Despite an onslaught of public criticism, NHS IT director, Richard Granger, remains adamant that progress is being made.

“The biggest mistake was taking on the job,” declares NHS IT director Richard Granger. He is joking of course. The man with the self-proclaimed “bad tempered old git” image is defiant in his steadfast rejection that his days are numbered as the man in charge of what we all know is the single biggest civil IT project in history. But for the many – and increasingly vocal – critics of the troubled multi-billion pound Connecting For Health initiative, there will be more than a few wish he were serious.

Among the most vocal critics has been Conservative MP Richard Bacon, a member of the influential Commons spending watchdog, The Public Accounts Committee, who is emerging as the most outspoken political opponent of the Programme, calling for it to be scrapped.

“The list of failures and delays grows ever longer. Two and a half years in, the programme is two years late,” he says.

“Now it seems that some of the most senior officials in the NHS know perfectly well that the National Programme will never work properly – indeed that many hospitals would now be better off if they had never taken part in the scheme in the first place.

“The Prime Minister’s decision to take central control over NHS computing has been an expensive and dangerous fiasco,” Bacon says. “The billions of pounds spent already could have been used to run 10 district general hospitals for a year. Now it is clear that patient safety and public health could be at risk. It is time to halt this programme before things get worse.”

Switching vendors

In December 2003, BT was awarded a 10-year £996m contract to upgrade NHS IT systems across London. Since buying IDX Corporation in January this year, GE Healthcare has been the main sub-contractor to BT in the capital. But BT has made limited progress in the acute hospital sector, installing just one instance of IDX’s Carecast at Queen Mary’s, Sidcup NHS Trust. Now IDX will be replaced by Kansas-based firm, Cerner.

This will be the second time Cerner has been brought in as a replacement for IDX. It was brought in by Fujitsu, the prime contractor in the southern region of NPfIT, in June last year. Fujitsu made the switch after it lost confidence in the BT-led and IDX-based ‘common solution’. “The arrangement between BT and GE Healthcare, which follows a routine post-acquisition review by GE Healthcare, is cordial and reflects the desire of all parties to ensure delivery to the NHS is the number one priority,” the release said.

The move means that IDX, which two and a half years ago won contracts to provide clinical software to both the London and the south of England regions under the NHS NPfIT, will be removed from the programme entirely.

Three London trusts running IDX patient administration and record systems – Queen Mary’s, Sidcup, Chelsea and Westminster and University College Hospitals London – are now left with systems that are not core to the programme. “BT’s plan to switch to Cerner was one of the worst kept secrets in NHS IT,” comments Ovum analyst, Tola Sargeant. ”Cerner has still got a lot to prove in the NHS market. Questions remain over whether the US software provider has sufficient resources in the UK to be able to ramp up the rollout in the southern cluster and also deliver in London,” she says. According to Gartner Group, the decision to replace GE is BT’s best attempt to jump-start “a flagging implementation programme”. Analyst Jonathan Edwards comments: “BT preferred to spend the time and money to switch vendors, rather than to continue with the status quo. Cerner and BT will need to overcome the problems that have beset Cerner and Fujitsu in the Southern region.

“Although Fujitsu had planned to install Millennium [software designed to enable electronic patient records to be shared across a local health community] at seven sites by April 2006, only one implementation occurred in that time frame, accompanied by serious difficulties. A second site went live in July 2006. Cerner will need to ensure it has sufficient resources for the London region and [to meet] its existing commitments.”

Bacon has also taken a stand against Granger’s management style, accusing him of dealing with contractors in an aggressive manner.

“Mr Granger is fond of using blood-curdling metaphors when speaking about IT contractors,” he says. “He intends, he says, to treat them like huskies: when one goes lame, it gets shot, cut up and fed to the rest – apparently, that keeps them keen. Managing a massive IT programme is not like running a dog sled. I believe that that brand of macho management threatens to bring yet more chaos to an already tottering system.”

