Tag Archives: NHS

Why was NHS e-Referral service launched with 9 pages of known problems?

By Tony Collins

Were GPs guinea pigs for live testing of the new national NHS e-Referral Service?

Between 2004 and 2010 the Department of Health marked as confidential its lists of problems with national NPfIT systems, in particular Choose and Book.

So the Health and Social Care Information Centre deserves praise for publishing a list of problems when it launched the national “e-Referrals” system on Monday. But that list was 9 pages long.

The launch brought unsurprised groans from GPs who are used to new national systems going live with dozens of known problems.

The e-Referral Service, built on agile “techniques” and based on open source technology, went live early on Monday to replace “Choose and Book” for referring GP patients to hospitals and to other parts of the NHS.

Some GPs found they could not log on.

“As expected – cannot refer anything electronically this morning. Surprise surprise,” said one GP in a comment to “Pulse” on its article headlined “Patient referrals being delayed as GPs unable to access e-Referrals system on launch day.”

A GP practice manager said: “Cannot access in south London. HSCIC debacle…GPs pick up the pieces. Changing something that wasn’t broken.”

Another GP said: “I was proud never to have used Choose and Book once. Looks like this is even better!”

Other GPs said they avoided using technology to refer patients.

“Why delay referral? Just send a letter. (Some of us never stopped).”

Another commented: “I still send paper referrals – no messing, you know it has gone, no time wasted.”

Dr Faisal Bhutta, a GP partner in Manchester, said his practice regularly used Choose and Book but on Monday morning he couldn’t log in. “You can’t make a referral,” he said.

The Health and Social Care Information Centre has apologised for the disruption. A statement on its website says:

“There are a number of known issues, which are currently being resolved. It is not anticipated that any of these issues will pose a clinical safety risk, cause any detriment to patient care or prevent users from carrying out essential tasks. We have published the list of known issues on our website along with details of how to provide feedback .”

But why did the Centre launch the e-Referral Service with 9 pages of known problems? Was it using GPs as guinea pigs to test the new system?


The Health and Social Care Information Centre is far more open, less defensive and a better communicator than the Department of Health ever was when its officials were implementing the NPfIT.

But is the HSCIC’s openness a good thing if it’s accompanied by a brazen and arrogant acceptance that IT can be introduced into the NHS without a care whether it works properly or not?

In parts of the NHS, IT works extraordinarily well. Those who design, test, implement and support such systems care deeply about patients. In many hospitals the IT reduces risks and helps to improve the chances of successful outcomes.

But in other parts of the NHS are some technology enthusiasts – at the most senior board level – who seem to believe that all major IT implementations will be flawed and will be improved by user feedback.

The result is that IT that’s inadequately designed, tested and implemented is foisted on doctors and nurses who are expected to get used to “teething” troubles.

This is dangerous thinking and it’s becoming more and more prevalent.

Many poorly-considered implementations of the Cerner Millennium electronic patient record system have gone live in hospitals across England with known problems.

In some cases, poor implementations – rather than any faults with the system itself – have affected the care of patients and might have contributed to unnecessary deaths when records needed urgently were not available, or hospitals lost track of urgent appointments.

A CQC report in March 2015 said IT was a possible factor in the death of a patient because NHS staff were unable to access electronically-held information.

In another incident a coroner criticised a patient administration system for being a factor in the death of three year-old Samuel Starr whose appointment for a vital scan got lost in the system.

Within NHS officialdom is a growing cultural acceptance that somehow a poor IT implementation is different to a faulty x-ray machine that delivers too high a dose of radiation.

NHS officials will always brush off IT problems as teething and irrelevant to the care and safety of patients. Just apologise and say no patient has come to any harm.

So little do IT-related problems matter in the NHS that unaccountable officials at the HSCIC have this week felt sufficiently detached from personal accountability to launch a national system knowing there are dozens of problems with the use of it.

Their attitude seems to be: “We can’t know everything wrong with the system until it’s live. So let’s launch the system and fix the problems as GPs give us their feedback.”

This is a little like the NHS having a template letter of regret to send to relatives and families of patients who die unexpectedly in the care of the NHS. Officials simply fill in the appropriate name and address. The NHS can then fix the problems as and when patients die.

It’s surely time that bad practice in NHS IT was eradicated.  Board members need to question more. When necessary directors must challenge the blind positivism of the chief executive.

Some managers can learn much about the culture of care at the hospitals that implement IT successfully.

