NHS Connecting for Health

NHS Connecting for Health is part of the UK Department of Health and was formed on 1 April 2005, replacing the former NHS Information Authority. It has the responsibility of delivering the NHS National Programme for IT (NPfIT), an initiative by the Department of Health in England to move the National Health Service (NHS) in England towards a single, centrally-mandated electronic care record for patients and to connect 30,000 General practitioners to 300 hospitals, providing secure and audited access to these records by authorised health professionals.

In due course it is planned that patients will also have access to their records online through a service called HealthSpace. NPfIT is said by NHS CFH to be "the world's biggest civil information technology programme".

The cost of the programme, together with its ongoing problems of management and the withdrawal or sacking of two of the four IT providers, have placed it at the centre of ongoing controversy, and the Commons Public Accounts Committee has repeatedly expressed serious concerns over its scope, planning, budgeting, and practical value to patients. As of January 2009, while some systems were being deployed across the NHS, other key components of the system were estimated to be four years behind schedule, and others had yet to be deployed outside individual trusts at all.

While the Daily Mail announced on 22nd September 2011 that "£12bn NHS computer system is scrapped...", The Guardian noted that the announcement from the Department of Health on 9th September, had been "part of a process towards localising NHS IT that has been under way for several years". Whilst remaining aspects of the National Programme for IT were cancelled, most of the spending would proceed with the Department of Health seeking for local software solutions rather than a single nationally imposed system.

Structure and scope of the programme

The programme was established in October 2002 following several Department of Health reports on IT Strategies for the NHS., and on April 1, 2005 a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced. CfH is based in Leeds, West Yorkshire.

As of 2009, it is still managed nationally by CfH, with responsibility for delivery shared with the chief executives of the ten NHS strategic health authorities.

Reviews

The refusal of the DoH to make "concrete, objective information about NPfIT's progress [...]available to external observers", nor even to MPs, has attracted significant criticism, and was one of the issues which in April 2006 prompted 23 academics in computer-related fields to raise concerns about the programme in an open letter to the Health Select Committee. 2006-10-06 the same signatories wrote a second open letter

A report by the King's Fund in 2007 also criticised the government's "apparent reluctance to audit and evaluate the programme", questioning their failure to develop an ICT strategy whose benefits are likely to outweigh costs and the poor evidence base for key technologies.

A report by the Public Accounts Committee in 2009 called the risks to the successful deployment of the system "as serious as ever", adding that key deliverables at the heart of the project were "way off the pace", noting that "even the revised completion date of 2014-2015 for these systems now looks doubtful in the light of the termination last year of Fujitsu's contract covering the South", and concluding "essential systems are late, or, when deployed, do not meet expectations of clinical staff".

The initial reports into the feasibility of the scheme, known to have been conducted by McKinsey, and subsequent reports by IT industry analyst Ovum among others have never been published nor made available to MPs.

Costs

Originally expected to cost £2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be £12.4bn over 10 years, and the NAO also noted that "...it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme". Similarly, the British Computer Society (2006) concluded that "...the central costs incurred by NHS are such that, so far, the value for money from services deployed is poor". Officials involved in the programme have been quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of 440% to 770%.

In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."

The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not £1bn, as the contract permitted, but just £63m. Granger's first job was with Andersen Consulting, which later became Accenture.

Deliverables

The programme is divided into a number of key deliverables.

Deliverable	Since	Name of software	Original delivery date	Progress 2007	Progress 2009
Integrated care records service	2002	NHS Care Records Service (NCRS) / Lorenzo	2004	"Real progress only just beginning", no go-live date specified	"Recent progress...very disappointing", completion date of 2014-2015 now looks unlikely following withdrawal of Fujitsu, arrangements for South region not resolved, Lorenzo still not live in a single acute Trust
Electronic prescribing	2002	NHS Electronic Prescription Service	2007	Implementation began in early 2005, used for 8% of daily prescriptions	70% of GPs and pharmacies had 1st release of software, but only 40% of prescriptions issued with readable barcodes
Electronic appointments booking	2002	Choose and Book	2005	Take-up slow, system reliant on outdated technology, GPs dissatisfied, target of 90% of referrals on system by March 2007 missed	Mixed, around half of new appointments made using system, additional training and time required
Underpinning IT infrastructure	2002	New National Network (N3)	March 2002	On schedule, with 98% of GP practices connected
Medical imaging software		Picture Archiving and Communication System (PACS)
Performance management of primary care		Quality Management and Analysis System (QMAS)
Central e-mail and directory service		NHSmail*

