Granger says NPfIT in danger of being derailed

Tags: A Audit Choice Choose and Book DH England Foundation Trust Government GPs Granger HIS iS NPfIT Office Spine US

14 Nov 2005

The director in charge of the £6.2 billion NHS National Programme for IT has warned that the project is in “grave danger” of being “derailed”, according to leaked Whitehall e-mails.

The claim was made by NHS IT director General Richard Granger, in an email to Margaret Edwards, director of access and patient choice, at the Department of Health. The e-mails were leaked to the Sunday Times.

A further report indicates that the leak has infuriated NHS chief executive, Sir Nigel Crisp. The Guardian said this morning (14 Nov) that Sir Nigel was preparing “a stiff note asking Mr Granger to explain his unconventional behaviour and lack of corporate discipline.”

According to the e-mail exchange reported in the Sunday Times, Choose and Book is unable to offer appointment bookings to any of the 32 foundation trusts in England because they are not on its “choice menu”.

Similarly, the 10 private sector treatment centres are also missing from the menu of treatment options. Neither foundation trusts or treatment centres are due to become available on Choose and Book until the middle of 2006 – six months after the system was due to be fully implemented.

In the e-mail exchanges in September, Granger blames Edwards, a senior DH director, for the fiasco, attributing delays to her repeated last-minute changes and failure to heed his advice.

According to the Sunday Times report Granger criticises Edwards, for allegedly adding numerous new specifications to the booking programme, known as Choose and Book.

Granger’s leaked email says: “Choose and Book’s £20m IT build contract is now in grave danger of derailing (not just destabilising) a £6.2 billion programme.”

He concludes: “Unfortunately, your consistently late requests will not enable us to rescue the missed opportunities and targets.”

The NHS IT boss has previously publicly criticised Edwards, blaming her for delays to Choose and Book. At June’s NHS Confederation conference and he attributed delays to Edwards, and in an interview with Computing magazine last week where he argued that the central technology had been successfully delivered, but that delays had been created by policy people and the failure of NHS organisations to implement locally – a contentious view challenged by many EHI readers.

Sir Nigel Crisp was forced to admit to the Commons health select committee two weeks ago that the booking system was at least a year behind schedule.

To date, including telephone booked appointments, the system has made only about 20,000 appointments for patients. It was supposed to have made 250,000 by December 2004. When it is fully operational the system is meant to be capable of making up to 9.5m first hospital appointments a year.

Granger’s comments were triggered by an e-mail on 9 September from Edwards which states: “We have a problem!” The e-mail is reported to state that patients and their GPs still cannot book treatment at any of the country’s 32 foundation trust hospitals by computer because they are not on its “choice menu”.

The 10 private sector treatment centres, set up by the government to reduce waiting lists, are also absent from the choice menu on Choose and Book. Edwards warns that treatment centres and foundation trusts will not be on the “choice menu” until next summer.

Edwards says in her e-mail to Granger: “We haven’t yet told ministers that there is a problem.” Despite Edwards’s original e-mail being encrypted and password protected, Granger sent it out with his reply and widened the distribution.

According to the Sunday Times, Granger complains that the project has been allowed to change beyond recognition from the original specification. “The original request from your predecessor and yourself was for an Electronic Booking System. The change of this to Choose and Book occurred in (the second quarter of) 2003. This was the first of what are now recurrent major changes in your requirements.”

The booking system has been dogged with difficulties since its inception. GPs have been reluctant to use it, the national spine it operates across has proved at times unreliable and early pilot schemes identified software design flaws.

Granger insists that the booking system works, and has publicly blamed civil service colleagues in the Department of Health for failing to get GPs to use the system. In an interview with Computing Magazine last week, he said: “Low usage is not something I can do anything about.”

The problems with Choose and Book raise serious concerns about the prospects for success of the far more complex systems set to follow – particularly the core NHS Care Records Service and local core clinical solutions – both of which are already running late.

A detailed National Audit Office report on the procurement and early implementation of the entire £6.2 billion NHS IT programme is due within the next two months.

Links

Granger answers Choose and Book critics

Readers Comments

Sir Nigel Crisp should spend some time giving true answers to the PAC

14 Nov 05 14:01

My impression is that of the ratehr modest number of bookings made through Choose & Bicker almost all have been made by phone.

I don't see how any of us can reasonably think otherwise unless the young knight stops refusing to answer The Hon Mr Bacon MP's entirely reasonable question.

