Government refuses independent review of NPfIT

10 Aug 2007

The government has refused to hold an independent review of the National Programme for IT in their response to the Public Accounts Committee report on NHS IT.

According to a report in Computerworld UK, the news is revealed in a set of Treasury minutes, where the government have promised to publish a full annual statement of the costs and benefits of NPfIT later this year, which was one of the recommendations of the report, but ignored calls for an independent review.

The announcement came out beneath the radar ahead of the summer recess of the Commons.

EHI has been unable to obtain a copy of the response despite contacting the Treasury, Cabinet Office and Department of Health. A DH spokesperson however confirmed that the story was correct, and that a review of the programme had been ruled out with publication of annual statement promised instead.

According to the Computerworld UK report the Treasury response says “There are no grounds for an independent review of the business case at this stage…The intention is to include details of both the financial and non-financial benefits within the annual statement of benefits realised.”

Instead of an independent review, the government says that the Additional Supply Capability and Capacity [ASCC] scheme will help to provide contingency in the programme.

“Work is underway with the NHS to determine its priorities. The results will be provided to the local service providers and will be adjusted as required…It is better to target reviews at individual problems.

“The intention [of ASCC] is to award a series of framework contracts to selected suppliers who can then compete for subsequent business if the need arises… these would be complementary to the existing suite of programme contracts and provide contingency.”

The response has not yet been uploaded on the Public Accounts Committee website and the DH press office was unable to give EHI a date as to when it would be available to the public as Parliament is on recess until September.

The PAC report, published in April provided a damning critique of the success of the programme to date and questioned the basic business case behind and contracts awarded for England’s £12.4bn NHS National Programme for IT.

The PAC report called on the DH to commission and publish an independent review of the business case for the programme "in light of the progress and experience to date".

A report by the Commons Health Select Committee into the electronic patient record is due in September.

Links

PAC says NPfIT suppliers are 'struggling to deliver'

Reader's Comments

The right spirit.

10 Aug 07 19:26

Let's hope the Public Accounts committee takes that in the spirit it was intended. One has to presume that the government could only permit such an inquiry if it thought CfH could survive public scrutiny. By declining such scrutiny - even in the face of the specific and unequivocal recommendation of the PAC - it offers a considerable vote of no confidence in CfH.

ASCC

12 Aug 07 12:41

"Instead of an independent review, the government says that the Additional Supply Capability and Capacity [ASCC] scheme will help to provide contingency in the programme."

The ASCC will be another be another multi-billion pound bill for the tax payer.

Has there been any sign so far of an attempt to ascertain user requirements this time around?

ASCC

david.hannam@strandtechnology.co.uk

13 Aug 07 10:54

The last correspondent doesn’t understand what the Additional Supply Capacity and Capability frame work is all about. It’s not costing billions as nothing is being purchased. ASCC is a process by which a catalogue of products and services from numerous suppliers will be published. Suppliers who are successful in winning a place on the framework are bound by previously agreed terms and conditions of contract and are not guaranteed any business. Should a Trust wish to purchase a product from the ASCC Catalogue they then have run their own competitive procurement with the suppliers of that product named in the catalogue. If you like ASCC will have completed the first stage of the procurement process on behalf of Trust and present them with a qualified short list of suppliers. It’s a faster more cost effective procurement route.

ASCC

13 Aug 07 15:30

Yes although Trusts do not HAVE to use the ASCC and are quite free to procure products and services from already established suppliers who they know can deliver what they need.

The unanswered question.

13 Aug 07 19:41

"Has there been any sign so far of an attempt to ascertain user requirements this time around?"

The response of the previous poster tends to suggest that the short answer is "No".

Missed his calling

14 Aug 07 10:32

The first commentator here clearly missed his calling - finding witches was done on pretty much the same logic.

Re: The Unanswered Question

david.hannam@strandtechnology.co.uk

14 Aug 07 13:08

ASCC have produced a detailed Statement of Need to which all shortlisted suppliers must respond to before they are selected to be part of the ASCC Framework contract (if you want to know who ASCC consulted with on the production of the SoN ask them, I'm sure they'll tell you). The purchasing authority (the Trust) will then run its own competitive procurement, they will have their own specific statement of need / requirements document that suppliers will have to respond. In short Trusts will select products and services that best meets their local requirements. Remember two things about the ASCC Framework 1) ASCC are not mandating systems, they are creating a shortlist of qualified suppliers 2) the NHS is not mandated to select any product or service from ASCC.

User requirements?

nhstechie@btinternet.com

14 Aug 07 20:21

"Has there been any sign so far of an attempt to ascertain user requirements this time around?"

Yes, of course there have and many readers of this site have been involved in the process. The real issue has never been around user requirements, it has always been around the ability of suppliers to deliver to those requirements within contracted timescales.

Of course requirements alter over time due to changes in the way health care is delivered and the legislative framework we, the NHS, operate within. Any contract worth the paper it is written must reflect such changes (normally enshrined in DSCNs) being made at no additional cost to the taxpayer.

Perhaps if CfH were able to share the content of its contracts more widely some of this speculation would die away, at least a little?

Witch-finding

16 Aug 07 13:32

"The first commentator here clearly missed his calling - finding witches was done on pretty much the same logic."

This is not correct. Witch-finding was done on the illogic of requiring the suspected witch to prove an historical negative - ie. that the person had never at any time performed witch-craft, something which is of course impossible. What is being asked of CfH is that they give evidence in favour of a contemporary positive. The Public Accounts Committee has been unable to find evidence that CfH is a cost-effective use of public money. They have therefore requested a public enquiry to find such evidence. This has not been permitted by the government. This naturally gives rise to the suspicion that such evidence may not if fact exist, as why else would the government refuse the perfectly reasonable request of the PAC. That is why this decision, in effect, is a vote of no confidence in CfH.

