Examination of Witnesses (Questions 1-19)
DEPARTMENT OF
HEALTH, PROFESSOR
PETER HUTTON
AND DR
ANTHONY NOWLAN
26 JUNE 2006
Q1 Chairman: Good afternoon. Today we
are considering the Comptroller and Auditor General's Report The
National Programme for IT in the NHS and I should like to
welcome the following witnesses: Sir Ian Carruthers, who is the
Acting Chief Executive of the NHS, Mr Richard Granger, who is
the Director General of IT, Mr Richard Jeavons, who is the Director
of IT Service Implementation, Professor Hutton and Dr Anthony
Nowlan. You are all very welcome to our hearing. You will see
that there are quite a few Members present today, so may I please
appeal for short answers because otherwise it will be a very long
hearing. If I feel that the answers given are unduly lengthy,
the only result will be that the hearing itself will lengthen,
so I appeal to you for crisp answers. Although I appreciate that
you will want to get your entire answer out quickly, because you
are obviously very heavily briefed on this, you will have the
best part of two hours to get your case across, so you will have
plenty of time to get it across. I shall address my remarks, if
I may, to you Sir Ian because you are the Accounting Officer,
but please feel free to bring any of your team in, either those
sitting on either side of you or anybody indeed sitting behind
you. This is not a point-scoring exercise: we are simply after
the evidence here, so feel free to bring anybody in. Could you
please start by looking at the Summary on page four where it says
in point 5m: "...the advanced integrated IT systems that
are central to the long-term vision for the Programme will now
be later than originally planned. Deployment of the National Clinical
Record is now planned in pilot form from late 2006, compared to
the original plan of December 2004". I am sure you will agree
that the National Care Records Service is the central part of
this programme. Why is it running two years later than originally
scheduled?
Sir Ian Carruthers: Before answering
that Chairman, may I introduce the colleagues with me because
we shall call on them. On my far left is Dr Mark Davies, who is
the Primary Care Medical Director for the Choose and Book programmes
and a practising GP in Hebden Bridge. Next to him is Professor
Sir Muir Gray, who is the Director of Clinical Safety for Connecting
for Health and next to him is Dr Gillian Braunold, who is a national
clinical lead and a practising GP. Your first question was about
the delay in the National Clinical Record. It is important to
recognise that the programme is amongst the largest in the world
and it is extremely ambitious. The delay was actually a decision
that was taken following two things: first of all some suppliers
were having difficulty in meeting the timetable and clinicians
wanted to pilot the scheme and see how it operated. It is for
those reasons that the timetable was deferred until 2006 when
we hope to pilot it and it will be operable in 2007. It is important
to recognise that with a programme of this scale there is bound
to be risk, there is bound to be some delay. However, as the National
Audit Office Report says, what we have achieved is substantial
progress in many, many other areas where targets have been exceeded
and indeed in some cases accelerated. We need to see this in a
wider context where much has been achieved with over 10,000 installations
already in place.
Q2 Chairman: It is not just delays,
important as those are. There are about 170 acute hospitals, are
there not? In terms of patient administration, the National Clinical
Record system has been deployed into just 12 hospitals and no
clinical systems have been deployed into any hospital. Is that
right?
Sir Ian Carruthers: No. PACS (Picture
Archiving and Communications Systems), for example, have been
employed across various parts of the country and large numbers
of other programmes have been done. If I may, I shall ask Mr Granger
to take that forward in detail.
Q3 Chairman: May I just ask the National
Audit Office? Are those figures right that I quoted of 170 acute
hospitals and the system only being deployed into 12 of those
hospitals in terms of patient administration alone?
Mr Shapcott: I believe there are
172 hospital trusts; a number of those may be on more than one
site. The clinical record element in the National Care Records
Service is not in yet, but there are other types of systems.
Q4 Chairman: Has not been deployed?
Has it been deployed into any hospitals?
Mr Shapcott: As I understand it,
not at all.
Q5 Chairman: Okay. Mr Granger, do
you want to comment?
Mr Granger: There is a highly
selective marshalling of the data about the 10,000 or so deployments
that have been achieved in the last 24 months. It is important
to note that 33 acute trusts are now not using X-ray film. I think
if you were having an X-ray, you would not draw the distinction
between a system which required a clinician to type and one which
required them to hold an X-ray film up to a light box.
Q6 Chairman: I am not sure that is
answering the question that I put. What is actually key about
this, you will accept Mr Granger, is the National Clinical Record.
My clinical record being able to be deployed into any hospital
in the country is the key part of it, is it not? What I was told
was that there are 170 hospitals and my clinical record, under
the systems that you are developing, cannot be deployed into any
hospital. Is that right or not?