Inside impressions

14 Nov 05 16:22

My 'impression', drawn from talking to people involved in implementing Choose and Book, is that most bookings have been made by GPs during a consultation - many of whom have found it surprisingly quick and easy to use once they've put aside their prejudices and had a go.

The system is flakey (not sure if this is improving) and it is attached to the political ball and chain of the government's choice agenda (hence it gets a good kicking from all and sundry). It is flakey because it was rolled out to politically driven deadlines that paid no head to the minimum elements that needed to be in place to make it work (N3, compliant PAS systems etc etc).

From a project management point of view this is a very basic mistake, and in this sense, the project has been set up to fail. Whilst Granger has a point about the politicians and civil servant screwing up the project, he has to shoulder a good chunk of the responsibility for allowing himself to be put in that position in the first place.

Some hard evidence would be nice!

14 Nov 05 16:49

The "inside impressions" are interesting, and possibly valid, but they do need to be backed up by some objective evaluation. This isn't just of academic interest but is arguably an important element in good governance of this type of public sector project. There may also be a case for separating out the issue of realisation of any benefits from CAB, from the issue of whether the project management has been adequate.

That people are increasingly vocalising opinions on CfH is a healthy development. Hopefully, the recent national press coverage will help build the momentum towards a more formal evidence-based audit of CfH.

the number is known

14 Nov 05 21:44

and no credibility can accrue to the project if it conceals it, including apparently from a view from within.

The evidence is there in the increased take up

15 Nov 05 08:44

The evidence is there - in that day by day a greater number of referrals are being made via the system.

Given that this is new software tied in with a major change in the referral process, good progress is being made. It was always the unrealistic targets that have had the greatest impact on the credibility of this programme. There have been software problems (predictable and being resolved), there has been opposition from GPs (predictable but being overcome now that integration is being achieved along with improved reliability of the software) and the many other issues to be expected with such a complex programme.

Yet again the NHS is beating itself up by measuring success against always unachievable targets, rather than setting realistic targets and being in a position of patting itself on the back for good progress.

What’s more for all the people working on this at the sharp end to make this good progress, despite all sorts of problems - because we did not achieve the unrealistic targets we will not receive the incentive money - which is plain bad management.

When will the NHS get real in its timescales for achieving such a massive programme (NPfIT) whilst carrying on with business as usual. Any other organisation would recognise and accept that either productivity would go down or that transition costs would be high to implement such a large change programme - but not the NHS. It’s do this on top of all the other initiatives, meet activity targets and don't expect any allowance in the PBR tariff to reflect the cost of doing this at the coal face. Utter madness and the sad part is that this blinkered unrealistic view from the centre is likely to kill the programme.

The evidence

15 Nov 05 10:12

And who set the aggressive timescales, and is very proud of most of them ?

C&B is the exception, the headlong rush to do this and PACS in advance of areas like spine authentication, and integrated patient identity has devalued these projects, and will lead to further data quality issues down the line.

Take up has been slow, and now we are beyond the financial incentive end of October, slowing. Integration and enhancements will help, but a lot of damage to co-operation of clinicians has been done, timescales driven by all those bickering at the centre.

Unrealistic Targets and interim solutions!

15 Nov 05 10:41

The comment about the targets for Choose and Book being unrealistic are spot on. When the project was first announced I firmly believed it should be implemented in 2007 when the majority of Acute PAS's would be in place and the software had been developed, tested and, for the most part, error free.

THe DoH set the unrealistic targets then added Choice to the original electronic booking solution making those targets impossible - not even the pilot sites using C&B since 2004 got near October's 50% target!

To have Choose and Book available in 2005 we had to go down the "interim" solution. Every time an "interim" solution is introduced it ends up causing more work and costing the NHS more money! Rather than admit that the C&B target was unrealistic in the first place and move the targets to a point where the PASs are in place and the clinical systems suppliers had developed their integrated software this interim solution was forced through.

The three main clinical systems suppliers only recently had their integrated solutions approved after testing, in fact, iSOFT is at the piloting stage in the NWWM cluster, IPS and EMIS are installing integrated systems (incidentally, C&B has required substantial hardware upgrades, particularly of EMIS servers, which of course has fallen to the PCTs to pay for not the national programme) which is hardly ideal.

I have to say Granger actually has a point in his comments ( I believe Choose and Book was outside the CfH programme and was instigated before he took up his post) - the worst thing you can do is change the specification of a solution such as Choose and Book once the programme of delivery is up and running, especially if you change it time and again but leave the targets set in stone!