*NHSmail was renamed to Contact in late 2004, before being reverted to NHSmail in April 2006.

The Spine (including PDS & PSIS)

The Spine is a set of national services used by the NHS Care Record Service. These include:

• The Personal Demographics Service (PDS), which stores demographic information about each patient and their NHS Number. Patients cannot opt-out from this component of the spine, although the can mark their record as 'sensitive' to prevent their contact details being viewed by 831,000 staff.
• The Summary Care Record (SCR). The Summary Care Record is a summary of patient's clinical information, such as allergies and adverse reactions to medicine.
• The Secondary Uses Service (SUS), which uses data from patient records to provide anonymised and pseudonymised business reports and statistics for research, planning and public health delivery.

The Spine also provides a set of security services, to ensure access to information stored on the Spine is appropriately controlled. There are, however, already suggestions these security measures are inadequate, with leaked internal memos seen by the Sunday Times mentioning "fundamental" design flaws. In addition, government spokeswoman Caroline Flint failed to dispel concerns regarding access to patients' data by persons not involved in their care when she commented in March 2007 that "in general only those staff who are working as part of a team that is providing a patient with care, that is, those having a legitimate relationship with the patient, will be able to see a patient's health record."

Exceptions

The NHS in Wales is also running a national programme for service improvement and development via the use of Information Technology - this project is called Informing Healthcare. A challenge facing both NHS CFH and Informing Healthcare is that the use of national systems previously developed by the NHS Information Authority are shared by the both these organisations and the Isle of Man. Separate provision needs to be made for devolution, while maintaining links for patients travelling across national borders.

NPfIT is currently focussed on delivering the NHS Care Record Service to GPs, Acute and Primary Hospitals, medical clinics and local hospitals and surgeries. Whilst there are no immediate plans to include opticians or dentists in the electronic care record, services are delivered to these areas of the NHS.

Clusters and Local Service Providers

The programme originally divided England into five areas known as "clusters": Southern, London, East & East Midlands, North West & West Midlands, and North East. For each cluster, a different Local Service Provider (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered. However, in July 2007 Accenture withdrew from the project, and in May 2008 Fujitsu had their contract terminated, meaning that half the original contractors had dropped out of the project. As of May 2008, two IT providers were LSPs for the main body of the programme:

• CSC Alliance - North, Midlands & Eastern (NME) cluster
• BT Health London (formerly BT Capital Care Alliance) - London cluster
• Accenture had full responsibility for the North East and East/East Midlands clusters until January 2007, when it handed over the bulk of its responsibilities to the CSC Alliance, retaining responsibility for Picture archiving and communication system (PACS) rollout only.
• The Fujitsu Alliance - had responsibility for the Southern cluster until May 2008, when their contract was terminated. Ownership of this cluster from that date remains uncertain.

Local ownership

In the first half of 2007, David Nicholson announced the "National Programme, Local Ownership programme" (known as "NLOP") which dissolved the 5 clusters and devolved responsibility for the delivery of the programme to the ten English NHS strategic health authorities (SHAs). Connecting for Health retains responsibility for the contracts with the LSPs.

Under NLOP, staff employed by CfH in the Clusters had their employment transferred to the SHAs, with some being recruited to revised national CfH posts.

National Application Service Providers

In addition to these LSPs the programme has appointed National Application Service Providers (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are:

• BT - NHS Care Records Service and N3
• Atos Origin and Cerner - Choose & Book
• Cable and Wireless - NHSmail

Changes to service providers

In March 2004, EDS had their 10-year contract to supply the NHSMail service terminated. On 1 July 2004, Cable and Wireless were contracted to provide this service, which was initially renamed Contact.