No way out

There is a massive amount of political pressure on this project, with the possibility of failure not openly countenanced. One NHS manager that MIS UK spoke to says that his own Trust executives had made it clear that any negative comment on the Programme would be “not helpful”. Does this explain the delay in publishing the National Audit Office’s (NAO) report on the project in June, held back it seems by lengthy consultations about its contents?

In the end, the report itself is somewhat mealy-mouthed in its critique, talking about “substantial progress” being made but covering itself with the proviso that it was too early to say if the finished systems would give value for money. The NAO report was seized on by ministers as proof that implementation of the IT system was showing great progress but the analysis in an anonymous leaked document – which is so detailed that it seems impossible that it was not written by someone on the inside of the Programme – takes a totally opposite view. “The NAO report is a travesty because it simply published what the National Programme [Connecting for Health] claims is its deployment statistics,” the document claims.

“This is useless without target data as to what was supposed to be deployed.” The 12-page document – which was sent from the computer of David Kwo, who resigned as implementation director for the Programme’s London cluster in April – argues that the NHS would have been “better off” without the £12.4bn National Programme for IT (NPfIT).

“The… NHS would most likely have been better off without the National Programme, in terms of what is likely to be delivered and when,” warns the anonymous author. “The National Programme has not advanced the NHS IT implementation trajectory at all; in fact it has put it back from where it was going.”

Standing ground

In the face of all this criticism, Granger remains defiant. While conceding that it is going to take longer than was originally planned, he insists that there plenty of things that are working well. “The things that are going well are the things you don’t hear about,” he argues, pointing to the new NHS network, N3 – “one of the largest VPNs on the planet” – which was delivered ahead of schedule.

The North West Trusts

Computer systems at 80 hospitals and NHS trusts across the West Midlands and the north-west crashed in early August for four days – the biggest IT failure in NHS history. The problem affected trusts in Birmingham and the Black Country, Cheshire and Merseyside, Cumbria and Lancashire, Greater Manchester, Shropshire and Staffordshire and the southern part of the West Midlands. It left staff unable to access patient administration systems used to log admissions and transfers.

Pennine Care Mental Health Trust, Bolton Hospitals, North Cheshire Hospitals and South Manchester Primary Care Trust, which runs clinics at Withington Community Hospital, were said to be the worst hit.

The downtime was attributed to storage area network equipment failure. Technical issues following power system interruptions meant that data held on computers in the central data centre for the region could not be accessed. “The nature of the incident meant that service could not immediately be provided by the back-up systems,” a spokesman for Connecting for Health admitted. But he went on to insist: “To date no impact on the delivery of patient care has been reported.”

However, the scale of the inconvenience may have been greater than the official party line, with reported severe disruption to patient care at Birmingham Children’s Hospital NHS Trust.

An internal email from Richard Beekan, the trust’s director of operations, said the loss of the Lorenzo patient administration system, provided by iSoft, had a major impact. “This system was introduced expecting the system only ever to be unavailable for a maximum of 12 hours and therefore during the last three days we have experienced issues we had not planned for.” The trust has stated that the unavailability of its patient computer system, and the consequent inability to track case notes had an impact in both out patient and inpatient care.

One of the things that clearly rankles Granger is that too few of his critics are ready to accept the sheer complexity of what the NHS Programme is out to achieve.

He cites the Choose and Book aspect as a case in point, noting that critics often question why airlines can run a similar booking system, yet it has taken so long to get the NHS equivalent up and running.

“Airline booking systems don’t have even a fraction of the complexity of Choose and Book,” he insists. “If they did, passengers would not only be able to choose which airline they wanted to fly on and at what time but they would also be able to pick what in-flight meal they wanted from a list of hundreds.”

Electronic Records Acceptance

The first phases of the NHS Care Records Service (CRS) will be introduced in a small number of locations from early 2007. The experience from those early sites will be evaluated with wider rollout during 2008.

Health Minister Lord Warner said: “We need to crack on with getting the NHS Care Records Service up and running next year. The NHS CRS will bring benefits from the moment it’s in place and we owe it to patients to do this as soon as possible.”

But the NHS Alliance has accused Connecting for Health of failing to consult the public about their views on the consent and confidentiality issues surrounding electronic records. It claims failure to do so could jeopardise the whole project.

