National Programme for IT

The National Programme for IT (NPfIT), is an initiative by the National Health Service (NHS) in England to move towards an 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. The Department of Health agency NHS Connecting for Health (NHS CFH) is responsible for delivering this programme. 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 the NHS CFH agency to be "the world's biggest civil information technology programme".

The cost and scope of the programme, together with its ongoing problems of management, have placed it at the centre of ongoing controversy, and the Commons Public Accounts Committee has expressed serious concerns.

Structure and scope of the programme
Following several Department of Health reports on IT Strategies for the NHS, the NPfIT was formally established in October 2002.

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.

The programme is divided into a number of key deliverables. These are:
 * The NHS Care Records Service (NHS CRS)
 * Choose and Book, an electronic booking service
 * A system for the Electronic Transmission of Prescriptions (ETP)
 * A new national broadband IT network for the NHS (N3) (see also external link to BT N3 website)
 * Picture Archiving and Communications Systems (PACS)
 * IT supporting GPs including the Quality Management and Analysis System (QMAS) and a system for GP to GP record transfer.
 * NHSmail – a central email and directory service for the NHS. 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 basic demographic information about each patient and their NHS Number.
 * The Personal Spine Information Service (PSIS). This 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.

Further information is available from the NHS Connecting for Health website.

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 divides 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. As of January 2007, three different industry consortia were LSPs for the main body of the programme: 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.
 * CSC Alliance - North East, East & East Midlands and North West & West Midlands clusters
 * The Fujitsu Alliance - Southern cluster
 * Capital Care Alliance - London cluster

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 1st 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. 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 Servelecrespectively. . 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.

Local ownership
In the first half of 2007, it was announced that responsibility for the delivery of the programme would be passed to the ten English Strategic Health Authorities (SHAs). Connecting for Health retains responsibility for the contracts with the LSPs.

Criticisms of the programme
NPfIT has been criticised for inadequate attention to security and patient privacy. 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.

Advocates of the NPfIT note that these concerns must be set alongside the necessity of care professionals having access to personal medical data if they are to deliver safe, high quality care. 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. This means that not only will the perpetrator lose their job, but any chance of getting another.

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.

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 in risk of becoming a white elephant.

In April 2006, 23 academicsSignatories of the open letter to the Health Select Committee: Ross Anderson, Professor of Security Engineering, Cambridge University ; James Backhouse, Director, Information System Integrity Group, London School of Economics ; David Bustard, Professor and Head of Computing and Information Engineering, University of Ulster ; Ewart Carson, Professor of Systems Science, Centre for Health Informatics, City University; Patrik O’Brian Holt, Professor, School of Computing, The Robert Gordon University ; Roland Ibbett, Professor, School of Informatics, University of Edinburgh ; Ray Ison, Professor of Systems, The Open University ; Achim Jung, Professor, School of Computer Science, University of Birmingham ; Frank Land, Emeritus Professor, Information Systems Department, London School of Economics ; Bev Littlewood, Professor of Software Engineering, City University ; John A McDermid, Professor of Software Engineering, University of York ; Julian Newman, Professor of Computing, Glasgow Caledonian University ; Brian Randell, Professor, School of Computing Science, University of Newcastle ; Uday Reddy, Professor, School of Computer Science, University of Birmingham ; Peter Ryan, Professor of Computing Science, University of Newcastle ; Geoffrey Sampson, Professor, Department of Informatics, University of Sussex ; Martin Shepperd, Professor of Software Technologies, Brunel University ; Michael Smith, Visiting Professor, Department of Computer Science, University College London ; Tony Solomonides, Reader in Computer Science and Medical Informatics, University of the West of England ; Ian Sommerville, Professor, Computing Department, Lancaster University ; Harold Thimbleby, Professor of Computer Science, Swansea University ; Martyn Thomas, Visiting Professor of Software Engineering, Computing Laboratory, Oxford University ; Colin Tully, Professor of Software Practice, School of Computing Science, Middlesex University in computer-related fields raised concerns about the programme and wrote an open letter to the Health Select Committee. 2006-10-06 the same signatories wrote a second open letter and created a wiki documenting their concerns.

However by July 2006, over 75 trusts were live in the NWWM cluster alone. Supporters of the scheme suggest the only other choice was to do nothing and this was unacceptable. Previously hospitals and GPs were expected to provide their own solutions and funding, with the end result that there was no standard interface or measurement of functionality.

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.

In April 2007, the Public Accounts Committee of the House of Commons issued a 175-page damning 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."

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. However, reports in the media have claimed that unpublished internal Government documents estimate the likely final cost to be far higher ; up to £20 billion.

Calculating the true cost of any significant IT programme is notoriously difficult. The £2.3bn figure related to the obvious costs (procurement, development and deployment) and is only part of the equation. Additional costs are incurred through a number of other dependent activities outside of the core contracts, such as hardware upgrades (to accommodate new software), business and clinical process redesign, training, stakeholder engagement, marketing and evaluation. It is these areas that make it almost impossible to know the true, final cost.

Impact on IT providers
The size of the programme means that it has become a substantial element in the UK activities of many IT providers. The onerous contract terms which have been an element in the process have therefore placed significant organisational and financial strain on some 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 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 28th 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.

Management team
The NHS has appointed a management team, responsible for the delivery of the system:
 * Richard Granger - is the 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 £280,000pa - £100,000pa more than former Prime Minister Tony Blair . Granger announced on 16/06/2007 that he would leave the agency "during the latter part" of 2007.
 * Gordon Hextall - Chief operating officer for NHS Connecting for Health. A career civil servant
 * Richard Jeavons - Senior responsible owner for service implementation. Previous posts include being CEO of the West Yorkshire Strategic Health Authority.
 * Harry Cayton - Chair of the Care Record Development Board.