Patients, nurses and doctors do not exist to tell hospital managers and IT suppliers when electronic records are wrong, incomplete, not available or are somebody else’s record with a similar name.

And GPs do not exist to be guinea pigs for testing and providing feedback on new national systems such as the e-Referral Service.

e-Referral Service “unavailable until further notice”

Hundreds of patients lost in NPfIT systems

Hospital has long-term NPfIT problems

An NPfIT success at Croydon? – Really?

Physicians’ views on electronic patient records

Patient record systems raise some concerns, says report

Electronic health records and safety concerns

Did officials exaggerate death of the NPfIT?

By T0ny Collins

In 2011 the Department of Health made a major announcement that implied the NHS IT programme, the NPfIT, was dead when it wasn’t.

The DH’s press release announced an “acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority”.

It said the Authority had concluded that the NPfIT was “not fit to provide the modern IT services that the NHS needs…” The National media took the press release to mean that the NPfIT was dead.

What the announcement didn’t mention was that at least £1.1bn had still to be spent, largely with CSC, provided that the company successfully completed all the work set out in its revised contracts, and that the projected end-of-life of some centrally-chosen NHS IT systems was 2024.

Some will say: who cares if the DH issues a press release that is misleading. Others may say that in a democracy one should be able to trust institutions of state. If the DH issues an official notice that has the effect of manipulating public perceptions – gives a false impression – can citizens trust the Department’s other official notices?

The press release in question did not say the NPfIT was closing but gave that impression. The announcement distanced the government and the Department of Health from an IT scheme, perhaps the world’s largest non-military IT programme, that was failing. This was the press release:

The government today announced an acceleration of the dismantling of the National Programme for IT.

“The government today announced an acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority (MPA). The programme was created in 2002 under the last government and the MPA has concluded that it is not fit to provide the modern IT services that the NHS needs…”

The press release was given added weight by those quoted in it. They included the Department of Health, Francis Maude, Minister for the Cabinet Office and Sir David Nicholson, Chief Executive of the NHS.

But the truth about the press release emerged this week at a hearing of the Public Accounts Committee.

Margaret Hodge, chair of the Public Accounts Committee, began a hearing on the NPfIT on Wednesday by asking Sir David Nicholson, the NHS chief, a canny question.

Hodge:  “There was a big announcement back in 2011 that you were closing the NPfIT programme.”

“Yes,” replied Sir David.

“That’s not true,” said Hodge. “It was a PR exercise to say you closed it.”

Nicholson: “It certainly was not a PR exercise.”

Hodge: “What changed?”

Nicholson: “The governance arrangements changed.  So there are separate senior responsible officers for each of the individual programmes [within the NPfIT].”

Hodge: “With the greatest respect, changing governance arrangements is not closing the programme.. .I think the impression you were trying to give was that you were closing the programme. All you were doing was shifting the deckchairs on the Titanic. You were shifting the way you were running it but you were keeping all that expenditure running… The impression given to the public was that you were going to get out of some of these contracts.”

On the basis of the press release the Daily Mail published a front page lead story with this headline:

£12bn NHS computer system is scrapped… and it’s all YOUR money that Labour poured down the drain

On the day of the press release the Daily Telegraph reported that the £11.4bn NHS IT programme was “to be abandoned”.  Similar reports appeared in the trade press.

But this week’s Public Accounts Committee heard that the NPfIT is very much alive:

– the estimated worth of CSC’s contracts under the NPfIT has risen from £3.1bn to £3.8bn at today’s prices.

–  officials expected to pay CSC a further £1.1bn on top of the £1.1bn it has already received, and this payment may include up to £600m for Lorenzo deployments at only 22 trusts. Hodge said: “You are going to spend another half a billion with this rotten company providing a hopeless system” – to which the DH argues that CSC has delivered thousands of (non-Lorenzo) working systems to the NHS which trusts and community health services rely on.

– About £500m of the £1.1bn still set aside for CSC will go on GP systems supplied by CSC’s subcontractor TPP Systmone.

– Further spending on the NPfIT may come as a result of Fujitsu’s legal action against the DH after it left the NPfIT in 2008, which leaves the taxpayer with a potential pay-out of £700m or more. The outcome of a formal arbitration is expected in about six months. The closing arguments are due at the end of this month.

– £31.5m has so far been spent on the DH’s legal costs in the Fujitsu case, mostly with the .law firm DLA Piper.

