Plundering The Public Sector

From Nhs It Info

How New Labour are letting consultants run off with £70 billion of our money

David Craig

with Richard Brooks of Private Eye

© 2006, Constable LONDON

ISBN-13: 978-1-84529-374-1

[Extracts provided here with the author's and publisher's permission.]

CHAPTER 10

Welcome to Connecting for Health

We’ve seen some impressively big projects, each costing many hundreds of millions of pounds, each wasting hundreds of millions more and most failing to deliver anything like the levels of service that were originally promised. But nothing can compare with the NHS IT systems programme that has been going on since October 2002. Previously called the National Programme for Information Technology (NPfIT) this has been renamed Connecting for Health (CfH).

A successful CfH would have an immensely beneficial effect on healthcare in Britain. It would provide comprehensive, up-to-date and immediately accessible medical information on all patients, thus dramatically improving doctors’ ability to diagnose and treat them. It would contribute to drastically reducing the annual 980,000 ‘patient safety incidents’ and 2,000 deaths from medical and prescription errors. It would free up time for clinicians to spend looking after patients instead of looking for medical records. It would greatly reduce bean counting, administration and paperwork by hundreds of millions of pounds per year, which could then be channelled into patient care. And it would automatically provide a wealth of healthcare information to target and measure the progress of performance improvement initiatives and to assist future healthcare planning. Conversely, in terms of cost, scope, potential for wasting money and potential for having a catastrophic effect on the NHS, which is probably our most critical public service, CfH far surpasses any previous New Labour scheme for modernizing the delivery of public services. It is almost a hundred times larger than most other New Labour projects. So if it goes wrong, with the all too depressingly familiar sight of budgets and timescales spiralling hopelessly out of control, our government will have caused the largest haemorrhage of taxpayers’ money from essential front-line services into the pockets of management and IT systems consultants in British history.

Connecting for Health: a Brief Guide

Between 1998 and 2002, a series of studies and reports identified the need for the NHS to drastically improve its use of IT systems. Perhaps the most significant was the April 2002 Wanless Report. It compared the inadequate use of IT in the NHS with the ‘improvements in performance and efficiencies gained from new technology seen in other spheres of industry and in other health services’. It recommended ‘an increase in IT investment; stringent centrally managed standards for data and IT; and better management of IT implementation in the NHS, including a national programme’. This led to a document called Delivering the NHS Plan which ‘developed a vision of a service designed around the patient offering more choice of where and when to access treatment’. In June 2002 Delivering 21st Century IT Support for the NHS - a National Strategic Programme set out ‘the first steps including the creation of a Ministerial Taskforce and recruitment of a director general for the National Programme for IT’. In October 2002 the National Programme for Information Technology (NPfIT) was formally established with (ex-Deloitte consultant) Richard Granger’s appointment as the director-general of NHS IT. Its task was ‘to procure, develop and implement modern, integrated IT infrastructure and systems for all NHS organizations in England by 2010’. In June 2004 another document, The NHS Improvement Plan: Putting People at the Heart of Public Services, detailed ‘the priorities for the NHS, including the purpose of NPfIT’. A month later the NHS Information Authority was merged into the NPfIT creating one body for managing IT within the NHS. In April 2005 CfH was established. In addition to supporting existing NHS IT systems, CfH has six main ‘products’ that it plans to deliver. These are:

• NHS Care Records Service (CRS) - building a central database with electronic patient records. This will lead to one unified electronic medical record for each patient to replace today’s inefficient mix of paper and electronic records often duplicating each other and often held in different places.

• Choose and Book (C&B) - an electronic booking system allowing GPs to offer each patient they refer to a hospital a choice of four to five hospitals and enabling them to make the booking immediately on-line. This is intended to replace the current process where patients often get a limited or no choice of hospital, where appointments are made by phone or letter and where the patient seldom gets much choice of a date and time that suits them.

• Electronic Transmission of Prescriptions (ETP) - allows prescriptions to be sent electronically from the prescriber to the dispenser and then to the Prescription Pricing Authority. This will reduce the reliance on paperwork for the over 325 million prescriptions issued each year.

