National Programme for IT

The National Programme for IT - ruthless standardisation

The National Programme for Information Technology (NPfIT) is a huge government procurement of health information systems and support services for the National Health Service (NHS) in England. By any measure, it is one of the largest IT procurements ever conducted anywhere in the world. It'll cost well north of £6 billion. It aims to ensure that every healthcare facility in England has access to electronic patient records, digital medical images, a nationwide appointment booking service and basic IT services like email, all configured for use by health professionals. It will replace the patchwork quilt of varied, incompatible, piecemeal systems that dominates the NHS. In time.

The NHS in England

Elsewhere in the UK, the NHS is the responsibility of the devolved regional governments, with some overall direction and oversight from the Department of Health (DH) in Whitehall. In England, the DH runs the whole service at a policy level. The English NHS is currently divided into ten regional "Strategic Health Authorities" (SHAs) who are responsible for performance management and monitoring amongst other things. Within each SHA are a large number of Primary Care Trusts (PCTs) (302 in total) which employ dentists (18,000 in total) general practitioners (29,000 in total) and run GP practices; and hospitals of various types. Hospitals are said to provide Secondary Care and Tertiary Care to their patients, from about 1,600 sites. About one million people work for the NHS in England°, one way or another.

Despite this hierarchy, the NHS is "National" in name only. Throughout its history, each GP practice and hospital has been largely autonomous in many ways. Of relevance here is the fact that they've been responsible for procuring their own IT systems and services. Therefore a very wide range of mostly-incompatible systems exists across the country; interaction between these systems is normally in the form of faxes and paper records.

How Healthcare Works

A typical care episode begins with a visit to the GP who will either deal with the problem directly with help and advice or with a prescription for drugs; or will refer to a Secondary Care organisation to see a consultant with a view to conducting a more thorough diagnosis and treatment. Traditionally, each GP will refer to a limited range of particular consultants or hospitals.

In the NHS, the PCTs receive about 75% of the huge national budget, and spend the majority of it on procuring procedures from Secondary Care organisations for their patients.

PCTs, Hospitals and SHAs are all under fairly onerous reporting regimes, run by various corners of the DH; complex reports are due weekly, monthly, quarterly and annually on every aspect of their operations, especially waiting times. Organisations receive video-game review-like "Star Ratings" based on their stats; those with the maximum 3 stars are rewarded with further autonomy; those with no stars face more intrusive command and control from the centre.

Recently, the DH has established a number of privately-run diagnostics and treatment facilities in particular areas of England, to reduce waiting times, increase overall capacity and introduce more choice for patients. Ultimately, these treatments are funded by PCTs, too.

Enter the NPfIT

The NPfIT¹ is a ten year programme run by an executive agency of the DH, now called "NHS Connecting for Health" (CFH). They have divided England up into 5 regions, called "Clusters". Each Cluster is coterminous with SHAs. A prime contractor was appointed to provide systems for every NHS organisation in that Cluster. These systems were largely vapourware when the contracts were being signed in 2004. Large "output-based specifications" were drawn up for each system type, listing all the services, functions and interfaces required. These contractors are known as Local Service Providers or LSPs. They were essentially granted a regional monopoly for IT systems supply- although this is not strictly enforced or enforcible.

A number of nationwide contracts were also drawn up, for a New National Network (N3), a data "Spine", and the centralised parts of the appointment booking system (now called Choose and Book). These contractors are called the NISP (National Infrastructure Service Provider) and NASPs (National Application Service Providers).

These contractors are as follows, with their total contract values over the 10 years:

• Local Service Providers (LSPs)
• North East; Initially Accenture; transferred to CSC in January 2007 - £1,099 million total
• North West & West Midlands; CSC - £973 million
• London; BT-led "Capital Care Alliance" - £996 million
• Southern; Fujitsu - £986 million
• Eastern; Initially Accenture (£110 million); transferred to CSC in January 2007 (£824 million for the rest)
• National Application Service Provider (NASPs)
• Choose and Book; Atos Origin - £64.5 million
• the Spine; BT - £620 million for this national patient records and messaging system.
• National Infrastructure Service Provider
• N3; BT - £530 million for the network.

