It has been clear for some time now that the English National Health Service (NHS) National Program for Information Technology (NPfIT) has been meeting a range of difficulties.
The initial vision was that, with the expenditure of approximately 4% of the NHS budget on IT, it would be possible to create a national E-Health environment that would provide a major improvement to the quality and safety of care both in the ambulatory and hospital environments over a period of about a decade and that this investment would support the dramatic re-shaping and modernisation of the NHS.
In concept a central data “spine” was to be developed which had a range of common services and which used common Informatics Standards (HL7 V3.0, SNOMED CT etc) and standardised products from a range of hospital and ambulatory care vendors to create and maintain a spine based shared Electronic Health Record for all UK citizens. The project was huge, involving expenditure of $A30 Billion over the decade.
The whole thing is one of the most ambitious public IT projects ever undertaken anywhere in world.
Two recent events have prompted the present commentary. Before this there have also been major controversy regarding patient consent issues, the financial difficulties of a major technology provider (iSoft) and contractual difficulties and changes in providers as well as some key delays. This is said to have contributed to major morale problems and uncertainty.
The two recent events have been:
1. Lord Warner the health minister responsible for the £12.4bn NHS IT project is to retire at the end of the year. Lord Warner was a strong proponent of the NPfIT and his departure is undoubtedly a major blow to confidence.
2. The British Computer Society’s (BCS) Health Informatics Forum has produced a careful and generally critical strategic summary of the current state of play.
This report is available on line at:
http://www.bcs.org/server.php?show=ConWebDoc.8970
“Key recommendations of the report include:
• The provision of a business context for the English National Programme for Information Technology (NPfIT) at national and local level.
• A focus on local implementations at Trust and provider unit level, for example hospitals, diagnostic and treatment centres, community and mental health Trusts, practices. Providing specialty and service-based systems within provider units will encourage clinical involvement and give quicker benefits.
• There needs to be a major emphasis on standards to enable systems to interoperate effectively, rather than focusing on a few monolithic systems.
• The strategy should be evolutionary, building on what presently works and encouraging convergence to standards over time, rather than revolutionary.
• To adopt a truly patient-centred approach at the local health community level
• There are major issues about the sharing of electronic patient data which need to be resolved. These must not be hijacked by technical issues, and informed patient consent should be paramount.
• Transform NHS Connecting for Health (CfH) into an open partnership with NHS management, users, the informatics community, suppliers, patients and their carers, based on trust and respect.
• The clinical professions, NHS management and informaticians should collaborate to provide clear and comprehensive guidance for all sectors on good record keeping and data management – clinical and other, and embed this in undergraduate and post graduate training. The NHS should facilitate the take-up of this guidance.”
Interestingly the summary of the report also says “The NHS CfH programme can still make a massive contribution to safer and more appropriate patient care and remains in full agreement with the Wanless report that 4 per cent of NHS turnover should be spent on business-led informatics, according to the BCS Health Informatics Forum (BCSHIF) Strategic Panel.”
On these eight bullet points, above, I would offer the following commentary:
1. The length of time between the original strategy development in 1998 and the present has allowed alignment of the IT and business needs to drift. This is a major risk and the BCS report very correctly says it needs to be addressed.
2. The BCS recognises the need to get quality basics in place quickly – and this is very sound. People need to see success to believe further success is possible.
3. The BCS is keen on standards based interoperability. I have some reservations this is achievable in the short to medium term – but if a sensible messaging strategy is adopted there is very little downside. The detail of the report makes it clear the BCS understands the practical difficulties of implementation of some of the standards and that time may be required to get things right.
4. The suggested movement from a centrally controlled implementation model to a more collaborative approach is clearly very sensible – although how this can be done at a practical level will need to be thought through.
5. The move to a patient-centred approach at a local level is sound if what is intended is more patient control of their information. The detailed text makes it clear this general direction is supported.
6. The BCS Forum clearly understands the complex issues around information sharing, consent and the like and wisely suggests progress be dramatically slowed until practical and acceptable solutions are found and properly evaluated.
The report also is keen that initiatives around PACS, Choose and Book and GP Record Transfer (GP2GP) continue saying they seems to be working as are some of the central spine services (Patient ID etc).
Overall I think this is a very, very sound twenty pages that has many answers for the UK and also is a valuable document for Australian readers as well. I commend it to you.
The real risk is that central NHS bureaucrats will loose their nerve and funding for the program will dry up, rather than an appropriate review and continued support for a forward direction and continued investment. (There is a real likelihood this is what happened in Australia with HealthConnect)
Should this happen the “I told you so” pundits and the risk averse will have a “once in a generation” win and IT enabled healthcare delivery globally will be a major looser. I really hope those involved in the UK can work through all this.
David.
6 comments:
BCS report written by disguntled gp system suppliers who have lost profits through contracting model and ex employees who lost their jobs when info auth shut down. your
re-organisation statement is garbage as all that is happening is that the nhs is now getting told to do what it was supposed to do originally. cfh was not set up to do the implementation.
spine in and working
you should get out more
and get real sources for your blog rather than third hand garbage.