• New National Network (N3) - this will provide IT infrastructure, network services and broadband connectivity to support the systems being implemented as part of CfH.

• Picture Archiving and Communications Systems (PACS) - this system will allow the replacement of film-based radiographic images by electronic images. Digital images will then become part of each patient’s electronic medical record and there will no longer be any need to print on film and to file and distribute images manually.

• General Medical Services Contract, Quality and Outcomes Framework (QOF) - a data collection and management system allowing payment of GPs, analysis of information, targeting of improvement initiatives and measurement of hospital and GP performance.

What Will it Cost Us?

When looking at where the money for CfH will come from, for the sake of simplicity CfH can be divided into two main parts - the smaller of these by far is what the government pays from central funds in order to build up the basic infrastructure and systems. The larger part is what health authorities will have to provide to get the new systems up and working in their areas. The money from health authorities is money that is being taken from their local budgets, thus leaving less for patient care.

The government has already awarded around £6.5bn of contracts to a very small, select group of about seven consultancies - many of whom have placed their people in influential position within government or have been generous contributors to the New Labour cause. This £6.5bn is often quoted in the press as being a lot of money to spend on IT systems. However, it is fairly modest compared to the other associated costs of the programme. So far, we only have a number of estimates for the total cost - the government has never categorically stated precisely how much we will pay for the whole adventure. Most estimates suggest that individual health authorities will have to pay between four and five times the cost of the basic £6.5bn infrastructure - so around another £25bn to £30bn of money that could be used for front-line patient care - to upgrade and adapt their systems for CfH to function. ¹ Management consultants are expecting about £10bn to come their way for ‘change management projects to ensure the successful implementation of NPfIT’.² In addition, in 2003 the head of the NHS predicted huge training costs: ‘there are recent articles indicating that other healthcare systems are investing six times the amount in training that they are in the IT systems themselves, and it will have to be in that sort of order if you take the true costs into account.’³ By the beginning of 2006, the figure of £50bn was being mentioned as the likely total cost of the programme.⁴

The total annual budget of the NHS is around £70bn. So whatever the final cost of CfH, it means that over the next few years a huge amount of money is being taken out of, and will continue to be taken out of, patient care to fund the CfH programme. Assuming about one million employees in the NHS will be affected in some way by the programme, CfH is going to cost over £35,000 per employee - that is really quite a lot of money for management and IT systems consultancy. In fact, with CfH we are seeing consultancy support per health service employee that is almost on the scale of the £45,000 per employee paid to consultants during the catastrophic Child Support Agency programme.

This is already causing some concern and even turmoil at a local level, as health workers see their hard-pressed budgets being diverted from valuable hospital medical consultants to expensive but probably less essential IT systems consultants.⁵ In October 2005, I had a meeting with the IT director of a regional health authority. He was at his wits’ end. He had IT systems consultants from the huge multi-national consultancy that had the CfH Contract for his area crawling all over his department telling him what he had to do to prepare for CfH and continuously coming to him with demands for money to ‘upgrade’ or change his systems and data to make them ‘compatible’ with CfH standards. He was not allowed to see the contracts CfH had agreed with the systems consultants as these were apparently ‘commercially confidential’. So he could not find out whether the consultants’ requests for cash were justified or not. Additionally, he could not find out whether their hourly rates were appropriate, though he personally felt they were exorbitant and much higher than those of the local companies he would normally use. Yet under pressure from the CfH organization, he had to go to his chief executive and get the funds transferred from front-line patient care to pay the IT consultants whenever the consultants asked for more money.

