What Ails the NPFIT

 
 
By Baselinemag  |  Posted 2006-11-13
 
 
 

In late September, Accenture, the global management and technology consultancy, announced it was walking away from a $3.73 billion contract as an information-technology services provider on the world's biggest non-military I.T. project, a hugely ambitious and complex attempt to transform England's entire National Health Service through technology. Accenture, which failed to respond to numerous requests for interviews, did not say why it was exiting the National Health Service (NHS) project, but earlier this year it had set aside $450 million to cover potential losses from its work in England. Its exodus represents the latest in a series of setbacks and missteps that have plagued the highly controversial program since its inception.

In scale, the project, called the National Program for Information Technology (NPfIT), is overwhelming. Initiated in 2002, the NPfIT is a 10-year project to build new computer systems that would connect more than 100,000 doctors, 380,000 nurses and 50,000 other health-care professionals; allow for the electronic storage and retrieval of patient medical records; permit patients to set up appointments via their computers; and let doctors electronically transmit prescriptions to local pharmacies.

To date, the NHS has delivered some of the program's key elements. For example, in late October Health Minister Lord Warner announced that 1 million patient referrals to specialist care have been made through a Choose and Book service that allows patients to book appointments electronically. As of August, 97% of doctors' offices were connected to a new national network, N3, which is a major component of the project.

Yet, many pieces of the project—including deployment of key electronic records software—have been delayed and the program's cost has ballooned.

The NPfIT was initially budgeted at close to $12 billion. That figure is now up to about $24 billion, according to the National Audit Office (NAO), the country's oversight agency. And it is as high as $28.4 billion, according to other estimates. Even the lower of those two amounts is more than the price tag for building the English Channel Tunnel or Boston's massive Big Dig project, considered to be the most expensive civil project ever. Worse, the funding established to pay for the system has, temporarily at least, dried up.

Among the problems the project has encountered:

  • One key health-care software subcontractor, IDX, was dropped from the program in April 2005 after one of the project's prime contractors, Fujitsu, "lost confidence" in its abilities, according to the NAO. IDX failed to respond to requests for a comment.

  • Another key health-care software maker, iSoft, is some two years behind schedule in delivering a new electronic health-care system called Lorenzo, according to British newspaper The Guardian.

  • A 2005 report issued by the NPfIT stated that the migration of data from computers in health-care practices into systems that complied with a new national health-care records system would take far longer than the five years originally projected by the NHS' Connecting for Health (CfH), the unit overseeing the NPfIT project.

  • The N3 network, deployed to connect the country's health-care workers, has been hit by more than 100 system and network failures. Most recently, in July a network outage disrupted for three days mission-critical computer services such as patient administration systems.

  • While a June 2006 NAO report praised aspects of the CfH's project management, notably the procurement process and its use of project management software, key elements of the project's management have come into question. The NAO report cited a need for strengthening project management skills, pointing out that "the shortage of such skills is an immediate risk to the timely implementation of the program." Speaking at the Towards the Electronic Patient Record (TEPR) conference in Baltimore in May, former NPfIT liaison manager Phil Sissons noted that as a result of the CfH's top-down, authoritative approach to change management, many hospitals are strongly resisting the NPfIT. "There's no ownership of this system because it is being imposed," he said.

  • The project has little support among health-care workers. For example, only 38% of the country's doctors feel the project is a priority for the NHS, and just 13% believe that the program represents a good use of NHS resources, says a recent survey by Medix, an independent market research consultancy in England.

    A report issued recently by two British Members of Parliament, Richard Bacon and John Pugh, concluded: "The [NPfIT] … is currently sleepwalking toward disaster. It is far behind schedule. Projected costs have spiraled. Key software systems have little chance of ever working properly. Clinical staff is losing confidence in it. Many local trusts are considering opting out of the program altogether." Local trusts are the regional agencies that administer the country's national health-care programs.

    "There have been enormous problems," says Martin Brampton, founder of Black Sheep Research, an independent U.K. technology and research consultancy. "We now have a situation where several years of increased levels of expenditure have largely disappeared into top salaries and I.T. projects, with little evidence of much change in the experience of patients. And the future looks bleak, since the spending on NHS I.T. is by no means over."

    In an e-mail to Baseline, the CfH responded: "It is unfair to speculate about failure. The NAO stated that the Program was well managed and has made good progress. Central budgets [core budgets for Local Service Providers, or LSPs] have not risen."