IDX Systems Corporation was removed from the Southern Cluster Fujitsu Alliance in August 2005 following repeated failure to meet deadlines. They were replaced in September 2005 by Cerner Corporation.

In early 2006, ComMedica's contract for supply of PACS to the North-West/West-Midlands cluster was terminated, and they were replaced by GE Healthcare.

In July 2006, the London region started the contractual replacement of IDX (which had been bought out by GE Healthcare in January 2006) as its supplier. Systems for secondary care, primary care and community and mental health services are proposed by BT to be provided by Cerner, INPS (formerly In Practice Systems) and CSE Healthcare Systems, part of the CSE-Global group of companies, respectively.. This is subject to contractual negotiation known as 'CCN2'.

In September 2006, the CSC Alliance, Accenture and Connecting for Health signed a tripartite agreement that as of January 2007, the CSC Alliance would take over the responsibility for the majority of care systems the North East and Eastern clusters from Accenture, with the exception of PACS. As part of the handover process, around 300 Accenture personnel transferred under a TUPE process to CSC, and CSC took over the leases for some of Accenture's premises in Leeds. Accenture now retains only a small presence in the city for the delivery of its PACS responsibilities.

In May 2008 it was announced that following the failure to conclude renegotiation of the contract for the Southern Cluster, CfH terminated the contract with Fujitsu.

Criticisms of the programme

Failure to deliver clinical benefits

The 2009 Public Accounts Committee report noted that the NPfIT had provided "little clinical functionality...to-date"

The latest PAC report here 18 July 2011

The National Programme for IT in the NHS: an update on the delivery of detailed care records systems

What’s the problem?

Simply put it is unrealistic expectations; typically ministers announce a new policy, assign a war chest to it and then expect the Department of Health to deliver. The timescales to deliver real benefits at scale via NHS IT are in the 10-15 year timeframe. But NHS leaders/finance/business cases demand returns on investment in sub 2 years. Compare this with any pharmaceutical development programme. 8-10 years from initial discovery to mass market launch, benefits realised thereafter. Somehow that's realistic and achievable, but for IT - equally complex - it isn't. That's the problem.

Q. Why does CFH ‘fail’ so often (if indeed it does?) The programmes span a number of different 'worlds' - political, commercial, technical, academic, and market forces – all with different institutional logics, as well as the patient (who mentioned them!).

Differences in norms, values, priorities and ways of working between these six worlds, and imperfect attempts to bridge these differences, account for most of the instability in the NHS and this programme - and this in turn explains many of the problems encountered. This is made worse by the increased creation of ALB’s (Arm’s length bodies) the NCB, IC, PHE, HEE, NTDA The task of designing and implementing ‘solutions’ is problematic as no-one organisation has the power or the mandate to produce a workable national solution. Policy can be created by government but then it’s treated as “job done: change enabled”

Political Problems

The National Programme was initially seen as an IT upgrade not a mechanism for organisational change (this is evidenced by the fact CFH only ‘publish’ guidelines not mandating them). Assumptions of the new bill: Smaller companies and shorter contracts will provide better ‘value’ When project overrun and costs to the supplier go up large companies can absorb losses but smaller ones will fail this will hurt contracts and commercials and latterly commissioning groups.

Q. Why were the original contracts so tough? Why did so many companies leave? What’s to stop this happening again in the future? The contracts were very tight because even the procurement teams didn't believe that delivery in the proposed political timescales was possible. Also there was little or no money for local implementation which is where most of the costs actually lie.