– DH has agreed a compensation payment to CSC of £100m. In return CSC has released the Department of Health from a contractual commitment for 160 NHS trusts to take the Lorenzo system. The DH has made a further payment to CSC of £10m in recognition of changes to its software which had been requested by the NHS but not formally agreed with CSC.


It appears there has been no deliberate deception and no deliberate manipulation of public perceptions of the NPfIT. But the fact remains that the DH made a major announcement in 2011 which gave the impression the NPfIT was dead when this was not true.

When a BBC Radio 4 journalist called me this week and we spoke briefly about the NPfIT he said: “I thought it was dead”.

Perhaps the mindset of officials was that the NPfIT was dead because everyone except the suppliers wanted it to be. But because local service provider contracts had to stay in place – the suppliers being much better equipped than the DH to handle any disputes over early termination – large payments to CSC and BT had to continue.

It’s a little like the political row over weapons of mass destruction in Iraq. It’s unlikely Blair lied over the existence of WMD. He probably convinced himself they existed. In a similar act of self-delusion officials appear to have convinced themselves the NPfIT was dead although it wasn’t.

But if we cannot believe a major DH announcement one starts to ask whether any of the department’s major announcements can be believed.

Uncoloured information on the NPfIT has always been hard to come by. So credit is due to the Public Accounts Committee and particularly its MP Richard Bacon for finding out so much about the NPfIT.  All credit to Margaret Hodge for picking up on Bacon’s concerns. Were it not for the committee, with indispensable support from the National Audit Office, the DH would have been a sieve allowing only bits of information it wanted to release to pass through.

The fall-out from the NPfIT will continue for years. We still don’t know, for example, what all the trusts with BT and CSC systems will do when the NPfIT contracts expire in the next three years. The hope is for transparency – and not of the sort characterised by the DH’s announcement in 2011 of the NPfIT’s dismantling.

This post also appears on ComputerworldUK

Campaign for electronic patient information centre

By Tony Collins

Shane Tickell, CEO of health IT supplier IMS Maxims, is leading a campaign for a national electronic patient information centre.

It would enable NHS staff, healthcare organisations and government suppliers to share details of, or learn about, innovative practices that work.

In a guest blog, Tickell argues that there are many examples of innovation in the NHS but information on the successes is scarce or not available in one place.

He advocates a physical and a virtual centre. Information, case studies, best practice and ideas from the NHS would be shared online. There are some websites that do this, but in isolation. The virtual site he proposes would be interactive and a way of collating information that exists in silos.

The physical centre, Tickell says, could be anywhere on the UK, potentially using some of the 2,000 acres of unused NHS estate. It would be a forum for education and sharing, where suppliers could showcase their systems, and NHS staff could speak openly about what they need from suppliers.

It would also be a place for policy to be explained by government officials, where quangos define their requirements, and NHS trusts share what they are doing and the lessons they have learned.

Shane Tickell writes:

“As an acceptance grows across the NHS that there is a crucial need for integration across health and social care, the extent to which our National Health Service is disjointed is becoming increasingly clear.

In many areas, although of course not all, there are so many examples of different approaches, poor collaboration and lack of joined thinking between organisations despite their attempts to achieve the same goals. On many occasions, I’ve seen examples where an NHS organisation has shared the results of a successful pilot with another organisation hundreds of miles away and yet the trust just a few miles down the road has no idea the initiative even exists.

In recent years, healthcare IT events such as EHI Live have helped suppliers of all sizes showcase their solutions, albeit just once a year.

However, despite best efforts, most often suppliers with the biggest marketing budgets often take the centre stage, while the smaller, more innovative companies huddle around the edges trying to grab the attention of the odd delegate who is less wowed by the exciting gizmos and freebies on the bigger stands.

Equally, these events have been valuable in enabling the NHS to share their experiences by allowing them to participate in best practice showcases. But while these shows are valuable in providing those once-a-year opportunities to network and see what is available, ideas and information gathered can soon be forgotten once back in the busy NHS setting, until the next time an event comes around.

There are more than 400 pilots across the NHS and 300 ‘examples of innovation’ alone, according to the BCS. On top of all of that, my team recently mapped more than 40 NHS organisations and bodies, who work virtually disparately to attempt to provide the NHS with direction, standards and protocols.

So where does this leave the NHS – confused? Disjointed? Not a clue where to start when they are told that they need to collaborate and innovate to improve patient safety and care while saving vast sums of money?

