MR RICHARD GRANGER, MR HARRY CAYTON AND DR GILLIAN BRAUNOLD

26 APRIL 2007

  Q40  Jim Dowd: Also the Patient Administration Systems have been delayed because they are replacing "legacy" systems. Briefly, can you tell us what defines a "legacy" system and why was it chosen to do that rather than starting from scratch? This must have been understood at the outset, surely?

  Mr Granger: There were about 180 major systems installed in hospitals in England in 2002 that ran the core administrative functions, and some of those have already been replaced, some of them have been upgraded.

  Q41  Jim Dowd: What is a "legacy" system?

  Mr Granger: A system that was already there in 2002.

  Q42  Jim Dowd: So where it says "an existing legacy system", the "legacy" word is redundant. You mean existing systems?

  Mr Granger: Yes. You have my apologies for the tautology in the drafting.

  Q43  Jim Dowd: Why was it not decided to start with these systems from scratch?

  Mr Granger: Because there is a vast quantity of data on the existing systems and hundreds of thousands of people trained to use them, and we cannot simply turn them off overnight and wait whilst suppliers develop new ones. The act of replacement, as I described a few minutes ago, is a complex process that, in a hospital setting, you typically have to do over a weekend, and you cannot do the whole of the country in a weekend, or you would be very naive if you tried. It is a gradual process. It is taking us longer than was envisaged in spring 2002, the suppliers have found it more difficult, the data quality is poorer than we thought it would be and it is a difficult job, unlike, for example, putting in picture archiving systems, which was not in the plan in 2002, which we have made excellent progress in and are running to schedule.

  Q44  Jim Dowd: That leads me to my concluding question. We have received a number of submissions, one of which says that "for the first three years of the programme, NPfIT was driven in an environment of ignorance of the true NHS environment". Is that why delivery of the new systems has slipped so far behind schedule? Do you respond to that as an accurate assessment of the position before you had any responsibility for it?

  Mr Granger: I do not know whether that is evidence you have received from an individual who has been personally disadvantaged by the programme so much or what the perspective is. The fact that we had an awful lot of staff who had 10, 20, in some cases more than 20, years' experience of working in IT in the NHS, working at the core of the programme, using materials that they had developed over that period, I think is a statement which does them a great disservice. I do not recognise that environment at all.

  Q45  Jim Dowd: What are the main causes then for the delays, if it was not the fact that the whole thing was far more complicated than was envisaged in 2002 and that the expertise and the assessments of 2002 were fundamentally optimistic and inaccurate?

  Mr Granger: Some areas of the programme have got delays, others have not. In terms of the overall 10-year programme that was set out in the contracts we have put in place in 2003-04, we will get most of that work done during that 10-year envelope. I have talked about the fact some aspects are more complicated, others have been quite straightforward. To have gone from an NHS which only had about 10,000 places connected up to the Internet in 2003 to the delivery of a 19,000 end-point network which is backed up everywhere with secondary circuits three months ahead of schedule is not late and is a greater scope than was originally envisaged. To have completed at the end of March the roll-out of picture archiving across the whole of the south of England and London, which was not in the original work programme, is not late; it must, by definition, be early.

  Q46  Jim Dowd: One last point, Chairman, and I accept your exhortation about moving on rapidly. When you say it has got more functionality than originally envisaged, is that because the original estimates were just wrong?

  Mr Granger: I do not know of a large-scale IT enabled transformation programme in a complex organisation that from its starting point to its mid point has a direct correlation. I think it would be a fantasy to imagine. I know people write fantasies, but in the real world it would be ridiculous to imagine that halfway through a ten-year programme you would only be doing the same things as you set out five years ago. I will give you some examples in addition to the digital imaging. Putting in a new secondary uses service, putting in an email service, putting in the standards for GP to GP record transfer, putting in a new payment system for GPs, taking the atrocious batch legacy number systems that the NHS was reliant on and putting in fresh, modern on-line databases, putting in bowel cancer screening systems, none of those was envisaged in 2002.

  Q47  Jim Dowd: The electronic X-ray storage was?

  Mr Granger: No, it was not. It was not in the strategy document in 2002.

  Jim Dowd: Okay, we will come back to that.

  Q48  SANDRA GIDLEY: You have been very bullish about the fact that extra things have been added since the introduction of the system, but you have played down rather what has been delayed. Do you accept that the electronic record system has been delayed?

  Mr Granger: Some aspects of it have been delayed by 24 months.

  Q49  SANDRA GIDLEY: Is that because of taking on extra tasks or is there another reason?