Mr Granger: What is correct is
that every day 375,000 patients have their details searched on
the demographic database which is a core part of the National
Clinical Record and there are over 240,000 people registered in
the NHS to use that system already and that covers all the major
acute hospitals. They are all now connected up to a secure national
network as well.
Q7 Chairman: Right. Well I cannot
pursue this point but other Members can come in on it. Sir Ian,
how are you going to make up for the lost time in implementing
the National Care Records Service? What is your plan? When will
it be delivered? You are two years behind already, although there
is some argument about the basis of the discussion. My essential
point is that it has not been delivered in essence to any hospitals
yet. How are you going to make up for lost time?
Sir Ian Carruthers: We have to
see the piloting, we have then to move on to implementation and
the overall part of the programme is that we would hope, as the
National Audit Office Report says, to have implemented most of
the compliant system by 2010. However, the scale of implementation
and the risks associated with it, because we are trying to do
something here that has not been done on this scale before, do
need to be recognised because what we want is a system that works
rather than a system which is put in quickly for its own sake.
The overall benefits that we shall achieve, clinically and in
terms of patient safety as well as value for money, will be significant.
Q8 Chairman: That is precisely the
point I want to take you to, because it is important that you
answer this essential criticism of what you are trying to do.
This is dealt with on page 29 of the Comptroller and Auditor General's
Report "Taking account of earlier experiences, the Department
decided to procure and manage the Programme centrally". Why
are you seeking to impose such a massive system from above on
the NHS instead of building on local initiatives?
Sir Ian Carruthers: First of all,
it is important to say that there are two parts to the programme:
one is the national procurement and the second is the implementation.
The national procurement is being undertaken nationally, but actually
implementation is locally driven. The reason why we are undertaking
it nationally is because we want to overcome past poor track record,
we want to get value for money, we want to deliver integrated
systems which we can upgrade and change in future at reduced costs.
There is a whole series of benefits such as standardising practice
and allowing people to move between employers without re-training.
It is the procurement that is being driven nationally and in fact
that has paid off, because the National Audit Office have been
very clear in saying that the procurement has brought with it
great benefit in terms of value for money, it has brought with
it a lot of good practice that others can learn from. Of course
within that we have tried to adopt the advice of this Committee
itself which is about saying "Can we be contestable? Can
we pay only on delivery?" and, firstly, "Can we actually
not rely on any single supplier?". So good practice elements
have been built in. The delivery locally is through each NHS organisation
and we have established a system where the chief executives of
each of the new strategic health authorities which come into being
on 1 July 2006 will be accountable for overseeing the actual delivery
in their local NHS. In any hospital or in any PCT, the implementation
will take place locally with national support, so it is not centralised
in that way at all.
Q9 Chairman: On the other hand, if
we read the key paragraph in this Report which you can find on
page 11, paragraph 1.8: "The scope, vision, scale and complexity
of the Programme is wider and more extensive than any ongoing
or planned healthcare IT development programme in the world. Whilst
other countries are seeking to adopt elements of the services
within the National Programme, such as electronic patient records,
these are not being introduced on a country-wide basis".
So you are doing something that no other country apparently is
attempting. Is this not unwise?
Sir Ian Carruthers: It is true
that we are doing it; we think it is the right way, but I shall
hand over to Mr Granger.
Q10 Chairman: May I just add a rider
to that? The NHS itself is very diverse. You are attempting to
impose centrally-imposed procurement from above on what is a very
diverse organisation in the biggest IT health project in the world.
Is this not a very dangerous undertaking you are engaged on Mr
Granger?
Sir Ian Carruthers: If I may,
there are risks, we have said that. I have also said that nationally
we are only procuring and the benefits of that have come through.
Implementation will be local and in fact, elsewhere in the Report,
it says that every local implementation has its own characteristics
and needs to be locally tailored. Yes, it is diverse but we need
to handle that in a local sense.
Mr Granger: The statement that
no other countries are implementing systems such as this is only
partially accurate.
Q11 Chairman: It is in the Report
which you spent a whole year arguing with the NAO to get right.
I have just read to you from the Report and one of the reasons
why you apparently had to "fight, street by street, block
by block with the NAO"—their own phrase to me—was
that you wanted to agree on this. I have just read it to you,
so please do not come back to me and say it is only partially
true. Why has this NAO Report been delayed a whole year then,
if it is not right?