The NHS needs a place that provides an educational and innovation forum covering everything related to electronic health and wellbeing that is available all year round – an electronic patient information centre.

At present there are pockets of innovation across the country. Initiatives set up by the National Innovation Centre and its associated ‘innovation hubs’ are providing a useful mechanism to support and adopt healthcare technology across the regions.

But an all year round centre would provide a central location for healthcare organisations, bodies, government and suppliers to meet, discuss and understand policy. Equally important, the centre would provide a valuable place to educate on future challenges and where they are being driven from and an opportunity to work together to help to address them as soon as they start to emerge.

Although it would require investment, such a centre would provide trusts, CCGs, private and independent organisations and just about anyone with an interest in health and social care regardless of their budget, size, location or IT savviness with the opportunity to attend at a time that is convenient for them.

Meanwhile, suppliers of any shape or size would have a level playing field from which to be represented and educate their current and potential customers, rather than trawling up and down the country trying to find inroads to speak to those on the frontline. In addition, it would ensure that all is not lost from the National Programme for IT and that lessons learned are shared.

For too long the NHS has had to rely on word of mouth and second-guessing how surrounding organisations are achieving success. Now is the time to really work together to ensure true innovation is shared and for everyone to have a chance to be part of it.”

LinkedIn group – Electronic Patient Information Centre 


Summary Care Record “unreliable”

By Tony Collins

The  central Summary Care Record database (which is run by BT under its NPfIT Spine contract) is proving unreliable, Pulse reports today.

The SCR is supposed to give clinicians , particularly those working in A&E and for out-of-hours services, a view of the patient’s most recent medicines, allergies and bad reactions to drugs.

But one criticism of the scheme has always been the lack of any guarantee that the data in the SCR could be accurate or complete.

Researchers at University College, London, led by Trisha Greenhalgh, found in a confidential draft report that doctors were unable to trust the SCR database as a single source of truth. They found in some cases that  some information on the database was wrong, and what should have been included in the patient’s record was omitted for unknown reasons.

Now Pulse reports that some GP-derived information is going on the patient’s SCR, and some isn’t. One problem is that GPs must use smartcards to update the SCR database and some don’t use them.

The General Practitioners Committee of the British Medical Association has raised the matter with the Department of Health.

Dr Paul Roblin, chief executive of Oxfordshire, Buckinghamshire and Berkshire local medical committee told Pulse that  smartcards were not often used in Buckinghamshire, because they slowed down the practice IT system for normal use, with one practice reporting that it had interfered with allergy data.

Dr Roblin said that this made the record ‘unreliable’ and said that although most GPs would prefer to take their own history rather than relying on the SCR, and would double check all details with the patient, other health professionals may not realise the record is incomplete, and may not check the data.

He said “Drugs lists might not be complete and recent allergies may not be uploaded. The Summary Care Record is unreliable. Don’t rely on it. It’s an expensive initiative without a lot of benefit.”

Dr Chaand Nagpaul, GPC lead negotiator on IT, said the current arrangements  undermine the benefit and usefulness of summary care records.

“The GPC have suggested workaround systems for practices who do not use smartcards, such as a ‘mop-up’ session where all new data is uploaded on to the national spine once a day. However, the DH decided against this option.”

There may be professionals who believe the SCR database  represents an up to date record said Nagpaul.

A DH spokesperson said that most practices which have created Summary Care Records use smartcards.

[Whether justified or not the SCR  scheme is believed to have cost about £250m so far.]

In 2010 Professor Ross Anderson at Cambridge University argued that the SCR could do more harm than good.

Richard Veryard also wrote on the unreliability of the SCR in 2010.

The Devil’s in the Detail – UCL report on the Summary Care Record.

Summary Care Record – where does the truth lie?

Will coalition sign a new NPfIT deal with CSC?

By Tony Collins

CSC has told investors that its discussions with the UK government on an interim agreement for deploying Lorenzo to the NHS are “continuing positively”.

CSC says that an agreement could commit a certain number of NHS trusts to take Lorenzo. Some of those trusts would be named in the interim agreement and the remainder within six months. CSC refers to them as “committed named trusts”.

[Such a legal commitment for named NHS trusts to take Lorenzo may run counter to the post-NPfIT coalition philosophy of giving trusts the freedom to buy what they want, when they want, and from whom they want. The named trusts might have indicated on a  DH questionnaire a wish to take Lorenzo but an agreement between the government and CSC would commit the trusts irrevocably, or the DH could have to pay CSC compensation for non-deployment.]