Authority & responsibility

15 Nov 05 12:47

What is becoming increasingly clear from this discussion is that there is a critical disjunction between authority and responsibility within the NHS IT programme. Richard Granger has responsibility to deliver, but no authority over critical decisions that threaten to wreck the project. Key players in the DH hold the authority, but seek to distance themselves from responsibility. This is far from being an unusual situation.

Is the solution then to give Mr Granger proper authority over the project, or is the Government saying that even with his 250K salary they don't trust him to make real decisions?

damage to relationships

15 Nov 05 12:48

I have just come back from a Project Board with secondary and primary care clinicans on to discuss electronic ordering by GPs into diagnostic services. When we showed them the demonstration of the software 2 months ago it was well received and they were very enthused to take up this solution. Now they are backtracking having been exposed to C&B rollout performance. Issues about login times and response times have killed off enthusiasm and now I am having to introduce another phase to the project to further include proof of concept with some "champions" with the proviso being if it's not easy, fast and reliable it's not going in. I might add this LHD is green lighted in this SHA for C&B (on the interim solution) so it's not for want of trying, despite RG suggesting the NHS is not delivering. (Post edited by E-Health Insider)

Increased uptake isn't evidence of benefits or good project management

15 Nov 05 14:11

The comment suggesting that increased uptake of C&B per se is evidence of any sort of real success should not go unchallenged. What matters - surely - is evaluation of benefits (i.e. how has the project realised its investment objectives to date?) and an analysis of the quality of the project management so far (i.e. could it have been done faster, cheaper, with better risk management / moitoring of slippage etc etc?).

Both these aspects are important: the first to vindicate the C&B concept as a priority for the NHS at this point in time (a notion that many have challenged); the second to allow executive decisions to be made about the management of further elements of the CfH programme.

It's too late to say I told you so.....but......

15 Nov 05 23:11

IMHO Mr Granger and his senior colleagues have never really understood a) the NHS, and b) the extent of the culture-shift required for the service to accept and adopt the National Programme. They have underestimated the task of making the National Programme work and they lack the credibility and experience to deliver the largest IT project ever undertaken in England.

NPfIT's original brief was about negotiating cost effective contracts and procuring services, and that's all. There was nothing about creating a megalithic organisation to undertake the implementation and roll out phases. A perfectly good and experienced vehicle in the form of the NHS Information Authority was already available.

This was the organisation that very successfully managed the introduction, implementation and operation of national services such as NWCS, N4B, NHSnet, NHS Web, National e-mail services, NLEH, security services, coding & classification and a myriad of other programmes, services and applications. In fact almost anything decent that has ever worked in the NHS!

It's demise was supposedly part of a cost saving move by the DOH, so how come NPfIT/CFH occupies far more costly office space, employ almost twice as many staff - including a large number of very expensive consultants, some in very senior roles, and have paid substantial amounts of redundancy and enhanced pensions to the very people who could have helped them deliver the National Programme, were it not for NPfIT's "not invented here" syndrome.

It's too late to say I told you so but there, I've said it anyway. (post edited by EHI)

Let's at least learn some lessons!

16 Nov 05 09:46

As an ex-senior manager with the NHS Information Authority, I echo your previous commentator's views (but then I would, wouldn't I?).

But can I add a couple more things that the NHSIA delivered that seem particularly pertinent to the C&B situation? (1) Pathology messaging (ie connecting GP surgeries to hospitals) and (2) ERDIP (with a wealth of findings on the issues facing "the centre" in rolling out IT).

As - in comparison - CfH appears to be delivering "less for more" it's sometimes hard to avoid a feeling of schadenfreude, especially as I see little evidence of the extensive (and usually well-documented) learning from NHSIA (and even IMG) projects being taken on board.

Identity, identity, identity

16 Nov 05 10:39

>> “Choose and Book’s £20m IT build contract is now in grave danger of derailing (not just destabilising) a £6.2 billion programme.” <<

How can a £20M service with no downstream dependencies derail the entire project? Is this hyperbole or something deeper?

Can any of the 'fab four' (NCRS, cross-institution PACS, C&B and ETP) work without the following in place:

1. A single cleansed, current patient demographics database (or confederated view of multiple databases): one patient-one identifier for every NHS patient! This database capable of being queried and updated in real time from anywhere in the NHS enterprise

2. A single staff database (or confederated view of multiple databases), not just NHS employees but the many other users e.g. community pharmacicts etc) capable of being queried and updated in real time from anywhere in the NHS enterprise

3. Role based access enforcment for the 1 milion plus users to the 50 milion plus patient records.

Without the above pre-requisites all we can ever have is flaky and insecure 'interim' solutions.

