Write the contract, then decide what to do
The NHS IT Tsar is deciding who shall build the new NHS systems, before deciding what should be built, argues Richard Sarson
On October 6, when Richard Granger finally took up his £250,000 job as Director General of NHS Information Technology, or IT Tsar, even the most cynical of NHS staff hoped for a new beginning. At last, someone was going to drive the rickety bus of NHS IT into the 21st century. The era of lost medical records, endless paper-chases through hospital corridors and out-of-date and incompatible computer systems would soon be over.It had been the Prime Minister who had demanded the appointment of a Tsar, after a seminar last February in No 10 had revealed the Augean stable of IT in the NHS.
The mood is very different now, only five months later. There is widespread dismay about the rate and direction of the shiny new bus.Misgivings started quite early, with Richard Granger's terms of reference. Instead of reporting directly to the minister, or at least to Nigel Crisp, the Chief Executive of the NHS, he was put in the Information Policy Unit, reporting to Sir John Pattison, Director Research, Analysis and Information - not even to the Head of the Unit. This seemed wrong, particularly as the Information Policy Unit is one of a group of Department of Health offices, like the NHS Information Authority and Modernising Agency, whose overlaps are sometimes blamed for the mediaeval state of IT in the NHS. As early as November 15, Mark Todd, Labour MP for South Derbyshire, asked the minister whether Mr Granger had the authority to direct the NHSIA, or indeed the regional health authorities. He did not get a very clear reply. Nor apparently does Sir John's power extend over NHS Direct - which is also outside the remit of the NHSIA and IPU. There are a lot of Boyars in Richard Granger's Tsardom, over whom his writ does not run.
It seems odd that the NHS Tsar should not at least have the same access to minister as the e-envoy has in the other Civil Service Departments. Much of Andrew Pinder's effectiveness has been because of his access to Patricia Hewitt, and the joint report that they make to the Prime Minister every month. Maybe the NHS Boyars had noted the e-envoy's success, and had decided that this Tsar should be strangled at birth.
When Florence Nightingale arrived with her young ladies at the hospital in Scutari during the Crimean war, she refused to let them tend the wounded until the commandant of the hospital agreed terms of reference that were acceptable to her. Richard Granger should have done the same.From October until Christmas, Richard Granger understandably kept very quiet. This was OK, as he had to take some time to get his feet under the table. His only foray into the outside world was an event for IT suppliers at the QE2 Conference Centre, when he made it very clear that the vendors would have to perform, if they were to keep their NHS business. He was also going to cut down the number of suppliers to a small number of large consortia. This tough stance was welcome, because he showed that he was going to tackle the fragmented easy-going procurement regime of the past, which has been one of the previous causes of poor IT. But it alarmed the myriad of small specialist vendors, who had often started life as the brain-children of practising medical professionals, and who claim that they understand the workings of healthcare computing better than generalist nerds in the big software houses.
And there was some puzzlement from the expectant but rather demoralised NHS troops that he should speak first to the suppliers before imparting his vision of the future to them. However they felt that the New Year would bring enlightenment.In the meantime, they bombarded him with advice. For instance, in November, a mixed "autumn forum" of about 100 clinicians, hospital managers and NHS IT people organised by BJHC (British Journal of Healthcare Computing) at the Royal College of Surgeons sent a letter to Richard Granger about their worries.
One concern was how to get clinicians, One concern was how to get clinicians, particularly consultants, interested in IT, particularly in Electronic Health Records. One obstetrician at the forum even claimed that EHR was a management plot to beat consultants over the head with league tables of post-operative death rates. The forum agreed that some way had to be found to unearth clinical IT champions: bribery or shaming. Alan Milburn has already started this process by insisting that every consultant's surgery should have a computer. But my experience as a patient is that these are switched off unless the doctor I am seeing is a very young registrar. (Similarly MPs have also been centrally provided with computers, but does this mean that they are using them properly!)
The forum also felt, rather surprisingly, that the fragmentation and lack of compatibility between present computer systems was technically soluble, but the human factors around incompatible systems were more challenging. It is a cultural thing.
The forum was happy about implementing national roll-outs of electronic booking of appointments and e-prescriptions, but they were extremely nervous about Electronic Health Records. For instance, 72 per cent did not understand what the "Integrated Care Record Service" is. (ICRS is NHS gobbledygook for Electronic Health Record.) Seventy three per cent believed that the timescales for ICRS were unrealistic. Fifty-four per cent believed that the ICRS vision is too ambitious, and only modest steps are appropriate for the next three to five years.