Commercial Problems

Procurement decisions are completely risk-averse, so they always go with the BT / Capita / Steria regardless of their prior performance. ‘better the devil you know’. The risk procurement (latterly the new commissioning board) faces is the prospect of criticism for choosing what may be perceived as an unknown quantity (the smaller company going bankrupt or worse for the government’s strategy being bought up by the larger supplier once they have won a contract) - not the risk that in 5 years when they have long moved on that the project will fail. (Even the chief technical officer can’t see the data!)CTO tries to understand complicated SBS situation via FOI

Technical Problems

To the NHS it is far more important that a system does what is needed, and is well designed to enable future modifications, extensions than when it is delivered or how much it cost at time of installation. What people remember about the Victorian sewer system in London (the largest improvement in public health in UK history) is the huge public benefit, and that it lasted for a hundred years - not whether it was late or cost money? The real critical need for NHS IT systems is not simply that they fulfil current requirements, but that they can be adapted to changing needs decades hence. Google and Apple don’t have ‘End Dates’ on the company ambitions. The NHS is happy if a deployment hits any kind of target. Their expectations are set by their home IT uses so when they receive a large corporate system they don't ‘get it ‘and training is an afterthought and irrelevant when there are so many disparate systems.(Set to get worse under local commissioning).

Academic Problems

We need to accept and make provision for the fact that over the course of a project the requirements will change sometimes for political reasons or sometimes technology has simply moved on. This is a good thing and should be embraced after all IT is here to stay and Moore%s law has yet to be proved wrong. Large companies intentionally bid low on the expectation they will make money from specification changes. This isn’t large companies being evil even one man band plumbers and builders do this. In this case Accenture /CSC/ Fujitsu haven't been allowed to do this which is why they are all leaving / have left. How else are they supposed to cover the risk of the requirements changing which the inevitably will (and that’s a good thing). The reality is that over the course of a multi-year project, organisations and priorities do change with or without politics. But that good requirements management and design can anticipate or account for that if the people that do it are in house otherwise we end up with 'well the supplier told us to do it' because they defined the requirements.

Market Forces

Some of the larger companies in the mid nineties had a lot of in house IT people. External suppliers provided spare parts like hardware, bandwidth, and databases with free techies so as to gain market share. At present the DH employs 2576 permanent staff and 1797 contractors, most of these contractors are for IT. There seemed to be a view mid 2003 that IT could be outsourced as easily as a cleaning contract. This was attractive for 2 reasons

1. It reduced costs (the assumption was that IT was a cost not an investment)

2. The old school management struggled to understand the IT and realised the techies had more influence on the future than they did so they sought to redress the balance by outsourcing so that they could treat the ‘IT department’ as junior employees once again.

However this led to them failing to realise that IT was now the business and should be driving the organisational change. (The shop makes 5% of the profit a year; the online business makes 20%). The large companies have realised this and once again have developed larger in house capabilities. It appears we are seeking to redress this balance by using lots of smaller suppliers which in itself is not a bad thing.

However there needs to be a centrally based organising force with the authority to sign off / and reject systems for compatibility.(CFH is not this).

How does this affect CFH?

There are great IT, Designers, Architects, Requirements managers, BA’s within CFH but they are hampered by the large IT contracts granted to major suppliers.

CFH can never assure what is being delivered if they can’t even see the contracts the DH have signed or have the in house expertise (as someone has to understand what is being proposed, in terms of technology and cost), to check whether it has been delivered let alone whether it is forwardly compatible.

The Real Supplier Model

The best part for the suppliers comes at policy change time which affects IT e.g. joining two previously un-joined departments. You then have two IT systems managed through two major supplier contracts which now need to talk to each other. The profit margins rise by the minute as quotes are given by each major supplier for feasibility studies, project management costs, and hardware and software procurement.

This explains why GP‘s are resorting to two PC's on each desk to log on to the systems they need. At the same time, Google and Apple are still seeing IT as a strategic tool for demographic and organisational change rather than simply a cost reduction of existing services. We are now so much more atomised in terms of Smartphone’s and the way we (and the patients; remember them) access services.

