NHS electronic care records project fails to achieve aim

How is the NHS electronic care records project failing and what can be done to address the problem?

The National Audit Office (NAO) recently published its third highly critical report of the National programme for IT (NPfIT), launched by the Labour government in 2002 to provide electronic care records for every NHS patient.

The report concludes that the project is failing in a number of key areas; in particular, it says the core aim of providing every patient in the UK with an electronic care record will not be achieved. Large chunks of the NHS have pulled out of the project – in places where it has been introduced it is not working as it should, and it is falling further behind schedule for those parts that remain in it. The programme has been condemned as not being good value for money.

So, in what ways is it failing?

Reduction in scope
"Significant reductions have been made in the number of acute trusts, ambulance trusts and GP practices to receive care records systems through the programme. These reductions mean the aim of creating an electronic record for every NHS patient will not be achieved under the programme."

Care records systems are no longer being delivered in every NHS organisation and the Department of Health (DoH) is no longer intending to replace systems wholesale.

Instead of introducing a new records system for all trusts, the DoH intends to build on local trusts' existing systems, allowing NHS organisations to introduce smaller, more manageable change in line with their local business requirements and capacity.

Reduction in benefits
Even where electronic care records systems are in place, they are not providing the benefits envisaged.

For example, clinical benefits, such as the ability to electronically manage the prescribing and administration of drugs in hospitals, are expected to be delivered in later releases of the systems that are not yet available.

Excessive delay in timescales
"At the outset of the programme, the aim was for detailed care records systems to be developed and delivered to all NHS trusts and GP practices (excluding GP practices in the south) by the end of 2007, with increased functionality and integration added until full implementation was complete in 2010. These timescales were not achieved and implementation is now scheduled to be complete by 2015-16."

However, based on performance so far, the NAO considers it unlikely the remaining work in the north, Midlands and east can be completed by 2016.

Indeed, in order to meet the revised deadline, more than two systems a month would need to be delivered in this programme area over the next five years, whereas in seven years, only four out of 97 systems have actually been delivered to acute hospital trusts in that area.

Not value for money
The scope of the programme has been significantly reduced, but without a proportionate reduction in costs. "We are seeing a steady reduction in value delivered not matched by a reduction in costs."

The report concluded that the £2.7bn spent on detailed care record systems "does not represent value for money" and that the NAO has "no grounds for confidence" that the remaining £4.3bn budget will be spent any better.

At the Public Accounts Committee (PAC) hearing on 23 May, Conservative Richard Bacon observed that the NHS had "thought it was buying a Rolls-Royce, but had ended up with a second-hand Datsun".

Why is the system failing?
The NAO report does not concentrate on the causes for the failure, nor does it seek to apportion responsibility for them.

It was, however, stated in the report that the "department's assessment does not measure progress against the original aims of the programme, but rather a minimum specification level of functionality agreed with clinicians in 2008, reflecting the move towards a more flexible approach. The department has recognised that the measure of functionality delivered should ideally relate to the detailed requirements set out in each of the original contracts, weighted according to the clinical benefit provided and complexity of implementation, but has not undertaken such an assessment." That strongly suggests the project is failing, in part because officials never measured progress against the original NPfIT aims.

More damningly, in an accompanying press release, head of the NAO Amyas Morse, said: "This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme."

The DoH accepted that "change is needed and the original vision is flawed", saying that is "why last year we announced a move away from a centralised, national approach to IT to localised responsibility and decision-making".

What can be done?

Review
In addition to the PAC hearing, a week-long Major Projects Authority review – run by the Cabinet Office and the Treasury – began on 23 May. The government will decide whether to continue with NPfIT based on the outcome of those reviews.

In the NAO report, it was stated that "given its past history, the major issues still confronting the care records systems, and with such significant funds still at stake, there is a compelling case for the recently announced Whitehall-wide review to re-evaluate the business case for the programme to determine what should happen now to safeguard against further loss of public value. That re-evaluation should include consideration of the significant risks outlined below."

The NAO warned that, in delivering the remainder of the programme, the DoH faces a number of significant challenges. These relate to delivering the programme within budget, completing the remaining work and maintaining governance of the programme.

Budget
Significant contract renegotiations to the value of £500m with the IT services provider CSC have not yet concluded.

The costs of the additional procurement required in the south, following the termination of Fujitsu's local service provider contract, are not yet certain.

And, of course, the NHS is seeking to deliver up to £20bn of efficiency savings by the end of 2014-15.

Outstanding work
Much needs to be done. Of the 4,715 NHS organisations in England now expected to receive a new system under the programme, 3,197 are still outstanding; and, as has already been noted, in order to deliver the systems by 2015/6, the pace of delivery required in acute trusts has to exceed the pace of delivery achieved to date.

Governance
By 2012, as part of the reorganisation of the NHS, strategic health authorities will be abolished and the existing governance structure for the delivery of care records systems will disappear. Although initial proposals have been discussed by the programme board, it is not yet known who will manage the existing contracts up to July 2016, and who will measure and report on the benefits of the programme.

Scrap the scheme
The problems have prompted some to call for the government to cut its losses and scrap the entire scheme.

Prior to the PAC hearing, Margaret Hodge, chair of the PAC, said: "We will want to question officials on whether the programme should be stopped, even at this late stage. We cannot, and will not, sit back and allow more public money to be spent, with ever-diminishing returns."

In her summing up of the hearing, she talked about how much money might be "salvaged" from the programme, strongly suggesting the committee would recommend it should be axed.

The NAO stopped short of suggesting that.

Senior NHS figures argued before the PAC suggested it could cost more to cancel the contracts than to continue with them. Sir David Nicholson, chief executive, and Christine Connelly, chief information officer, told MPs that cancellation would cost hundreds of millions of pounds in penalties and transition arrangements.

Further, a spokesman for the DoH said: "We think the investment made so far in the NPfIT will potentially deliver value for money now that we have a more flexible approach that allows the local NHS to be in charge of its own requirements. However, that is a future possibility, which was treated with considerable scepticism by the PAC."

Reduce scope further
As already stated, to achieve cost savings there has already been a reduction in the number of care records systems being delivered and changes to the approach for delivering them. It is stated in the NAO report that the DoH is in negotiations to reduce both the scope and functionality of the programme further still.

However, the NAO warned that giving responsibility for procuring services to individual local NHS organisations might risk a return to the haphazard procurement practices the programme sought to address.

It also gives rise to an increased risk of not achieving adequate interoperability across the NHS to support joined-up healthcare effectively.

In a paper presented to the National Programme Board in January 2011, however, the DoH noted that to deliver on its revised approach, accepted standards need to be developed and adopted by sufficient suppliers to support local interoperability needs.

Further, the DoH estimates that supporting the required interoperability of the systems will cost at least £220m.

Mark Lewis is partner at IBB Solicitors and leads the information technology practice