As many hospitals faced funding problems in late 2005, the Health Secretary resisted demands to bailout NHS hospitals that were heavily in the red and avert a winter crisis. As one newspaper reported, ‘dismissing calls for more money, she said, “No - there is more money going into the NHS than ever before.’” She went on to point out that if hospitals were in financial difficulties, it was probably because they were wasting taxpayers’ money: ‘I don’t know whether Marx ever said waste is theft from the working class, but he should have done, because it is. We have asked them to pay higher national insurance contributions. We have got to give them maximum value for money.’⁶ The Health Secretary clearly had no time for poor and wasteful management of public-sector money when she also said, ‘I want to make it clear that inefficiency and poor financial management are not acceptable.’⁷ Although there was no money available to help hospitals avoid closing wards and reducing patient care, the Department of Health did at the same time manage to find almost £100m to offer as financial incentives to various medical professionals who could show that they were using some of CfH’s new IT systems, so that the government could claim that CfH was the stunning success it most clearly was not. In the same month, the Health Secretary also blamed doctors, rather than her own department, for a shortage of flu jabs to protect those who were most at risk.⁸ So there seems to be an emerging pattern of government claiming that we are truly fortunate to have such a wondrously effective department as the Department of Health while asserting that all problems in the health service are due to wasteful hospitals and incompetent doctors. Such political posturing can ring a little hollow to the people on the ground who are experiencing cost-cutting, recruitment freezes, reductions in numbers of beds and corresponding reductions in numbers of operations.

Progress So Far

How is CfH progressing? Actually, it is difficult to say. Firstly, because although CfH issues an impressively shiny Business Plan full of such high-sounding fashionable management gobbledegook as its ‘mission, values and strategy’, the document contains many more photos of happy healthcare workers than figures explaining how much money is being or will be spent. Moreover, although the Business Plan details all the remarkable achievements of CfH, nowhere does it compare these achievements with an original schedule. So we cannot see if they are on target, behind or ahead. Not only is the Business Plan less than informative, but it is also almost impossible to get any information from the CfH organization about what is happening. A cult of secrecy seems to have descended over the project. This got so extreme that journalists from one of Britain’s leading computer publications, which had been critical of the way CfH was being run, were allegedly banned from attending a CfH press conference.⁹ Requests for information on whether the project is going off schedule are met with a stony silence or patronizing denials. Answers to parliamentary questions are also either singularly unenlightening or else consist of reams of figures detailing CfH’s many achievements - reminiscent of Soviet newsreels claiming over-performance against the five-year grain production plan, while most people are going hungry. The suspicions that something truly horrible is happening behind the CfH iron curtain is not helped by the fact that the publication date of the NAO report on the project keeps getting put back. One journalist voiced their doubts about the length of time it was taking to produce the NAO report when they wrote, ‘it is not unknown for government departments to deliberately spin this process out to delay what they perceive to be potentially embarrassing reports.’¹⁰

Most failed IT systems projects (and remember that a study of over 13,500 organizations showed that this is around 73 per cent of all IT projects) go through four well-known and exasperatingly predictable phases. First there is a huge ambition to ‘revolutionize’ and ‘transform’ the working practices of the lucky future system users. CfH certainly gave us that: ‘We will deliver a twenty-first century health service through efficient use of information technology.’ Then there comes pride as the leaders of the great venture mistakenly equate the sight of huge numbers of consultants, being paid huge amounts of money, with making real progress towards delivering a system that meets users’ needs. Again, CfH has demonstrated this: ‘The National Programme for IT has a strong record of achievement. For example, since our inception two years ago, we have mobilized a skilled workforce capable of meeting the challenge.’ By this time tens of millions have usually been spent. Now the project can go two possible ways. Very occasionally, it delivers working prototypes and systems that match the original promises, in which case the worthies in charge are usually only too happy to continually advertise their tremendous achievements to anyone with the time and energy to listen. Alternatively, and much more frequently, endless problems start to surface: it is discovered that the business processes being computerized have not been fully understood; that the complexity of the system has been drastically underestimated; that the hardware is found to be inadequate; that response times are ludicrously slow; that the initial budgets look like pocket money compared to the fortunes that are now being poured into the consultancies’ bank accounts. And those responsible eventually come to the horrible realization that, ‘Oh, shit! We got it wrong. It’s not going to work!’ But by this time so much money has gone up in smoke and so many reputations are on the line, that there can be no turning back. The project is in a hole and in their desperation to try and sort out the mess, everybody just keeps on digging faster rather than pausing to check whether they are actually digging the right kind of hole in the right place. Meanwhile, the tens of millions turn into hundreds of millions as the consultants, who had previously apparently agreed a reasonably fixed price for the work, now start billing the client, in this case the government, by maintaining that every bug and inadequacy they fix is new work for which they need to charge extra. Anxious to avoid a bust-up with their suppliers which would leave them both high and dry and looking particularly inept, the civil servants are trapped and have to keep on handing over millions of our money in the hope that something can be salvaged from the wreckage so that their careers can be protected. This is when the third phase - secrecy - kicks in. Given the iron curtain that seems to have been erected around CfH to prevent anything but the official line leaking out, it’s hardly difficult to guess that inside the monolith all is not light and joy and popping champagne corks.

