A new book, The Delivery Gap: Why Government Projects Really Fail and What Can Be Done About It by Jonathan Simcock (Emerald Publishing), looks behind the scenes to uncover the problems that plague government projects and offer fresh solutions.
Successive UK governments have a terrible track record when it comes to large-scale projects. Almost universally, they are either late, over budget, deliver less than promised – or all three. Some, like HS2, are never completed at all.
In this edited extract from The Delivery Gap, Jonathan Simcock explores how arrogance thwarted the NHS National Programme.
In February 2002, Prime Minister Tony Blair hosted a seminar in Downing Street. He was convinced that the National Health Service in England could be transformed with the help of better IT. It was said that he had been enthused about the subject after a discussion with Microsoft CEO Bill Gates. Blair himself was there for less than an hour, but those present, including the Department of Health ministerial team of Alan Milburn and Lord Hunt, senior executives from NHS England, and several senior representatives of the IT industry, came away convinced that a step-change in the use of computers could make enough of a difference to NHS performance that Labour would be rewarded by voters at the next election.
Milburn and the NHS committed to present the Prime Minister with a national implementation plan by the end of May. It would set a timetable for hospitals and GPs to benefit from a network of new systems. Implementation of new IT would start within a year. A year earlier, Chancellor Gordon Brown had commissioned banker Derek Wanless to investigate what was required to turn the NHS in England into a service which provided safer, higher quality treatment. Amongst other findings, Wanless was scathing about the NHS’s use of IT. He concluded that, ‘A major programme will be required to establish the infrastructure and to ensure that common standards are established. Central standards must be set and rigorously applied.’
The prospectus for a massive IT Project for Health, to be known as the National Programme, was published in June. It promised greater central control and ruthless standardisation. The scope of the programme was rather vague but would include new infrastructure and a number of services including a national booking service, a national prescriptions service, and a national health records service which would be accessible round the clock from anywhere in the country. By September, the National Programme was launched, and an external expert had been hired to run it. His name was Richard Granger, a consultant from Deloitte. He had no background in health, but he did have a reputation for hard-nosed delivery.
On appointment, he was reputed to be the country’s highest paid civil servant. Granger quickly developed a plan for procuring the new systems. To counter the risk of lashing the NHS to a single IT provider, Granger decided to divide the country into five regions and procure a monopoly service into each one. As with the Astute Submarine project a decade earlier, the idea was to generate an intense competition and to load the supply chain up with as much risk as possible. In the National Programme, suppliers would be paid nothing until they delivered working services. And anyone not performing would have their region taken from them and redistributed to the other suppliers. Granger told the media that if you are using huskies to pull you to the pole, then “when one of the dogs goes lame, and begins to slow the others down, they are shot. 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.”
By the end of 2003, the five regional contracts had been let to four providers: BT, Accenture, Fujitsu and an American company, CSC, which won two regions. Although there were four service providers, they had between them only two developers for the most important of the new software solutions. These electronic patient record systems would allow information to be exchanged seamlessly between healthcare professionals, managers and patients. BT and Fujitsu selected a US company, IDX, and Accenture and CSC chose the UK firm, iSoft. The ten-year contracts had a total value of £6.2 billion and Granger’s commercially aggressive approach had won him plenty of fans in the centre of government.
But the input from clinicians into what the new systems would have to do was superficial to say the least. A director of the NHS Information Authority told the Public Accounts Committee two years later that the consultation process amounted to ‘asking some clinicians to comment on hundreds of pages of text in systems-speak in the space of a few weeks’. The Chair of the National Clinical Advisory Board told the same Public Accounts Committee that the NHS National Programme “was like being in a juggernaut lorry going up the M1 and it did not really matter where you went as long as you arrived somewhere on time”.
Perhaps in recognition of the lack of clinical understanding in the project, Professor Aidon Halligan, the deputy Chief Medical Officer, was appointed to work alongside Granger as joint head of the project in the spring of 2004. But it was too late to influence the contracts which had already been signed. These health experts found escape routes from the project, but none of them went public. The director of the NHS Information Authority was made redundant, the Chair of the National Clinical Advisory Board was asked to resign, and Professor Halligan quit his role in the project after six months, although he stayed on as deputy Chief Medical Officer.
Procured in a hurry, and without sufficient involvement from NHS professionals, neither of the electronic patient record system developers, IDX or iSoft, were able to get to grips with the complexities of healthcare provision in the NHS. The extremely aggressive commercial approach imposed by Granger produced predictably miserable results.
A large part of the problem was underappreciation of the fundamental differences between how healthcare is provided on different sides of the Atlantic. In the United States, the health system is administered so as to bill insurers or patients for every intervention. This isn’t how UK hospitals work. And no-one in the US health system has to administer patient waiting lists – a matter of huge importance in the NHS. Eventually there were only two regional suppliers and two electronic patient record system developers, and none of them were making acceptable progress. Parts of the clinical community were now in open revolt.
One health professional posted his disgust: ‘Now and then I check myself from hatred of what Richard Granger stands for and has done to NHS IT, and then the sheer arrogance and ignorance of his public statements brings me back.’ It was evident by 2007 that centrally implemented system deployments were not achieving the project’s objectives. Although the project limped on, 2008 was the year in which hope seems to have left the project team. Richard Granger exited quietly at the beginning of the year. Accenture and Fujitsu were gone. BT and CSC were facing huge losses. Neither of the solution providers was delivering software that was up to the job. Virtually nothing was being deployed into NHS hospitals.
The problems, always an open secret in the NHS, were now making national news. The Guardian reported that where new systems were being deployed, lack of patient data was causing delays in Accident and Emergency, cancer treatment and planned operations. Patients were exposed to the risk of infection while records were being updated manually, and in one Trust complaints from the public about their service tripled. In what could have been the final nail in the coffin, the NAO reported that the programme had largely failed to deliver on its central objective. Eventually, after the 2010 general election, the Coalition Government killed off the NHS National Programme.
To be fair to the hundreds of professionals in the National Programme over the years, there were some strands of the project that were completed and eventually gained an enduring place in the NHS. These included ‘Choose and Book’, which allowed patients to select a hospital outpatient appointment from a range of options while sitting with their GP, and ‘National Spine’, a messaging service which allowed authorised users to access a high-level summary of patient records. But the electronic patient record systems at the heart of the programme were a complete failure, which cost years of potential improvement across the NHS.
Overall, the National Programme had been a disaster. The project is a tragic case-study of how not to manage IT enabled change. You start with blindly ambitious but inexact requirements and proceed through commercially naive contracts with impossible timeframes. The results are entirely predictable. The National Programme was swamped by technical and delivery complexity. The systems’ end-users were kept as far away from involvement as possible. Lengthening timelines were met by refusal to acknowledge reality and the project ploughed on until it finally suffered the huskies’ fate that Granger had predicted for some of the IT companies.
The years lost during the failed NHS National Programme have seriously retarded the digital transformation of health provision in England. Twenty-two years after the programme was conceived, a new Health Secretary, Wes Streeting, asked surgeon, academic and peer Lord Darzi to diagnose the ills of the NHS. Amongst many other criticisms Darzi took aim at the NHS’s failure to embrace digital technologies.
“The NHS, in common with most health systems, continues to struggle to fully realise the benefits of information technology. It always seems to add to the workload of clinicians rather than releasing more time to care by simplifying the inevitable administrative tasks that arise. The extraordinary richness of NHS datasets is largely untapped either in clinical care, service planning, or research.”
This is an edited extract from The Delivery Gap: Why Government Projects Really Fail and What Can Be Done About It (Emerald Publishing, £19.99).
Recent Comments