    Next page: A Bold Vision of Lifelong Electronic Patient Records

    Bold Vision

    Specifically, the systems and information-technology services the NHS is attempting to deliver include the NHS Care Records Service (NHS CRS)—individual electronic NHS lifelong care records for every patient in England (Scotland, Northern Ireland and Wales are not part of the system), securely accessible by the patients and those caring for them. This is also known as the National Spine. Electronic transmission of prescriptions is also in the offing.

    Other pieces of the project, already partially functional, are Choose and Book, which provides patients of hospitals or clinics with convenience in selecting the date and time of their appointments; and N3, which provides information-technology infrastructure and broadband connectivity for the NHS so patient information can be shared among organizations.

    To supervise the NPfIT, the NHS created a unit, Connecting for Health, to deliver "new, integrated I.T. systems and services to help modernize the NHS and ensure care is centered around the patient," according to the agency's Web site.

    If the CfH succeeds, the benefits could be enormous. "This is very much a pioneering effort," notes Gartner European health-care analyst Jonathan Edwards. "No country has ever implemented anything on this scale. If successful, it could be of great value to health-care providers around the world. It's important to understand the program and learn from its successes and challenges."

    "It is the boldest vision that any government has ever taken with respect to I.T.—and it comes against a background of high-profile failures in big government computer projects," adds Sean Brennan, author of The NHS IT Project: The Biggest Computer Program in the World … Ever!

    David Craig (a management consultant writing under a pseudonym) and Richard Brooks, co-authors of Plundering the Public Sector, have reported on some of those failures, among them part of an e-government initiative in 2000. At the time, Customs and Excise launched a program to provide e-services. By June 2004, the department had spent close to $200 million on its e-VAT (value added tax) service. According to the U.K. Parliament's Public Accounts Committee, the project proved a failure because the new system was more complicated than the previous paper-based version.

    And what if the NPfIT project fails? "If it goes wrong, with the all too depressingly familiar sight of budgets and time scales spiraling hopelessly out of control, our government will have caused the largest hemorrhage of taxpayers' money from essential [medical] services into the pockets of management and I.T. consultants in British history," Craig and Brooks wrote in Plundering the Public Sector.

    Next page: In the Beginning, Bill Gates Pitches Tony Blair

    From the Beginning

    Established in 1948, the National Health Service is now the largest health-care organization in Europe and has been recognized as one of the best health services in the world by the World Health Organization. Controlled by the British government, it is also a vast bureaucracy, employing more than 1 million workers and providing a full range of health-care services to the country's 50 million-plus citizens.

    Organizationally, the NHS is managed at the top by the Department of Health, under Health Secretary Patricia Hewitt. The Department of Health oversees 10 so-called Strategic Health Authorities (SHAs), which provide supervision to:

  • Primary Care Trusts (PCTs), which number slightly more than 300. PCTs oversee 29,000 general practitioners and 18,000 dentists.

  • NHS Hospital Trust. These 290 entities administer about 1,600 hospitals as well as treatment centers and specialist care.

  • NHS Ambulance Trusts, Acute Care Trusts and Mental Health Services Trusts.

    The inspiration to digitize this far-flung bureaucracy first surfaced in late 2001, when Microsoft's Bill Gates paid a visit to British Prime Minister Tony Blair at No. 10 Downing St. The subject of the meeting, as reported by The Guardian, was what could be done to improve the National Health Service. At the time, much of the service was paper-based and severely lagging in its use of technology. A long-term review of NHS funding that was issued just before the Blair-Gates meeting had concluded: "The U.K. health service has a poor record on the use of information and communications technology—the result of many years of serious under-investment."

    Coming off a landslide victory in the 2001 general election, Blair was eager to move Britain's health services out of technology's dark ages. Gates, who had come to England to tell the CEOs of the NHS trusts how to develop integrated systems that could enhance health care, was happy to point the way. "Blair was dazzled by what he saw as the success of Microsoft," says Black Sheep Research's Brampton. Their meeting gave rise to what would become the NPfIT.

    At the time the NPfIT was conceived, no one could possibly have imagined that it would balloon into such an ambitious and complex effort. "It was initially a procurement exercise," notes a health-care I.T. strategist who was involved with the NHS for years and who agreed to talk to Baseline on the condition that his name not be used.

    "Procurement, and specifically cutting down on the cost and the bureaucracy of buying computer systems, was always a major objective of the program," adds author Brennan.

    Brennan, who has held senior-level I.T. positions with the NHS and in 2002 launched Clinical Matrix Ltd., a technology and strategic consulting company, says that when the NPfIT was conceived in 2001, hospitals throughout the U.K. were dealing with multiple vendors, many of them small to midsize U.K. systems and software houses. Several major U.S. firms had gone after the U.K. market, only to withdraw because of the red tape and expense involved.

