The National Programme for IT (NPfIT) is the flagship programme of the Department of Health Informatics Directorate, United Kingdom. The programmes mandate is to maintain and improve the NHS national IT infrastructure. NHS Connection for Health (NHS CFH) is the agency with is charged with implementing NPfIT. The programme is in charge of a number of national services and applications. Three services are under NHS CFH: Spine, N3 and NHSmail. A number of applications are also being supported including Choose and Book, Electronic Prescription Service (EPS), Secondary Uses Service (SUS), Summary Care Record (SCR), GP2GP and QMAS. The initiative is aimed at connecting millions of patients, 30000 general practitioners and 300 hospitals. In the future, the initiative will grow to enable patients to view access an electronic database of health records.
Figure 1Outline of NPfIT
The policies behind the NPfIT program are to improve the quality of the health care data, improve the management of the data and provide better access to patients, doctors and other decision makers in the national health sector. These policies are well intentioned. Doctors and patients also agree on the potential of improved data quality and its timely availability. Inspite of this, NPfIT, the largest civilian IT programme in the world, has run into a number of problems (Hackett, 2009). Some of the major problems have been escalating costs, which are currently at £12 billion; delays in implementation, concerns from healthcare professionals about patient confidentiality and lack of support from NHS staff. Problems related to NDfIT have spanned different functions including technology, contracts, timescales, organisational change, and user acceptance (Pagliari, Singleton, & Detmer, 2009).
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In the formative presentation, our group analysed the issues of abandonment of NPfIT. For analyzes, the group decided to split the topic across the following perspectives: Individual, Organisational, Society, IS Development and Change Management. In this essay, the author aims to analyze the issue of implementing the NPfIT from the perspective of the organisation. The author takes systems view and tries to understand the overlapping issues in the context. By doing this analysis, the author aims to throw some light on the challenges of implementing large scale ICT projects in the national health care sector. The first section is a review of related literature, the second section provides an overview of NPfIT, the next section analyzes the findings with the use of relevant literature and the last section synthesizes the analysis in a conclusion.
“The UK NHS is a highly institutionalised and complex system, which exists and operates both as a material resource environment and a set of beliefs, rules and ideas.” (Currie & Guah, 2007). Research regarding NPfIT has spanned many areas including social, organizational, political and economic angles. NPfIT an ambitious programme to utilize IT to overhaul NHS was launched after years of underinvestment. NPfIT faced many problems right from the start. Many researchers have tried to analyze the problems around NPfIT.
Problems related to NDfIT have spanned different functions including technology, contracts, timescales, organisational change, and user acceptance (Pagliari, Singleton, & Detmer, 2009). Various aspects of NPfIT have been analyzed in different lenses to understand factors that led to the abandonment of the initiative. Researchers have focussed on economic aspects of the initiative. As NPfIT, the largest civilian IT programme in the world ran into a number of problems (Hackett, 2009). Researchers like (Coiera, 2007) show the losses faced by the government and private sector agencies involved. Accenture quit after it lost an estimated of £290 million. iSOFT announced an estimated loss of £344 million due to delays in delivering the projects on time and penalties. Such research shows the drawback of incorrect management functions such as procuring and contracting.
Brennan (2009) analyses various issues such as contracting and procurement. He analyzes how the contracting mechanism used insulated the government from monetary loses, but resulted in time delays. The contracting mechanism imposed penalties to service providers for late delivery. Technical aspects of the system have also been analysed. Becker (2007) identifies many challenges related to security and confidentiality policy specification with respect to Spine, the “cradle to grave” patient record summary for 50 to understand the issue of abandonment of NPfIT it is important to understand how societal, organizational and individual factors directly and indirectly influenced the initiative.
