The rise and fall of England's National Programme for IT
Authors: Ann Robertson, David W Bates, Aziz Sheikh
Journal: Journal of the Royal Society of Medicine (2011)

During nine turbulent years, the most enduring features observed in the landscape of the National Programme for IT have been continual change and uncertainties. The Government's new announcement of the disbanding of the National Programme's Board clarifies its plans to accelerate the Programme's end, but leaves the landscape of NHS IT in England strewn with uncertainties.

The promised statement on a new structure to support NHS IT is still awaited. In the meantime, the Government's Major Project Authority's review of the Programme,1 published in redacted form this September, echoes some content of earlier reviews by the Parliamentary Public Accounts Committee and National Audit Office,2,3 and a Department of Health statement that NHS Trusts needed more control over local IT implementation.4 Parliamentary bodies have been scathingly critical of the Programme's value for money and its management of the delivery of national electronic health records (EHRs). The Department of Health statement had already announced that the Programme's initial, centrally driven strategy of ‘replace all’ to implement standardized NHS IT systems was no longer ‘appropriate’ and would be superseded by locally chosen and implemented systems.4

While local choice of systems is now official policy, simultaneously, central Government is increasingly taking control of overall NHS IT strategy, where it can be directed in line with its central ICT Strategy and Efficiency and Reform Group policies. The NHS in England is already under instructions to make £20 billion in ‘efficiency’ savings within four years. It faces the prospect of further, fundamental restructuring when the Health and Social Care Bill before Parliament becomes law.5 Taken together, these factors have worrying implications for the IT-enabled modernization of the NHS and delivery of healthcare.

From its outset, the Programme was politically driven. The vision of a modernized NHS and a single, sharable, digital healthcare record for every patient was championed by Prime Minister Tony Blair shortly after New Labour had won a landslide general election victory in 1997, bringing with them a national mandate for reforms. Despite widespread GP use of computers in the 1990s, hospital IT systems were less common and they were typically small-scale ‘home-grown’ initiatives. There was no means of exchanging confidential healthcare information securely between NHS settings. In 2002, frustrated by lack of progress with NHS informatics, Blair launched the National Programme for IT. Comprehensive EHRs and secure data exchange throughout the NHS were to be achieved by 2010.

Despite some notable successes, especially with respect to developing a national infrastructure for healthcare IT, the principal stumbling block for the Programme was, and remains, implementing the envisioned, cradle-to-grave EHRs.

An independent evaluation of the implementation of the summary care record concluded that the benefits were more subtle and contingent than had been anticipated;6 particularly noteworthy was the finding that clinicians did not always access a patient's record even if it were available.

Our own independent evaluation of the implementation of the detailed care record in hospitals revealed the extent to which the Programme's initial, top-down strategy was already being forced to evolve to try to meet the wishes of NHS hospital Trusts.7,8 We found NHS staff to be supportive of replacing paper with digital records, but many viewed the Programme's delivery strategy, a deployment schedule that was seen as politically-driven and rushed, and the proposed scale of data-sharing as highly problematic. The NHS consists of diverse and in many cases largely autonomous healthcare providers. Since the introduction of commissioning and ‘internal markets’ within the NHS, healthcare providers may also be business competitors.9 Furthermore, the contracting arrangements – whereby Trusts receiving the new systems are not party to the contracts with Local Service Providers for delivering those systems – hampered communications and undermined relationships between suppliers and Trusts, and made any local tailoring of the systems particularly challenging. But, importantly, we also found evidence of considerable organizational learning in the NHS with respect to healthcare IT implementations.8

In late 2011, there are still vestiges of Programme life. The national infrastructure is to be retained and some national applications, such as the system for electronically booking appointments, will in the future be run as services under NHS control. The national rollout of the summary care record seems likely to go on. Limited deployments of detailed EHR systems under Programme contracts will also continue until 2015, albeit now in fewer hospitals and with reduced functionalities, and while the NHS IT market simultaneously opens up to multiple systems suppliers.

In our experience, NHS staff welcome the move to greater local choice for IT suppliers and systems. Yet it is not clear how the NHS can afford to pay for new systems delivered outside the reduced Local Service Provider contracts, or when those contracts end. The outcome of protracted contract re-negotiations with one of only two, remaining Local Service Providers is currently a matter for speculation. Nor is it clear how the NHS will successfully take back local responsibility for developing healthcare IT when many local NHS organizations have been found in the course of the Programme to have very limited informatics experience and expertise. In others, successful efforts to build up effective informatics teams may be knocked back if individuals seek more attractive employment prospects outside the NHS. Importantly, it is now far from clear what structures and mechanisms are to be put in place to ensure sufficient functionalities in NHS IT systems and adequate, national standards to support systems interoperability and information sharing.

Democratic governments throughout the developed world are struggling to bring about large-scale health service transformations based on healthcare IT. The English experience shows that a political champion can usefully start the process, but a realistic timescale for achieving national EHRs will be long while conflicting interests are contested, implementation strategies are modified and political and economic challenges are negotiated. Despite conflicts and uncertainties, it is time for this Coalition Government and the NHS ‘to step up to the challenge’10 of building on the foundations for EHRs laid by the condemned Programme, and not to lose sight of the fundamental reason for doing so – the delivery of better patient care.