  Mr Granger: The consultation process has been far longer than was originally scheduled, because the work that had been done in 2000 to 2002 by way of preparation required significantly further work. I will not say it was defective, but the work that my colleagues have done around patient consultation and consultation with the professionals who are using the system created an environment in which the specification that was drafted up in 2002 had to evolve, and until the specification was stable it would have been inappropriate to have got on with finalising the software because it would have had to have been reworked at a cost to the taxpayer, to strike a balance between consultation, a ministerial taskforce, professional involvement and rework work that had been undertaken by Anthony Nolan, in particular, through in 2002.

  Dr Braunold: I think it may be worth explaining a little bit more that some of the work that Dr Taylor was referring to earlier about how are we going to get to where we are going to in terms of the picture on the lid of the jigsaw puzzle, that consensus building about how it would work—engaging with clinicians and making sure that they, as people who are going to be using the system, has taken time to engage with clinicians and gain consensus about prioritising what will come around the consent model which has taken a very long time—has been very difficult to move forward on content and design in some areas when you are still having discussions about the consent model.

  Q50  SANDRA GIDLEY: You have both talked about engaging clinicians. I found it quite interesting to note that the Royal College of GPs, NHS Alliance, the Royal College of Surgeons, the Royal College of Nursing, the British Medical Association, amongst others, all in their submissions to us mentioned that there had not been sufficient engagement with clinicians and with patient groups. A number of patient groups commented in the same way. Is this a bit after the event that we are talking?

  Dr Braunold: I am the fourth attempt at clinical engagement. That is the tier that I am: the National Clinical Lead.

  Q51  SANDRA GIDLEY: You are "the fourth attempt". What does that mean?

  Dr Braunold: I will explain that. There were other clinical engagement efforts that happened before the National Clinical Lead's appointment, three previous ones, and the National Clinical Lead's appointment was praised in the report from the Public Accounts Committee and the National Audit Office in terms of starting to make real efforts and quality improvements in the clinical engagement with the community. We were sponsored by the BMA and the Royal Colleges as jointly owned individuals who were accountable back to those bodies and as named individuals that they would be prepared to work with who were sponsored into the programme.

  Q52  SANDRA GIDLEY: How long have you been involved?

  Dr Braunold: Two and a half years. I was nominated by the BMA. I was nominated by the General Practitioners Committee. My job-share, Professor Mike Pringle, was nominated by the Royal College of GPs, and we two together work as clinical champions from the general practitioner community with a track record with GPs, who are accountable back to the profession, for making sure that systems are built that are fit for purpose from a GP perspective, and it is our responsibility to do an ambassadorial role for the National Programme from a General Practice perspective. There are equivalent roles. We have hospital doctor colleagues, Dr Simon Eccles and Mr Ian Scott, and we have Jan Laidlow from the Allied Health Professionals and we have our nursing colleagues. We have done quite a lot—I think it is an enormous amount—in terms of setting up advisory groups and interfaces with our colleagues and making sure that they are involved at every stage in every important programme. There is a National Clinical Reference Panel for the Summary Care Record for which every one of those colleges has been asked to nominate people who are able to make sure that the Summary Care Record has the right advice about what should be in it and what should be not in it and that it fulfils the criteria for the Care Record Guarantee, and that has all been slowing things down, frankly, from the original intention because we wanted to make sure that it had proper clinical sign off, and that tension is evident.

  Q53  SANDRA GIDLEY: But that is only the last two and a half years. What engagement was there in the first three years?

  Mr Cayton: Could I come in here. The Care Record Development Board took over from two committees, one of which was called the National Clinical Advisory Board, on which every single one of those bodies was represented, and that existed well before I became involved in the programme. So, if that group, which consisted of the Royal Colleges and their colleagues, was not delivering four years ago, that is actually the responsibility of the clinicians who lead those colleges. I have had innumerable meetings with Royal Colleges and with the Pharmaceutical Society, and so on, over the last three years. I have had very positive relationships with them. I have actually found them extremely constructive in practice, and I think we are just in one of those situations where what people say in public (because it is a posture to take), "We have not been adequately consulted", is not the same as what is happening in practice. We have had patient organisations involved throughout. Only last week we had an open session in which we had over 30 patient organisations taking part, the Care Record Development Board has an annual conference which is open to the public, and to the press, and to clinicians, and we have had over 100 patient organisations and certainly over 350 people attending those conferences every year. We have actually done a great deal to try and engage with clinicians at all levels, and certainly, since my involvement, I have been personally entirely committed to that process.

  Q54  SANDRA GIDLEY: How long have you been involved?

  Mr Cayton: The Care Record Development Board was set up three years ago.