We need to hear more about the details and progress on these Mr Granger please!

Identity,Identity, Identity...delivered

16 Nov 05 13:20

1. A single cleansed, current patient demographics database.

This is the Personal Demographics Service. It went live in June 2004. For more information, check out http://www.connectingfor health/demographics

2. A single staff database 3. Role based access enforcment

These were delivered in 2004 by the Spine Directory Service and the Access Control Framework. For more information, please see:

http://www.connectingforhealth.nhs.uk/publications/comms_tkjune05/Spine.pdf

These services are used by all NHS CRS implementations, including C&B and eTP.

On the meaning of "delivery"

16 Nov 05 13:36

When your latest commentator uses the word "delivered" does he or she mean (1) Tested from both technical and semantic perspectives? (2) Scaled up to a level of implementation that represents full load? (3) Integrated with all the other bits of CfH software and across operational computer networks?

That's what I'd understand by the word "delivered" in the context of CfH's ambitious objectives. Perhaps someone could confirm that I've got this right?

re: Identity,Identity, Identity...delivered

16 Nov 05 17:02

>>3. Role based access enforcment These were delivered in 2004 by the Spine Directory Service and the Access Control Framework.<<

A remarkable achievement given legitimate relationships are only due to go live this December (2005)!

http://www.e-health-insider.com/news/item.cfm?ID=1421

The 'delivery' issue goes beyond implementing the core services and interfacing systems to them.. these databases have to be fully populated and maintained too.

"If a tree falls in the forest, and no one is there to hear it, does it make a sound?" And if no one can hear it, NPfIT can say it fell whether or not it actually did :-(

LRS

16 Nov 05 18:23

LRS slated for delivery mid June 2006. I heard...

Derailment - don't worry the train is late !

16 Nov 05 20:16

Re: The correspondant above returning dejected from their project board.

As an indicator for a Data Centre delivered, supposedly modern system, Choose and Book has turned many clinicians off the whole concept of trusting CfH to deliver anything.

Post edited by E-Health Insider

National standards, realistic targets, local delivery

elisabeth.crowe@cambridgeshire.gov.uk

17 Nov 05 11:44

Re "Let's at least learn some lessons", I was an NHS IT manager when these programmes were rolled out. The reason they succeeded was because the different elements of the NHS IT community did what they were good at. The DoH set standards that would be effective on the ground and provided funding, local services decided how to deliver and negotiated locally with their suppliers, local trainers trained local clinicians and support staff, who agreed that the system would be useful, the whole thing backed by central mandation to get suppliers to develop systems. If only this model, especially the part about giving local services the funding, had been applied to the whole of CfH I am sure the hospitals would have PACS and electronic patient records and GPs would have functional systems talking to each other and capable of sending referrals to & receiving summaries form to their local providers. Is it too late for this lessons to be taken on board by CfH?

Getting off on the late train

17 Nov 05 11:48

And aren't a lot of people just thrilled by the 'crisis' in Connecting for Health and the possibility of saying 'I told you so' about another NHS IT failure?

As someone working inside CFH I'm far from blind to the organisation's manifold failings - I could probably write a (very dull) book about the experience. But some of the attitudes expressed and the behaviour of some colleagues in relation to CFH does them little credit: narrow minded parochialism coupled to smug self-satisfaction isn't going to deliver the infrastructure to support safe, coherent healthcare at a national level.

However, it might help to maintain the status quo of pockets of excellence amid a sea of mediocrity.

Your crisis is disappointing rather than thrilling.

17 Nov 05 13:01

It's reassuring to see that a CfH insider has (apparently) publicly acknowledged the existence of a 'crisis'! Personally, I don't know many people who are either thrilled or self-satisfied by CfH's predicament. I have, however, encountered a range of emotions (including anger, frustration and disappointment - but no surprise) that this programme has failed to heed the lessons of previous projects and has found itself in its current situation.

In my opinion, nobody looking at its track record on C&B would ever believe that CfH will deliver the national infrastructure mentioned by your previous commentator without a major shift in approach. And one risk of pressing on without that shift is that those very islands of excellence (from which CfH could learn so much) will be swamped by a tidal wave of less effective top-down initiatives imposed from "the centre".