Close to delivery, things generally change yet again for most of these kinds of projects, and Connecting for Health doesn’t seem to be any different. By the end of 2005, one piece of the system should have been close to delivery - the Choose and Book system for GPs to make hospital appointments for their patients. Planned to cost £65m, this first system has now cost over £200m. In 2004, it managed to make 63 hospital appointments compared to a planned 205,000. In 2005, despite the fact that the Department of Health pulled £95m from front-line care to give to any doctors who used Choose and Book, only about 0.7 per cent of hospital appointments were made using the system and in most cases created extra paperwork that had not been required before. Of course, CfH denied that there were problems with the system, denied Choose and Book was over budget and claimed it was always intended to cost £200m. (It is odd that when the press first reported that Choose and Book would only cost £65m, the CfH press office didn’t correct this apparent ‘inaccuracy’.) In the light of the Health Secretary’s comments about hospitals being in the red due to their own waste and mismanagement, it is interesting to note that the total budget deficit for NHS hospitals in the 2004/5 financial year was around £140m. Coincidentally, this almost exactly matches the current £140m overspend on Choose and Book. Though, of course, as we know from CfH, this £140m was not overspend at all, it was always in the budget. This reminds one of the congenitally incompetent MoD bosses claiming that their £6bn overspend was not ‘overspend’ either, it was just a £6bn ‘level of disappointment’. Let us hope that we do not get similarly huge, or even larger ‘levels of disappointment’ at CfH.

This brings us to the fourth phase of failing or failed IT systems projects - blame. This is when the original budget has been overspent by millions, tens of millions, hundreds of millions or even, as will be the case with CfH, billions. Years after the planned date, either nothing is yet installed or else some sort of system may be working, but it does incomparably less than was originally promised, is tortuously difficult to use and is probably costing more per transaction than the previous, largely manual way of doing things. At this point, those responsible for the system’s implementation blame those who work with it for continually changing their requirements and for not using it properly. Although by November 2005 CfH was far from completion, a rather unsightly public spat had already broken out between the director of the programme and the head of the NHS. Richard Granger reportedly wrote to a senior civil servant at the Department of Health claiming ‘ehoose and Book’s IT build contract is now in grave danger of derailing (not just destabilizing) a £6.2bn programme. Unfortunately, your consistently late requests will not enable us to rescue the missed opportunities and targets.’¹¹ So that’s the predictable bit about changing user requirements being responsible for the cost increases and delays. Additionally, in an interview with a computing magazine, the director of CfH said, ‘Low usage is not something I can do anything about.¹² And there we have the equally predictable criticism of users for not using the marvellous new system that has been developed especially for them.

When a complex public-sector project goes well, those involved are usually seen enthusiastically clapping each other on the back and smiling delightedly for the cameras as they contemplate their forthcoming knighthoods and lucrative positions as highly paid, top level advisers and directors - they are not usually knifing each other in the back by sending accusatory emails in an apparent attempt to shift responsibility for an impending disaster. This altercation could be seen as yet another sign that CfH is decidedly moving into the ‘Oh, shit! It’s not going to work!’ period and is casting around for somewhere convenient to hang the blame, while everyone inside the project struggles to fix the unfixable before the outside world spots the meltdown. Of course, when talking to the press, CfH claim that all is well in the best of all possible worlds. But given the careful control on information from the project, one could suspect that there is an ever widening chasm between what is said by CfH spokespeople in public and what they really believe.

Learning from Past Mistakes?

