Here you can browse the report together with the Proceedings of the Committee. The published report was ordered by the House of Commons to be printed 26 March 2007.
Contents
Conclusions and Recommendations
3. Managing implementation and ensuring that the systems meet the needs of the NHS
4. Securing the benefits of the Programme
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
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Conclusions and Recommendations
1. The delivery of the patient clinical record, which is central to obtaining the benefits of the programme, is already two years behind schedule and no firm implementation dates exist. By now almost all acute hospital Trusts should have new NPfIT patient administration systems (PAS) as the essential first step in the introduction of the local Care Record Service. As of June 2006 the actual number was 13 hospitals. In June 2006 the Department wrote to us stating that by October 2006 there would be a further twenty-two. So far as we are aware, up to the end of February 2007 the number has increased by only five acute hospitals. The introduction of clinical as opposed to administrative software has scarcely begun; indeed, essential clinical software development has not been completed. The Department should develop with its suppliers a robust timetable which they are capable of delivering, and communicate it to local NHS organisations who may then have greater confidence as to when systems will be delivered.
2. The Department has not sought to maintain a detailed record of overall expenditure on the Programme and estimates of its total cost have ranged from £6.2 billion up to £20 billion. Total expenditure on the Programme so far is over £2 billion. The Department should publish an annual statement outlining the costs and benefits of the Programme. The statement should include at both a national and local level original and current estimates of total costs and benefits, costs and benefits to date, including both cash savings and service improvements, and any advances made to suppliers.
3. The Department's investment appraisal of the Programme did not seek to demonstrate that its financial benefits outweighed its cost. The main justification for the Programme is to improve patient services, and the Department put a financial value on benefits where it could. The Department should also quantify non-financial benefits, even if they are not valued, to better inform decision making and to provide a baseline for work after implementation to ensure that the intended benefits are being fully realised. The Department should commission and publish an independent assessment of the business case for the Programme in the light of the progress and experience to date.
4. The Department is maintaining pressure on suppliers but there is a shortage of appropriate and skilled capacity to deliver the systems required by the Programme, and the withdrawal of Accenture has increased the burden on other suppliers, especially CSC. The Department should review with suppliers their capacity to deliver, and use the results of this review to engage, or to get suppliers to engage, additional capacity where required. It should also regularly review suppliers' performance for any signs of financial difficulties potentially affecting their ability or willingness to discharge their obligations. In view of the slippage in the deployment of local systems, the Department should also commission an urgent independent review of the performance of Local Service Providers against their contractual obligations.
5. The Department needs to improve the way it communicates with NHS staff, especially clinicians. The Department has failed to carry an important body of clinical opinion with it. In addition, it is likely that serious problems with systems that have been deployed will be contributing to resistance from clinicians. It should ask the heads of the clinical professions within the Department, such as the Chief Medical Officer, to review the extent of clinical involvement in the specification of the systems, and to report on whether they are satisfied that the systems have been adequately specified to meet the needs of clinicians.
6. We are concerned that leadership of the Programme has focused too narrowly on the delivery of the IT systems, at the expense of proper consideration of how best to use IT within a broader process of business change. The frequent changes in the leadership of the Department's work to engage NHS organisations and staff have damaged the Programme and convey that the Department attaches a low priority to this task. The Department should avoid further changes in the leadership of this work, beyond those necessary to improve its links with clinicians, and strengthen the links between the Programme and the improvement of NHS services that the Programme is intended to support.
7. The Department should clarify responsibility and accountability for the local implementation of the Programme. At a time when many changes are taking place in the configuration of the local NHS and a range of other initiatives require implementation, it is essential that Chief Executives and senior managers in the NHS understand the role they need to play in the implementation of the Programme. The Department should make clear to Chief Executives and senior managers their objectives and responsibilities for local implementation, and give them the authority and resources to allow local implementation to take place without adversely affecting patient services.