  Mr Granger: It is undoubtedly the case that we could always do more in this space. It is undoubtedly the case that the concept of professional consensus about some of these issues is challenging. Generally, when you put disparate professionals together on some of these issues, you do not get agreement, you get at least one opinion per person.

  Q55  SANDRA GIDLEY: That is within a profession?

  Mr Granger: Yes, a medical consensus is undoubtedly oxymoronic, but if you look, for example, at your profession, would you like us to wait until the pharmacists and the GPs agree on how much data would be visible in dispensaries, or would you like us to get on and roll out electronic prescriptions with the benefit that that delivers? We have those challenges across the whole programme because the tribal nature of clinical practice means that these different groups all take different positions and different postures, and we have tried to strike a balance around achieving progress rather than just wait for everybody to agree. I suspect we would be waiting an awful long time.

  Q56  SANDRA GIDLEY: I gather the prescriptions are problematic as well, but we are not here to discuss that. We can probe this further with those groups themselves. My final question at the moment: why has so much effort been diverted into Choose and Book rather than into the detailed clinical systems that actually support patient choice?

  Mr Granger: I will ask Gillian to come in in a moment on this. If you look at the strategy document from 2002, you will see Choose and Book did not exist. What you will see is electronic booking. One of the many areas where we got additional work was the delivery of choice, and electronic booking was quite a straightforward proposition which had been extensively piloted, which was about packaging up a referral and sending it electronically. The delivery of an on-line booking system that produces a confirmed appointment connecting up the best part of 10,000 locations with an on-line processing system is something that is far more complicated. So, the task got more complicated with the announcement of choice. It is a government priority and it has been first out of the gate in terms of putting on-line connectivity into GP practices, and it is dependent upon a lot of different moving parts, all working at the same time, only some of which are controlled from the National IT Control Centre in Leeds. I can vouch for the network, I can vouch for the Choose and Book system—I know when that goes down. I run some of the PAS systems already, I only run some of the GP systems. All those bits all have to work in order to complete the transaction. Gillian, you are a user of Choose and Book.

  Dr Braunold: I am, and I think that some of the issues are that Choose and Book, being the first out of the stable, have had to take the pain of connecting to the Spine. So, the first thing that people know of is their smartcard. I have heard so many GPs and colleagues around the country call it their Choose and Book card, because they think that this is only to do with Choose and Book and they do not think it has anything to do with the rest of what is being built, and actually it is their key, as guardians of NHS care records, of their patients' data. It is far more important than Choose and Book, but it is just that that is the first out of the stable. It is also, of course, informed around whether there were speed problems, problems with your network or, more likely (which we found to be the case), sometimes it is actually the configuration of the computers at the end-user end, which does not change the experience of the person at the end, although it is taking a long time for it to work, and complaining about Choose and Book when actually you need to do some further diagnosis about what is going on under the bonnet. Choose and Book has had to take a lot of pain, but an enormous amount of the issues for me have been around performance managing the take-up of IT. Speaking as a GP here, and I do not have anything to do with the delivery of Choose and Book from the Department of Health perspective, I personally believe that targets are not the way to get people to use information technology. The NHS is commissioning tools that it expects people to use, and it expects people to use them if they derive a benefit, and I know that clinicians will use tools and use them to greater effect when they see them being beneficial. As you start to find a better use of service delivery because you have got a tool, it spreads like wild fire and people use it more and more, but they need to have time to grow into using those things. I actually believe that the rest of the service which we have protected from having any kind of targets, like the Summary Care Record, and letting PCTs go at their own pace when their GPs and PCTs feel ready to go with the Summary Care Records, is a really important part of how that is going to go forward and grow with confidence, and when people are ready to go they will try it out. I have no doubt that the value of a coded record on the summary, as people see suddenly they have got access to care pathways because they can click on the code, will have GPs and patients crying out for the Summary Care Record faster than we can deliver it.

  Q57  Chairman: We did discuss the issue about the content of the Detailed Care Record when we were having the earlier exchanges. What do you say to people who say that the main plank of that—the PAS hospital system being developed by Lorenzo, Millennium—is not going to be providing what they were originally providing. Is that because it is a moving picture? This is an accusation that has been put to us and I put it to you to answer.