As seen above, various aspects of NPfIT have been analysed by researchers. Researchers have explored the multidimensional nature of the initiative by using analysis techniques such as institutional analysis. Currie & Guha (2007) use institutional analysis to find out if the investment in NPfIT is justified or not. They base their research on data collected from six NHs organizations over a 4 year period. They analyse the institutional field, the governance systems and institutional logics to find out the factors that facilitate the change. They argue that NPfIT should be viewed across a wider environment and should not be limited to the technical issues. Currie & Guha (2007) uncover many issues regarding NPfIT. The author feels that NPfIT should be studied with a systems perspective as there are many shortcomings with institutional analysis. Firstly, institutional analysis is vague (Hasselbladh & Kallinikos, 2000). Secondly, institutional analysis does not throw much light on the agency. There is no ‘agency’ in data interpretation.
Earlier, Information Systems as a field had ignored systems thinking as a method of analysis (Checkland, 1988). As the insufficiency of the older methods of using information theory and focussing on project were realised, researchers adopted systems thinking and started to look at information systems as ‘systems’. System thinking moves away from looking at parts of a system as isolating a part from a system changes its nature. It no longer remains the system we aim to analyse. Using systems thinking in information systems allows us to analyse the various social, political, economic, and organizational aspects of the system. Systems thinking can be used in various stages in information systems from requirements gathering to final implementation and post mortem analysis. In this particular essay, the author applies system thinking to analyze issues that led to abandonment of NPfIT. In doing so, the author tries to include a subset of the perspectives discussed above.
The case outline for NPfIT is split into the following sections: NPfIT Vision, Need for NPfIT, Benefits of NPfIT and Implementation Timeline.
NPfIT’s vision to provide more choice and control to the citizens. This policy forms the heart of National Health Service (NHS). NPfIT was conceptualized in such a way that it helps both the patients and workers at NHS (National Health Service, 2005).
Need for NPfIT
NPfIT provides patients with nationwide access to their healthcare data. The new services NPfIT offers can be classified under 4 headings: New healthcare records, better information access, easy appointment bookings, and safer and convenient prescribing.
Benefits of NPfIT
New Healthcare Records
As per the programme, all patients will be provided with new electronic healthcare records. The records will be accessible only to the patients and practioners, who are providing healthcare services. Patients will also have an option not to share their records. Once the system is complete, patients will have option to say when their information can be shared. For example, a patient might want his record to be accessed only in case of an emergency.
Better Information Access
Patients will be able to access their information more conveniently. NPfIT will also make it easier for healthcare professionals to share reports between themselves. For example, a doctor might practioners a MRI (Magnetic Resonance Imaging) report with an expert to seek his opinion. Or a student, who gets injured during summer break, might want his x-ray report to be sent to a doctor near his parent’s home. NPfIT will also make the documents more secure by logging information every time a document is accessed, which is very cumbersome with paper records.
Easy Appointment Bookings
The NPfIT was designed to allow easy appointment bookings. Patients could book an appointment from a choice of available dates and time slots. The booking can be done via a call centre, internet or at a General Practioner (GP).
Safer and Convenient Prescribing
With the new system, GPs will be able to send prescriptions directly to the pharmacy. This prevents patients from visiting the GP for repeat prescriptions. Electronic prescriptions will also be monitored to alert GPs about combination of drugs that are not compatible.
The changes envisioned as part of NPfIT are complex and have far reaching effects for both patients and healthcare service providers. The initiatives part of NPfIT will be implemented in phased manner. It is expected to be completed by 2010, when it is expected to be completed.
NPfIT has received criticism from all quarters. In 2006, 23 academics from across the United Kingdom wrote an open letter to Health Select Committee highlighting the concerns and controversies surrounding NPfIT. The criticism of NPfIT reached an all time high when the Public Accounts Committee of the House of Commons published its report in 2009 condemning the progress achieved on the NPfIT programme. “Some systems are being deployed across the NHS. The Care Records Service, however, is at least four years behind schedule, with the Department’s latest forecasts putting completion at 2014-15. At 31 August 2008, new care records systems had been deployed in 133 of the 380 Trusts. Trusts in the North, Midlands and East have been receiving an interim system and will have to go through a further deployment in due course to implement Lorenzo, the care records software for the North, Midlands and East, which has suffered major delays. By the end of 2008, Lorenzo had not been deployed throughout any Acute Trust and in only one Primary Care Trust.” (Public Accounts Committee, 2009). NPfIT has failed to provide the promised benefits to healthcare professionals and patients alike.
