It is the biggest single IT project in the nation’s history; it is all about computerising one of the great public sector holy cows; and it is currently attracting a heavy degree of criticism from those who think the money could be better spent elsewhere. The NHS IT Programme? No – this is the Scottish NHS IT Programme.

Scotland has always operated a separate health system – just as it has always had separate education and legal systems – but since the introduction of devolution the prospect of the country tackling projects such as NHS computerisation was all the greater. Anything Whitehall can do, the Scottish Parliament can do better… or can it?

“This is a very exciting time for the Health Service in Scotland,” argues Professor Stuart Bain, chief executive of NHS National Services Scotland. “We are better positioned to deliver on our ambitious modernisation plans for the next 10 years through our ‘Delivering for Health’ strategy.

“The development of advanced patient information systems coupled with time and cost savings will mean more resources can be directed towards patient care. IT services will help provide NHS Scotland with the information it needs to deliver effective healthcare and the technology needed to deliver that information to the right person at the right time.”

History repeating

So how similar are the two projects? And given the escalating costs and increasingly acrimonious criticism of the English version, can its Scottish counterpart perform any better? The starting points of the two projects are similar. In common with England, the NHS in Scotland has taken a piecemeal approach to IT systems development and procurement.

IT services will help provide NHS Scotland with the information it needs to deliver effective healthcare and the technology needed to deliver that information to the right person at the right time
Professor Stuart Bain, chief executive, NHS National Services Scotland

The number of localised IT systems increased with the advent of NHS Trusts, although the consequences of this was not the introduction of 32 different systems – the worse case scenario. In fact, many Trusts went down the same route with only five going entirely their own way, so there is not the same degree of incompatible systems as in England.

State of the nation

Again in common with its English counterpart, the Scottish version began with a report into the state of the nation’s health, this time by Professor Brian Kerr.

His 2005 report concluded that there was an urgent need for an overhaul of the service’s IT strategy and that a common ICT system was essential if the NHS was to deliver the integrated continuous care required of it.

“The NHS in Scotland needs to change,” urged The Kerr Report. “Not because it is in crisis as some would have us believe – it is not; but because Scotland’s health care needs are changing rapidly and we have to act now to ensure we are ready to meet the future challenges. There could not be a more appropriate time to undertake a review of Scotland’s NHS and plan its future.”

Reformed strategy

The report recommended the Executive should refocus its e-health strategy and have in place by 2008 at the latest, a single information technology system with the following key features: an electronic health record available to all those who require it to provide patient care across the whole NHS; patient access to the record and the facility to update it; picture archiving and communications (PACS); electronic prescribing; electronic booking; telehealth and telecare.

The Scottish Executive’s response to The Kerr Report was ‘Delivering for Health’. In this policy document, the Executive accepts that a common ICT system will be essential: “A comprehensive health information system built around an electronic health record (EHR) is vital to achieve the shift away from reactive, crisis-management, acute-oriented care towards anticipatory, preventative and continuous care.”

Record time

Work is now underway on the EHR. “Currently, most health information is stored on paper files that are kept in different places,” says Health Minister Andy Kerr.

“The services provided in this contract will help prepare the health service for the future and ensure patient records are stored in a secure electronic environment. For example, if someone requires emergency treatment outside their health board area, clinicians will be able to quickly find out if the patient is on any medication or has suffered an adverse reaction to any medication in the past.”

So far, so similar. Of course in England, there is enormous unhappiness among frontline medical and clinical staff about the NHS IT rollout.

Many argue the money could be better spent elsewhere while more than half of all GPs are currently threatening not to put patient records on to the Spine national database, citing worries about security and patient confidentiality. It is the latest in a long line of rejections by hospital and GP personnel, reflecting overall unhappiness with the project.
Bain is determined that such rejection will not be replicated in Scotland. “Many clinicians down there are not using systems such as choose and book because they were not part of their development,” he argues. “They are not sold on those systems as a means of providing the kind of healthcare that they want to deliver, in the way in which they want to deliver it. We have engaged with many clinicians and have thought about how we want our health service to be run.”