Mr Granger: Let us clear that
point up. The Department of Health had possession of the Report
for review for 59 days[1]
out of the last year and a half. Aside from that, if we look at
what other countries are doing, many of them are now looking at
implementing a central infrastructure that will move patient information
around. It is already present in Holland, it is already present
in Denmark, it is being implemented in Sweden, Canada has a scheme
to do the same thing which is rolling out across several provinces
at the moment, Australia are procuring a system to do that as
well. Some of these are procurements which are ongoing or schemes
which have been partially implemented to date. Many countries
are looking carefully at what the NHS is doing; it is at times
uncomfortable being in a leadership position. As the NHS is a
diverse organisation, one of the things that binds it together
and moves millions of messages between trusts and between GP practices
right now today is the Spine infrastructure which is live; that
provides a coherent backbone to the NHS to move clinical messages
around in a secure and reliable manner.
Q12 Chairman: Let us go on as quickly
as possible. Can we look at some of these contractors, some of
whom are showing signs of strain? Is it right that Accenture has
made provision for £450 million losses on this contract?
Mr Granger: No, it is not.
Q13 Chairman: $450 million sorry,
dollars not pounds.
Mr Granger: They have made a provision
against potential future losses which have not crystallised.
Q14 Chairman: Are some of your suppliers
showing signs of strain on this?
Mr Granger: They are and better
they are than the taxpayer.
Q15 Chairman: Can you be sure that
they have the strength to handle these risks?
Mr Granger: Yes. We regularly,
in conjunction with Partnerships UK, the Treasury agency, assess
the financial fitness and capacity of our prime contractors. At
the last report from Adrian Kamellard of Partnerships UK, a body
of the Treasury, he confirmed that all the key contractors have
sufficient financial capacity to fulfil their liabilities and
continue to discharge their obligations under the contracts.
Q16 Chairman: Page 27, paragraph
1.33 on the cost of this. Why do you not know how much the NHS
is spending on implementing the programme? "NHS Connecting
for Health has not sought to monitor systematically the actual
impact the Programme is having on local IT spending." Is
that not a fairly key point?
Sir Ian Carruthers: First of all,
as you have just said, we want to do this as locally as possible.
On that page, if we go back to the earlier paragraphs, what people
are saying is that £3.4 billion is based on forecasts which
have come from business cases, £770 million of that, or thereabouts,
is from PACS and the other is £2.6 billion. Individual business
cases are actually being prepared and have formed the basis of
that and we shall not know the true savings until they are implemented.
If I might ask Mr Jeavons, he could give you one or two examples
because significant savings are being made.
Mr Jeavons: On PACS, for example,
where we projected £682 million worth of cash savings against
the contracts, we are already seeing clear evidence from both
business cases and post-implementation reviews that the scale
of those cash releasing savings are there. That is not surprising
because they are extremely clear and very predictable.
Q17 Chairman: Are you worried at
all about patient confidentiality? My records are potentially
going to be driven around the countryside, if this works. Am I
really happy with that idea? I know some doctors have expressed
concern about this.
Sir Ian Carruthers: What we should
say is that obviously we recognise the importance and Mr Jeavons,
who is leading that part of the programme, will comment.
Q18 Chairman: Can you give me an
absolute reassurance that your systems are sufficiently robust
that there is no way in which my clinical records can leak out?
Mr Jeavons: The position is that
the policy has always been implied consent, the programme is implementing
the highest levels of security and access ever seen in any public
project and so is setting standards which have never been surpassed.
Q19 Chairman: Lastly, there has been
a lot of criticism from the doctors, that this is being imposed
by diktat from above rather than getting the consent of the medical
community. Do you have any comment to make on this Professor Hutton?
Professor Hutton: I do feel that
the clinical community was disadvantaged in the early stages of
the programme and that this has led to some of the problems we
now see. I am pleased that you have concentrated on the issue
of the healthcare record because it is absolutely central and
does not really get very much mileage in the Report. The Report
fails to emphasise that key decisions were taken in the early
period without proper clinical input and that the resulting consequences
are still having a major impact on the viability of the core programme.
Nowhere does it mention that the recommendations on the care record
were actually only developed towards the end of the contracting
process, so one can ask what was actually being contracted for.
It fails to state that there is no good audit trail for clinical
input into the production of the output-based specification, which
was the basis of the contracts and the placing millions of pounds
of public money.
1 Clarification of matters of fact (by witness):
The NAO provided the Department with a draft accompanied by supporting
evidence on 17 March 2006. It was some 59 working days later that
the final Report was agreed. In this time, the NAO was waiting
for responses from NHS Connecting for Health during two distinct
periods between 17 March and 7 April and between 12 May and 22
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