CSC says the deployed product would be categorized as “base product” or “additional product” for pricing purposes. The DH would commit money to the base product. Other funds would be available centrally available for “additional products,  supplemental trust activity and local configuration”.

The DH would give CSC a structured set of payments following certain product deliveries, as well as additional payments to cover various deployments for the named trusts and payments for work already performed.

If the government does not sign a new deal, and allows CSC’s existing contracts to run down until they expire formally in 2015, this could keep further NPfIT-related costs to the taxpayer to a minimum.  But it risks legal action from CSC, which says the NHS contract is enforceable and that the NHS has no existing right to terminate the contract, unless for convenience (which is unlikely).

If the government had terminated CSC’s contracts for its convenience (as opposed to alleged breach of contract) it would have had to pay CSC a termination fee capped at £329m as of 29 June 2012. CSC would also have been entitled to compensation for the profit it would have earned for the 12 months after the contract was terminated.

If the contract is not terminated, a new deal not signed, and no legal action is taken by either side, the amounts the UK government would have to pay CSC are likely to be minimised.  It is in CSC’s interests to maintain and enhance Lorenzo for those NHS sites that have deployed it.

So will the government sign a new deal with CSC at least to reduce the risks of CSC legal action? Or could the government hold out not signing any agreement until expiry of the contracts in 2015 on the basis that CSC has not delivered all it promised?

If a new deal is signed – and CSC indicates that an agreement is likely – the government may face accusations that it has broken its undertaking to dismantle the NPfIT.

David Camerson intervened personally to have the Cabinet Office’s Major Projects Authority look closely at NPfIT commitments.  His “efficiency” minister Francis Maude is likely to resist the signing of any new agreement

But will CSC accept the government’s refusal to sign a new deal, when such a deal could enable CSC to recover at least some of the $1.485bn (£0.95bn) it recorded as an NPfIT contract charge in the third quarter of 2012?

All change at the DH, CfH and on NPfIT – or not?

By Tony Collins

Katie Davis is to leave as interim Managing Director of NHS Informatics, says eHealth Insider which has seen an internal memo.

.The memo indicates that Davis “intends to focus on being a full-time mother to her two children”.

She joined the Department of Health on 1 July 2011, on loan from the Cabinet Office where she was Executive Director, Operational Excellence, in the Efficiency and Reform Group.

Before that she was Executive Director of Strategy at the Identity and Passport Service in the Home Office.

The memo indicates that the director responsible for the day-to-day delivery of NHS programmes and services, Tim Donohoe, will take-over Davis’ role until NHS Connecting for Health shuts down at the end of March 2013.

CfH’s national projects look set to move to the NHS Commissioning Board in Leeds, while its delivery functions will move to the Health and Social Care Information Centre.

Davis had told eHeath Insider that her priorities included concluding a piece of unfinished business on the NPfIT – the future of the [CSC] local service provider deal for the North, Midlands and East.


Davis has been a strong independent voice at the Department of Health. Partly under her influence buying decisions have passed to NHS trusts without penalties being paid by the NHS to NPfIT local service provider CSC.

It is a little worrying, though, that high-level responsibility for the rump of the NPfIT – CSC’s contracts, Choose and Book, the Spine, Summary Care Record and other centrally-managed projects and programmes – may fall to David Nicholson, Chief Executive of the NHS.

Labour appointed Nicholson in 2006 with a brief that included making a success of the NPfIT. He has been the NPfIT’s strongest advocate.

Indeed a confidential briefing paper from the Department of Health to the then PM Tony Blair in 2007 on the progress of the NPfIT said:

“… much of the programme is complete with software delivered to time and to budget.”

It is difficult to see the NPfIT being completely dismantled under David Nicholson. It’s probable that CfH will be shut down in name but recreated in other parts of the NHS, while the NPfIT programmes and projects run down very slowly.  It’s even conceivable that CSC’s and BT’s local service provider contracts will be extended before they are due to expire in 2015/16.

A comment on eHealth Insider says:

“My understanding is that NPfIT is leaving us with a legacy of ancient PAS systems barely fit for purpose which cost a fortune to operate and which will transfer to a massive service charge once national contracts end. That’s if you don’t count the most expensive PACS system in the universe. And I wonder what Lorenzo cost?”