I am interested in comments on this post as my comments are based on watching this project since 1998 and have not heard views like this before. Other feedback more than welcome.
David.
Although I'm certainly no expert on the workings of the BCS, I think it's a big call to say that the BCS Strategic Panel (see http://www.bcs.org/server.php?show=nav.7561) is driven by the interests of GP system suppliers. I'd suggest taking another look at the credentials of all of the people who are members of The Panel. Anonymous's view is a little over-simplified in my opinion.
It's not exactly clear what Anonymous means by 'reorganisation comment' ... is he/she referring to the evolution not revolution idea?
This idea is perhaps the most insightful of all the recommendations of the BCS. Unfortunately, it's one that seems a little lost in the Australian political landscape.
Perhaps 'Anonymous' is closer to the action and has a more informed view of what is going on? On the other hand, perhaps Anonymous really is 'out there'.
I think an interesting question is, who will end this ?
To me, it seems that no one at isoft is going to say "we stuffed up, we can't deliver, we are way over budget and way over our heads" - basically, a corporate suicide.
At the same time, at the various government agencies, who is going to say "this project is completely messed up, lets cut our losses and give up / abandon / restart / etc"
Not only you have the fact that government officials rarely like to admit/point out their own mistakes, there's also the fact that this project keeps the money rolling around. I am sure various private concerns make generous contributions/business trips/lunches/etc to various government decision makers, all in order to keep the money flowing through this project. Then there is the fact that the person who blows the bubble will have a lot of negative press attached to their name. Do you think both internally (corporate culture) and externally (media wise)the said person will be called "the brilliant analyst who saved the government from losing more millions" or "incompetent bureaucrat finally admits to government blowing away millions"
SO yes, it does appear to be failing, haemorrhaging, various experts finding problems (details pointed out by this blog on a number of occasions), the actual scope ie beyond the current budget and the budget is way of initial scope.
Maybe its like war? - Keeps the economy healthy by shuffling very large amounts of money around. Who wants to be the party pooper ?
It may be worth watching progress at the NHS Strategic Tracing Service (NSTS).
The NSTS will be replaced by the Personal Demographics Service (PDS), part of the NHS Care Record Service (NHS CRS), in a phased manner during the period 2005 to 2007.
It seems to me NSTS is the core Identity Management (IM) agency for NHS. If so, I wonder how it will mesh with the new direction for the
UK's master IM structure? ID
card plan sparks fears over data security (John Reid scraps proposal to build database from scratch.)
Originally, the record system, known as the national identity register, was to have been entirely newly-built, in order to avoid contamination from errors in existing database files on individuals. But, in a 33-page progress report on the timetable for an identity card scheme, the home secretary revealed that instead the database would be compiled from amalgamated information from three separate Whitehall databases. The information will be split between computers at the Department for
Work and Pensions, the Home Office and the immigration and passport
service.
John Reid's announcement is synchronous with Australia's Office of Access Card. Here, we will be looking for 'proven
applications', and No "bleeding-edge tech" for access card. "We're not interested in elaborate, customised solutions that put at risk the program budget," Hartland said. Does that cut out the smart people in academia?
Nor is it clear to me how the NSTS interacts with NHS Numbers For Babies (NN4B).
Atos bought the company (a part of SchlumbergerSema) that took the
contract for NSTS. It's probably spelt out somewhere which arm - public or private - has rights to ownership of data., but who knows how it would stand up to a legal challenge under corporations law?
The NHS Strategic Tracing Service is delivered by Atos Origin as part of a Public/Private Partnership (PPP). The service is managed by NHS Connecting for Health, which is responsible for monitoring its use as well as data quality, security and confidentiality and ensuring
that the service levels agreed in the contract are met.
With regard to the Q&A
session on the Oz Access Card, it is clear that the issue of
intellectual property is a key consideration, as it should be. In the UK, collaborative systems being led by academic schools may have some hope of protection under Crown Copyright (see the imprint at the foot of the NSTS pages). Major projects in the public sector always contain significant input, at all stages from concept through to maintenance, from public sector employees. I suggest that essential component may not be as forthcoming as it has been in the past, because there is no inbuilt acknowledgment of the contribution of, say, front line health care workers. The BCS, as the MSIA, is darn right to hammer away at the business models, and the rights to intellectual property ownership. Just a matter of sustainability. But some people will want to contribute from beneath the umbrella of 'public service'. If the UK government, not to mention the uber-Thatcherite Australian enterprise, is not willing to craft legal structures to enable public and private to work together, it's going to be long series of disappointments.
(NSTS offers subscription to an email update service via Listserv, but my attempt failed.)
Having worked at CFH, it felt like a lot of square pegs being forced into round holes. Applications that did less than existing systems were being implemented- you can only imagine the joy for those who were stuck with so called 'interim' solutions whilst isoft was meant to be working on Lorsenzo.
It's not so much the wheels are coming off now - I don't think they were attached well in the first place. Ambitious high level plans and a lack of skills to get it from paper to the real world, combined with a NHS wide re-organisation of Strategic Health Authorities in 2006, huge budget problems within Trusts, the implementation of Payment by Results and too many layers of red tape in between...
but I hear PACS is going well!
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