The NHS and IT systems have not, in the past, been the happiest of bedfellows. There have been two major NHS IT strategies in recent memory. In 1992, the NHS developed a strategy to ‘ensure that information and information technology are managed as the significant resources they are and that they are managed for the benefit of individual patient care as for the population as a whole’.¹³ Despite its lofty intentions, it seems that the 1992 NHS IT plan turned out to be something of a damp squib when words had to be turned into actions. The PAC noted that: ‘Design and implementation of the 1992 NHS IT Strategy demonstrated many of the key failings we have seen on public-sector IT projects generally. In particular: the absence of an overall business case; errors in business cases that were produced for individual programmes; failure to identify interdependencies between programmes leading to a lack of cohesion; and failure to set budgets for the full costs involved. The NHS executive decided not to set specific, measurable, achievable, relevant and time-related objectives for the six main projects and programmes. Neither did they consider how the projects related to one another.’

As part of the ill-fated 1992 plan, a project to standardize IT systems in the Wessex Regional Health Authority was abandoned after about £43m had been spent. A flurry of civil lawsuits and allegations of criminal fraud ensued. The NHS then waited four years before reviewing what had gone wrong, slightly limiting its ability to learn from the unfortunate experience. In 1990 following a severe attack of NIHS (see Chapter 1), the NHS decided that the US clinical coding standards were not suitable for Britain. It then went on to waste about £32m trying to develop its own new electronic language for health. By 1998, the NHS had given up and just adopted the US clinical coding standards after all. And at least £10m was lost when the West Midlands Regional Health Authority supplies division junked their plan to set up an electronic trading system because ‘proper market research was not carried out, suppliers were not consulted, estimates of supplier take-up were significantly overstated, potential customers were not consulted and the royalty projections were unrealistic’.¹⁴

In 1998, the NHS launched a package of new and existing IT projects and service aspirations called Information for Health - An Information Strategy for the Modern NHS 1998-2005. Reviewing the 1998 Strategy, the PAC felt that the NHS had learnt something from previous mistakes, but expressed its concern that, ‘again the NHS chose consciously not to make the objectives specific or fully measurable, leading to a failure to clearly link targets’ to objectives. There is no full business case for the strategy:’ It was also felt that the 1998 Strategy ‘risked a similar lack of cohesion’ to the 1992 plan. Is CfH definitely and expensively heading for the same fate as virtually all other New Labour projects? Or could it still turn out to be a shining example of best practice showing that our Civil Service have, as they repeatedly claim, learnt from past mistakes?

One thing the government seems to have found out from their impressively long list of IT screw-ups is that civil servants are not capable of running major projects. So, in hiring Richard Granger for CfH, the government seems to have made the effort to find someone from the private sector who already had a track record of successfully delivering large, complex projects. As Sir John Pattison, then head of the NHS, said to a House of Lords select committee: ‘What we have done is to secure for ourselves Richard Granger, who is Director-General of NHS IT. He comes from the private sector. He has experience of putting in large computer systems. We can look at the experiences of the Passport Office as one experience; we can look at the experience of what Richard Granger installed for congestion charging in London as another experience; and say that we may well have somebody who is capable of delivering on time and on price something that works.’

Sir John Pattison, who would have retired well before the results of CfH were apparent, for better or for worse, then went on to explain that the new Director-General had been drafted in due to a lack of capability in project management in the public sector: ‘However, if I may just make a personal comment, I cannot exaggerate the value of Richard Granger to this programme, and the likelihood of its success. These are skills and experience which we simply do not, or have not had up till now in the Department of Health and the NHS. We are good, and we have introduced somewhere in the NHS everything that we want to install, but we have never done it on a scale that is implied as necessary and correct in order to support the National Health Service. So he is bringing in people who we would not automatically have brought in and did not know about, and I think that is increasing the likelihood of success of this enormous project.’