8. The use of only two major software suppliers may have the effect of inhibiting innovation, progress and competition. In addition, the fact that the Programme has lost Accenture, Commedica and IDX, three key suppliers, is running late and is having difficulty in meeting its objectives raises doubts over whether the contracts will deliver what is required. The Department should seek to modify the procurement process under the Programme so that secondary care trusts and others can if they wish select from a wider range of patient administration systems and clinical systems than are currently available, provided that these conform to national standards. This approach could have the benefit of speeding up the deployment of new systems and of making it easier to secure the support of clinicians and managers. We are concerned in particular that iSOFT's flagship software product, 'Lorenzo'—on which three fifths of the Programme depends—is not yet available despite statements by the company in its 2005 Annual report that the product was available from early 2004.
9. At the present
rate of progress it is unlikely that significant clinical benefits will be
delivered by the end of the contract period. As a matter of urgency the
Department must define precisely which elements of functionality originally
contracted for from the Local Service Providers will be available for
implementation by the end of the contract period and in how many NHS
organisations it will be possible to have this functionality fully operational.
The Department should then give priority to the development and deployment of
those systems of the greatest business benefit to the NHS, such as local
administration and clinical systems.
1. The Programme is the most extensive IT healthcare development of its kind in the world and constitutes the largest single IT investment in the UK to date.[2] Its aim is to enable the NHS in England to treat patients more effectively by, for example, making accurate patient records available at all times, transferring information rapidly between different parts of the NHS, and accurately transmitting prescriptions to pharmacies.[3]
2. At present, NHS patient records are primarily retained on paper; and even when information is stored electronically, the large number of incompatible NHS IT systems makes the sharing of information difficult.[4] The central vision of the Programme is therefore to introduce an integrated system called the NHS Care Records Service.[5] This consists of two elements. The first is the local detailed clinical record, for use within local healthcare communities where the overwhelming majority of patient care is delivered. It contains the information which needs to be available to GPs, community clinicians and hospitals (such as pathology test results, drugs prescribed or hospital discharge notification) and it enables clinicians to record diagnoses, order tests and prescribe drugs. The second element is the national summary clinical record which aims, for example, to support emergency care for people injured or taken ill while away from home. The Programme will also provide additional services, such as electronic transmission of prescriptions, an email and directory service for all NHS staff (NHSmail), computer accessible X-rays (Picture Archiving Communications Systems), a facility for patients to book first outpatient appointments electronically (Choose & Book) and a broadband network (N3).[6]
3. Most of the planned expenditure on the Programme is on local systems (Figure 1). The Department believes that the Programme's integrated national IT system will deliver significant financial, service and patient safety benefits.[7]
Figure 1: Planned local and national expenditure on the Programme
Source: C&AG's Report, paras 1.19-1.26
4. The National Programme was established in 2002 and follows Information Technology Strategies for the NHS in 1992 and 1998 which were examined by our predecessors in 2000.[8] In their examination our predecessors noted that the NHS Executive had recognised the need to take a stronger lead in the procurement of core NHS IT systems and were in discussions with suppliers and government advisory bodies about drawing on government catalogues for systems and were thinking about piloting a collaborative procurement for an agreed short list of suppliers so that local organisations would have some form of limited discretion[9]. With the National Programme, the contracts for the Programme were procured centrally rather than locally. This change in practice was driven by the Department's desire to overcome the past poor track record of the NHS in procuring and delivering IT systems, to get value for money and to deliver integrated systems that could be upgraded in the future at reduced costs.[10]
5. The Department recognised that this approach carried many risks and that implementation needed to be local and tailored to local characteristics. Moreover, whilst other countries are seeking to adopt elements of the services within the National Programme, such as electronic patient records, these are not being introduced on a country-wide basis elsewhere.[11]
