Is the NHS National Programme for IT terminally ill?

A damning report from the National Audit Office (NAO) has revealed the woeful state of the NHS National Programme for IT (NPfIT), nine years after the hugely ambitious project was launched. The report effectively called for a vote of no confidence in the programme. But could there still be a cure for NPfIT's long-term ailments?

While there have been successes along the way, it is the failures of the NPfIT that have been most heavily documented. Since its inception in 2002 it has left a trail of cancelled contracts, overspends and delays in its wake. Originally intended to create a fully integrated electronic patient records system, the NAO says the programme has fallen far below expectations.

Some £6.4bn has so far been spent on the programme, with a further £5bn earmarked for investment. However, there remains great uncertainty as to whether the remaining roll-out will be delivered in time and on budget.

Of the 4,715 NHS organisations in England expecting to receive a new system under the programme, 3,197 are still outstanding. The contract with key supplier CSC alone requires delivery of 3,023 GP systems and over 160 deliveries of the Lorenzo patient administration software by July 2016. Successful implementation of Lorenzo by this date would require a delivery rate of between two and three NHS trusts a month over the next five-and-a-half years, says the report.

The NAO also outlined concerns about suppliers continuing to miss timescales, including a £500m contract renegotiation with CSC which has not yet gone through; and the costs of additional procurements in the South of England following the termination of Fujitsu's local service provider contract, which remain uncertain until November 2011.

This is all in addition to the £20bn of efficiency savings the NHS has been tasked by the new government to make by 2014-15, and a controversial structural shake-up which will see the termination of the 10 strategic health authorities responsible for the programme's implementation locally.

Time for action

Tola Sargeant, research director at analyst TechMarketView, believes the NAO report has come as a loud wake-up call for all involved.

"Until earlier this month the Department of Health and CSC appeared surprisingly upbeat, despite delays and lack of progress on Lorenza and delays at the Pennine Trust roll-out. The direction of travel still seemed the same and that things would continue to muddle through, despite the obvious issues. But now the NAO has come down so strongly and sceptically about the delivery, particularly with CSC, things appear quite different," she said.

"I wouldn't be surprised if something more radical is going to happen now, such as a substantial rethinking of the programme or termination of contracts. They could even put the brakes on the project and use funds for local procurement instead."

Such a move was voiced by Richard Bacon MP on the Today programme on Radio 4, where he called for the programme to be scrapped entirely - describing it as a turkey that couldn't fly. "NHS trusts must be set free to choose the systems that meet the needs of patients and medical professionals. They should have the power to source products locally that suit their needs, subject only to common standards," he said.

Sargeant agrees this approach is feasible: "Many trusts don't have modern patient record systems, which they are crying out for, so I imagine in that case they would at least try to find budgets locally as they will need something at some point. We have already seen a trend for some trusts doing this. But there is still an argument for investment in this area."

Hope for NPfIT yet

John Enstone, legal partner at Faegre & Benson, has worked with several IT companies previously involved in the programme and believes there is hope for its survival if its contract structures are substantially changed.

"This has been one of the most difficult and complex projects in the world, with a history of mismanagement. But I don't see why it can't pull out of fire - I just haven't seen a solution for doing so yet," said Enstone.

"This would involve some additional spending and would depend on creating precise and deliverable contracts with suppliers and proper commercial-focused management, albeit with patience in allowing more time. The secret is creating contracts that suppliers can actually deliver on, which may take some back-pedalling and further investment of money," he said.

"Very few systems cannot be fixed and I don't believe there is the stomach for starting again. But I would like to see someone in government take hold of it and say we are going to take on the headline problems and in three months, stay with it and fix it."

The other key task is to bring doctors and healthcare professionals on board, says Enstone: "Someone has to sit down and talk to GPs. In the past the approach has been too top down."

Chaand Nagpaul, a GP and member of the British Medical Association's working party on NHS IT, says the government needs to form policy in a way that is realistic for health professionals.

"These lessons need to be learnt by every government, not just the previous administration. Any [IT] strategy needs to be realistic, not driven by political ambition or aspiration," he said.

But Nagpaul is adamant that IT modernisation must push ahead. "We need to ensure that there is not a counter-productive response to this report because the NHS needs IT in order to be cost effective. What needs to happen is that IT must be developed in a way that is meaningful and realistic in timescales."

The Department of Health agrees that change is needed following the NAO report, but appeared to suggest the department would stand by the programme.

"We do think the investment made so far in the NPfIT will potentially deliver value for money now that we have a more flexible approach that allows the local NHS to be in charge of its own requirements," said a spokesman.

Given the many problems involved with the NHS IT programme, few would disagree that it will need a dramatic re-scoping if it is to succeed at this late stage. But the question remains as to whether the political will exists to do so.

Sargeant believes it may: "I would probably put money on some form of more radical scaling back of the CSC contract. Not necessarily complete termination, but a more radical rethink than I would have thought a few months ago."