Consortium contract

There are other differences of approach. Whereas the English version has split up the award of contracts among a myriad of multiple suppliers and sub-contractors – and NHS IT chief Richard Granger has exhibited ludicrously macho behaviour towards vendors – the NHS in Scotland has put more of its eggs in one basket, albeit a consortium basket.
An 11-year deal for IT services was struck in November with a consortium comprising Atos Origin, Sopra Newell & Budge, BT and IBM. The consortium will have more than 350 people working for the NHS, from sites across the country including Livingston and Edinburgh.

Atos Origin will provide IT infrastructure, datacentre hosting, security management, help desk, business continuity, application development, support and network services. The deal also involves a multi-million pound investment to set up a new datacentre in Livingston to host and support infrastructure, applications and vital patient data.

Value for money

So is it all a shining example to its southern cousin of how to run a public sector IT project? If only. A report by Audit Scotland is warning that a ‘major cultural shift’ is still required, revealing that the service gets poor value for the estimated £100 million currently being spent on IT.

The Audit office calls for an overhaul of funding based on a system that clearly sets out the justification for the investment over the whole lifetime of the project and the benefits that will be delivered. This does currently occur but only when spending on a particular contract exceeds £2m.

Budgeting is major concern for the simple reason that the NHS in Scotland just does not know how much it spends on IT. In its report, Informed to care: Managing IT to deliver information to the NHS in Scotland, Audit Scotland warns: “The NHS in Scotland does not know exactly how much it spends on IT overall. Funding should be based on a sound business case which clearly specifies the justification for the investment over the whole lifetime of the project and the benefits that the investment will deliver.”

Financial concerns

Ironically, while the soaring budget of the English IT project is ringing alarm bells, Audit Scotland actually warns that not enough money is being spent – and certainly not enough to meet the targets set out in The Wanless Report on health service funding in 2002.

“An estimated national IT revenue budget of £65m and £35m in capital expenditure in 2006/07 falls well short of the target of 3-4 per cent of total health spending,” it warns.
“This would be over £373m for 2006/07. Even so the growth in investment is substantial and will continue into 2007/08, when the revenue budget is expected to be over £100m and the capital budget some £40m. The challenge is to ensure that it represents value for money and delivers the information that people need to provide services to patients.”

Nonetheless, in a less defensive echo of Richard Granger in England, Bain remains confident that success is achievable. He cites examples such as 35,000 electronic referrals being made via SCI Gateway every month, 60,000 records transferred through GPEX, the Scottish equivalent of GP2GP – the English patient health record transfer system – and 1 million electronic prescriptions processed through the e-pharmacy initiative.

“We are not complacent – we do not think that we have got everything right,” he says. “If one looks at the figures, there is a huge amount of evidence of success and progress on which to build.”

The good

In a bid to reduce software licensing costs, NHS National Services Scotland has signed a landmark agreement with Microsoft to save £8m over three years. Microsoft will supply its latest desktop and mobile computing software licences for 75,000 computer desktops across NHS Scotland.

Access to the consolidated licensing agreement will enable Scotland’s 14 health boards and seven specialist health boards to reduce administration costs and provide some consistency to administrative and clinical users of ICT, wherever they work in the organisation. Covering existing and future editions of the desktop software released over its three-year lifespan, the contract’s 75,000 desktop licences will include Windows Office 2003 Professional, Enterprise Edition, upgrades to Windows XP Professional and 10,000 client access licences.

Another benefit will be a standardised ‘look and feel’ across the NHS.
Ron Anderson, director of IM&T for NHS National Services Scotland, says: “We’re expecting better integration of systems. It will enable us to standardise desktops and move to the development of electronic patient records.”