6. The Department estimated that the central procurement of the contracts through the Programme would result in a saving of £4.5 billion,[12] although any final figure for savings is contingent on the successful implementation of the Programme. Competition for the IT contracts was secured by avoiding a preferred bidder stage and procurement of the contracts was completed in under a year, and in most cases within ten months.[13] The Department's aim from this speed of procurement was to reduce risks from technology obsolescence and from higher costs as suppliers attempt to recover the cost of lengthy procurements.[14] However, Dr Nowlan told us that the production of the specification was done at breakneck speed, and largely by putting together, and then reducing, a wide range of previous specifications. Professor Hutton had been concerned at the safety of the process, and that it might result in a product that would not fulfil the Department's goals.[15] In a submission to us Mr Thomas Brooks, a member of the Worshipful Company of Information Technologists and of the all party Parliamentary IT Committee, stated that he considered the view that central procurement would produce systems that met local requirements was a fundamental error.[16]
7. The patient clinical record is to be delivered through a combination of a central system called the Spine and local systems delivered by Local Service Providers. The central and local systems work together to operate the National Care Records Service, which, in addition to the clinical record, holds non-clinical information on patients through the Personal Demographics Service, controls access to many of the Programme's service and handles the transmission of information between systems (Figure 2).[17]
Figure 2: NHS Care Records Service
Source: C&AG's Report, paras 5m, 1.8, 1.12; Figure 3
8. The Spine first went live in June 2004 as scheduled but the achievement of later milestones for increasing its functionality was delayed by up to ten months. By the time of our examination, the Personal Demographic Service held 72 million live records, 375,000 patient searches were being conducted every day and over 240,000 users had been registered, although this is only a small part of the overall scheme.[18]
9. The patient clinical record itself, however, had not yet been deployed at any location. It was due to be available in pilot form in late 2006, and in full form a year later, two years later than originally planned.[19] The Department told us that the decision to delay had been taken because some suppliers were having difficulty in meeting the timetable and because clinicians wanted to pilot the scheme. It hoped to have implemented most of the system by 2010, but the scale of the implementation and the risks associated with it needed to be recognised.[20]
10. At the time of our hearing in June 2006, some 13 acute Trusts had had their Patient Administration System (PAS) replaced, which itself provides no care record functionality beyond what they already had. In those regions where iSOFT is the main software supplier, the replacement has been an old iSOFT PAS which pre-dates the Programme because the PAS element of the new system, Lorenzo—which is being developed for the Programme and which the company stated was available from early 2004[21]—is not yet available. In those areas in which GE/IDX was originally contracted as the main software supplier but has now been replaced by Cerner, there are delays in anglicising the Cerner product. A considerable number of Primary Care Trusts and mental health Trusts who previously had no corporate patient administration system at all have been supplied with iSOFT's old PAS. No published plans exist for implementing shared electronic patient clinical records in line with the original vision for the Programme.
11. The other projects making up the Programme have made varying degrees of progress.[22] The New National Network (N3) was three months ahead of schedule.[23] Choose and Book, the electronic system to enable patients to book first outpatient appointments, had been deployed to over 7,600 locations by April 2006, but accounted for only 20% of referrals from GPs to first consultant outpatient appointments in the week preceding our examination.[24] The Department accepted that some GPs had not had a good experience of using the system, which it believed was often attributable to local implementation issues or to the hospital's patient administration system not being up to date.[25]
12. Deployment of the electronic prescription service and the computer accessible X-ray systems had been slower than anticipated, but the Department believed that later deployment targets would be met.[26] It reported that many other local systems had been deployed, including 13 acute hospital patient administration systems.[27] Two thirds of people had access to services that were dependent on services delivered by the Programme, and the Department said that would move to 100% over the next twelve months.[28] However, in June 2006 the Department told us that it would deliver at least 22 new Patient Administration Systems (PAS) to NHS Acute Trusts between June and October 2006. But even by the end of February 2007, only a further five had been deployed, suggesting that the Programme is still unable to meet short term targets.[29]
13. The experience of PAS systems that have been delivered has been patchy. Some Trusts have experienced problems including inability to report activity statistics,[30] missing patient records[31] and extended shut-down of some systems.[32] Clinical consequences have included waiting list breaches[33] and significant delays in providing inoculations to children.[34]