Thankfully for the taxpayer, the contracts are paid on delivery, and since only a fraction of the functionality has been delivered so far, only a fraction of the total budget has been paid out. To make a significant profit, the contractors will have to demonstrate that not only do their systems work well, but that patient care has been improved due to them. These conditions appear to have been too stringent for Accenture, who have recently bailed out of their two LSP roles.

You may draw your own conclusions from the latest figures available (June 2006)- from the £6.2 billion accounted for above only £654 million have been handed over. The total cost to the public purse is undoubtedly higher, since the running costs of the CFH agency and inevitable disruption to the NHS are not included here. A recent² National Audit Office report identifies these costs as including £375 million for consultants in 2005 alone.

The Systems and Services

Typically, LSPs deliver a suite of software including a Patient Administration System (PAS) to each location, and upgrade it to integrate with national standards and new functions as the programme develops. This often means replacing locally-procured long-established software with a new package, whether the clinicians like it or not. Richard Granger, the Director General of NHS IT approvingly calls this "ruthless standardisation". The NASPs and NISPs provide the centralised systems that allow for communication and coordination between sites. The services thus constituted are as follows:

• N3- That nationwide network. At the start of NPfIT, around 10,000 English healthcare organisations had access to the old NHSnet Wide Area Network. But the deployment of NPfIT will require an additional 8,000 sites to be connected, and all sites will have to be upgraded to much higher capacities. Connection sizes range from DSL-based 512kbps for small GP practices to 100mbps pipes to large acute hospital sites. WAN nerds might be interested to know that it's MPLS-based.
• the Spine- a series of databases and an encrypted XML-based Transaction Messaging System (TMS) for the rest of the programme. The databases include
  • the Personal Demographics Service (PDS) listing basic, non-clinical data on all patients;
  • the Personal Spine Information Service (PSIS) giving summary information on the health of each patient, and their history of NHS attendances and outcomes (based on Read Codes);
  • the Secondary Uses Service (SUS) which manages the regular statistical reports for the DH; and
  • various other housekeeping databases.
  Every time a message goes from a GP to a hospital, the TMS can ensure that the appropriate data is stored in each database above. The Spine also establishes a smart card-based Access Control Framework to ensure that only relevant NHS staff can see the information.
• Choose and Book (C&B)³- The NASP is responsible for establishing and maintaining a central bookings system for the NHS in England. This system allows every organisation to list their secondary care services with details of their locations and available time slots (the Directory of Services). GPs can then search for an appointment and let their patient choose when and where they will receive their treatment. LSPs are responsible for creating and deploying GP and hospital systems that can use TMS to keep the Directory of Services up-to-date automatically and create new bookings interactively.
• Picture Archiving and Communications (PACS)- This system is deployed locally by the LSP in each hospital, and provides an database of medical images from x-ray machines, CT scans, MRIs, PET scans and other imaging systems. Without PACS, images are often stored and viewed on large "plain films", familiar to the layman from the introductory sequence to "Scrubs". With PACS, very high-resolution images will be stored on huge servers and viewed on enormous high-spec two to three megapixel monitors. Local PACS deployments are well underway, and LSPs will soon establish mechanisms for images to be viewed in other hospitals in the Cluster, and eventually in other Clusters. This will be no mean feat, since some of the images are hundreds of megabytes in size, and cannot be compressed with familiar technologies for risk of introducing distortions and artefacts.
• Electronic Prescriptions Service (ESP)- A comparatively simple system that allows prescriptions to be transferred from the prescriber to the pharmacy electronically.
• NHSMail- An email system, with a single, central server and directory. It grants any NHS user an @nhs.uk email address, and is certified with the General Medical Council as being sufficiently secure for communication of sensitive medical data - as long as both the sender and recipient are using NHSmail accounts. It was first known as NHSmail, then as "Contact", and at the time of writing is called "NHSmail" once again. It was almost impossible to form sentences using the term "Contact" that were both valid and informative. Previously, email in the NHS was run by the individual organisations; each hospital trust and PCT running their own server on their own domain.