It’s hard to argue with that. Meanwhile the costly NPfIT go-lives are due to continue, at Imperial College Healthcare NHS Trust, for example.

End game for Davis and CfH announced.

We operated on the wrong organ – but hey, it’s OK.

By Tony Collins

When a surgeon operates on the wrong organ the NHS calls it “wrong site surgery” (a euphemism which makes it sound like an official part of a medical student’s curriculum).

A surgical intervention on the wrong organ could never be a source of reassuring news unless it’s in the board papers of an NHS trust.  NHS board papers are, more often than not, the source of good news announcements, statistics and graphs. Bad news is between the lines.

This was North Bristol NHS Trust’s account of what it said was a “surgical intervention [that] was performed on the wrong organ in a patient”. The operation was complex due to distortion of the patient’s anatomy. “This incident has resulted in some long term harm for the patient although the patient has since fully recovered.” The trust reports more reassuring news:

–  the patient has been fully informed

–   and given an apology

–    a full investigation has been carried out and lessons learnt

–   the consultant surgeon was experienced, and was assisted by another specialist

–   the World Health Organisation Surgical Safety Checklist was used correctly and as such, could not have prevented this error.

–  the case was discussed at directorate clinical governance meetings and disseminated widely to raise awareness of distorted anatomy with clinical staff.

–  the Clinical Risk Committee, Commissioners and the National Patient Safety Agency are assured that human error is an acceptable reason for this incident and that all procedures were carried out correctly.


It sounds reassuring that all procedures had been carried out correctly, and that the World Health Organisation Surgical Safety Checklist was used correctly. But if a sleeping driver injures someone, should his colleagues be assured that he’d just put the car through an MoT and was driving under the speed limit?

Trust board papers need to connect with everyday reality. I’d venture to suggest they are not the place for announcements on managerial successes.

The same trust reported the separate case of an  “Unintended retention of a foreign object post surgical intervention”. The retained object was a small microvascular clamp and this was removed during a subsequent operation,

“which resulted in a satisfactory outcome for the patient”.  Good news then.

We wonder how the trust will report the findings from its investigation of recent IT troubles.

How London IT director saves millions by buying patient record system.

By Tony Collins

An NHS organisation in London has bought an electronic patient record system for less than a third of the cost of similar technology that is being supplied by BT to other trusts in the capital and the south of England.

The £7.1m purchase by Whittington Health – a trust that incorporates Whittington Hospital near Archway tube station – raises further questions about why the Department of Health is paying BT between £31m and £36m for each installation of the Cerner Millennium electronic patient record [EPR] system under the NPfIT.

Whittington Health is buying the Medway EPR system from System C which is owned by McKesson. The plan is for the EPR to operate across GP, hospital and social care boundaries.

It will include a patient portal. The idea is that patients will use the portal to log on to their Whittington Health accounts, see and save test results and letters, and manage outpatient appointments on-line.

In a board paper, Whittington Health’s IT Director Glenn Winteringham puts the case for spending £7.1m on a single integrated EPR.  Winteringham puts the average cost of  System C’s Medway at £8m. This cost, he says, represents “significant value for money” against the average deployment costs for the NHS Connecting for Health solution (Cerner Millennium) for London of £31m. In the south of England the average cost of Cerner Millennium is £36m, says Winteringham in his paper.

He also points out that the new EPR will avoid costs for using “Rio” community systems. The NPfIT contract with BT for Rio runs out mid 2015. “From this date onwards the Trust will incur an annual maintenance and support cost. Implementing the EPR will enable cost avoidance to the [organisation] of £4m per year to use RIO (indicative quotes from BT are £2m instance of RIO and the [organisation] has 2 – Islington and Haringey).

BT’s quote to Whittington for Rio is several times higher than the cost of Rio when supplied directly by its supplier CSE Healthcare Systems. A CSE competitor Maracis has said that, during a debrief, it was told that its prices were similar to those offered by CSE Healthcare for a Rio deployment – then less than £600,000 for installation and five years of support.

In comparison BT’s quote to Whittington for Rio, as supplied under the NPfIT, puts the cost of the system at more than fifteen times the cost of buying Rio directly.

In short Whittington and Winteringham will save taxpayers many millions by buying Medway rather than acquiring Cerner and Rio from BT.

Why such a price difference?

The difference between the £31m and £36m paid to BT for Cerner Millennium and the £8m on average paid to System C could be partly explained by the fact that Whittington (and University Hospitals Bristol) bought directly from the supplier, not through an NPfIT local service provider contract between the Department of Health and BT. Under the NPfIT contract BT is, in essence, an intermediary.

