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By Martin Brampton, 19 September 2006 12:30

COMMENT

Martin Brampton tallies up the organisational and financial missteps that have put the NHS IT overhaul in dire straights - and surveys what solutions could be put in place at this juncture.

Attacking NHS IT may seem like shooting at sitting ducks. But the issues are so important for us as a society that they cannot be ignored. Those who are tied to the project continue to defend it but other opinions range from doubtful to contemptuous. The aspect that I want to consider most is the financial one. Before coming to that, though, what are the main reasons for pessimism with regard to NHS IT?

The most damning evidence is the failure of the project to maintain the confidence of those who will use it in their daily lives. Their view has increasingly been that the project is driven from the centre and will not deliver what is needed. Surveys of NHS staff are showing decreasing buy-in and senior doctors have been publicly critical. The National Audit Office has been driven to comment on the lack of staff commitment.

Leaders of the project have talked about unprecedented levels of consultation, and referred to consulting hundreds of people. That fails to deal with the issue. If the perception is of a project that is out of touch with its users, then there is little purpose in arguing the point. In such matters, perception is all.

Another crucial area that is too readily dismissed by sponsors of the project is security, and in particular the interests of individual patients. Most people probably still think of their relationship with doctors as one of strict confidentiality. That is how most doctors would like it to be. A number of changes have seriously undermined that position.

Changes to greater reliance on electronic systems have shifted the ownership of data away from doctors towards administrators, who are much less constrained by ethical commitments. With ever increasing centralisation, data becomes the property of faceless bureaucrats. Deliberate actions exacerbate the situation, such as the transfer of PC ownership from general practitioners to Primary Care Trusts and the Health Act which imposes compulsory disclosure of medical information. Recently doubts have been cast on whether patients will be permitted any kind of opt-out from this all-embracing approach to personal data.

Of course plenty of bland assurances are given about how information will be kept secure. But with leaks from banking or criminal records systems commonplace, it is highly unlikely those promises can be met. Another problem is the accuracy of records, notably illustrated by the case of Helen Wilkinson who had to go to parliament to get a potentially damaging slur in her records removed.

What, then, of the financial issues? The NHS is a huge organisation, so all the figures are inevitably large. We started from a situation where the NHS, whatever its failings, was delivering a reasonable standard of care while consuming a substantially lower proportion of national income than healthcare systems elsewhere. There are many difficult and complex questions about resource allocation in healthcare but there was widespread agreement the NHS needed more money to meet the population's expectations.

But we now have a situation where several years of increased levels of expenditure have largely disappeared into top salaries and IT projects, with little evidence of much change in the experience of patients. And the future looks bleak, since the spending on NHS IT is by no means over.

A delayed and over budget project is doubly damaging - the excess costs are painful but the delay in the benefits makes the situation far worse. Always supposing the benefits will actually materialise. With the Chancellor of the Exchequer looking to constrain any further increase in NHS spending, the failure of IT looks likely to eat into money that could otherwise have been spent on paying front-line staff and avoiding closures.

The huge IT costs are not money that has just disappeared. The cash has found its way mostly to highly paid consultants and contractors within IT. There is nothing intrinsically wrong with highly paid IT people. But when they fail to deliver value to the public sector it brings disrepute on the IT business and unfairly transfers money from the ordinary taxpayer to a generally privileged sector of society. One might have thought this was not the objective of a Labour Party.

So what do we learn from all this? Unfortunately very little that is new. Imposing sweeping change on a large and complex organisation from the centre has a poor likelihood of success - especially where large numbers of professional staff are involved. Excessively centralised systems are brittle and fail easily. Consultants do not deliver value unless they are exceptionally well managed. Senior management frequently fails to understand how organisations really work. The NHS is not a business, and it is a nonsense to treat it as one. Government cares little for the security of personal data.

What kind of solutions are available? We would be much better off with more diverse provision of IT services to the NHS, which actually has many varied needs. Efficiency gains would be achieved more readily by the setting of standards for data exchange rather than the imposition of all-embracing systems. Incremental improvement is a more reliable way to achieve gains than a big bang. And open source solutions, as used effectively by the US Veterans Health Administration, have huge potential for gain - both through cost cutting and also through opening up developments to greater diversity and innovation.

Will any of this happen? With the current posturing by leading politicians, and numerous signs of blame-passing around NHS IT, the prospects are poor.