The only good news for Richard Granger is that 69 per cent agreed that a centralised approach to Health Records is necessary, and 74 per cent agreed that a fundamental redesign of computer systems would be necessary.Richard Granger also got advice from outside, some of which echoes what the forum says. The British Computer Society wrote a paper last autumn, Radical Steps in Health Informatics, which proclaimed that: "The main problem is not the IT but the culture; IT is for patient care, not just the needs of the organisation; develop best practice, do not throw it away, some of it leads the world; promote clinical awareness of the benefits of informatics; training, training, training."
Another outsider, EURIM, the all-party Parliamentary/industry grouping, has written a report on joined-up medical records which emphasises, among other things, that: "Those responsible for NHS policy and implementation must enlist the informed support and consent of healthcare professionals and patients (including politicians at all levels), as well as of suppliers of systems and services, in setting realistic and trusted frameworks within which practical progress can be made. The roles, responsibilities and obligations of staff must be clearly set out, especially where medical data is exchanged across organisational boundaries and/or with those responsible for providing community care."
You could argue that all this advice is rather woolly and feel-good, and much of it should be ignored on the Mandy Rice-Davies "they would say that, wouldn't they" principle. But one might also have thought that it all should have alerted Richard Granger that he has a desperate morale, awareness and cultural problem, which he should address with at least some stirring should address with at least some stirring words. And he should do it quickly, to bolster any trust that he, Richard Granger, was the Messiah who would save the NHS from itself.
Not a bit of it. His next move on January 31, was to produce a document called the Key elements of the Procurement approach, which, as the title implies, dealt almost exclusively with the responsibilities and tasks of the suppliers. There is a short section on the contributions of the NHS, the strategic health authorities and the hospital trusts. There is nothing about GPs, who in fact have developed their own computer systems rather more effectively than the hospital sector. The national bit of what is expected of the central planning functions of the NHS is described as: "define service and systems specifications, common datastructures and interoperability, scalability and durability standards".
The rest, it seems, will be done by the suppliers. Nothing about providing training for the consultants. Nothing about involving the clinicians in the planning process. Nothing about reassuring the trusts and small suppliers about "planning blight", while the contracts with the big boys were worked out. Nothing, most importantly, to fire up the NHS troops into battle with the realisation that this is the biggest public sector project that has ever happened in Europe. A cynical friend of mine, at one time a management consultant himself, commented "what do you expect if you hire a management consultant to do a leader's job"?
Someone pointed out to me that I am being harsh on Richard Granger. His job is to deliver the NHS IT plan, not to sell it - or design it. I am not convinced about this. The main seller, Lord Philip Hunt, the e-health Minister, has been uncharacteristically quiet in the last two months. The main designers of the new systems, the IPU and the NHSIA have also said little.
This is odd because in the summer of last year, before Richard Granger came on board, they were very active. In June they produced the Delivering 21st Century IT Support report for the NHS, and followed it up in July with a specification for the Integrated Care Record. Both these were useful documents because they not only defined in broad principles what was required, but set some phased timescales. However neither could be considered to be specifications for working computer systems or national data standards. Nor did they answer the question in everybody's minds: how far can existing local systems be converted or integrated into these new specifications, or will the old local systems have to be scrapped to make way for the new national ones?
Anybody waiting for answers since July to these difficult questions would have been disappointed. The flow of specifications seemed to slow through the autumn. It seems as if the planners were waiting for the word from Granger. The word never came. To be fair, the planners were also waiting for something else. This was the results of ERDIP (Electronic Record and Development and Implementation Programme), several live tests of Electronic Health Records in various parts of the country. The ERDIP report finally came out on January 27 and, although it showed general support for the EHR among the Trusts which took part, it also indicated that clinicians were slow to adopt it and not all the implementations were done very well. A lot more planning will have to be done if a national scheme is to have any chance of success.
After six months of lost momentum, the internal NHS planners need more time for defining data standards, deciding on the contents of the EHR, and engaging the active participation of the clinicians. Richard Granger called the medical professionals together two weeks ago, and asked them for the first time for their input to the ICRS, presenting them with a "punishing timetable". One attendee at the meeting, Dr Paul Cundy, Chairman of the BMA's IT panel for GPs, has written to the Information Authority for more time.Time is not really available. Richard Granger's procurement juggernaut is thundering down the track. He hopes to start negotiating contracts from April. Perhaps he is hoping that the medics will not have time to define the standards etc, and he can give the job to his suppliers!
At the moment he is like somebody who is building a house, and has engaged building contractors, before the architect has presented his designs. He is deciding how it should be built and who should build it, before deciding what should be built. I know that the Prime Minister believes in delivery, delivery, delivery, but this is ridiculous.