    "Vendors would spend as much as $100,000 in marketing a system to a single trust," Brennan says. "Every hospital typically bought a collection of systems and paid up front rather than waiting till implementation was complete."

    The predictable results: a hodgepodge of systems throughout the NHS, many of them incompatible; and excess costs. The June NAO report summarized the situation thusly: "In the past, procurement and development of Information Technology (I.T.) within the NHS has been haphazard, with individual NHS organizations procuring and maintaining their own I.T. systems, leading to thousands of different I.T. systems and configurations being in use in the NHS. These are provided by hundreds of different suppliers, with differing levels of functionality in use across the country. The large number of different and incompatible systems has meant that the NHS's I.T. system infrastructures have been built up to create silos of information, which … are not shared or even shareable."

    After a February 2002 meeting at 10 Downing St. chaired by Blair and attended by U.K. health-care and Treasury officials as well as Microsoft executives, the NPfIT program was launched.

    In quick order, a unit was established to purchase and deliver I.T. systems centrally. To run the entire show, NHS tapped Richard Granger, a former Deloitte and Andersen management consultant. Granger signed on in October 2002 at close to $500,000 a year, making him the highest-paid civil servant in the U.K., according to The Guardian.

    In one of his first acts, Granger commissioned the management consulting company McKinsey to do a study of the massive health-care system in England. Though the study was never published, it concluded, according to The Guardian, that no single existing vendor was big enough to act as prime contractor on the countrywide, multibillion-dollar initiative the NHS was proposing. Still, Granger wanted to attract global players to the project, which meant he needed to offer up sizable pieces of the overall effort as incentives. The result: He divided England into five regions—London; Eastern; Northeast; Northwest with West Midlands; and Southern—each with a population of about 10 million.

    Each of the five areas would be serviced by a prime information-technology vendor, known as a Local Service Provider (LSP).

    The process for selecting vendors began in the late fall of 2002. It was centralized and standardized, and was conducted, Brennan and others say, in great secrecy. To avoid negative publicity, NHS insisted that contractors not reveal any details about contracts, a May 2005 story in ComputerWeekly noted. As a byproduct of these hush-hush negotiations, front-line clinicians, except at the most senior levels, were largely excluded from the selection and early planning process, according to Brennan.

    "We would challenge the assertion that there has been secrecy," the CfH told Baseline in an e-mail. "There has been a great deal of engagement with key stakeholders."

    NHS offered 10-year service contracts to the LSPs for the five regions, worth slightly less than $2 billion each. According to the CfH Web site, the LSPs "are responsible for delivering services at a local level and supporting local organizations in delivering the benefits from these. They ensure the integration of existing local systems … while maintaining common standards."

    In conjunction with the software suppliers they select, they are also responsible for implementing clinical and administrative applications, which support the delivery of patient care and enable acute-care trusts and PCTs to exchange data with the National Spine. In addition, the LSPs provide the data centers to run the applications.

    Next page: Selecting Suitable Vendors

    Vendor Selection

    Concurrent with the LSPs' work, NHS needed vendors to take on three other mega-projects. The first was construction and management of the National Spine, which would evolve, Brennan claims, into "the biggest computer database in world history. … It is the core service in the program; it will bring a number of benefits to the NHS including access to integrated patient data, prescription ordering, proactive decision support and best-practice reference data."

    Second was Choose and Book, which the CfH describes on its Web site as "a national service that for the first time combines electronic booking and a choice of place, date and time for outpatient appointments."

    Finally, there was the N3 national network, which Granger in public statements described as "one of the largest virtual private networks on the planet." N3 is a secure wide-area network that integrates enterprise-class broadband DSL, fiber-based Ethernet and other data network services as needed. It is designed to provide a seamless, efficient and cost-effective service linking NHS sites.

    As described by the CfH on its Web site, N3 will enable electronic communication among different elements of the NHS and support Choose and Book, electronic prescriptions, transfer of patient information and many other initiatives that are part of the NPfIT. It will replace NHSnet, the NHS's current private communications network.

    With so much money at stake over the 10-year life of the contracts, more than 30 major players vied for the business, but, Brennan says, "I think some of the vendors didn't realize how complex the program was going to be."

    However, at least one group, a consortium that included Deloitte and Lockheed, opted at the last moment not to bid, fearing the project was "simply too risky," according to a member of the vendor team who asked that his name not be used.

