By Tony Collins

Criticisms by official auditors of the £12.4 billion NHS information-technology scheme were removed or neutered under government pressure.
  Draft versions of a report by the national audit office (NAO) into the project, disclosed under the freedom of information act (FOIA), reveal what the covered-up criticisms were.
  The changes raise questions about the independ-ence of the NAO, which audits £800 billion of annual government spending, from Whitehall.
  The FOIA disclosures reveal sharp differences between three draft NAO reports and the final report on the project for the national health service (NHS), the UK's biggest IT investment.
  They make public for the first time the extent to which draft NAO reports can change, while being “cleared” with the government department being audited. NAO reports must be signed off by the body being audited before publication.
  The final report on the NHS national programme for IT (NpfiT) published in June was strongly supportive of the scheme and full of praise for the department of health and its agency, NHS connecting for health.
  Lord Warner, health minister, portrayed the report as a vindication of the work carried out so far on the programme, while connecting for health has quoted from it to rebuff criticisms of the scheme in local newspapers.
  Greg Clark, a Conservative MP on the parliament-ary public accounts committee (PAC), which oversees the NAO’s work, said at the time: “In a year on the committee, I have read 62 NAO reports. This is easily the most gushing.”
  However, draft versions released under FOIA show that passages critical of the programme were removed or substantially altered. In addition, passages were added to the final report that showed the scheme more positively. And concerns expressed by NAO auditors in their draft reports are omitted from the final version.
  The NAO's report was delayed for several months while auditors and Whitehall officials debated the contents of the drafts. The FOIA disclosures suggest that they argued over almost every sentence, with even single words being changed.
  The overall changes, which seem minor when considered in isolation, altered the tone of the report.
  For example, the final version omits a report, commissioned by the NAO, suggesting that the UK may be out of step with the US and the rest of Europe. Other countries, such as Germany, Sweden, and the Netherlands, are reported to be moving towards linking locally maintained systems through technical standards and messaging facilities rather than adopting a centralised patient record.
  The report, by Cambridge university's foundation for information policy research, also found that, as a result of NpfiT, the NHS spends some 30 per cent of the European total spend on health-care IT.
  The final report also omits passages from a draft report showing the negative effect on NHS trusts of delays in the delivery of core software by suppliers to the national programme. Instead, it suggests that suppliers are absorbing the effects of delays in the delivery of their software.
  The first draft in January 2006 shows that the pro-gramme has deep-rooted weaknesses that put its success in jeopardy.
  It refers to concerns among NHS trusts about the affordability of the programme. It quotes surveys as suggesting that there is considerable distrust and cynicism about the scheme, reveals that trainers in trusts are already working to capacity, and that hospitals and the programme's suppliers are trying to recruit from the same scarce pool, which is driving up salaries.
  All these points are omitted in the final report.
  The  first  draft  has  19  sections, of which five are critical, including concerns about possible structural weaknesses in the programme. One, for example, says: “Not all contractual arrangements have worked.”
  The final report has 21 sections and the negative ones have disappeared, except one which is only mildly critical: it says that national leadership of parts of the programme has changed several times. The phrase, “Not all contractual arrangements have worked,” has gone.
  Some of the praise in the final version – not included in the first draft – introduces discrepancies into the report. Figures for savings were revised upwards by billions of pounds; words and construction of sentences were changed to remove negative connotations; and some changes go further by turning a neutral or critical statement into a positive one.
  The draft says that deals negotiated with Microsoft and other suppliers are expected to save about £470 million. By the final report, the estimated savings have risen to £860 million.
  A draft of May 2006 says that connecting for health commissioned a report from analyst firm Ovum. The report compared the prices achieved by connecting for health with estimates of the prices that could have been achieved by individual organisations buying the same services separately. “On this basis, it estimated a saving of some £3.8 billion from central procurement by NHS connecting for health.”
  By the final report, the saving had increased: “On this basis, it estimated a saving of some £4.5 billion from central procurement by connecting for health.”
  Similarly, the draft says that connecting for health “achieved significant price reductions from the eight prime contractors, the difference between their initial and final bids totalling £4.5 billion.”
  This figure of £4.5 billion remained in the drafts of May and June 6, two weeks before the final report was published. But, by the final report, the saving had increased by £2.3 billion.
  The January draft has a neutral recommendation that advises connecting for health to “continue to closely monitor suppliers' performance.”
  The same recommendation in the final report has been altered slightly to praise the agency, saying that it should “continue its strong management of suppliers' performance.”
  And between the draft and final reports, a negative comment about Cable & Wireless becomes more positive.
  The comment refers to the company's contract with connecting for health to provide a secure e-mail service for the NHS. The draft says that Cable & Wireless did not achieve go-live and availability targets between October 2004 and March 2005.
  The final version wraps this sentence in a longer one that ends on a positive note. It says that although Cable & Wireless did not achieve go-live and availability targets between October 2004 and March 2005, these were not termination grade failures and the number of users increased.
  But the most striking changes are omissions.
  For  example,  the final report omits a criticism ab-out the output-based specification for the national programme. “We encountered a widespread view that there had been a lack of consultation about the development of the output-based specification,” one draft says.
  A draft also expresses uncertainty over whether trusts will set aside enough money to implement national systems locally. “Money will only be available if trusts give IT spending priority over other demands on their budgets,” says the January draft. This concern is removed by the final version.
  The June draft says of a failed implementation  of an x-ray picture archiving and communications system: “The Royal Liverpool University Hospitals NHS Trust rejected [the system] for its Broadgreen Hospital after an abortive three-month implementation effort." This is not mentioned in the final report.
  The June draft also says that Norfolk and Norwich University Hospitals Trust had “decided that it could no longer continue with delays in the delivery of the implementation of the new local service provider solution and it suspended the implementation of iSoft's patient administration system to be supplied by Accenture as it was not confident that it would be delivered to the timescale it needed.” Again, this does not make the final report.
  A research paper published in August 2005 by the London School of Hygiene and Tropical Medicine about implementing an electronic care record in four acute hospital trusts is excluded from the final report. The paper, says an NAO draft, “reported that uncertainty and poor communication were leading to a lowering of morale amongst NHS staff responsible for implementation.”
  Even a reference to criticism is removed. A draft says: “The programme represents the largest single IT investment in the UK and it is important for taxpayers and patients that it pays off. However, the programme has attracted criticism from many sources, which, whatever the basis of this criticism, emphasises the need for the programme to be well managed and open to public scrutiny.”
  But the final version says that it is “important for taxpayers and patients that the investment pays off, and for the programme to be well managed and open to public scrutiny.”
  The final version is longer than the first draft, despite the deletion of lengthy passages of criticisms. The extra space is given over largely to comment, explanation, clarification, and speculative statements in praise of the programme or connecting for health.
  By contrast with the January draft, much of the final report reads like a defence of the programme compiled by the department of health.
  Had the January draft been published, even allow-ing for minor corrections, it would have given the impression that the programme had much right with it, and much wrong. As it is, the final report gives the impression that the programme is one of the most outstanding successes in government IT.
  The NAO told Computer Weekly that the changes were part of the normal process of clearance that precedes every major report it publishes and claimed that conclusions and recommendations of the drafts had not changed.
  Meanwhile, the NAO said that it would produce a further report on the programme, with MPs on the PAC expecting to hold hearings based on it next year
Tony Collins is executive editor of Computer Weekly, where another version of this article first appeared.

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NHS neutered NAO’s criticisms of IT scheme
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