The other major change that shows CfH have learnt something from previous projects can be seen in the way they have structured their contracts with suppliers. For almost the first time on a government project, CfH have imposed major cost penalties on suppliers if they miss critical project dates. Moreover, they are also applying them. BT were reported to have paid £4.5m in penalties in 2004 and to be facing further fines in 2005. BT denied that the £4.5m had been a fine and insisted it had just been an ‘adjustment of payments’.¹⁵ The DirectorGeneral of CfH, however, seemed fairly unambiguous in his views of BT’s performance. He accused them of having made ‘a very shaky start’ to the contract and of being ‘behind the original contracted schedule’. Moreover, he said, ‘their project management wasn’t good enough, the people they had on the job weren’t good enough and they still have some distance to go there.’¹⁶ Nevertheless, whether the £4.5m was a fine for late delivery or ‘adjustments of payments’, in theory this new tougher stance should push IT systems suppliers to perform better than they have done on previous programmes.

However, this approach has been derided within the IT industry. At a conference in November 2005, the chief legal counsel of one of the world’s top three systems consulting companies explained that the problems on government projects stemmed from the limited management capabilities of the civil servants running the projects and so would not be solved by the imposition of fines: ‘The changes in the style of the process were typified by the NHS NPfIT Programme procurement in 2003. This can be summarized as the “big stick” rather than the partnership approach to procurement. At a recent meeting of industry trade body Intellect’s healthcare group, Richard Granger, Director-General of the £6bn NHS NPfIT told his audience that he wants to “hold suppliers feet to the fire so that the smell of burning flesh is overpowering”. Suppliers have expressed concern to the OGC that the Government is increasingly relying on punitive contracts and the inevitable fines (which have already begun at NPfIT), rather than developing its own programme management capacity and becoming the “intelligent customer”.’ ¹⁷

Of course, given the typical business practices used by the larger consultancies, one should take such protestations of innocence with a not inconsiderable pinch of salt. Too often, civil servants’ inexperience and incompetence have suited the consultancies as they have enabled consultancies to double, triple and even quadruple their prices once they got their public-sector contracts signed. Some consultancies even boast that the way they make money from public-sector contracts is to submit a low bid, in the full knowledge that the government contract will be so full of holes that it offers the consultancy a captive client and an almost unlimited licence to raise prices once the project has begun. However, there is probably also some justification for the IT company’s chief legal counsel at the conference going on to accuse the government side of, among other things, ‘lack of clear senior management and ministerial ownership and leadership, lack of skills and proven approach to project management and risk management, lack of understanding of and contact with the systems supply industry at senior levels, too little attention to breaking development and implementation into manageable steps, inadequate resources and skills to deliver’. Failings from the government side that, as we have seen, seem to be a recurring feature of large public-sector consultancy programmes.

Sadly, as I review and also discuss with experts and insiders how CfH have designed and set up their programme, it seems that, apart from these two areas, they are taking exactly the same approach as previous catastrophic projects and so wilfully repeating the mistakes of the past. It is said that one sign of madness is to carry on doing the same thing and to expect a different result. Unfortunately for us taxpayers and for our health service, CfH seem determined to follow in the ill-fated footsteps of their unfortunate predecessors, while somehow expecting the results to be quite different.

CHAPTER 13

WHAT DO WE DO NOW?

Connecting for Health (CfH)

If Choose and Book is still not working, it should be put on hold for a few years and the money from the programme fed back into front-line patient care. An investigation should be conducted into the suppliers, Atos Origin, to understand if they are in any way responsible for either the delays or cost increases. If they are, the government should seek full compensation, which should also go straight back into patient care.

We should probably stop the CfH programme in its present form and cancel all the contracts with the Local Service Providers as they are against the public interest. Here, of course, there will also be much bluff and bluster from the consultancies and threats of legal action for breach of contract. But measures like whistle blowing rewards and the threat of investigations into whether they have defrauded public funds or have been complicit in doing so, and the possibility of subsequent prosecutions should help some of the consultancies understand that their longer-term interests lie in cooperation with government rather than confrontation. The only CfH consultancy contracts that should be kept should be those for routine maintenance of existing systems.

