Richard Granger's departure may jeopardise NHS IT programme

It is a pity Richard Granger, director general of NHS IT, is to leave as head of Connecting for Health, the agency that is running the National Programme for IT (NPfIT). The decision was his - he was not asked to leave. Indeed, officials at the Department of Health may soon recognise that they are losing the NPfIT's most valuable asset.

Without Granger the NPfIT is at risk of falling apart, for he has given the programme a credibility it would not otherwise have had.

Long before he joined the Department of Health as director general of NHS IT, the future of the NPfIT was to a large extent sealed.

By then a key lesson from the failures of three separate IT-related programmes - Wessex Regional Health Authority's Regional Information Systems Plan (1992), the Read Codes version three (1998), and the Hospital Information Support Systems initiative (1996) - should have been learned. And that was that large, centralised IT schemes imposed on semi-autonomous NHS sites rarely work. They engender a scepticism among doctors that becomes impossible to overcome.

Instead of avoiding this mistake, officials at the Department of Health and Downing Street made it the central ingredient of a new scheme of unprecedented scale and boundless complexity. Ministers further deepened scepticism among clinicians by conceiving the national programme in secret and announcing it as a fait accompli.

Need for an electronic system

Later, when Granger joined the programme in autumn 2002, he gave it a credibility based on a conviction that it was needed. And he was right. Reliable electronic health records are needed urgently. Paper notes go missing, and are not generally available after hours.

So there is no disagreement on the need for easily accessible electronic medical records. But local patient record systems were already being installed successfully before the NPfIT was born. It was just happening slowly. So it is understandable that ministers wanted progress to be accelerated.

The answer was for national standards to be set, money put aside for modernisation, teams from successful sites deployed as troubleshooters within the NHS, and incentives paid to GPs, IT specialists and chief executives for successful implementations in which benefits for patients were measurable.

Instead, the Department of Health wanted in early 2002 to put itself at the centre of everything that happened. Bureaucracies love complexity. And so an amorphous national programme without a simple, clear objective grew around the sound idea of electronic records for everyone in England.

Later, Granger joined the programme. And he and his team have achieved much. IT is now a high priority for NHS trust boards and he has broken new ground in his firm dealings with suppliers. The NPfIT has also done much to force trusts into identifying duplicate and inaccurate patient records, and some trusts have had antiquated IT replaced with more modern systems.

Connecting for Health has also delivered a number of useful systems that most people have never heard of, including the Secondary Uses Service (a healthcare planning, clinical audit and research tool), the Personal Demographics Service (a database of names, addresses, dates of birth and NHS numbers), and the Quality Management and Analysis System (a means of assessing the work of GPs).

Though successful, these systems may, for the NPfIT as a programme, represent "scope creep" in that they were not among the original four main NPfIT systems. These four were an electronic system to book hospital appointments, national electronic health records, a new broadband infrastructure and e-prescriptions.

Our verdict on the NPfIT systems

BT has successfully delivered the broadband infrastructure, though critics attack the cost of making changes to bandwidth. The electronic system to make hospital bookings is working, and though a significant number of GPs refuse to use it for a variety of mostly understandable reasons, they may support it when it is quicker and they are used to its idiosyncrasies.

E-prescriptions have been hit by delays, but may in time prove a useful system. A national electronic health record is the main reason for the NPfIT and it looks to be years away. Many experts now question whether it is needed. An accurate, comprehensive and secure locally-available electronic health record may be a better idea.

Since some of the NPfIT's main systems have yet to materialise fully, ministers have sought to direct positive publicity towards x-ray systems, known as Picture Archiving and Communications Systems (Pacs). But these were being installed before the advent of the NPfIT.

Pacs is a technology that has unanimous support in the NHS - it replaces x-ray film, which can easily go missing, with digital images that can be viewed on high resolution monitors - if necessary by consultants who are miles away from the patient.

But Pacs was not one of the four main NPfIT systems, so its success does not make the NPfIT a success, though ministers in their statements treat the two as the same.

And this is arguably the biggest weakness in the NPfIT: ministers have politicised it.

Too political

In the private sector the project would have been reviewed independently. If there were parts that did not work, and it was thought unlikely they would ever work, they would be scrapped. Money and people would instead have been directed into installing systems that yielded measurable patient benefits at an affordable price.

But in politics, changing direction can be seen as a weakness, or even, dare we say it, a mistake. So changes must be made below the radar, without anyone really noticing, while transient ministers declare that all is well.

Unannounced changes are indeed being made to the NPfIT. Local NHS trusts are installing standalone systems that are being adapted to national standards. These may be integrated in years to come when, for example, there is agreement among clinicians on how records can be shared.

But with Granger's departure, the programme is losing a rock. About a dozen ministers with overall responsibility for the programme have come and gone, and the health minister Lord Hunt has gone and come back again. But Granger has for years remained as senior responsible owner for the IT parts of the scheme.

So we are disappointed that he is leaving. And it is surprising the Department of Health is not doing more to keep him. A figure as charismatic and demanding will prove difficult to replace. We are by no means sure the programme can be held together without him.

Computer Weekly's National Programme for IT site >>

Tony Collins' blog >>

NAO report on The Hospital Information Support Systems Initiative - 11 April 1996 >>

NAO report on Read Codes - 12 March 1998 >>

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