14. Plans published by NHS Connecting for Health in January 2005 indicated that by April 2007, 151 acute hospital Trusts would have implemented Patient Administration Systems of varying degrees of sophistication.[35] As of February 2007 only 18 had been deployed.[36] Such delays can cause considerable cost and disruption to Trusts, since they may have to replan expected live dates and spend money on preparing for expected dates that are not met. Mr Brooks told us in his submission that in his view there was no evidence that Local Service Providers have added any value to the National Programme and a cluster wide contract has not delivered any identifiable benefits.[37]
15. Total expenditure on the Programme to the end of March 2006 was £1,542 million.[38] This comprised £654 million on the contracts with suppliers against expected expenditure of £1,448 million; and a further £888 million on new projects added to the scope of the Programme, additional services, non-core projects, National Programme support for local NHS implementation, expenditure by local NHS organisations, and central administration.[39] The shortfall in expenditure on the contracts with suppliers reflected the slower than planned delivery of some systems and contractual provisions that suppliers would only be paid once services were delivered and working.[40] The Department told us that although it retained a timescale risk, it had transferred finance and completion risk for the most part to the suppliers.[41] However, the Department told us it also made advance payments to suppliers covered by a letter of credit from a bank or a charge on the company's assets of at least an equal value. By 31 March 2006 the Department had paid £443 million in forward payments to Local Service Providers and by December 2006 this figure had risen to £639 million.[42]
16. The Department told us that central expenditure on the Programme between the end of March 2006 and 31 December 2006 had risen by £532 million from £1,083 million to £1,615 million.[43] The Department had no information on expenditure by local NHS organisations after 31 March 2006, but even counting in local expenditure only to that date, total cumulative expenditure on the Programme to the end of December 2006 is not less than £2,074 million; and because of the unknown amount of local expenditure must in practice have substantially exceeded this amount.
17. The Department had brought in resources from abroad, though with poor results for some suppliers which were requiring close attention.[44] The Department regularly assessed the financial capacity and fitness of its prime suppliers in conjunction with Partnerships UK, whose most recent review had confirmed that all the key suppliers had sufficient financial capacity to fulfil their liabilities and continue to discharge their obligations under the contracts.[45]
18. However, continuing financial problems with key suppliers including iSOFT have been widely reported.[46] Shares in iSOFT lost more than 90% of their value after a series of profit warnings and the discovery of alleged accounting irregularities.[47] The company is now under investigation by the Financial Services Authority, while its former directors and former auditors are under investigation by the Financial Reporting Council's disciplinary body, the Accountancy Investigation and Discipline Board.[48] Although iSOFT has received loan support from its banks, there is a continuing risk to the National Programme if it is overly dependent on the future stability of a small number of suppliers.
19. In September 2006, the Department, Accenture and CSC announced that Accenture was to transfer its responsibility as local service provider for its two clusters to CSC by 8 January 2007, further reducing the supplier base, though Accenture would retain its responsibility for computer accessible X-ray systems in these clusters.[49] Commedica, the PACS supplier in the North West and West Midlands cluster, has also been replaced, and IDX has been replaced by Cerner as the main software supplier for the Southern and London clusters.[50]
3. Managing implementation and ensuring that the systems meet the needs of the NHS
20. The Programme is a combination of national and local projects, with local implementation organised in five regional clusters (Figure 3). Each cluster has a Local Service Provider which is responsible for delivering services within the cluster, working in conjunction with the Strategic Health Authorities and local NHS organisations within the cluster.[51]
Figure 3: The five regional clusters and their current local service providers
Source: National Audit Office
21. The scale, specialisms and fragmentation of existing IT systems has made the delivery and implementation at each NHS site more complex than other IT implementations, and the Programme is being implemented against a background of change in the configuration of the NHS.[52] The Department told us that although procurement had been carried out centrally, implementation was local through each NHS organisation. Every local implementation had its own characteristics and needed to be locally tailored.[53] It had established a system where the chief executives of the new strategic health authorities that came into operation on 1 July 2006 were accountable for overseeing implementation in their local NHS.[54] Within each organisation, the chief executive was responsible, and at both levels, chief executives should be supported by a chief information officer.[55] If anything went wrong in a particular implementation, the strategic health authority would intervene, and NHS Connecting for Health would intervene if the programme was going wrong on too big a scale.[56] It is unclear how much the localising of responsibility will help unless local Trusts are also given flexibility in the choice of systems so that local needs can be taken into account.