    Accenture proved the big winner. In December 2003, the Bermuda-based firm was named LSP for two regions, Eastern and Northeast; Computer Sciences Corp. (CSC) was awarded Northwest with West Midlands; BT beat out IBM to get London; and a Fujitsu-led alliance won the Southern region. BT was also given the contract to build both the N3 network and the National Spine, while yet another vendor, Paris-based I.T. services provider Atos Origin (formerly SchlumbergerSema), was commissioned to provide Choose and Book.

    The LSPs, according to the June NAO report, were to act as prime contractors for their respective regions, "who have to decide how best to deliver the service specified by the NHS CfH, assembling and integrating software and other products from a range of services." Each LSP was informed that it was to pick its own software vendors and subcontractors.

    "The CfH wanted only to deal with the LSPs," Brennan says.

    Two of the four—BT and the Fujitsu group—selected Burlington, Vt.-based IDX (now part of GE Healthcare), an established health-care services and software provider, to develop health records software. Accenture and CSC went with iSoft, a U.K.-based supplier of health-care software and the largest company in Europe devoted to health care.

    Significantly, the NHS's contracts with the LSPs had one thing in common: Vendors wouldn't get paid until they delivered the goods—working systems. This meant that the subcontractors would also lose out if the project faltered.

    Meanwhile, the NHS signed an Enterprise Subscription Agreement with Microsoft for 350,000 desktops for Office Professional, Windows desktop operating systems and various client access licenses. That agreement has since escalated to allow NHS to use up to 900,000 desktop licenses. In a separate agreement, Microsoft also is developing a common user interface for

    the CfH. "This would provide common formats despite differences in the underlying software being used," says Gartner's Edwards.

    Next page: What Ails the NPFIT??">

    What Ails the NPFIT?

    The last of the contracts—the deal for BT to build the N3 network—was signed in February 2004. "The focus of the national program has now moved to the challenge of ensuring the timely implementation of high-quality I.T. services to help deliver a patient-centered NHS," Granger wrote in a 2004 article put out by the NHS. "Once in place, patients will benefit from a modern, I.T.-enabled NHS, every time they come into contact with it. The electronic revolution will help deliver coordinated convenient and integrated care, placing the patient at the heart of the NHS."

    As Granger defined it, the NHS was building "a single electronic health-care record for every individual in England; a comprehensive, lifelong history of patients' health and care information, regardless of where and when and by whom they were treated."

    Additionally, the NHS would provide health-care professionals with immediate access to summaries of care encounters and clinical events held in a national data repository, and support the NHS in collecting and analyzing information and monitoring health trends to make the best use of clinical and other resources, Granger said.

    Before this utopian, cradle-to-grave vision of a centralized, monolithic national health-care system could become anywhere near a reality, however, a succession of daunting obstacles had to be overcome.

    For one thing, there's the sheer size of the country's health-care system. Between 2002 and 2003, NHS served 52 million people; dealt with 325 million consultations in primary care, 13 million outpatient consultations and 4 million emergency admissions; and issued 617 million prescriptions.

    Granger and the CfH had also inherited what Brennan terms "a mixed bag of incompatible computer systems, islands of technology that may work well in isolation but which cannot communicate with other systems. This wasn't a greenfield opportunity."

    All of the systems had to be replaced with systems that could interact directly with the National Spine records system, but not before the data from the old computers was transferred from the old systems to the new, Spine-compliant systems.

    Considering that the NHS alone, Brennan estimates, had 20,000 computers, that was a sizable task.

    Then there was the little matter of managing the contracts and the LSPs effectively. Some critics of the program such as Brampton have charged that the CfH has dealt with perceived vendor deficiencies largely through Granger's threats to punish poor performance, and that it hasn't been flexible enough in dealing with unexpected problems confronted by the contractors.

    A heavy hand on the whip, in other words, and little in the way of a carrot. At one point, Granger likened the NHS project to a sled and the LSPs to huskies. "When one of the dogs goes lame and begins to slow the others down, they are shot," he said, according to The London Times. "They are then chopped up and fed to the other dogs. The survivors work harder, not only because they've had a meal, but also because they have seen what will happen should they themselves go lame."

    "He's not a diplomat," says John White, iSoft's director of corporate communications, of Granger, "but you need to be tough to manage something like this."

    Spelling out the challenges confronting the NHS, Edwards wrote in an April 2005 Gartner report: "The larger the project, the greater the risk of managing vendors inadequately. Putting the prime contractors at risk for not delivering value is a sound idea. The challenge is one of balance. The stringent nature of the CfH contracts, which allow for payment only upon completion, reduces the scope for flexibility. It also increases the danger that when problems arise, the CfH and the prime contractors will become absorbed in arguments over contractual details, rather than concentrating on overall goals."

