by trusts and GPs'. These advanced payments are thought to exceed£30m.

Programme boss Richard Granger told the Commons public accounts committee in June this year that it had made 'advanced payments' to contractors who could produce a bank letter of credit. The level of these payments has not been quantified.

The National Audit Office has flattered to deceive in its work to date. Its director Sir John Bourn had unusually warned in advance that the NAO's first report on the IT programme would be critical, yet the eventual document (published in June) couched its comments in the mildest terms, praising the 'substantial progress' made.

Several media organisations requested the original draft of the report under the Freedom of Information Act, and the watering down of its language attracted widespread comment. This is now followed by the highly unusual announcement of a second report into the programme, starting this Autumn.

Reasons to be cheerful

CfH director of external affairs James Herbert says: 'There has been much good delivery already under CfH. Hundreds of new systems have been installed, benefiting tens of thousands of clinicians and millions of patients.

Parts of the programme are ahead of schedule and others - such as the NHS summary care record - are up to two years behind. This is because the new software is challenging and also because there is an ongoing debate about what information the records should include.'

Mr Herbert adds that 'implementing a programme the size and scale of the national IT programme is complex and remains a challenge. But the existing IT situation in the NHS is not sustainable. There are hundreds of different systems in operation, of variable age and reliability and that don't link up.'

The programme is expecting the majority of picture archiving and communications system (PACS) deployments to be completed by March 2007, with full completion across the NHS in England following by December 2007.

They also aim to ensure that the electronic prescription service is fully operational by 2007. Although this is dependent on GP and pharmacy system suppliers making their systems compliant.

The programme has invited primary care trusts to participate in early adopter implementations of the NHS summary record. Live running of the early adopters is planned for early 2007, and early adopter implementation will focus on the general practice element of the NHS summary record, enabling it to be shared with appropriate healthcare professionals within the PCT area.

It is understood that the programme is undergoing some internal review. So it seemed logical to ask how this 'refresh' is going? A CfH spokesman replied: 'There is no "refresh" of the programme. In March 2006 Richard Jeavons [CfH senior responsible owner for service implementation] mentioned refresh in the context of work being done by the DoH on information in the context of health reform policy.'

So how will the programme be affected if there is a wave of supplier market consolidation? 'The contractual model and procurement anticipated this and is prepared for changes in the supplier community.'

And the spokesman was confident that the IT programme will take recent consolidation of PCTs and strategic health authorities in its stride. 'We have a team looking at how the reorganisation will affect our work, and we shall continue to deliver what the NHS wants and needs.'

Engagement party

Given the resistance of some doctors to the software and the requirements to make patient data widely available, some are worried about engagement in the clinical community.

But joint national clinical lead for hospital doctors Simon Eccles says CfH's national clinical leads are working closely with the clinical community. 'Thousands of doctors, nurses, midwives and allied health professionals have already contributed to shaping the systems and services being delivered.

'Since January 2006, the leads have had 58 meetings with professional bodies. Representatives of 72 professional organisations, including 13 royal colleges, are members of the national advisory groups which provide a key forum for debate on the IT programme and for sharing expertise and experience. There is clinical engagement but we will need more and will continue to open up opportunities for as many clinicians as possible to get involved.'