But why should an EPR system cost several times more under the NHS IT scheme than bought outside it?


Did officials who agreed to payments to BT for Cerner and Rio mistakenly add some digits?

Whittington’s purchase of System C’s Medway again raises the question – which has gone unanswered despite the best efforts of dogged MP Richard Bacon – of why the Department of Health has intervened in the NHS to pay prices for Rio and Cerner that caricature profligacy.

Perhaps the DH should give BT £8m for each installation of Cerner Millennium and donate the remaining £21m to a charity of BT’s choice. The voluntary sector would gain hundreds of millions of pounds and the DH could at last be praised for spending its IT money wisely.

Whittington buys Medway and scraps Rio – E-Health Insider

NHS IT supplier “corrects” Health CIO’s statements

MP seeks inquiry into BT’s £546m NHS deal

NPfIT go-live at Bristol – trust issues apology

The real reason NHS Risk Register is a State secret?

By Tony Collins

Yesterday  (15 May 2012) the Information Commissioner Christopher Graham issued a finely-crafted report to Parliament on his concerns about the Government’s use of a ministerial veto to stop publication of the Transition Risk Register relating to health service reforms.

Graham’s concern is that the veto represents a new and worrying approach to Freedom of Information.

Graham cannot do anything about the veto but he can warn MPs when he feels the Government has gone too far. This he has done in his report which says that the previous three occasions on which the ministerial veto has been exercised related to the disclosure of Cabinet material under FOIA. Now the Government has applied the veto to information held by the Department of Health.

Says yesterday’s report: “ The Commissioner would wish to record his concern that the exercise of the veto in this case extends its use into other areas of the policy process. It represents a departure from the position adopted in the Statement of Policy and therefore marks a significant step in the Government’s approach to freedom of information.”

The Government’s decision to ban publication of the health service risk register is particularly relevant to IT-related projects. This is because the government uses exactly the same arguments to ban contemporaneous publication of Gateway reviews and other independent assessments of IT-related projects and programmes.

Risk registers and Gateway reviews of IT-enabled change projects are similar. They are designed to identify all the main risks associated with the project or programme and have a red/amber/green system of rating the risks.

The Government’s argues that risk registers (and Gateway reviews) are researched and written in a “safe space” that allows civil servants to give advice and recommendations in a frank way. This candour would be compromised if the civil servants thought their advice would be published, says the Government.

In issuing a veto on the health risk register Andrew Lansley, the Health Secretary said, in essence, that he could not trust civil servants to be entirely honest if they knew their reports would be made public.

Said Lansley:  “If risk registers are routinely or regularly disclosed at highly sensitive times in relation to highly sensitive issues, or there is legitimate concern that they could be, it is highly likely that the form and content will change: to make the content more anodyne; to strip out controversial issues or downplay them; to include argument as to why risks might be worth taking; to water down the RAG [red,amber, green] system.

“They would be drafted as public facing documents designed to manage the public perception of risk; not as frank internal working tools. These consequences (many of them insidious) would be to the detriment of good government.”

Lansley also wanted to ban publication to pre-empt sensational media coverage.  In this he was repeating the arguments made by civil servants under Labour who refused, under the FOI Act, to publish risk registers and Gateway reviews.  Said Lansley “I consider that the form and the frankness of the content of TRR [health service Transition Risk Register] would have been liable to create sensationalised reporting and debate.

“The content would also have been inherently highly open to misinterpretation by both the press seeking a headline and/or for political reasons. The likelihood of this occurring is particularly acute where the subject matter is, as with the Transition programme, controversial and the proposals at a highly sensitive stage.”

But the Commissioner did not accept that disclosure of the Transition Risk Register would affect the frankness and candour of future risk registers. The Commissioner also said that a ministerial veto should, by law, be made only in exceptional circumstances.  But the Government has failed to explain why there are exceptional circumstances in this case.  Said the Commissioner:

“The Commissioner does not consider that sufficient reasons have been given as to why this case is considered to be exceptional, particularly in light of the [Information] Tribunal’s decision dismissing the Department’s [Department of Health’s] appeal.

“The Commissioner notes that much of the argument advanced as to why the case is considered to be exceptional merely repeats the arguments previously made to Commissioner and the Tribunal and which were in part dismissed by the Tribunal.”

