The publishing of Gateway reviews for the £12.7bn NHS National Programme for IT has revealed that many of the criticisms now leveled at the project have been concerns from the start.

The 31 Gateway reviews released last week cover all parts of the programme including e-prescriptions, e-booking and the N3 broadband network, but most of the focus will be on the implementation of the care records system (CRS) because of its status as the most delayed and controversial part of the project.

The first Gateway review in October 2002 found widespread support for the idea of electronic patient records across the NHS, though there were concerns about the method of implementation.

The review highlighted the importance of “an education campaign to enable the full range of NHS staff, especially clinicians and senior management, to understand the scheme.”

And the document showed that project staff “detected a nervousness among some of those interviewed that the nature and scale of the requirement is not fully understood by the centre.”

“There is much talk of what the IT programme will achieve, but little recognition of its potential impact on current practices, procedures and systems, both technical and organisational,” said the report.

The Gateway 2.5 review, carried out six months later, echoed concerns that the cultural change required to adapt to the programme was being underestimated.
It said: “Much of the effort so far has been based on a view of this as an IT programme whereas it is really much more to do with fundamental business change. The means to deliver this are now being put in place but are not yet mature.”

That review was the first to express concerns over the aggressive timescale and noted: “There is a difference between driving hard to meet challenging milestones and letting the milestones distort the shape of the project and the quality of its deliverables.”

The document also warned: “There is no formal machinery for gaining clinical input to the programme,” and stressed: “The success of the programme depends on clinical acceptability and the management of change at a local level.”

By this point, the programme had been broken down into a national “spine” and five local regions ­ each run by a supplier. Subsequent reviews began to focus more closely on regional implementations.

A review of the North East six months later noted: “Repeated complaints of a paucity of other communications from the central programme team”.

But a review of the spine implementation around the same time said a programme-wide communication strategy was soon to be under way to highlight the benefits to staff and the public, and showed foresight in stating that “an effective communications strategy will be vital to the avoidance of unhelpful media attention.”

By April 2004, communication and clinical engagement had improved in the Eastern region, though there were still concerns that “only the surface of the challenge of wider NHS stakeholder engagement has been scratched.” The review praised Accenture’s progress ­ but the supplier for the region was later to pull out.

A review of the London region at the same time was more damning and highlighted serious concerns over progress. It said the implementation team had “a highly centralised approach that focuses on delivering its outputs rather than the needs of the trusts in preparing for implementing” ­ a longstanding criticism of the whole programme.

A review of the North West region at that time documented an over-focus on IT, rather than “developing business processes that make best use of the coming technology”, and again cited clinical involvement as lacking. A simultaneous review of the Southern region said this problem was common to all regions.

By the time of the final reviews in June/July 2005, serious cracks were starting to appear and the lack of engagement with NHS staff had been exacerbated by late delivery from struggling suppliers which underestimated the scale of the challenge ­ only serving to further alienate clinicians.

The review for London said that: “Repeated slippage of milestones and the failure to deliver a core CRS product have resulted in significant tensions and losses in confidence and trust between… the NHS and the suppliers.”

And it seemed the consistent warnings to persuade staff of the benefits of care records had been ignored with serious consequences.

“We have seen little to suggest the Cluster or the NHS are giving thought to the benefits of the successful implementation of a care records product,” said the final report.