Geoffrey Sampson

Whistleblowing for Health

This account of an episode which happened in April 2006, when I was one of 23 signatories to an Open Letter urging reconsideration of the world’s largest-ever civil computing project, was written shortly after publication of the Open Letter. Postscripts bring the story up to date as far as early 2010, at which point it seems appropriate to draw a line under it.

I became interested in the project when one of my MSc students, a G.P. in off-campus life, wrote a dissertation about it in 2005. I know from the surveys he carried out that there is unease in his profession about how the system will work, if it does work; many doctors fear that it threatens patient confidentiality, for instance. Issues like that lie outside my professional expertise. But there are also doubts about whether the system will succeed in executing its intended functions, and that is an informatics rather than a medical issue.

Government has a bad record of bringing software projects to a successful conclusion. In the health field we remember the London Ambulance Service debacle of the 1990s, which involved a far smaller-scale system. And, to a computer scientist, a culture of secrecy rings alarm bells. Companies which studiously maintain commercial confidentiality about other aspects of their operations tend nowadays to realize that the best hope of getting value out of their investments in software is to lay their cards openly on the table wherever possible.

There is no mystery about why government and computing mix badly: the two domains are founded on contrary assumptions. In the government world, it is a given that sufficient authority will elicit any desired action: if it is not appropriate to say “I am Lord High Pooh-Bah and I say you must do this”, then “There could be a peerage in it” will probably do the trick. In the world of informatics, authority is impotent. Bring as much pressure as you like to bear on a flawed software system, and what you get will be a worse-flawed system. (That is one reason why we insist that computing students learn to program. Many of them will go into jobs where they never write a line of code; but anyone working in our industry needs a feeling for the intractable nature of the industry’s basic resource, and only personal experience can create that awareness.) The Department of Health has been bullish about Connecting for Health remaining on track despite hiccoughs, but the reasons quoted for optimism seemed inadequate.

Connecting for Health is too big for failure to be accepted as just one of those things. Under contracts signed to date it is projected to cost £6.2bn, about £1bn of which has been spent so far – even by public-sector standards this is a great deal of money, and completing the project will undoubtedly require further expensive contracts. More important, success or failure of the project will affect the welfare of almost every citizen, and will surely mean the difference between life and death for some. So when a number of British computing academics decided to write an open letter to the House of Commons Health Select Committee, calling for a technical review of the project, I was glad to add my signature – thinking that this was probably a futile gesture, but the right gesture.

The response, when our letter with 23 signatories was published on 12 April 2006, was astonishing. It received coverage on television and in papers ranging from the Times to the Mirror, and sparked lively discussion in numerous medical and computing magazines. And the tone of the comments, by people knowledgeable about the project but not themselves responsible for its success, was overwhelmingly supportive – nobody seemed to be saying “Your worries are unnecessary, in reality it’s going fine”. The only sour note I spotted was from someone who thought we were only calling for a review because we hoped to get the commission to conduct it. (In fact, early drafts of our letter explicitly ruled ourselves out of the running for this, though we cut that sentence out of the final version for fear of weakening our argument. My personal view is that the best, most independent review would be one carried out by non-Britons.)

The man in overall charge of Connecting for Health, who would end up carrying the can if a review found serious shortcomings, is Richard Granger, Director General of NHS I.T. He responded to news of the open letter by inviting us to a meeting with him and his team. This meeting was prominently publicized in advance by the NHS, which I cynically took as a bit of government spinning to reassure the public that these sceptical professors’ doubts were being suitably allayed by the experts.

I was wrong. Once the Director General understood at the 20 April meeting that we were not querying the goals of Connecting for Health but only its execution, to the very considerable surprise of our side he agreed that an independent review was appropriate; we shall be meeting again to settle methodology and terms of reference. One must remain alert to the possibility that this is a civil-service stratagem to kick awkward publicity into touch, but on the face of it we have achieved exactly what we aimed for. If our initiative causes billions of pounds of public money not to be wasted – still a big if – then I would have to count my small share in the initiative as my best single career achievement.