Graham concludes:

“In light of previous commitments he has made, and the interest shown by past Select Committees in the use of the ministerial veto, the Commissioner intends to lay a report before Parliament under section 49(2) FOIA on each occasion that the veto is exercised. This document fulfils that commitment.

“ Laying this report is an indication of the Commissioner’s concern to ensure that the exercise of the veto does not go unnoticed by Parliament and, it is hoped, will serve to underline the Commissioner’s view that the exercise of the ministerial veto in any future case should be genuinely exceptional…

“The arguments employed by the Department at the Tribunal and by the Secretary of State in explanation of the subsequent veto, both in the Statement of Reasons and in exchanges in the House of Commons around the Ministerial Statement, certainly use the language of ‘exceptional circumstances’ and ‘matter of principle’. But the arguments are deployed in support of what is in fact the direct opposite of the exceptional – a generally less qualified, and therefore more predictable, ‘safe space’.

“As such, the Government’s approach in this matter appears to have most to do with how the law might be changed to apply differently in future. This question falls naturally to consideration by the Justice Committee who have been undertaking post-legislative scrutiny of the Act.”


The reason for the veto in the case of the health service risk register has little to do with protecting a safe space for frank discussion.

Civil servants already compile risk registers, Gateway reviews and similar reports on the basis that they may, at some point, be published. Officials are no more likely to be frank if they know their reports will be confidential than more guarded if they know the documents will be published. They will do what their job entails. Their job requires honesty. They will do that job whether or not reports are published.

The real reason for the veto – and the refusal of departments to publish all contemporaneous internal reports on large and complex programmes, particularly those with a large IT element – is that some new schemes within Government operate at a shambolic level.

Any new government, whatever its hue, soon learns to keep secret the fact that such programmes are sometimes characterised by near anarchy.

One outsider to the UK government, Australian David Pitchford, discovered the truth when he became Executive Director of Major Projects within the Efficiency and Reform Group which is part of the Cabinet Office. Pitchford may not have realised his comments would be reported when he told a project management conference in 2010 that “nobody in the UK Government seems to know how many projects they have on the books, nor how much these are likely to cost”.

He found that projects were launched, and continued, without agreed budgets or business cases.  Today, there is better scrutiny of major projects, by the Cabinet Office’s Major Projects Authority. But the MPA is limited in what it can do or scrutinise. Which leaves government in a general mess when it comes to implementing anything new.

Evidence for this mess comes from the National Audit Office. Its auditors tend to investigate departments as a whole more than they do specific projects but when they do the careful reader can see that projects such as the Rural Payments Agency’s Single Payment Scheme (a scant regard for public funds, said the NAO) and the C-NOMIS project for the prison service (kindergarten mistakes, said chair of Public Accounts Committee) were without a structure. Chaos prevailed – and ministers were among the last to know.

Publication of project reports encourages professionalism. Departmental heads can be held to account if Parliament knows what has gone wrong. That’s precisely the reason departmental heads don’t want risk registers and other project reports published. It’s why all internal reports on Universal Credit, the government’s biggest IT-related project, are kept secret in spite of FOI requests.

The ministerial veto in the case of the NHS risk register is the government and civil service colluding in keeping the public and Parliament in ignorance of internal management’s inability to run complex new projects and programmes in a professional way.

Ministers and permanent secretaries don’t especially mind media criticisms that are based on speculation. They don’t want their critics having authoritative internal reports. That’s why the Cabinet agreed the health service veto – and it’s one reason the government has a not-very-hidden aversion to the FOI Act.

The coalition cannot justly claim to cherish open government while it is refusing so many requests under FOI to publish contemporaneous taxpayer-funded reports on its major schemes.

We agree with the Information Commissioner that use of the ministerial veto is a step too far. No number of announcements by the Cabinet Office on open government will gloss over the fact that the coalition is even more secretive about mega-projects than Labour. That’s saying something.

The campaigners’ view of the Gloucestershire case on social enterprise and the NHS

By David Bicknell

Left Foot Forward recently carried a piece discussing the impact of the recent case in Gloucestershire where campaigners had “argued that the local PCT had acted unlawfully in planning to hand over management of nine county hospitals and 3,000 community health staff in what would have been the biggest planned transfer (so far) to a social enterprise in the country.”

It is written from the perspective of the campaigners who question, now that the Health Bill is passed, how far are current NHS providers obliged to put existing services out to competitive tender?