    "The attitude was that the LSPs were responsible for solving all problems," Brampton says. "But you need to manage the contracts and the vendors, especially on something of this magnitude."

    The CfH responds that this wasn't the case. "There is a mix of central, supplier and trust project management resources deployed in support of implementations," the agency stated to Baseline in an e-mail.

    Another challenge spelled out by Edwards in April 2005 is the need for the CfH to remain focused on clinical adoption and change management. "Ensure that clinicians are adequately consulted and involved from the earliest stages of the I.T. program," Edwards wrote. "Allocate sufficient funds for change management and training. Identify and develop clinician champions in different geographic and functional areas of your organization. Work with them to determine what effects the program will have on the way clinicians practice medicine."

    Edwards noted at the time that in a then-recent survey of clinicians in England, only 5% stated that the CfH had adequately consulted with them. "Evidence indicates that CfH has made insufficient progress in getting the wider community of clinicians involved and in motivating them to adopt the new applications," he noted.

    This didn't happen at the program's outset. "Clinicians couldn't be brought in early on," Brennan explains, because of the secrecy surrounding vendor negotiations.

    One consequence of excluding front-line health-care professionals from the early phases of the program, says the consultant, is that it fell largely to the I.T. vendors and the bureaucrats to create the system: "To a large extent, the result is a black box NHS is trying to sell to physicians who were not engaged from the outset." That black box is flawed on a number of counts, says the consultant. Among them, he claims, is that the program is too focused on administrative needs and not enough on clinicians' concerns.

    Another challenge with the vendors was that in the early stages of the project, the LSPs, according to Brennan, focused on the easier applications and establishing links from the existing general practitioner systems to the National Spine. That should have been a relative cakewalk. A confidential report commissioned by NPfIT that was leaked to the U.K. newsletter E-Health Insider in April 2005, however, showed that the job of transferring 10 years or more of data from existing practice-based systems into the Spine-compliant systems that were being provided by the LSPs was far more complicated than had originally been anticipated, requiring clinical and computer expertise that often wasn't readily on tap. Typically, it took up to six months and cost around $9,000 per practice to enact the transfer, the report stated.

    The overriding problem, however, was the software that was being developed. Both iSoft and IDX had to write some of the software for the CfH from scratch and to specifications established by the CfH. As an example, White, iSoft's corporate communications director, notes that one of the requirements for the clinical applications was that they had to have a communications interface that would enable them to transmit data to the National Spine.

    iSoft was writing a new core application set called Lorenzo at its development center in India. Similarly, the IDX system, Carecast, was being written from the ground up in Seattle in conjunction with a team from Microsoft.

    The difficulty was that the programmers, systems developers and architects involved didn't comprehend some of the terminology used by the British health system and, more important, how the system actually operated, the CfH conceded. The solution: In August 2005, the CfH announced it was looking for at least 100 clinicians to spend several weeks in India and Seattle working hand-in-hand with developers to anglicize the new software and "make sure their product is fit for purpose."

    Next page: Waiting for Lorenzo: Software Needs Major Surgery

    Waiting for Lorenzo

    In selecting iSoft as their clinical and administrative software vendor, both Accenture and CSC were banking on iSoft's Lorenzo application suite, which at the time was in development. It was being touted as a next-generation health-care system based on Microsoft's .NET software development platform.

    "This is a significant step toward fulfilling our commitment to deliver an integrated care records service for individuals in the East and Northeast," said Ken Lacey, global managing partner of Accenture's Health & Life Sciences practice, in a news release when his company signed the iSoft deal in June 2004. "Ultimately, this service will enable the NHS to provide the right information to patients and clinicians at the right time."

    "This release of Lorenzo demonstrates our ability to produce comprehensive, leading-edge health-care applications for delivery by third-party organizations," said Tim Whiston, CEO of iSoft, in the same news release. "We are delighted to work with Accenture to deliver an application service that supports the information management requirements of an entire health community."

    Whiston was speaking of the first release of Lorenzo, which provides basic security and communications. But at the time there wasn't much to Lorenzo beyond this first layer. The second layer, services, according to iSoft's annual report for the year ended April 30, 2006, consists of development building blocks. Elements of Lorenzo's services architecture and tools, the report noted, were being tested in Germany. The third level, solutions, provides end-user modules. Early Lorenzo user modules are being tested to replace third-party applications in early adopter sites.