22. The procurement of the systems was based on an "Output Based Specification", a statement of the functions that the system was intended to perform. Development of the specification began in February 2002, and drew on information from various sources, including specifications developed by NHS bodies for their own patient record services and consultation with NHS staff. The specification was initially published for consultation in July 2002. Following further revisions, it was issued to potential suppliers in May 2003. After contracts had been placed, clusters also established clinical advisory groups to obtain clinical input as specific systems were developed.[57]
23. An appraisal commissioned by the National Audit Office of the development of the specification found that it was developed after engagement with a broad spectrum of NHS stakeholders but that there was no recorded link between the detailed items in the specification and the person or group making that contribution.[58] The Department's explanation was that NHS Connecting for Health had not had the resources to record the attributions individually.[59] Dr Nowlan told us that in his view this explanation for the lack of documented validation was not credible.[60] Professor Hutton also told us that there was no good audit trail for clinical input into the production of the specification, and that key decisions were taken in the early period of the Programme without proper clinical input.[61] He and Dr Nowlan also both told us that they felt that clinicians and the local NHS were not taken into account and did not have sufficient say.[62] The Comptroller and Auditor General told us that "the approach from the top down had not permitted the full degree of consultation".[63]
24. The Department commented that hundreds of people had input to the design process. Not only had there been clinical input in the original specification, but as the Programme had proceeded clinicians and other users had been involved in much more detail. For example 470 clinicians had recently been involved in looking at the national requirement to support e-prescribing, although this appears a very late point at which to do so, since the specification of the solution and the terms of the contract had been set before it began.[64] Other action had included establishing the Care Record Development Board to strengthen patient involvement, and the appointment of national clinical leads.[65] In their examination of NHS information technology our predecessors stressed the need to involve end users, noting that getting the commitment of everyone is crucial to successful implementation of complex IT projects.[66]
4. Securing the benefits of the Programme
25. One of the conclusions of our predecessors' examination of the 1992 and 1998 Information Technology Strategies for the NHS was that getting ownership of developments by clinicians, general practitioners and other healthcare staff was essential.[67] However, although there was support for what the Programme was seeking to achieve among NHS staff, there were also significant concerns, for example that the Programme was moving slower than expected, and that deployment plans had been unreliable.[68] Professor Hutton told us that the Department did not adequately engage the medical community, and surveys of staff by Medix indicated that support for the Programme had fallen between 2004 and 2006 (Figure 4).[69] The Department's own Ipsos MORI surveys of NHS staff also showed a decline between 2005 and 2006 in favourability towards the Programme so far, with reasons given for unfavourable ratings including not enough input or communication with the people that would be using it, and poor organisation and planning.[70]
Figure 3: Support for the Programme has fallen amongst GPs and other Doctors
Source: C&AG's Report, 4.13
26. In the case of the Programme, the Department decided to conclude the bulk of procurement activities before focusing on communicating with and engaging NHS staff.[71] Wider consultation on the Programme with NHS staff did not commence until the procurement phase had concluded at the end of 2003, working initially through the clusters.[72] Leadership in securing support from NHS staff and organisations has changed several times over the life of the Programme: at the time of our examination, responsibility for this task had passed between six Senior Responsible Owners.[73]
27. The Department told us that some systems, such as the new network connections, had been well received by clinicians, but that clinicians found it more difficult to assimilate systems that were more disruptive to their working practice.[74] While it was necessary to recognise that a Programme of this scale would cause a degree of controversy and dissent, the Department said thousands of clinicians were already using the system and quietly getting on with it.[75] The Department had been working to establish further support for the Programme through the Care Record Development Board, for example in building a consensus over the last year on the content of the clinical record.[76] It said it had engaged clinicians, but recognised that there was very much more to be done.[77]