The initiative also ran into problems with local service providers. Of the 4 service providers initially selected, only two were remaining. Both the existing providers are responsible for all the major components of the project. This high dependence on only two suppliers is a cause for concern. The department had to pay the service providers even if the trusts decided not implement the system. The department had control over NHS Trusts and it could force them to take the system, but it could not do the same with Foundation Trusts.
The needs of the NHS staff was not given due consideration. For the success of the initiative, it is very essential that NHS staff support the initiative. The initiative failed to win over their support. Issues were also raised about security of the systems and mechanisms used to address data security issues when they occurred. The department had not laid out plans for punishing staff members responsible for such breaches.
There are many instances where confidentiality and hence, the security of patients has been compromised at NPfIT. A woman was sacked after her employer found out about her mental health history. The Internal Revenue Service (IRS) accessed the Electronic Patient Records of a police officer and used it against him.
Analysis and Discussion
The NPfIT is a multidimensional programme covering social, political, organizational, technological and economic aspects. In the above section, the author has introduced many problems the initiative faced. Analysing the initiative from all the dimensions is beyond the scope of this work and therefore, the author has chosen to look into a subset of issue earlier identified in the formative presentation. The initiative is analyzed under 6 sections given below.
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“The successful implementation of NPfIT is presented as the responsibility of NHS managers (as budget-holders), IT firms (as service providers) and clinicians and administrators (as users). The problem is that the vision for NPfIT is a centralized one, designed by politicians with the delivery decentralized to external firms and hospital staff. This fragmentation of roles and responsibilities is confusing, but the politicians have made sure that failure to achieve targets is the responsibility of the professionals and not the politicians”. This quotation by an IT Manager, as captured by Currie and Guah (2007), correctly captures the way NPfIT was designed and how this led to a lot of pressure for all players including staff, suppliers, service providers, clinicians and administrators. This pressure resulted in unrealistic expectations, which accelerated the collapse. The programme was revised and revised again by the politicians, which also led to uncertainty.
NPfIT is a top down initiative which is championed by political class and the IT industry. The politicians wanted the NPfIT to enable knowledge sharing in this knowledge economy. On the other hand, patients and practioners wanted to secure the data and did not want a system which encouraged sharing. The expectations of the politicians, who decided the funding, and patients and practioners, the ultimate users, resulted in great pressure for implementers. And in hind sight, the task of delivering a successful system was impossible.
Though NPfIT chose suppliers competitively and imposed penalties on late delivery, the supplier delivery was not satisfactory. Two of the four Local Service Providers, who were in charge of major components of NPfIT quit in the early stages of this big project. Accenture quit after it lost an estimated of £290 million. iSOFT announced an estimated loss of £344 million due to delays in delivering the projects on time and penalties (Coiera, 2007). Different parts of the projects were sub contracted out to different suppliers. Any delay in one supplier affected other suppliers who were delivering projects that were to be integrated. Overall performance of the suppliers is evident from the list of firms whose services were terminated. This list included Fujitsu, EDS, IDX Systems Corporation and PACS among others.
As discussed in the above sections, one of the key features of the NPfIT programme was the central procurement of IT resources. The central procurement became necessary after it was identified that budget allocated to IT initiatives was being diverted and uniform standards were not maintained in procurements (Wanless, 2002). The central procurement did not solve the intended problems and it also introduced new ones. The procurement had a central control right from the beginning, later it gradually allowed local ownership. The procurement was done against a tight schedule. The procurement involved NHS wide systems, agreements with enterprise wide systems, and contracts with local service providers to implement the systems in different regions. The local service providers were free to choose sub contractors. The procurement secrecy resulted in delays. Since, the suppliers would be paid only when they delivered a working product, monetary losses were largely confided to suppliers and the companies they sub contracted (Brennan, The National Programme for IT: Is there a Better Way?, 2009).