Other enabling technologies are being introduced:

• Smart cards- Every NHS user who needs to access NPfIT systems (pretty much all of them, sooner or later) will need a smart card; and any device or PC they'll use will need a USB smart card reader. The cards themselves are in the credit card form factor, with a chip and a photograph. A user inserts the card and logs-on to the system with a password. Eventually, only users who have a "legitimate relationship" with a patient will be able to view confidential data regarding that patient. The smart card should ensure that the user is who they claim to be, and the Spine will hold a record of who is allowed to see what. NHS employers nominate each of their staff for a number of roles (consultant, administrator, GP, etc), and a card issuer will then establish their identify using the normal range of ID documents- passports, driving licences etc, and an individual interview.
• Help Desk- a single, nationwide helpdesk is being deployed for the whole of NPfIT.

Policy Entanglements

One of the reasons for the introduction of NPfIT is probably to create a technological means for enforcing the adoption of DH policy. Health professionals have often been slow to abide by policies that will inconvenience them, are of dubious merit health-wise or that they don't like the look of.

One case in point has been the Patient Choice policy. In a nutshell, this means that patients who need to be seen in hospital must be given a choice of 4 or more "providers" of that service; typically four nearby NHS hospitals, contracted independent hospitals or even specialist GPs. This means that the cosy relationship between GPs and their favourite consultant golfing buddies is broken up, and will cause funds to flow to the most popular secondary care providers.

The NPfIT Choose and Book system is designed to facilitate this policy. The Directory of Service will list all the secondary care providers, along with key statistics, including wait times. GPs should show their patients a list of providers and let them pick one.

By having a national, central system running the choice and bookings process, the DH can easily see which GPs are playing ball and which ones aren't. In the end, they've had to institute a series of deadlines and financial rewards for GPs and hospitals to encourage greater use of the system.

Controversies

The main gripes of healthcare professionals are focussed in two areas- the systems don't always work as expected; and they were given no say in their design until very late in the process. In those regions where the healthcare organisations have enthusiastically adopted their own IT systems, the current versions of NPfIT systems may be a step backwards.

There is a feeling that have to use an IT system for every transaction in the health system strips away the independence of the practitioner and could automatically generate a log of those not following the latest modish guidance or policies du jour.

Recently, the use of the Spine to store patient information has come under the press spotlight. In a national, state-run healthcare system, "patient" is synonymous with "citizen"- so the Spine can be seen as a state-run national database of confidential data on all citizens. You can expect to see further controversy and perhaps widespread public resistance as these databases are populated, and inevitable misuses and failures are encountered.

Final Thoughts

The NPfIT is a remarkably ambitious project, which promises the country and its health service much. Whether all the promises will be delivered and when will depend on the government's ability to manage huge and complex projects; and on a positive attitude to change from the health professions. Recorded history show few examples of either.

° - Estimate based on the UK-wide size of the workforce and the relative populations of England and the UK.

¹ - Pronounced "En Pee Fit" or "Nip-fit"; corrected by spellcheckers to "unfit".

² - Quoted in "In the Back", Private Eye no. 1175, 5th January 2007.

³ - A semi-featured version of C&B, properly called "Indirect Booking Service", used where hospital scheduling systems are not fully up and running, is jokingly called "Go Book Yourself" by some.

Sources:

• Regional Cluster Breakdown - http://www.connectingforhealth.nhs.uk/regions
• Contract values from a parliamentary answer - http://www.theyworkforyou.com/wrans/?id=2006-06-27b.74061.h (which date from 27th June 2006, and vary significantly from other sources.)
• NHS stats, http://en.wikipedia.org/wiki/NHS
• Some years experience on the fringes of NPfIT