The UK’s National Audit Office recently published an update on the delivery of patient care record systems in the country’s National Health Service (NHS). This initiative forms part of an £11.4 billion programme that launched in 2002 and was to have been delivered by 2007, with further enhancements being completed until 2010. The care record systems are intended to enable selected health care providers to access full details of patients’ medical history and treatment and make critical information, such as allergies, more widely available. Four large suppliers were engaged to roll out the systems to NHS trusts and GP practices in four separate geographic regions.
The programme has been plagued by numerous problems. Delays were first announced in 2006 and in 2007, one of the major suppliers ran into serious problems delivering on its responsibilities and had its contract terminated and work transferred to one of the remaining three providers. In 2008, further delays were announced and another supplier contract was terminated, resulting in wrangling over responsibilities for the problems – the supplier complaining of scope creep, the Department of Health (DoH) putting the extra work down to remedial rework.
In its main report, the NAO reports that “the creation of the Detailed Care Record has proven to be far more difficult than expected” (p. 6) and that “fewer systems will now be delivered to NHS organisations, although the cost of delivering care records systems remain substantially the same” (p. 8).
The report also recounts how the decision was made to reduce the consistency of the systems being developed in different localities, to allow for smaller, more manageable changes to be made to meet specific local needs. In fact, “the Department [of Health] no longer intends to replace systems wholesale, and will instead in some instances build on trusts’ existing systems” (p. 8).
This means that the aim of creating a detailed electronic record for every NHS patient has not and will not be achieved. Apparently the DoH has not commented on the implications this has for the overall benefits of the programme, but the NAO notes, “there is an increased risk of not achieving adequate compatibility across the NHS to effectively support joined up healthcare” (p. 8).
The NAO goes further and criticises the DoH for the way in which it has chosen to report progress, arguing that it creates an unrealistically positive impression. The DoH apparently reports completion in terms of technical module development (not successful release, functionality or usage) for single NHS bodies (not the wide variety of organisations intended to be joined up) and allegedly ignores the degree of functionality of the systems and other original objectives of the programme.
The NAO concludes, “the £2.7 billion spent on care records systems so far does not represent value for money, and we do not find grounds for confidence that the remaining planned spend of £4.3 billion will be different” (p. 13).
Is this sorry tale simply an unsurprising operational disaster, or is it a catastrophic failure of strategy execution? I think certainly the latter. The introduction of streamlined and integrated IT systems to join up the plethora of sub-organisations in the NHS was and should remain central to its strategy. Patients rightly care little about the arbitrary divisions within what is called and supposed to be a national heath service. The inability of the organisation to communicate and operate effectively across its internal segments is a serious threat to its performance and the service and care that patients receive. Although there are other vital elements to delivering first class health care, integrated modern IT systems are critical.
This programme was truly ambitious; it was the world’s largest civil IT programme. That in itself should have rung alarm bells, given government departments’ records on managing complex change programmes. The way in which it was approached was unusual – particularly inviting four separate suppliers to undertake what would ideally be the same work in different geographies. It is little surprise that only two suppliers remain and that the complexity of the programme has necessarily been reduced.
Perhaps the most illuminating point, for those of us interested in the underlying causes of the problem, is they way in which success is being measured – not by benefits to patient care or even by cost savings – but by technical roll-out according to the schedule of an IT change programme. That is not the raison d’être of the NHS, as I understand it.