I take two lessons from this episode. One concerns the role of the academic profession. The worries raised in our open letter included nothing that has not been raised by other individuals and organizations over many months past, yet suddenly when these things were said by 23 “academic heavyweights” (as one paper called us) the country sat up and listened. Looking at what has happened to our salaries and conditions of work over the last twenty years, it would be easy to conclude that Britain has written off its academics as a waste of space; evidently, whatever our paymasters think of us, for society as a whole we still count for something.

The other lesson is about the power of individuals. In a period of spin, image-based politics, and supranational government, individuals can seem nowadays to be puppets powerless to influence what happens in public life. Not true. If the country makes a mistake, individual initiative is the only way to put it right. So get stuck in: it still works.

Postscript, written over the period August–December 2006:

In the months since I wrote the above, I have learned much that I did not know before about Connecting for Health, and many new things have happened with respect to it. (Among other things its total cost, which was being quoted at about £6 billion in April, is now being quoted as £12 billion.) Looking back, I feel I was naïve in the optimism I expressed at Easter. The technical review which the Director General seemed then to accept as valuable has not occurred. It has become difficult to avoid the conclusion that Connecting for Health is an eleven-figure white elephant which is already seriously damaging the ability of the NHS to carry out its day-to-day functions (by diverting large proportions of NHS budgets to itself), but which has no real chance of ever delivering its intended benefits. Indeed, it will do worse than fail to deliver. It is eliminating successful small-scale/local health I.T. systems, in order to replace them with grandiose national systems that will never work – though many people’s welfare will be damaged, and probably some will die, because the medical profession is forced to try to make it work. By late 2006, I sense that many relevant participants in public life are coming to agree with this assessment – but that in itself won’t help, unless Government can be persuaded to put the juggernaut into reverse.

Our group of 23 Open Letter signatories have continued to draw attention to the problems and dangers; among other things, we have assembled a large dossier of factual information from numerous sources, most of which has been made publicly available online – our “NHS 23” website featured in the Guardian’s list of the 100 most useful sites in December 2006.

One fascinating sidelight was reported in the national press on 12 November: the mother of the Director General Richard Granger, reputedly Britain’s highest-paid civil servant, announced that she “can’t believe that my son is running the IT modernization programme for the whole of the NHS”, pointing out that he had failed his computer studies course at Bristol University (though he later managed to gain a mediocre degree in geology, after she had appealed to the University Visitor on his behalf for him to be allowed to re-sit). You really couldn’t make this up. It is laughable – but very depressing. Computing teachers endeavour to instil in their students lessons which the profession has learned the hard way over the years about what works, in software development, and what does not. It is crucial, for instance, that projects must engage from an early stage in intensive consultation with potential users, so that the details of their working practices can inform software design rather than the software enforcing changes on the users. With Connecting for Health, story after story coming in from the medics who are beginning to be told to use pieces of the new system imply that this kind of consultation was never adequately done. For instance, a consultant physician responsible for I.T. within his hospital group reported in October 2006 on an NPfIT Clinical Records Software system:

As soon as the contract for NPfIT was awarded in our cluster, I was immediately in contact with the supplier, asking for systems analysts to come and spend weeks and months with me in the workplace, so that they could learn how clinicians work. … In the 18 months of the project only one supplier employee came on one ward round for one morning …

A few months ago I had my first glimpse of the system and asked how it would work in outpatients? The supplier’s consultant asked in an American accent “What is outpatients?”

Perhaps, if Richard Granger had been a more successful student at Bristol, billions of pounds of public funds would not now have been squandered on a system which any competent computing teacher should have been able to predict as a failure.

For a well-informed, succinct analysis of the problems with Connecting for Health, as well as of other aspects of the current culture of government partnership with private-sector consultants, I warmly recommend a book which has come out since we took the initiative I describe above: David Craig, Plundering the Public Sector: How New Labour are letting consultants run off with £70 billion of our money (Constable). Reading Craig, one wonders how on Earth we British could possibly have allowed our public life to become so corrupt; but I believe Craig’s account is in fact realistic. He comments,

Instead of improving public services as part of an enlightened social democratic vision, New Labour have allowed them to be desecrated by profit-seeking private-sector companies to an extent that even the most rabid Tory free-marketeers would not have imagined possible.