The dubious

The Scottish Consumer Council (SCC) is leading concerns about NHS Scotland’s plans to introduce the single electronic record at the heart of its IT overhaul.

Based on eight focus group discussions across the country which asked people what they thought of the plan to introduce an Emergency Care Summary, the SCC found that people were concerned about sensitive information falling into the wrong hands and the planned move had not been publicised enough.An SCC report says: “To raise public confidence, the NHS needs to raise awareness of what it is doing, the reasons for it, the benefits for patients and the safeguards that are in place to protect patients against breaches of privacy.” SCC chairman Graeme Millar says people should be made aware of their rights and the public informed before any sensitive medical information is shared. Patients should be able to see what is stored about them and have the chance to correct any factual errors.

“The idea of sensitive personal information being stored on computers is scary for many of us,” he says. “Our research found that people appreciate the benefits that data sharing can bring but they want to be assured that everything is being done to ensure their personal information is secure. Most importantly, they don’t feel informed or involved in what is happening. The clear message is that the NHS in Scotland needs to pay greater attention to informing and involving members of the public in the move towards a single electronic health record.”

The bad

The fate of the long standing General Practice Administration System for Scotland (GPASS) is uncertain as the software looks set to become a casualty of the move towards electronic care records.

Andy Kerr, Scottish Health Minister, insists that GPASS will be, “an incredibly important part of IT developments in Scotland and be central to the development of a national electronic record”. This claim is being met with considerable scepticism.
The joint IT committee of the Royal College of General Practitioners and the General Practitioner Committee is claiming that GPASS is putting patient care at risk and threatening the development of electronic care records. It now looks as though there is a bandwagon momentum away from GPASS with a quarter of the 875 practices using the system submitting business cases to move away from it as part of Scotland’s system choice initiative.

Most recently the Scottish Local Medical Committees’ conference passed a series of motions calling for GPASS to be abandoned, claiming that the system is not fit for purpose. It is calling for central funding to be made available for practices to switch from GPASS to another system. Dr Andrew McElhinney, GPASS user group chairman, says: “The user group doesn’t feel that GPASS is good enough to be seen as a building block for the single patient record. We feel it’s okay for basic tasks but it’s not viable for a single patient record.”

There have been serious delays in the deployment of GPASS’s new software, GPASS Clinical, which has so far only been deployed to 27 practices, representing 3 per cent of GPASS practices in Scotland – 90 per cent of practices should have the system installed by now. McElhinney adds: “It’s very frustrating that GPASS has had this new version of the software for over a year and yet only 27 practices have had it installed so far. There’s a big gap between the reality and what GPASS needs to be to form a significant part of the electronic patient record.” Stuart Bain, the chief executive of NHS National Services Scotland, admits there are problems but insists that these are exaggerated.

“There is legitimate criticism but it has been overblown,” he says. “GPASS is getting all the bad news although the vast majority of it has nothing to do with the GPASS product. It concerns the revolution that we are attempting to bring about in the primary care environment. The different systems that enable administration and clinical support to the GPs have been tested against that range of scenarios and then scored by the GPs. GPASS has scored well in those tests. Indeed, in a recent test in the Ayrshire and Arran trust, it came second of the four systems. The new product that we are testing, GPASS Clinical, is excellent. It will serve the NHS in Scotland well for the future, just as GPASS has served it well for the past 26 years.” But there could be a shift in thinking soon. The Scottish Executive is now initiating a study that will “identify, from a range of current stakeholders, where GP IT is currently positioned and identify and analyse a number of proposals which can be compared with the status quo”.

Paul Gray, director of primary and community care for the Scottish Executive Health Department, explains: “At the moment, GPASS is run and managed by NHS National Services Scotland (NSS). We need to ask ourselves how that fits into a commercial environment in which there are at least four other main commercial competitors in the marketplace. That is not to say that we are predisposed to the idea that NHS NSS should or should not continue to run it but we thought that the study was the appropriate point to address the issue.”