A lot of time, effort and money has gone into the National Programme for IT, however, a new report from the National Audit Office says it's failing. Why is this, and what can be done?
After several years and many billion pounds, users, patients, IT suppliers and the government remain mired in a healthcare IT programme that has not made anyone appreciably better off. A recent National Audit Office (NAO) report says as much and so makes for depressing – albeit not surprising – reading.
By creating the foundation for developing a solution to long-standing problems, the NAO report has a good deal to recommend it. Considering the report, the history of the programme and the self-interest of the protagonists together leads to the conclusion that more positive and effective underlying conditions have the ability to turn a failure into a success. The value of IT in the more efficient delivery of better healthcare should not be underestimated, so moving rapidly to a solution would benefit everyone.
Creating a solution
Now is the time to create an environment that will foster more progress and less conflict, and to move beyond the recriminations. Ask people involved in the birth of the current programme and they will almost uniformly agree that it was painful. Some would go as far as to say that being in at the birth was indistinguishable from being in at the kill. Substituting politics and expediency for pragmatism was never the way to deliver IT systems.
The first step in forging a solution to the IT challenges in the healthcare sector is to examine what the NAO report actually says and, at least as importantly, what it does not say. The second is to see what experience tells us about the mindset of the protagonists. And the last is to develop a strategy that gives users, patients, suppliers and the government a safe and satisfactory way forward.
One illusion that no one can afford is that major IT systems are straightforward to deliver, regardless of how well they are managed. In fact, transformational IT systems are brutally difficult to design and deliver. In other words, using IT to provide better healthcare across an entire country was always going to take the best minds the users and suppliers have to offer, together with a great deal of dedication, patience and hard work. It is rare indeed to find a major IT implementation in which the responsibilities of the users/government and the suppliers are not so heavily interdependent that working out who is ultimately to blame for the failure of a programme is a productive endeavour.
Against the backdrop of this brave, new world of cuts and proposed changes in the provision of health services, one thing that should most certainly change is the way we deal with the rollout of useful technology.
One preliminary but vital point is that the NAO does not seem to say that a new care records system along the lines of what has been contemplated cannot be delivered – at least not from a technical point of view. This gives us reason to believe that fixing the current problems can lead to improvements in healthcare delivery by the intelligent use of IT, hopefully for less effort and expenditure than starting again would require.
A moving target
For those of us immersed in this and other IT programmes, two recurrent themes predominate in the NAO report. The first is that after so many years the deliverable is still a moving target. The other is that the protagonists have assumed the stances of budding litigants, each blaming the other for the difficulties. If we are to achieve a positive result we must correct both of these major shortcomings.
One of the challenges, of course, is that the ability to agree on and stick to the deliverable is intertwined with the willingness of the protagonists to sit down and do so in a spirit of cooperation. This spirit is understandably weak, given the traumatic birth and early life of NPfIT.
IT professionals look at flux in a deliverable and immediately worry about its ultimate quality and integrity, delays in handing over a working system and cost over-runs. Even if the contract can accommodate changes in the specification of the deliverable through a workable change order process, the delays and cost over-runs will remain.
It is far better to agree on and stick with a specification that is close to what is needed than to add precision later or make changes as improvements and refinements come to mind. How many would consider setting a sat-nav to travel from Bristol to Edinburgh (or, worse still, somewhere as yet undetermined in the North) and, as Newcastle recedes from sight, reset the sat-nav for Brighton, all the while thinking that doing so will be without significant time and cost implications?
The users' views
The users of the system, seemingly excluded even from the early planning, understandably have their own grievances and have been articulate in expressing them.
Lawyers – one can be absolutely sure that they have been extensively consulted – regard the protagonists' stances as consistent with standard legal advice: reduce or eliminate downside risk by blaming the other side. Even their usual language, namely the expression "the other side", makes it sound like a war.
We are certainly not seeing those halcyon days to which users and suppliers refer – usually when contract negotiations have reached a particularly painful stage – which involve living happily ever after by putting the signed contract in a drawer and never looking at it again.
There is nothing wrong with putting one's best legal foot forward and establishing a trail of evidence that shows one in the best light possible and the other side in the worst. It is even better sometimes if that trail of evidence is subtly established so that the other side does not realise what is happening until it is too late for them to defend.
The test of good contract management and legal advice, however, is to balance these legal strategies with the overarching need to achieve the objective, specifically the successful delivery of a system that provides useful services to the users and benefits to the patients at a reasonable cost.
A rapid adjustment is required if we are to reap the rewards that IT investment can provide. Get the priorities wrong and everyone ultimately loses.
So, what will drive the protagonists toward success and away from collective failure?
Commercial experience suggests that the motivation of sensible people to act in the way described by the NAO results from the absence of underlying conditions that offer a safe course toward the successful delivery of a system. Human nature, reinforced by competent legal advice, will usually lead to conduct that includes covering one's own back. Only when there is little apparent chance of success will rational business people and, in this instance, healthcare providers begin to ignore the need to deliver a working system in favour of self preservation.
The objective is to create a new deal that represents a workable solution for all the protagonists. They may not come to like each other, but if we can get them to cooperate toward a well-defined deliverable and the collective good we will have achieved a significant result.
Creating the underlying conditions that will allow the protagonists to work together instead of against each other is essential. Appointing a knowledgeable, practical person to get the protagonists speaking constructively would be a good start. That person should quickly set some ground rules for this conversation.
A key element of these rules would be that the conversation be free of legal ramifications, specifically that what people say cannot be used against them later. To be clear, existing rights and remedies should remain available until a new deal has been agreed.
In addition to creating a "without prejudice" footing, there needs to be an acceptance that learning from the past and using what has been learned to solve problems are productive, but debating the past is not. We all accept that the protagonists (past and present) have had a difficult time, but these conversations are not an acceptable forum for placing blame.
The foregoing leads to the third, key ground rule: not only should blame not play a role in solving current difficulties, but the protagonists should be encouraged not to seek extensive compensation for past wrongs. That is not to say that effective remedies for future defaults should be eliminated. On the contrary, the approach should be to take a realistic view of what each of the protagonists can and should be required to deliver and the price at which a system will be provided. Realism on these points is important to moving forward and to establishing the credibility of remedies that make sense given the size, importance and cost of the programme. The Draconian remedies of earlier NPfIT contracts should be avoided – more effective incentives to perform well are generally available through bonuses.
Finalising the deal
Time is of the essence with regard to finalising the new deal. For all of the criticism of the way NPfIT was born, the time from release of the RFP to contract signing was short for a programme of its magnitude and complexity. As one of the participants in that marathon, I am convinced that taking more time would not have made for a better result. So an abbreviated schedule for the protagonists to agree a new deal is appropriate and workable.
All the protagonists have had the opportunity to refine and express their own views and to understand those of others. There is, therefore, no need for a lengthy period for them to formulate and present their positions. A short paper from each setting out the five or six key points that each wishes to achieve would be helpful.
To some, the approach outlined above will doubtless appear naive. There are certainly challenges in bringing protagonists with entrenched views together in this way with the objective of agreeing a new deal. Experience suggests, however, that when an IT programme is failing there is often an attitude of "better the devil you know than the devil you don't". Disengaging and disentangling can be much more challenging, and no more likely to produce a working and useful improvement to the delivery of healthcare. It would also be wrong to ignore the various legal requirements that apply to the public sector.
Constructive criticism is valuable, cynicism is not. The benefits of the programme are worth the effort of implementing a solution.