  Mr Granger: I think the problems are different. The Millennium product from the Cerner Corporation is a very rich system, as I say, in use by a third of hospitals across the US. There are two issues with that. One is the Anglicisation of it so it does things the way we do things here, where we want to, and in some cases we may want to do things differently, so that is a problem with that product. Can we change it as much as we need to and can we take the good things from it, which we currently do not do? That is a kind of process redesign issue. The Lorenzo system is a new build system. What has in fact happened for the first time under the national programme on Saturday morning in Ipswich was that the latest upgraded version of the old product was implemented with quite a lot more clinical functionality, but the core problem we have with Lorenzo is building a new system, a task which is estimated to cost around £250 million and is taking longer than the prime contractors that brought that to us (Accenture and CSC) estimated and has caused the company doing it (iSoft) significant difficulty. In the meantime, we have been getting on putting in systems which deliver immediate benefit and are a transitional step, and with that system we have a problem of getting sufficiently rich functionality developed, but we do not have a problem with Anglicisation because its heritage is in the UK. These were not unforeseen problems, which is why, unlike a lot of other major procurements, and not just in the public sector, we did not just go with one solution. We did not go with a plethora of solutions because of the cost and inefficiency of that, we went with a couple of solutions. It is also why we deliberately did not contract with the suppliers of those systems, because they failed financial viability and scale tests that we set as part of the procurement, and, again, you can see with the passage of four years the accuracy of the procurement approach, which we published in January 2003, and what has actually happened by spring 2007. It will continue to be difficult and, of course, if it was easy from the late eighties when the other major paper factories of civil administration in this country got computerised, it would have already been done. The reason health is being done last is because it is most difficult. Building the software to satisfy a highly educated end-user group who often have quite difficult circumstances around balancing time between accessing data, entering data and dealing with patients creates lots and lots of specific problems.

  Chairman: Thank you for that. We are going to move on now to one or two questions about patient consent.

  Q58  MR JACKSON: In the pilot of the Summary Care Record, there is an assumption that patients have consented to having their data uploaded into the new system if they do not specifically opt out within a certain period. Is this approach consistent with patients having more control and ownership over their personal data? Can I just say that in evidence we have recently received the point has been made, "We are very concerned that Connecting for Health's insistence that section ten of the Data Protection Act 1998 should remain the exit justification for patients who do not want a Summary Care Record. We believe this is counter to Lord Warner's verbal assurances and also all ethical, professional, moral and legal principles." What is your response to that?

  Mr Cayton: It is an awful lot of moral, legal and ethical principles to be against at the same time, and my first statement is I try to be in favour of most legal, ethical and moral principles.

  Q59  Jim Dowd: But you are not dogmatic!

  Mr Cayton: Let me start off by trying to outline the position that was taken by the ministerial taskforce, because that is the position that we are currently in, and also by clarifying, I hope, what Lord Warner said when he announced that the department was accepting the recommendations of the taskforce. The fundamental debate (and it is an entirely legitimate debate, and I do not think any of us have ever suggested that we take this in a trivial or light way) is a debate between the utility of having a system where informed consent is required explicitly from every person and a system where it is clear that consent is implied and informed consent is a matter of choosing not to take part. We debated that quite robustly in the taskforce, and it is quite clear from experience in other countries and in other systems that if you have an informed consent to be part of the system, then large sections of society, particularly some of the most vulnerable people in society, do not take part. They do not take part because they do not know how to give informed consent, they do not take part because they do not understand what is being asked or offered and they do not take part because of physical immobility—so older people, some of the frail people living at home in the community who might be most likely to benefit. So, there is that issue that arises, an equity issue, and you have to start by believing this is a good thing, which clearly we do. So, there is an equity issue. Are we going to deny the good thing to a large group of patients in the population and, secondly, there is a practical issue for doctors and GPs in particular. We did a sort of back-of-the-envelope calculation, which I am sure we could try to do more accurately if you wanted, and we worked out it would take 100 years of GP time to go through the consent process for every single patient in the country. We were not sure that was ethically a good use of people's time. We came to the agreement (and this was an agreement absolutely with everyone on the taskforce) that the model that we had adopted which said we will inform people very carefully about what is being done, we will give them every opportunity to choose not to take part if they wish to, was the most practical, ethical and appropriate way forward. Clearly there can continue to be a debate about that, but that is the position the taskforce took, including the BMA and the Society for Emergency Medicine and the patient organisations who were there. The recommendation that we should do that and that we should allow people who did not want to have a record to have a number of different positions that they could take: one is to have a shared record but not allow anyone to see it—so to have it uploaded but locked down so that at some stage in the future, should they change their mind, they might be able to unlock it—or not to have any data uploaded to the system at all. The issue that I think your evidence raises around section ten of the Data Protection Act is that we believe that the processing of data in the NHS is actually a requirement for the proper functioning of the NHS. So, for that reason, in order to secure the proper functioning of the NHS under the Data Protection Act, we merely require people to sign a form saying that they understand the consequences and the choices that they are making when they opt out from the system. It is not intended to be in any way a sort of Draconian system, it is not intended to ask anyone to prove anything under section ten, it is merely in order to secure the legality under the Data Protection Act of processing data.