Witches?

17 Aug 07 17:53

Some of my best friends are witches but thats another story...

Having worked in the IT industry for 25+ years (the last few supporting numerous clinical systems) I think folks have lost sight of the big picture.

The concept of getting an entire region or country on a common platform so that information can be consistently and reliably shared is a fundamentially sound strategy. Getting this accomplished however is an entirely different box of fish althogether.

People resist change and no one is better at resisting it than the healthcare sector.

Cerner is no better or worse than any other software that you've worked with. Yes its different than what you are used to and out of the box it may not have everything that you think is sexy about the current system but without ever seeing it I can guarantee that it wasn't everything you needed it to be when it was first implemented.

I applaude the government for refusing to cave in to demands for a public inquiry.... Its time for healthcare to stop moaning and get on with the job of getting its IT systems sorted out.

Not all change is progress.

20 Aug 07 10:11

Not all change is progress. In healthcare, thalidomide taught us that Admittedly that was before my time, but the lesson has stuck. As a result, we now have stringent procedures to assess whether or not proposed changes meet criteria of efficacy, safety and (what is particularly relevant here) cost-effectiveness. It is precisely this point which fell within the remit of the Public Accounts Committee. To give an idea of what CfH is up against, the principal tool currently used in measuring cost-effectiveness in healthcare is the Quality-adjusted Life Year (QALY). Recent judgments by NICE have placed the value of a QALY at approximately $26,000. Therefore, for CfH to justify its $12.6 billion price, it would have to show evidence for saving (12.6B / 26,000 =) 484,615 QALYs within the life of the project. Since this is manifestly implausible, it is not terribly surprising that CfH does not wish this calculation to be done in public. What is surprising and disappointing is that the government has acquiesced in this. That is why this is so damaging to public confidence in CfH. As the article correctly notes, this is not likely to escape the attention of the Health Select Committee next month.

QALY

20 Aug 07 11:11

Was QALY a standard part of any IT business case in the NHS pre-NPfIT? Are you saying that all proposals for NHS expenditure are tested against this criteria and NPfIT is the only exception? I thought this was only a test for drugs and treatments. Have I missed something?

QALY calculation

25 Aug 07 10:48

QALY calculation

Source: http://www.jr2.ox.ac.uk/bandolier/band24/b24-7.html

"Outcomes from treatments and other health-influencing activities have two basic components - the quantity and quality of life. Life expectancy is a traditional measure with few problems of comparison - people are either alive or not.

Attempts to measure and value quality of life is a more recent innovation, with a number of approaches being used. Particular effort has gone into researching ways in which an overall health index might be constructed to locate a specific health state on a continuum between, for example, 0 (= death) and 1 (= perfect health). Obviously the portrayal of health like this is far from ideal, since, for example, the definition of perfect health is highly subjective and it has been argued that some health states are worse than death (see QALY Release 2.0 below).

Construction of such measures has a number of uses - to identify public health trends for strategies to be developed, to assess the effectiveness and efficiency of health care interventions, or to determine the state of health in communities.

The Quality Adjusted Life Year (QALY) has been created to combine the quantity and quality of life. The basic idea of a QALY is straightforward. It takes one year of perfect health-life expectancy to be worth 1, but regards one year of less than perfect life expectancy as less than 1. Thus an intervention which results in a patient living for an additional four years rather than dying within one year, but where quality of life fell from 1 to 0.6 on the continuum will generate:-

4 years extra life @ 0.6 quality of life values 2.4

less 1 year @ reduced quality (1 - 0.6) 0.4

QALYs generated by the intervention 2.0"

The above was, I believe, originally posted in 1996.

Time for QALY Release 2.0

Life = 1

Death = 0

NPfIT = -1

QALY calculation

director@doctors.org.uk

26 Aug 07 20:51

I would like to commend that excellent summary of QALYs by the previous poster. While his final comment may be a little tongue-in-cheek, the serious point are: 1) that any very large expenditure of public money should demonstrate cost-effectiveness. 2) that any very large expenditure of public money in health care should demonstrate cost-effectiveness in terms of health outcomes per unit cost. 3) that the Public Accounts committee is right to require evidence of such cost-effectiveness. 4) that the Government is wrong to prevent the PAC from obtaining the independent review required to assess the cost-effectiveness of CfH.

Measure CfH against what it claims

03 Sep 07 20:59

Previous IM&T projects have not raised the same level of alledged and unproven benefits as NPfIT have. The main justification for CfH has been improvements in patient safety through decision support and sharing information.

I think it is therefore appropriate and interesting to apply the QALY calculation. What CfH has achieved is a permafrost on local innovation, (with opportunities lost), whilst NCRS has failed to deliver more than a very expensive PAS to a few sites.

I think the calculation of -1 for NCRS is generous.

Wanless report

director@doctors.org.uk

12 Sep 07 12:51

It looks like the Wanless report has picked up exactly this point:

"At the strategic level the report identifies three factors that is says have had an impact on the 2002 review's original productivity assumptions. "The first is the failure to develop and ICT strategy whose benefits are likely to outweigh costs". It says the failure to produce a business case which shows benefits outweighing costs is a serious criticism, "implying either the absence of an original business case for investment or investment made in spite of a business case that did not justify the spending".

The report goes on to highlight the lack of evidence provided for the ICT investments made by CfH in particular technologies, quoting BCS concerns about poor value for money from the project.

It concludes: "It is difficult to understand why Connecting for Health is being allowed to pursue a high-cost, high-risk strategy that cannot be supported by a business case.""

Hmmmm! - and the Health Select committee report to come tomorrow!