NPfIT contracting policies from framing and allotting contracts, to their termination has been subject to criticism. Fujitsu was one of the local service providers who dropped out in the middle. Fujitsu’s contract was terminated and efforts made to revive the contract failed. After Fujitsu’s exit, the Department planned to allow local trusts were to select one of the 2 remaining service providers. This was ineffective as many trusts did not have any related experience (Public Accounts Committee, 2009). The termination of contracts resulted in the programme being extended by 4 years to 2014 – 2015.
According to the original contract policy, when a supplier withdraws, then he is responsible for 50 per cent of the project value. However, when Accenture withdrew, NPfIT did not press this clause which saved £900 million to the company.
Security Management Problem
The Department of Health Informatics Directorate did not have a clear picture of the security issues. Many doctors and patients had serious and valid concerns about data security (Public Accounts Committee, 2009). The now defunct Care Record Development Board (CRDB) was charged with running the Care Records Guarantee programme to ensure data security. The concerned department claimed that the Care Records Guarantee programme was extensive and it addresses the concerns of practioners and patients. However, the programme lacked policy to punish staff involved in security breaches. Since there is always a human hand behind breaches, this lack of punitive policies is a severe drawback in the system. This resulted in severe loss of confidence among practioners and patients.
As presented in the above section, NPfIT has faced challenges on the policy language front specifically on policies related to security and confidentiality requirements. Becker (2007) identifies many challenges related to security and confidentiality policy specification with respect to Spine, the “cradle to grave” patient record summary for 50 million patients. They are:
Size and amount of information held in the records,
Probability of changes in the underlying legal, official and ethical laws
Communicating complex, novel and controversial issues in plain English is ambiguous and incomplete
The current Role-base Access Control methods or discretion based access cannot handle these problems. Becker (2007) suggests the usage of formal policy specification to overcome these challenges. Becker’s arguments are mainly based on the case of Spine, but they also hold for other aspects of NPfIT. Becker and Sewell (2004) had earlier presented a language for expressing policy called Cassandra. They present a case study of Electronic Health Records of NHS and include 310 rules and 58 different roles. Their research shows that Cassandra and formal policy specification languages in general are ready for real world application and NPfIT will definitely benefit from it.
NHS is one the major public sector organizations in the United Kingdom. The services offered by NHS serve 50 million patients. The scale and the scope of NHS’ work have made it a political magnet. And hence, NHS has been a very contentious right from the early days. Politicians routinely fight on issues related to the NHS. The NPfIT programme was conceived to overhaul the NHS and provide more and better services to the citizens. The stated intentions behind NPfIT are definitely welcome by the citizen sector. There was a disconnect between the expectations of the politicians and users. This resulted in a system and policy specification, which was not only acceptable to the users, but was also not in line with the culture. “The decision to develop the NPfIT was politically ambitious and culturally and technically risky” (Currie & Guah, 2007). The author believes that the then government decided to jump on the ICT bandwagon and overemphasized the technology aspects of NPfIT. This is in line with the spending on governments across the world on ICT initiatives. Transitional and developing economies alone spend £520 billion on ICTs (Heeks, 2010).
The NPfIT is a multidimensional programme covering social, political, organizational, technological and economic aspects. An analysis of all these aspects is necessary to understand the various factors contributing to the failure of the initiative and to derive learnings for future ICT related projects in the public sector. The essay makes an effort to look at subset issues, management and policy, that led to the failure of the project. In the earlier decades, corporations made the mistake of treating ICTs as pure technology artefacts and faced a number of issues in implementing ICT projects and realizing expected benefits. The NPfIT program also fell into the same trap. The top leadership had to acknowledge that ICT systems are eventually social systems and that they need to be analyzed in conjunction with various overlapping aspects discussed above. This acknowledgement would have led them to build policies, procedures and products that would gain acceptance from all circles and deliver expected benefits in the real world.
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