NHS etches path forward
British newspapers and technology blogs were abuzz this past month, with news that England's long, problem-plagued and expensive experience with top-down, nationwide health system digitization would soon be drawing to a close.
On Sept. 22, the Department of Health announced "an acceleration of the dismantling" of the National Programme for IT (NPfIT), an initiative of the National Health Service (NHS). Launched back in 2002 by Tony Blair's Labour government, the massive £11 billion project was billed as the biggest civilian technology undertaking in the world - audacious in its plans to outfit hospitals and health trusts across the country with electronic patient records and link them into an interoperable NHS-wide framework.
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Some £6.4 billion has already been spent on NPfIT, but nearly a decade of doctor resistance, delays and cost overruns have finally led policymakers to cut bait, having concluded that the project is untenable - unfit to provide "the modern IT services that the NHS needs," according to a press release from the Department of Health.
One overarching problem, as choruses of observers have made clear over the years, is that the government's prescriptive approach, by which it entered into massive contracts with vendors for one-size-fits-all nationwide IT implementations, paid little heed to feedback from physicians.
"Labour's IT programme let down the NHS and wasted taxpayers' money by imposing a top-down IT system on the local NHS, which didn't fit their needs," said Andrew Lansley, the UK's secretary of state for health.
So what now? A new approach: scrapping the components of NPfIT that didn't work and salvaging the infrastructure that still does. But how exactly that will be accomplished is still up in the air.
An NHS official, speaking on background, said details on how the "dismantling" of NPfIT would proceed - along with some specific direction for providing informatics support for NHS hospitals and clinics - will be forthcoming later this autumn.
In the mean time, NPfIT's governing board has been disbanded, and a move is being made toward a much more decentralized approach, which will see various health trusts nationwide able to make their own choices about what systems to implement - systems that can then linked together after the fact.
"We will be moving to an innovative new system driven by local decision-making," said Lansley. "This is the only way to make sure we get value for money from IT systems that better meet the needs of a modernized NHS."
Key to achieving that goal is "the development of a vibrant marketplace for healthcare IT," added Katie Davis, managing director for informatics at the Department of Health. "We have a great opportunity to build a new way of working which helps patients and clinicians gain the best value for public money."
Toward that end, the Department of Health has enlisted Intellect, a London-based technology trade group, to help it look for ways to bring more small- and medium-sized IT firms into the fold for various NHS projects going forward.
To be sure, NPfIT's track record with vendors over the past 9 years has been less than ideal. Suppliers have signed onto the project and subsequently signed off. Others have been slow to deliver the technology they promised, and missed crucial deadlines.
On Oct. 4, it was reported that Falls Church, Va.-based CSC, a key contractor to the project, had been compelled to repay £170 million to the NHS, having failed to deliver NPfIT's crucial patient records software, called Lorenzo, on time.
Now CSC is also facing a class action suit from its investors, who claim Lorenzo's poor track record in recent years was "fraudulently concealed" from them. The Guardian reports that "as early as May 2008 CSC knew, through reports and testing, that Lorenzo was 'dysfunctional and undeliverable.'"
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CSC had pledge to implement Lorenzo at 166 NHS trusts by 2016, but has yet to install "a fully functional version" of the technology at any of them, the suit alleges.
But vendor woes are only one exacerbating aspect of this mess, which ultimately stems from NPfIT's formative flaw: a willful disregard, from the beginning, of the wants and needs of doctors, nurses and clinicians.
Recently The New York Times spoke to former National Coordinators David Brailer, MD, and David Blumenthal, MD, and asked what lessons they'd learned from watching the "slow-motion train wreck" play out across the Atlantic these past few years.
"The thing that brought them to their knees was the confrontation with doctors," Brailer told the Times.
"In a complex health system, you have an enormous number of independent actors," added Blumenthal. "Physicians and health care professionals have to be part of the process every step of the way."
"What we're seeing in Britain is the final result of a number of fundamentally bad decisions," said Brailer. "It was classic top-down re-engineering that was forced upon physicians and nurses. The British government treated it as a big procurement program, putting out bids, selecting contractors, picking winners and concentrating their bets. They crushed what had been a pretty vigorous health information technology marketplace in Britain."
But all is not lost.
The hope is that, from the ashes of this debacle, a new and more robust health IT system can emerge in England, informed by smarter decision-making and embraced by more autonomous care providers.
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The NHS official we spoke to pointed to significant progress in laying down the a nationwide IT infrastructure. Indeed, more than two thirds of the money spent so far on NPfIT has been on infrastructure and applications for interoperability.
The Department of Health touts "substantial achievements" from the multi-pronged program that are "now firmly established," such as the N3 Network, billed as one of the largest VPNs in the world; the Spine, a secure central database where electronic records are stored; NHSmail is a national email service provided free to NHS staff; and Secondary Uses Service, a database that mines anonymized patient records for research and public health initiatives.
As the field is opened to new vendors with new capabilities, there are plenty of players who should be eager to jump in and help build on those early infrastructural successes, or expand their roles in helping move toward NPfIT's original vision of a seamlessly connected health IT system.
"It is clear that the National Programme for IT has had many challenges since its inception and we, for a long time now, have been calling for a radical rethink," Matthew Swindells, senior vice president of Cerner (whose "Choose and Book" software is another of the successes of NPfIT - enabling some 37,000 hospital bookings each day) tells NHINWatch.
But he says his firm remains committed to working with the government to ensure similar successes "are extended" and "clinical engagement in IT is increased" while also "suggesting alternatives for those areas of the programme which have failed to deliver."
The NHS official says one of the reasons for NPfIT's original top-down approach was a concern that England's healthcare system would not feel the need to invest in health IT if left to its own devices.
But a lot has changed since 2002. The IT literacy of clinicians has developed, and the case for the technology's necessity has been bolstered considerably. The technology itself has grown by leaps, and public attitudes have become attuned toward its value.
[See also: Mapping the future of NwHIN.]
The hope, then, is that by loosening the yoke of the initial, ill-conceived program and leaving local organizations in charge of their own destiny, that a flowering of a truly connected and interoperable health system can finally take root in the UK.
"The exchange of information between patients and clinicians and across the NHS is a fundamental part of how we are centering care on patients and making sure innovation and choice are fully supported," said a Department of Health official. "The NPfIT achieved much in terms of infrastructure and this will be maintained, along with national applications, such as the Summary Care Record and Electronic Prescriptions Service, which are crucial to improving patient safety and efficiency."
But beyond that, said Sir David Nicholson, chief executive of NHS, "a modernized NHS needs information systems that are driven by what patients and clinicians want. The NPfIT has provided us with a foundation but we now need to move on if we are going to achieve the efficiency and effectiveness required in today's health service. Restoring local control over decision-making and enabling greater choice for NHS organizations is key as we continue to use the secure exchange of information to drive up quality and safety."