Except; However the IT forever model is not a panacea there is still a place for National IT in the NHS as for example when Google attempted an Electronic Patient Record in a “build it and they will come” approach and it has been cancelled due to poor take up rates. http://en.wikipedia.org/wiki/Google_Health

There are many and varied physiotherapists, occupational therapists, pharmacists, midwives, paramedics, doctors patients etc who all need to share read and write access to the records all have their own linguistic and cultural conventions which complicates information sharing. Even within any one of these professions the different nuances of practice which have grown up in different organisations /hospitals/ primary care trusts mean that there is no simple shared taxonomy. When you then want the patient & their relatives to also be able to view and understand the record then the problems are multiplied.

Q. ===Where do we go from here?=== The clinicians currently blame CFH for the additional work loaded on them... CFH /DH blame the clinicians ... for the delays in implementation. This is reflected in their reports to the Public Accounts Committee / Andrew Lansley/ the Media.

This further alienates the Clinicians’, CFH and the suppliers. Time scales are extended. Functionality is postponed... the end of the project descends into a spiral of mutual recriminations, disappointment and then finally the GP's asked if they would like a go at running not just 80% of the health service but the IT project as well it to which of course they (quite reasonably as it is not their area of expertise) object. So the beneficiaries of the system / new health policy end up not wanting any part of the solution even if they are inviting to the meeting!NHS changes: Critics 'not invited' to PM's meeting

Data security risks

NPfIT has been criticised for inadequate attention to security and patient privacy, with the Public Accounts Committee noting "patients and doctors have understandable concerns about data security", and that the Department of Health did not have a full picture of data security across the NHS. In 2000, the NHS Executive won the "Most Heinous Government Organisation" Big Brother Award from Privacy International for its plans to implement what would become the NPfIT. In 2004 the NPfIT won the "Most Appalling Project" Big Brother Award because of its plans to computerise patient records without putting in place adequate privacy safeguards.

The balance between the right to privacy and the right to the best quality care is a sensitive one. Also there are sanctions against those who access data inappropriately, specifically instant dismissal and loss of professional registration^{[citation needed]}.

More worryingly, a January 2005 survey among doctors indicates that support for the initiative as an 'important NHS priority' has dropped to 41%, from 70% the previous year. There have been concerns raised by clinicians that clinician engagement has not been addressed as much as might be expected for such a large project.

Concerns over confidentiality, and the security of medical data uploaded to the Spine have also led to opposition from civil liberties campaigners such as NO2ID the anti-database state pressure group and The Big Opt Out who provide patients with a letter to send to their doctor so that their records are withheld from the database.

Reservations of medical staff

As of August 5, 2005, research carried out across the NHS in England suggested that clinical staff felt that the programme was failing to engage the clinicians fully, and was at risk of becoming a white elephant. The Public Accounts Committee observed in 2009 that "the current levels of support reflect the fact that for many staff the benefits of the Programme are still theoretical".

Surveys in 2008 suggested that two-thirds of doctors will refuse to have their own medical records on the system.

Impact on IT providers

According to the Daily Telegraph, the head of NPfIT, Richard Granger, 'shifted a vast amount of the risk associated with the project to service providers, which have to demonstrate that their systems work before being paid.' The contracts meant that withdrawing from the project would leave the providers liable for 50% of the value of the contract; however, as previously mentioned, when Accenture withdrew in September 2006, Granger chose not to use these clauses, saving Accenture more than £930m.

The programme's largest software provider iSOFT has been seriously affected by this process and is under investigation by the UK Financial Services Authority for irregular accounting. On 28 September 2006, the consultancy Accenture announced its intention to withdraw from £2bn of 10 year contracts with NPfIT, which were taken over in January 2007 by the CSC Alliance - both Accenture and CSC laid blame with iSOFT, although CSC has said it will be retaining iSOFT as its software provider for all its clusters. Earlier in the year Accenture had written off $450m from its accounts because of 'significant delays' in the programme. iSOFT announced in March 2011 that trading in its shares would be suspended pending a corporate announcement. Subsequently in April 2011, the company announced that it was recommending a cash offer from CSC. CSC acquired iSOFT in August, 2011

Implementation

The first trusts in the London & Southern Clusters to implement the new Cerner system found it problematic, with NHS hospital trust board minutes revealing a catalogue of errors. Difficulties with the system meant that:

• 2007: Enfield PCT were unable to obtain vital data on patients awaiting operations and were obliged to delay 63 patients of the Barnet and Chase Farm Hospitals. Further, 20 patients were not readmitted for treatment within 28 days towards the end of the year because the surveillance system for tracking them "was not operational in the new ... system". Buckinghamshire Hospitals NHS Trust found that problems with the system had meant potentially infectious patients with MRSA were not isolated for up to 17 days, requiring six weeks work by staff to update them manually.
• April 2008: Enfield PCT found that the system had failed to flag up possible child-abuse victims entering hospital to key staff, "leaving the responsibility to the receptionist"
• May 2008: Enfield PCT found that 272 elective operations were cancelled at the last minute for "non-clinical reasons"
• May 2008: Barts and The London NHS Trust blamed their failure over the preceding six months to meet targets for treating emergency patients within four hours on staff not being familiar with the new computer system. The same report cited "breaches of the two-week urgent cancer access guarantee" and delays in assessing 11 patients with possible cancer as being due to the computer system.
• July 2008: the Royal Free Hampstead NHS Trust said 12,000 patient records had to be manually amended over a three-week period due to the system, and noted that "The outpatient appointment centre has experienced a significant increase in the time taken to process individual patient appointment bookings. This has had a consequent and negative effect on call-answer performance."

Management team

The NHS appointed a management team, responsible for the delivery of the system:

• Richard Granger - is the former Director General of IT for the NHS. He took up his post in October 2002, before which he was a partner at Deloitte Consulting, responsible for procurement and delivery of a number of large scale IT programmes, including the Congestion Charging Scheme for London. In October 2006, he was suggested by The Sunday Times to be the highest paid Civil Servant, on a basic of £280,000 per year, £100,000 per year more than former Prime Minister Tony Blair. Granger announced on 16 June 2007 that he would leave the agency "during the latter part" of 2007. Granger finally left the programme in February 2008. Granger's credentials were questioned by his own mother, a campaigner for the preservation of local health services in her area, who expressed her amazement at his appointment, criticising the whole scheme as "a gross waste of money".
• Gordon Hextall - Chief operating officer for NHS Connecting for Health. A career civil servant. On Richard Granger's departure, Hextall assumed overall responsibility for the programme.
• Richard Jeavons - Senior responsible owner for service implementation. Previous posts include being CEO of the West Yorkshire NHS strategic health authority.
• Harry Cayton - Chair of the Care Record Development Board.

As of 2009, overall leadership of CfH was described by the Public Accounts Committee as having been "uncertain" since the announcement that Richard Granger would be leaving the project.

See also

• Megaproject
• National Identity Register
• Citizen Information Project
• Cost overrun
• Universal Child Database
• Medical privacy
• Health Informatics
• N3 (NHS)
• NHS Care Records Service
• Choose and Book
• OPCS-4
• Picture archiving and communication system (PACS)
• NHS Electronic Prescription Service
• Quality Management and Analysis System
• NHSmail

External links

• NHS Connecting for Health website
• NHS number
• Personal Demographics Service (PDS)
• "A guide to the National Programme for Information Technology" (PDF), NHS Connecting for Health, April 2005
• PC Coaching appointed to provide Trainers & MTUs for NPfIT, NHS Connecting for Health award contract for NPfIT Trainers and Mobile Training Units
• Programmes and Systems Delivery, NHS Connecting for Health, retrieved October 30, 2005
• NHS Connecting for Health NPfIT site
• NHS Connecting for Health History Page
• BT Health, Delivering three major contracts to the NHS as part of the NPfIT
• June 2006: NHS risks £20bn white elephant, say auditors
• Times Online: Patient records go on database
• Computer loophole hits hi-tech NHS trial
• NHS IT upgrade success 'at risk'
• The Big Opt Out, Advice to patients - How to opt out
• Opting out of the NHS Database Detailed information from Dr Neil Bhatia, a GP in Hampshire
• NHS Information Standards Board for Health and Social Care