    Those like Brennan who saw early versions of the software were impressed with features such as its clear navigation. "It was a very good demonstration model," says Brennan, who was given a preview. Problem was that the delivery date kept getting put back.

    A July 2006 Gartner report on iSoft touched upon several of the key reasons for the delays. "Large-scale products such as iSoft's Lorenzo typically require substantial investment following early implementation to rework certain aspects," the report noted. "iSoft appears to have seriously underestimated the time and effort necessary to develop the Lorenzo applications suite."

    In January 2006, almost two years after Lorenzo had been scheduled for deployment, iSoft announced in a news release "that delivery of iSoft application solutions to NHS trusts will occur, in general, later than previously expected by the company."

    This meant that under the collect-on-implementation contract NHS had signed with its LSPs, neither Accenture nor iSoft would be generating revenue. In a Catch-22, this also left iSoft short of the cash it needed to finish developmental work on Lorenzo. For the year ended April 30, 2006, it reported a loss of more than $600 million. Acting chief executive John Weston, who would resign in June, said that the previous year had been a "turbulent" one and that a stream of negative publicity had damaged the firm's reputation and customers' willingness to sign contracts with it.

    At the time these slippages began occurring, iSoft was offering a number of existing health-care applications, most of them obtained through earlier acquisitions of other software vendors including Torex and Northgate Information Systems. In 2001, it had also signed an agreement with Eclipsys, a Boca Raton, Fla.-based health-care solutions provider, for the code to the company's Sunrise Clinical Manager, an enterprise medical records solution that Eclipsys claims provides secure, immediate access to patients' complete records. As part of the same deal, iSoft is partnering with Eclipsys to develop health-care software applications for the international market.

    With the ongoing delay of Lorenzo, specifically layers two and three, both Accenture and CSC found themselves in a major quandary. Should they continue to wait for Lorenzo or lock into the older, existing applications?

    "Either way, it's a tough call," Brennan says. "You're rolling out a system that's going to change clinical behavior." Since no one really knew when, or even if, Lorenzo was going to be delivered, there was a big risk in waiting 18 months to two years in hopes that the solution would be ready. On the other hand, Brennan says, if CSC or Accenture committed fully to the interim systems, they would have to roll out a second system, Lorenzo, when it eventually came out. "Clinicians are adverse to change," Brennan says. "Getting them to switch to another new system after 18 months or so would be a huge challenge."

    A CSC spokeswoman in the U.K. declined to comment on this on the grounds that CSC would only deal with British publications regarding its work on NPfIT. Accenture, as noted earlier, failed to respond to numerous calls and e-mails.

    Accenture opted to wait and roll out Lorenzo. In contrast, "CSC took a different approach," says Joe Vafi, an analyst who covers government I.T. for Jefferies & Co., an investment banking firm.

    CSC chose to implement iSoft's existing line of products. "We use iSoft iPM for our Patient Administration System, iCM from iSoft for clinical functionality and management, the Ormis theater system, and Evolution for maternity systems," a CSC spokeswoman explained. The last two are also iSoft products.

    Adds iSoft's White, "CSC went ahead and used existing iSoft solutions, then used a Lorenzo communications interface [level one] to transmit the data from those solutions to the National Spine."

    While waiting for Lorenzo, Accenture, according to White, focused on working with general practitioners—in contrast to CSC, which was focusing almost entirely on hospitals. The problem here from Accenture's point of view, White says, was that general practitioner (GP) implementation was extremely difficult because there are so many general practitioners and the NHS had given them an option called GP Systems of Choice. This meant the doctors didn't have to follow Accenture's lead in selecting a system but could choose on their own. This, in turn, made the transfer of data from old systems to the Spine-compliant systems being provided by Accenture more complicated.

    Accenture's decision to wait for Lorenzo rather than use existing iSoft software had far-reaching financial implications. In March, Accenture announced that it was setting aside nearly a half-billion dollars to cover expected losses because it couldn't collect its consulting fees from the NHS until its work was complete. The company's CEO, Bill Green, said at the time that he hoped to renegotiate the NHS contracts. Instead of showing any of the flexibility that Gartner's Edwards suggests is critical in dealing with vendors, however, Granger, who is described by Brennan and others as "robust" and "resolute," dug his heels in.

    At the March 2006 World Health Conference in Paris, he claimed that Accenture shouldn't blame anyone else for its troubles and joked oddly that Accenture's announced losses would be enough for the company to hire "every Bulgarian hit man to take me out." If Accenture thought it was going to get a new deal, it was sadly mistaken. "We came up with a new model where the people doing the work took the completion risk," Granger said. And if Accenture tried to bail out, it would have to pay at least 50% of the value of the contract for disrupting the project, Granger threatened.