The Department of Health appears to have given ground on the records issue. A NHS Summary Care Record Taskforce is being set up to help the introduction of the first phase of the NHS Care Records Service by addressing outstanding issues and concerns.

It will be chaired by Harry Cayton, the Department of Health’s National Director for Patients and the Public. Members will include the chair of the BMA, the Chair of the Royal College of GPs, the General Secretary of the Royal College of Nurses, the President of the College of Emergency Medicine, and representatives of patients.

The Taskforce will identify and look at the concerns of patients and the clinical profession about the creation of the summary care record.

In conjunction with Connecting for Health, it will draw up an agreed plan for the implementation of the nationally available summary record. At the end of November it will report back to ministers.

“Perception is reality,” says Granger. “In the NHS, there is an interesting perception that around 80 per cent of people will believe that their experience of the NHS is either good or very good. We know that from lots of surveys. We also know many of them believe the reason for that is that they were lucky.

“It’s the same with IT. Most people believe that there is a problem. The fact that they have a secure network in place with digital imaging and systems that went in okay is just luck. There is a schizophrenia in human behaviour.

The three core planks

Choose and book – A system to allow patients to book hospital appointments at a place, date and time of their convenience from GP surgeries. Nearly 10m such referrals are made each year.

NHS Care Records Service (CRS) – An electronic database of patient medical records which will allow NHS staff across the country to access information wherever someone is treated.

Electronic Prescriptions Service (EPS) – More than 325m prescriptions are made each year. By 2007 the paper-based system should be replaced with an electronic version, which will allow patients to pick up repeat prescriptions from any pharmacy in the country.

“We have delivered vast quantities of things that work every day but it’s very unlikely that people will have heard about them. There’s a 50 per cent probability in the south of England that wet film x-rays will have disappeared. It’s a quiet revolution. By the end of next year, there will be no traditional x-rays in the NHS,” he claims.

“By the end of the decade, people will have forgotten what it was like to have an organisation that was totally dependent on paper.”

Finding scapegoats

But it is difficult to escape the conclusion that there is a sense of increasingly public paranoia creeping in here.

Messengers are not only being blamed but shot on sight. Try this for size: “There are two groups of people at football matches: those on the terraces and those on the pitch. I’ve often felt we have too many people on the terraces and not many on the pitch. There are two kinds of journalists: those who read the things they’re writing about and those who just write about what they’re thinking!” So the poor perception of the project is the fault of the media.

Spine upgrade

Critical to the successful deployment of Connecting For Health is an incremental series of central ‘spine’ software releases.

The prime contractor for it, BT, was due to deploy a new software release to the spine over the weekend of 29-30 July 2006 to enhance the Electronic Prescriptions service functionality. But that did not take place after it was decided that the system supplier EMIS needed more time to deploy a required software ‘patch’ before this upgrade to the spine can take place.

Without this patch, a substantial number of EMIS supplied GP practices would have stopped interoperating with the spine if the upgrade had proceeded. The upgrade will take place at some point in the future.

There is also a tangible sense of irritation about politicians asking too many questions about where public money is being spent. “We have been subject to a number of instruments of scrutiny,” he complains. “Now we have calls from some quarters for a public inquiry. I don’t know how the NAO feels, but after being under 18 months of scrutiny, calls for a public inquiry seem to call into question its adequacy. We had 40 Parliamentary questions in one month. There’s nothing wrong with Parliamentary questions but do we really need another inquiry?”

He does admit to some mistakes. “I wish I had fought harder around the mobilisation of my team but I got waylaid by various processes which meant that I couldn’t hire certain people,” Granger recalls.
“In an ideal world you wouldn’t set a timetable for computerising something like the NHS until you’d gone through 10 per cent or so of the implementation and had some empirical evidence on which to base a timetable.”

So it is full steam ahead for Granger, distracted but not deterred by the volume of criticism aimed in his direction. “The news of my resignation has been consistently exaggerated over the past two years,” he says. “I wish I’d been clearer that when I stop doing this, everyone – including my wife – will be surprised. It won’t be a pre-determined event.”