The resulting "pan-mediocrity" would at least be consistent and live up to the promise of "ruthless standardisation" made at NPfIT's inception!

Crisis? What crisis?

17 Nov 05 14:12

I'll risk the comparisons with the late Sunny Jim, but you'll notice that the 'crisis' mentioned in my earlier posting was in inverted commas - intending to suggest that it isn't anything of the sort. Apologies if anyone misunderstood.

The truth is that CFH is weathering some storms, it may even be taking in a bit of water here and there, but the bilge pumps are working and it is making some significant headway. So I wouldn't look for anyone manning the lifeboats just yet - even if Captain Granger is bickering with the Owners.

Anyone see an iceberg?

Parallel trains

17 Nov 05 15:44

I don't doubt the dedication of many CfH staff that I have met, I know they work long hours to ridiculous deadlines. In the headlong rush I just don't think there has been enough detailed thought about how we might truly achieve the 'electronic future'.

I am passionate about getting the best for hardworking clinicians, patients and the taxpayer. Lack of funding having always been the rate limiting step, I am galled to see the conspicuous waste in the CfH approach. Not thrilled, but deeply disappointed.

We've previously dodged many of the potholes that CfH is now forcing us through. And delivered systems that clinicians clamour to use across a health community with minimal funding.

The idea that healthcare has to be delivered at a national level is flawed, as are the contractural concepts of a paperless record that has not adequately considered how to get there.

I'm not smug, but desperately sad at the opportunity being lost.

A long term view

17 Nov 05 18:21

I really do think we must all try to see the overall long-term picture. I firmly believe that in ten years time we will look back in amazement that a National Health Service ever thought it could run a modern health care service with every individual hospital, surgery or healthcare provider being able to make its own decisions on local IT systems, solutions and providers.

It will take time (some, or many of us may be retired by then), but ultimately a national patient record, national services and national standards are the only way to deliver effective IT support to health care. As a prospective patient I would expect nothing less.

These individual set-backs, bickerings and political shenanigans will, in time, be seen in proportion - and whilst I may or may not agree with some of the detail, overall Richard Granger has proved that he has the will to stay the course and continue single mindedly to focus on the long term goal and benefits. The worst thing would be for him to bail out now - the NHS (including CfH) needs a period of stability if it is ever to deliver real solutions.

Local and national

18 Nov 05 09:50

I have to agree with the Long Term View above. Pretty much all healthcare is delivered locally, but IT systems have to work locally and nationally. Historically, the former has been patchy and the latter largely non-existent.

Making systems work locally is the primary concern from an organisational point of view. Systems working nationally is what patients expect (and many assume this happens already). So maybe it's time to recognise that the rhetoric of providing patient centred services might mean making organisational compromises for wider patient benefits.

As to the debate around centrally mandated systems versus central standards / local decisions, the case of websites offers a good illustration. How many NHS organisations have implemented eGIF, eGMF and the full spectrum of DH branding guidelines? Not that many I'd say - and that's Janet and John stuff in IT terms.

Apparently implementation has been much better in local government, so it's not impossible, but this has been at the expense of a lot of carrot and a lot of stick.

Accessability - perhaps Mr Granger can help?

18 Nov 05 10:12

Following on from the last comment it's interesting to note Margaret Edwards', the DH director of access and patient choice, own website doesn't appear to meet web accessibility standards set by government.

I noticed that there is a sizing problem in all web browsers other than IE. I wonder if someone dare tell her about the problem, suggesting that she contact Richard Granger whose web sites all work to W3C- WAI specs, for advice!

http://www.18weeks.nhs.uk/public/default.aspx

3 years is a long (ish) time in health informatics!

21 Nov 05 09:00

Whilst single-mindedness and a long-term focus are undoubtedly important - as a previous commentator suggests - the three years since Richard Granger took up his post is a longish honeymoon period by anybody's standards. And the actual widespread roll-out element of the programme (always the main challenge in NHS informatics) still seems to be deficient. In my opinion, the questions that now need to be urgently addressed are: (1) Is the current direction of travel (the "view") correct? (2) Are the current management arrangements (individual and structural) capable of getting us there (if - indeed - that's still where we want to be after answering the first question)?

Three years sounds like the right sort of interval after which an extensive review is needed to address these questions. Single-mindedly pressing on unchallenged does not really seem to be in the public interest given the track record to date.