    As for Accenture's problems implementing Lorenzo, the CfH issued a statement calling for certain Accenture managers to be kicked off the program. "We believe that the issues are within Accenture's control and have requested key personnel changes within the Accenture organization," it said in a statement issued in April. The message was clear: CSC had managed iSoft effectively as a core supplier without Lorenzo. Accenture should have done the same.

    Indeed, in retrospect Accenture's gamble on Lorenzo seems increasingly ill-advised. In August, a report produced jointly by CSC and Accenture stated that "there was no believable plan for delivery … no well-defined scope and therefore no believable plan for lease." White says it will finally be ready in 2008.

    On Sept. 28, Accenture announced it was walking away from the NHS. It agreed to repay more than $100 million to settle its legal obligations under the contract—roughly $800 million less than the figure Granger had originally cited as a disruption fee. "It would have been in no one's interests to enter a dispute," the CfH said in an e-mail to Baseline.

    The same day, CSC announced it was taking over Accenture's effort. A sled dog had fallen; another had gotten to eat its dinner.

    Meanwhile, there were concerns with GE Healthcare's IDX as well. According to the NAO report, both Fujitsu and BT had agreed to develop a Common Solution Program that provided unified governance arrangements. This would ensure that the application was developed just once for the NHS in both the Southern cluster, Fujitsu's region, and in London, which had BT for an LSP. By mid-2004, the CfH became concerned about the effectiveness of IDX, according to the NAO report. By April 2005, with little progress seen, Fujitsu, according to the NAO, lost confidence in IDX's ability to deliver the Common Solution project. Fujitsu subsequently replaced IDX with Cerner, the Kansas City, Mo.-based health-care I.T. company. The replacement of IDX, NAO says, put Fujitsu 18 months behind schedule.

    IDX (GE Healthcare) failed to return phone calls requesting comment. A Fujitsu spokesman said the company was unable to respond to inquiries because the CfH wishes to handle all media calls themselves.

    In August, BT also dropped IDX for Cerner, though a Cerner spokeswoman says a contract between BT and Cerner has not been signed yet. Both parties have signed a letter of intent, she explained. BT has not responded to e-mailed inquiries.

    According to an August Gartner report, in the 2 1/2 years BT struggled to deploy acute-care systems in London, it has only achieved one implementation of the GE Healthcare/IDX Carecast application.

    Next page: Health-Care Executives Under Fire

    Under Fire

    Despite such setbacks, Granger vigorously asserts that the CfH is creating numerous benefits to the NHS on a timely basis. He points to the many positives detailed in the NAO report as proof of this. In addition, at a recent GC Expo, a U.K. technology conference for the public sector, he enumerated what the CfH delivers in a typical month. On his list:

  • 600 new N3 connections.

  • 3 Patient Administration Systems implemented.

  • 500,000 patient records converted and cleansed; 14,000 smart cards issued, allowing secure access to new systems.

  • 8.5 million X-rays and other images stored.

  • 1.8 million pathology results sent electronically to general practitioners.

    Of course, Granger is far from alone in extolling the benefits of the NPfIT. "Just from standardizing and centralizing the procurement process, the savings have been enormous," Brennan points out. The NAO report claims that deals negotiated by the CfH with Microsoft and other suppliers are expected to save about $1.5 billion.

    Still, the departure of Accenture, by far the CfH's most important contractor, has sparked questions about the CfH's overall approach and its long-term viability.

    Noted Members of Parliament Pugh and Bacon: "The program badly needs to be simplified, and likely future costs need to be brought down. The fundamental error made when setting up the program was to assume that centralized procurement of single systems across the NHS would be more efficient than local decision-making guided by national standards."

    In late August, the British Computer Society expressed a number of worries about the project, stating in a letter run by ComputerWeekly: "Our main concern [is] that a centralized system will not work in the complex organizational structure of the NHS. A distributed architecture would have been more flexible. We also have major problems with the lack of architectural planning about the detailed structure of the Electronic Health Record … this is an entity which does not fit well with other I.T. methodologies and needs considerable thought." A distributed architecture would have been far more flexible, the BCS noted.

    "The availability of key information about patients—both clinical and demographic—at any place where it is needed and at any time is the core value of the approach," the CfH responded to concerns about its centralized approach.