The board of CfH should all be removed and replaced - they have too much personal capital invested in the way the programme is currently being run to accept that it should be radically changed. CfH is so critical for the country that it should be treated as an issue of national importance rather than risking becoming a massive profiteering opportunity for just four huge companies. In the same way as we create a government of national unity in times of emergency, we need to transcend the interests of one party and four big companies and run CfH for the public and not for a few New Labour politicians and their consultants. A cross-party programme board of MPs should be set up. They should be allocated a sum of money - say £5bn. They should then invite the smaller and medium-sized specialist medical systems suppliers to form a consortium to propose how the useful elements o fCfH can be implemented in a tactical, low cost way rather than the current high cost juggernaut approach. Re-use of existing technology, interoperability, distributed databases and market competition should be the guiding principles rather than unnecessary reinvention, monolithic uniformity, centralized databases and monopolistic market control. The elements that should be implemented are electronic patient records, electronic prescriptions, electronic imaging and cost and management information.

We should set up a project management board made up mainly of clinicians representing the main groups of hospitals. Moreover, the useful systems should be developed at just a couple of test locations using an iterative prototyping development approach. Once the project management board was satisfied with the systems' effectiveness and robustness, they could be rolled out to other locations. We will probably find that this approach will give us a fully implemented CfH in a greatly accelerated time-frame for less than £5bn for the whole NHS, rather than the over £30bn that the existing approach will cost. This will get us back to the kind of figures that were mooted when the programme was originally launched. Moreover, rather than just enriching four already massive IT consultancies, this encouragement of many smaller companies to create a competitive market for medical IT systems will probably result in Britain developing a world-beating medical systems industry with massive export potential as other countries also inevitably move to improve the use of technology in their health services over the next few years.

An axe should be taken to NHS administration. The government should pass a law requiring non-medical and non-cleaning staff expenses in hospitals not to exceed say 10 per cent of overall staff costs by the end of 2006, 8 per cent by the end of 2007 and 7 per cent by the end of 2008. Any hospital breaching these targets should be found to be committing an offence of wasting public funds and the chief executive should be barred from any form of employment in the public sector for five years. Any employee reporting management fiddling the figures should be rewarded with a percentage of the savings made after the employee's reporting of the incident and the hospital chief executive should be automatically dismissed with loss of pension rights. Moreover, any communication departments or marketing departments should be closed, the people fired and the budgets returned to front-line care. If hospitals have something important to say, the clinical staff are probably quite capable of saying it.

Hospital cleaning should be brought back in-house with cleaning staff employed by the NHS and made to feel they are an important and integral part of a team providing safe medical and care services for the sick, rather than being easily disposable low cost labour for profit-maximizing outsourcing companies. This measure alone will probably lead to a halving of the annual 600,000 plus hospital-acquired infections and of the 5,000 plus deaths from hospital-acquired infections. The money to pay for the employment of hospital cleaners as NHS employees could come from the money saved from reducing hospital administration costs to the levels proposed above and from the savings from an almost immediate reduction in levels of hospital acquired infections. This new policy could be piloted in four or five hospitals and, when it is found to be at least self-funding (and probably generating a cash surplus that could go back into patient care), rapidly rolled out across the whole NHS.

Notes

1. Daily Telegraph 30 October 2004, Accountancy Age 17 November 2004, www.theregister.co.uk 12 October 2004.
   
2. http://www.topconsultant.com 16 June 2004 quoting British Computer Society estimates
   
3. House of Lords Committee on Science and Technology 13 March 2003
   
4. The Times 8 February 2006
   
5. Computer Weekly as reported on http://www.theregister.co.uk 12 October 2004
   
6. Independent 21 November 2005
   
7. The Times 12 December 2005
   
8. The Times 23 November 2005
   
9. Computer Weekly 17 January 2005
   
10. http://www.e-health-insider.com 26 January 2006
    
11. Sunday Times 13 November 2005
12. ibid
    
13. PAC Report The 1992 and 1998 Information Management and Technology Strategies of the NHS Executive
    
14. PAC Report Improving the Delivery of Government IT Projects
    
15. The Times 14 October 2005
    
16. http://www.e-health-insider.com 14 October 2005
    
17. Society for Computers and Law 5th Annual Conference November 2005