28. One issue causing concern among GPs was the future of their IT systems.[78] Under the General Medical Services contract, Local Service Providers were required to offer a choice of systems to GPs, but had only been contracted to provide two and it very quickly became apparent that one of these was not being delivered.[79] The Department had now attempted to address this problem through an initiative called GP Systems of Choice.[80] The development and implementation of the scheme was subject to discussions with suppliers.[81]
29. Another issue that has prompted concerns amongst doctors and others is the protection of patients' confidentiality, where Dr Nowlan told us that the most important issue was the arrangements for governance and trust, and compliance with these arrangements.[82] The Department told us that the security systems in place will be more secure than the Chip and PIN arrangements utilised by credit and debit cards in the UK. It was also supporting the Information Commissioner in his demands for higher penalties for information abuse.[83]
30. When the main contracts for the Programme were let in 2003 and 2004, the Department announced that they would cost £6.2 billion.[84] Subsequent estimates of the cost of the Programme reportedly attributed to the Department have ranged up to £20 billion, but the Department clarified that this figure relates to total IT expenditure within the NHS during the life of the Programme and that it expected the cost of the Programme itself to be £12.4 billion.[85] Amongst other things, this higher figure includes, on top of the cost of the original contracts, central expenditure; contracts and projects added to the scope of the National Programme; additional services to be purchased beyond the scope of the original national core contracts; extrapolation of costs beyond the terms of the existing contracts; and an estimated £3.4 billion local NHS expenditure.[86]
31. The estimate of local expenditure on the Programme of £3.4 billion dated from the time the contracts were let and the actual level of ongoing local NHS expenditure on the Programme was not systematically monitored.[87] Further costs have arisen for the local NHS Trusts where they have been required to pay suppliers a total of £24 million in order to be released from contractual obligations to provide staff to help suppliers develop the systems.[88] Delivery delays have also had an impact on local NHS expenditure, with a number of Trusts having had to renew their own patient administration systems, for example because they were time expired, or upgrade them to make them compliant with the National Data Spine. Deploying such interim systems would affect both costs and benefits.[89] The Department was providing some financial support to Trusts for upgrading, and where new systems came in, Trusts did not have to pay for the old system anymore.[90]
32. In the business cases for the various elements of the Programme, the Department sought to put a financial value on the benefits of the Programme where it could.[91] Its main aim with the Programme, however, was to improve services to patients rather than reduce costs, and there was a gap between the estimated financial value of the benefit of the Programme and its costs.[92] The Department was unable to give a full statement on the extent of this gap but said that the business case for the computer accessible X-rays contract had identified cash savings of £682 million against a contract cost of £1.3 billion.[93]
33. The Department believes that the patient safety benefits achieved through the Programme's successful implementation could be worth many billions over ten years, for example from reductions in preventable fatalities arising from medication errors; the number of patients requiring treatment as a result of medication errors; and in the amount paid by the NHS each year to settle clinical negligence claims. No detailed analysis had been carried out in order to substantiate these estimates.[94] The Department also predicts that the Programme will result in further savings by improving staff efficiency, by for example reducing the amount of time spent repeatedly taking patients' medical histories and demographic details.[95] The Programme would also help standardise practice and allow people to move between employers without re-training, improve information available when patients were referred to hospitals, and improve resource use and efficiency.[96]
34. The Local Service
Providers were contracted to deliver Local CRS systems to NHS organisations in
three phases. Phases 2 and 3 are the key to the delivery of clinical benefits
and were the core of the business case for the high cost LSP contracts. Phases 2
and 3 provide the NHS with functionality that would enable organisations to
support integrated clinical care processes (scheduling, investigating,
prescribing, treating, assessing, etc.) by healthcare staff no matter in what
organisation (hospital site or GP practice) or in what care setting (primary,
mental health, community, tertiary). Phase 1, the least important from a
clinical point of view because it contains mainly administrative functionality,
is already late with no published dates for its completion. The implementation
of Phases 2 and 3, may, therefore, scarcely have begun by the time the Local
Service Providers were originally contracted to have implemented completely all
three Phases to all hospitals and Trusts in England.