Post-postscript, written February–March 2007:

A couple of months later, I begin to think that after all we are prevailing. A front page story in the Daily Telegraph for 13 Feb 2007 is headlined “£20bn NHS computer system ‘doomed to fail’”. ( – Another eight billion already? Six billion here, eight billion there, pretty soon we’ll be talking real money … ) It reports on a conference on implementation of the CfH programme held the previous week, where a responsible representative of one of the main I.T. suppliers himself acknowledged that it was heading for collapse. (The Telegraph story is based on a fuller report in Computer Weekly for the same date.)

Andrew Rollerson is “healthcare consultancy practice lead” at Fujitsu, the company which has an £896 million contract to deliver CfH systems for the South of England. Among other things, Rollerson said “What we are trying to do is run an enormous programme with the techniques that we are absolutely familiar with for running small projects. And it isn’t working. And it isn’t going to work.” Precisely so.

When the Telegraph checked their story with Fujitsu, Fujitsu said that Mr Rollerson “was not directly involved in the NHS contract and was not a senior executive … the contents of his [presentation] slides ‘may have been ill-considered’ but [Fujitsu] insisted that his quotes had been taken out of context and that he supported the programme.” Well of course, we all support the programme in the sense that we would like to see the NHS make successful use of I.T. to achieve its goals better and more efficiently; but the CfH project is not the way that that is going to happen.

(Interestingly, although the quotation I have just given, in which an unnamed Fujitsu spokesman plays down the significance of Andrew Rollerson’s talk, appeared in the story as printed in the copy of the Daily Telegraph delivered to my house on the morning of 13 February, when I looked at the online version of the story on the Telegraph website that afternoon, this passage was missing. I cannot guess what was going on there. The Telegraph believes that Mr Rollerson is a “top executive”; they described him as such both in the printed newspaper in the morning and in the online version later in the day. Already two years ago Mr Rollerson was being billed as Fujitsu’s Head of Change Management: that sounds like a senior executive to me.)

I don’t know who at Fujitsu the Telegraph spoke to, but Computer Weekly spoke to its NHS account director, Ian Lamb, who said “This is a significant misrepresentation of a presentation made in support of the National Programme. We refute any inference that has been drawn to the effect that Fujitsu in any way questions the success of the National Programme.” In other words, a man responsible for technology is saying “this isn’t going to work”, and a man responsible for company profitability is saying “he doesn’t mean that, of course it’s going to work”. In a case like that I think most third parties know who to believe. For the Times on the same day, Rollerson’s talk triggered a leader on Connecting for Health: “The question that ministers must face now, however much pride has to be swallowed in the process, is whether the grandiose vision of one standardised system for the entire NHS is the right one, and whether it is achievable.”

The online medical-informatics newsletter E-Health Insider commented on 15 February that Mr Rollerson’s “public warning echoes concerns that key suppliers have repeatedly acknowledged … in private, about how intense pressure to deliver [is leading to] known problems being let through, a focus on targets and payments rather than quality.” According to the newsletter, some in the industry saw his comments as a “welcome breath of fresh air, providing a necessary and honest account of the state of the NPfIT programme.” It also reported a claim that the Health Secretary has now been ordered by the Prime Minister to explain how the project has gone wrong.

It must have been brave of Mr Rollerson to speak so directly against the interests of his employer. One can only feel considerable gratitude for his frankness. (On 8 March it was reported that Fujitsu have suspended Mr Rollerson in advance of possible disciplinary action.)

Even now, I do not imagine that Government will straightforwardly say “CfH was a mistake, we are pulling the plug”. They have invested a lot of political capital in the programme, and governments hate admitting mistakes even when they are on a smaller scale than this. But it is now beginning to seem likely that Government and senior NHS management between them will quietly but radically redefine and scale down what CfH is supposed to deliver, so that some worthwhile things come out of the programme for a far lower cost. – And indeed, by mid-March it appears that this is now beginning to happen. The Health Service Journal for 15 March 2007 reported that

there is now a sense that the programme is coming to an end, and that the agency which runs it, Connecting for Health, will evolve into a standards-setting and infrastructure body … These changes will be welcomed as they are in line with those demanded by the NHS 23 group of academics …

Let’s just hope that this apparent change of heart has occurred in time to avoid too much damage being done to existing NHS systems.

