Jüris Kelley
President, Knowledge In Motion — An IT/ICT strategy and services company specializing in the public sector.

The NPfIT program has a lot going against it, including the probability of success. Generally speaking, the larger the program the greater perceived risk of failure due to cost overruns. Along with its mammoth size, NPfIT must overcome:

• Notoriously complex scope of automating medical records
• A poor sourcing strategy
• Sourcing partnership in name only.

Automating any medical community with a centralized patient records database system is a notoriously complex endeavor on any scale. The way to achieve medical records cost savings is to truly eliminate paper from the process, and that requires many processes to be completely automated. It appears that NPfIT did not anticipate this, which is the primary cause of their scope creep.

Overcoming an ill-conceived sourcing strategy can be a challenge, which is what the NPfIT’s contractors are now attempting to do. The Government's idea of dividing the program into five geographic clusters to reduce risk seems silly in retrospect. It has only increased risk.

Separating the scope into logical components — such as infrastructure and applications — seems only logical for such a large program. The Government generally did not do that, but the remaining NPfIT contractors have recognized this and are attempting to divide the work into logical — not geographic — functional areas.

A program of this size requires excellent program management, governance, and a partnership with risk borne by the customer and the contractors. NPfIT was never a partnership if the delivery risk remained solely with the contractors.

Clinical professionals do not like change. They prefer to focus on providing quality health care to their patients rather than typing medical records into a mandated patient records database. From their individual perspective, the average General Practitioner probably is less efficient in using an automated system. Therefore, engaging them to understand the long-term, macro-level view of the program is vital for success.

So does NPfIT have a chance? It’s probably too early to tell, but clearly time is not on their side. 

A Senior Sourcing Executive from a Large U.S.-based MNC
At the outset, when I say that the project was based on lofty goals, I must add that no one related to the project had any bad intentions. And that’s usually the case. NHS wanted to transform itself into an organization that provided the best patient care in the world and they chose to go the big-bang way. The providers that opted to join evidently shared the same dreams. But together, they were not aware that the ‘unknown unknowns’ in this project was far greater than the ‘known unknowns.’

Consequently, the planning or blueprinting stage carried the same risks and at some stage the risks even multiplied. That’s when execution became difficult and with a moving target (expanding scope) some of the key milestones got missed.

Some key observations:

• Even when you get people with the right skill-sets, the results depend on how you structure them to deliver. The same is true of processes: Discrete number of perfect processes need to be structured to beget one large process. Take the case of a vendor management organization (VMO) or a program management organization (PMO). In the case of NHS, it seems that the projects were so highly multilayered that it would have robbed the efficiency of the PMO or VMO. With the project being split regionally, it introduced the chance of one mistake appearing in five places five times. 
• The continually expanding scope of the NHS project is a symptom of inadequate requirements gathering and deficient current state analysis. While these have to be done in a duly diligent manner, in projects of this scope and scale, there has be coherence in analysis, which would give early red flags about project progress. 
• This is a good case of multisourcing approach. But when it comes to matters like governance, governing multiple suppliers adds huge complexity. One would expect suppliers to collaborate but it vastly depends on the rewards systems in place. One may have SLAs with each supplier and stringent penalties for not meeting it, but what about handovers between suppliers? This is an important part in managing such large projects. 
• Consider the time in which this project was incepted: It was the era of mega-deals that attempted transformation of large organizations. One cannot negate the philosophic foundations based on which the project was handled. In other words, if it were to be done today, it would have been surely done very differently. 
• The service providers involved in the deal bit off more than what they could chew. It seems they did a poor job of assessing their financial risks. It could well be pointed out that unlike North American companies, most European companies are very tightly managed (both in terms of money and time) and there is very little scope of cutting off the fat.  Providers who come in with a consulting pedigree usually pad themselves heavily but when they realize that a services implementation is about throwing people at the problem, their pads wear off quickly. This is exactly what happened. 
• Five years ago, governance was a fluff term, but no longer. There is enough appreciation for governance, and it has now become an operational task. But it is important to note that good governance requires good investment, something that NHS might have ignored.

Despite this, NHS deserves all praises for the results it has delivered. In the end, one does not even know whether there is a fault-free way to pull off such a project with all due constraints. Granger’s successors might know best how to fast track the landmark project to completion.