1 C&AG's Report, Department of Health: The National Programme for IT in the NHS, HC (2005-06) 1173 Back
2 Q 9; C&AG's Report, para 4 Back
3 C&AG's Report, para 1.4 Back
4 C&AG's Report, paras 1.1, 1.2 Back
8 Committee of Public Accounts, Thirteenth Report of Session 1999-2000, The 1992 and 1998 Information Management and Technology Strategies of the NHS Executive, HC 406, para 9 (vi) Back
9 Op cit, para 9 (vi), paras 31, 34 Back
10 Q 8, C&AG's Report, para 2.5 Back
11 Q 10, C&AG's Report, para 1.8 Back
13 C&AG's Report, paras 3.1 and 3.4 Back
14 Q 116; C&AG's Report, para 3.4 Back
15 Qq 57, 189 Back
17 C&AG's Report, paras 5m and 1.11-1.12; Figure 3 Back
18 Qq 6, 233; C&AG's Report, para 5m Back
19 On 19 July the Department announced that the first phases of the patient clinical record would be introduced in a small number of locations from early 2007, with wider roll out during 2008 (Department of Health Press Release 2006/0265, 19 July 2006). Back
20 Qq 1-7, 233; C&AG's Report, para 5m Back
21 iSOFT Group PLC 2005, Annual Report and Accounts, page 6 Back
22 C&AG's Report, Figure 3 Back
23 C&AG's Report, paras 3.17-3.19 Back
24 Q112; C&AG's Report, para 1.13 Back
25 Qq 112-113 Back
26 C&AG's Report, para 5m Back
27 Qq 226-228 Back
29 Ev 52-54, NHS Connecting for Health website Deployment statistics Back
32 e-Health Insider, 1 August 2006 Back
34 CDR Weekly Volume 16 Number 25 page 11. Published by Health Protection Agency, 22 June 2006 Back
35 NHS Care Record Service: Indicative Deployment Plan-January 2005 Back
36 NHS Connecting for Health website Deployment statistics Back
39 Loc. cit., C&AG's Report, para 1.22 Back
40 C&AG's Report, para 5q Back
42 Qq 150-152, Ev 55-58 and 81-82 Back
47 http://www.isoftplc.com/corporate/investor_centre/share_info.asp; http://www.isoftplc.com/corporate/news_media/2633.asp Back
48 http://www.isoftplc.com/corporate/media_files/Interim_Results_111206.pdf Back
49 Accenture, CSC and NHS Connecting for Health press notices, 28 September 2006 Back
50 C&AG's Report, Figure 3; Q 46 Back
52 Q 94; C&AG's Report, para 1.8 Back
56 Qq 100-101 Back
57 C&AG's Report, paras 2.10-2.13, 4.3 Back
58 Q 26; C&AG's Report, paras 2.11-2.13 Back
59 C&AG's Report, para 2.13 Back
66 Committee of Public Accounts, The 1992 and 1998 Information Management and Technology Strategies of the NHS Executive, HC (1999-2000) 406, para 33 Back
67 Committee of Public Accounts, The 1992 and 1998 Information Management and Technology Strategies of the NHS Executive, HC (1999-2000) 406, para 9 (v) Back
68 C&AG's Report, paras 5k, 4.14 Back
69 Qq 19, 31; C&AG's Report, para 4.13 Back
70 A Baseline Study on the National Programme for IT, MORI, 9 September 2005; Wave 2 Study on the National Programme for IT, Ipsos MORI, 20 July 2006. Back
71 C&AG's Report, para 4.2 Back
72 C&AG's Report, para 4.3 Back
78 C&AG's Report, paras 3.27-3.28 Back
79 Q 64 ; C&AG's Report, para 3.28 Back
81 C&AG's Report, paras 3.27-3.28 Back
82 Q 28; C&AG's Report, paras 2.17-2.18; Appendix 3 Back
84 C&AG's Report, para 1.20 Back
86 C&AG's Report, paras 1.20-1.28 Back
87 Qq 15, 47, 123-124, 130; C&AG's Report, paras 5r, 1.26, 1.33 Back
88 Qq 234-247; DoH note on Qq 242, 247 Back
91 C&AG's Report, para 1.29 Back
92 Q 153; C&AG's Report, para 1.29 Back
94 C&AG's Report, paras 1.29-1.32 Back