PPPS, written May 2008:

A year after Fujitsu, one of the three main suppliers for the CfH system, rubbished their own executive Andrew Rollerson for predicting that the system would never work, they have now effectively admitted that he was right by pulling out of their NHS contract unilaterally (at very considerable cost to themselves, I believe). The Daily Telegraph of 29 May 2008 reported that Fujitsu had withdrawn from negotiations with the NHS “as it did not feel there was any prospect of an acceptable conclusion”. (I do not know what has become of Mr Rollerson.)

Over the past eighteen months or so, this and many other events have made it abundantly clear that our “Group of 23” was thoroughly justified in writing our 2006 open letter to the Health Select Committee. (It would be tedious to summarize everything that has happened here, but full details continue to be placed on the NHS 23 site by our indefatigable webmaster Brian Randell of Newcastle University.) Government continues to make noises suggesting that the problems CfH has encountered are no more than teething difficulties, but I am not sure that its spokesmen themselves believe that any more. Unfortunately, now that the NHS has waded partway into this morass, it is not obvious what its best path forward will be – it is too late now simply to revert back to the pre-CfH situation and start in a new direction from scratch. We can only hope that further NHS computerization happens in a not too counterproductive manner, and that not too much more public money is wasted.

Closing remarks, August 2009–March 2010:

In August 2009, an “NHS and Social Care IT Review” was published by a group that had been commissioned a year earlier by the opposition Conservative Party to carry out an independent review of the CfH project. The review group was chaired by Glyn Hayes, previously chairman of the British Computer Society’s Health Informatics Forum and president of the U.K. Council for Health Informatics Professionals (and a Worcester G.P. for 25 years of his earlier career).

In summary, the 186-page Hayes Review confirmed what we were saying in 2006: a top-down, centralized system cannot hope to achieve the aims set for NHS I.T. Interviewed by the BBC, Glyn Hayes said “The review makes clear that NHS I.T. will only succeed in improving patient care if information is held locally and centred on the patient.” The Conservatives (who at the time seemed virtually certain to be in government in a few months’ time) pledged to “renegotiate the monolithic ‘local service provider contracts’, allowing NHS trusts to pick their own I.T. systems”.

Some have been arguing that the nature of the CfH contracts already entered into by Government mean that little public money could now be saved by scrapping Connecting for Health. If the project is actively harmful to patients’ interests, as by now seems clear, then that might not be a good argument against scrapping it. But in any case, a few days before the Hayes Review was published, “Wat Tyler’s” Burning Our Money blog produced a carefully-reasoned analysis which calculated that pulling the plug on CfH now would save, at a conservative minimum, £1 billion annually for the next five years. Even by public-spending standards, that is money worth saving.

A spokesman for the health ministry dismissed the Hayes Review – in advance, before it was published. But then, in late 2009 our Government are dead men walking. Whether their Conservative successors will be an overall improvement is a very open question; but on this particular issue (provided they keep their promises) they evidently will be.

By early 2010, with weeks remaining to the General Election, the Labour Government is still trying to preserve the fiction that CfH remains a live enterprise, simply because publicly acknowledging its failure would be a large vote-loser. But intelligent observers are no longer taken in. Quoting the (left-leaning, therefore relatively Labour-friendly) Guardian of 21 March 2010:

The government’s ailing £12.7bn IT programme to overhaul paper-based NHS patient records in England is close to imploding, potentially triggering a deluge of legal claims against the taxpayer running into billions of pounds … the Department of Health … is locked in frantic contract renegotiations with contractors to keep the project alive … As the National Programme moves into its seventh year, the Department of Health and regional contractors are trying to thrash out a back-room compromise over how to apportion the bill for an army of IT workers who have failed to deliver … The government has offered to slash the functionality requirements …

Geoffrey Sampson

last changed 22 Mar 2010