    While some criticism is political and comes from the Tory camp, there is considerable justification for at least some of the concerns about the NPfIT that go beyond cost overruns and schedule slippages. Most serious perhaps is a lack of support shown for the front-line clinicians, an indication that the CfH has fallen well short in its change management efforts.

    Comparing the result of the recent Medix survey of doctors and nurses with a poll the organization conducted three years ago shows a big change in health-care worker attitudes about the project. In the earlier survey, 67% of British general practitioners said they believed the project was an important priority for the NHS. Only 38% feel the same way today, while just 13% believe that the program represents a good use of NHS resources. Only 5% of British MDs say they've been given adequate consultation regarding NPfIT, up 3% from the old Medix survey but still a poor showing.

    Nurses responded in much the same way. Just 5% said they had received fully adequate information about the NPfIT; 35% said they'd been give reasonably adequate information, and 25% said they'd been given no information at all. "That's pretty damning," Brampton says.

    The CfH differs, noting: "We have undertaken a great deal of high-quality stakeholder engagement and change-management work," in an e-mail to Baseline.

    There have also been a number of seismic I.T. shocks recently that may indicate fault lines in the core I.T. services the CfH hopes to provide.

    As an example, in July, mission-critical computer services such as patient administration systems, holding millions of patient records being provided by the CSC alliance across the Northwest and West Midlands region, were disrupted because of a network equipment failure, according to the CfH. As a result, some 80 trusts in the region were unable to access patient records stored at what was supposed to be either a foolproof data center or a disaster recovery facility with a full backup system. Every NPfIT system in the area was down for three days or longer. Service was fully restored and no patient data was lost, the CfH says.

    That was not the first such failure. In fact, in the past five months more than 110 major incident failures having to do with NHS systems and the network have been reported to the CfH, according to ComputerWeekly.

    The CfH responded in an e-mail to Baseline: "It is easy to misinterpret the expression 'major incident.' Some of these could have been, for example, individual users experiencing "slow running." We encourage reporting of incidents, and we are open and transparent about service availability levels, which we publish on our Web site."

    Finally, according to the NAO report, there has been slippage, in some cases substantial, on many key elements of the program. For instance, the National Spine first went live as scheduled in June 2004, but the milestones for building up its functionality have been delayed by up to 10 months.

    Delivery of the first phases of the CRS and the advanced integrated I.T. systems that are central to the long-term vision for the program also are lagging, according to the NAO. Meanwhile, Choose and Book is running well behind schedule, the NAO report notes, in part because of the time needed by suppliers of existing systems to make their systems compliant.

    Still, for every setback, Granger, CfH and Tony Blair's Labour Government announce a step forward. Blair, in fact, is CfH's biggest ally. Addressing some 80 senior doctors earlier this year earlier and, according to The London Times, sweating profusely under the bright lights, Blair said, "The truth is that we have now reached crunch point where the process of transition from the old system to a new way of work in the NHS is taking place. Each reform was in its time opposed. Each is now considered the norm. The lesson, especially at the point of difficulty, is if it's right, do it. In fact, do more of it."

    More recently in September, Blair toured hospitals as an opportunity to defend the NPfIT: "This is going to be a place where people come from all over the world and say: 'This is how health care should be done.'"

    Ironically, with Blair a year from leaving office, the NHS has run short of funds, and recently reported a deficit of almost $1 billion—resulting in huge layoffs, possible closings of hospitals, reductions in services and a mad scramble by Health Secretary Hewitt to bring costs under control.

    "The money is no longer there," says Gartner's Edwards. "There are no funds for implementation or training." Given that by some estimates it will take yet another $15 billion to get the NPfIT initiative fully functioning, that indeed might end up as the NPfIT's epitaph.

    .K. Dept. of Health Base Case">

    U.K. Dept. of Health Base Case

    Headquarters: Richmond House, 79 Whitehall, London, England SW1A 2NS

    Phone: 020 7210 4850

    Chief Executive: Patricia Hewitt, Health Secretary

    Chief Technology Officer: Richard Granger, Director General of I.T., National Health Service (NHS)

    Financials in 2005: The Department of Health has a budget in excess of 27 billion pounds ($50 billion U.S.).

    Challenge: The National Program for Information Technology is a 10-year initiative to deploy new computer systems, reform the way the NHS uses technology and, in the process, improve services and the quality of patient care.

    Baseline Goals
  • Connect electronically more than 100,000 doctors, 380,000 nurses and 50,000 other health-care workers.
  • Store health information on 50 million people in England.
  • Reduce the time it takes to send medical images, such as X-rays, from about four minutes to less than one minute.