HL Deb 01 February 1993 vol 542 cc20-36

3.44 p.m.

Lord Dean of Beswick rose to ask Her Majesty's Government what is their response to the recent report of the Audit Commission, Caring Systems: A Handbook for Managers of Nursing and Project Managers.

The noble Lord said: My Lords, Members of your Lordships' House will know that over the past few months I have on more than one occasion raised the matter of the use of computers within the National Health Service. As a result of the replies I have received and reports that are now being issued, I believe it is time that some kind of discussion takes place on this matter. I do not believe that the Unstarred Question I have tabled today will be adequate to deal with this matter across the board as it constitutes a massive subject. However, as sure as I am standing here today, this will not be the last time the growing use of computers in the health service is debated.

This Unstarred Question concerns the Audit Commission's report, Caring Systems. However, I must cast my net a little wider than that report as this matter has reared its head on other occasions. A report was commissioned of the National Audit Office by another place. That report was published on 14th November 1990. It is impossible to discuss that entire report in the time available to us today but it was in effect an examination of the use of computers in various health authority regions.

Noble Lords will recall that some weeks ago I tabled a Question about the Wessex Regional Health Authority. My Question was based on the assumption that the loss to that health authority was £43 million. However, I understand that some £20 million has been recovered. The Minister who replied to my Question told me that investigations were taking place. I believe that they had already reached the stage of being dealt with by the Crown Prosecution Service. I shall not refer to those matters as in my opinion they are sub judice.

When I read the report of the National Audit Office I was alarmed to discover that even as far back as November 1990 such a report could be written. The Wessex Regional Health Authority affair has been referred to as a scandal. I emphasise that that is not my term. I wish to quote briefly from the report of the National Audit Office which refers to the Wessex Regional Health Authority. It states under the heading "Costs and benefits" with regard to Wessex: Original estimate of £26 million (£2 million interim systems). But it soon became clear that £45 million would be needed to fully meet requirements. By 1989 the original estimate had been spent, half on interim systems and total programme costs had risen to £69 million (interim £16 million). Delegation of responsibility for investment to districts makes future expenditure on RISP uncertain. Recent studies have identified quantifiable benefits.

RISP is the regional information systems plan. After the Audit Commission's report was published in August last year, Wessex Regional Health Authority abandoned that system. It would appear the authority had to bear the loss of more than £20 million of the £43 million I have referred to. The other £20 million or so of the £69 million I have already referred to is money which I think was spent by the area health authority in preparing for the system.

Nothing in the document gets to the heart of the problem of what should be done about computers in the health service. It makes some helpful suggestions, as does the Audit Commission's report on caring systems. A week after the Audit Commission's report was published the Department of Health issued a press release which was launched by the Parliamentary Under-Secretary in another place, Mr. Tom Sackville, who said: I have been encouraged in my visits around the country to see the enthusiasm of doctors and nurses for the use of computers in patient care. Though there have been some well publicised failures of information technology to meet the needs of users, my overall impression is that computers are being used more and more effectively to improve patient care.

I put down a Question for Written Answer asking what the National Health Service had spent on computers and back-up systems so far. The noble Baroness, as usual, replied very quickly. The aggregate figure given by the noble Baroness was approximately £250 million. However, responsible medical journals, going back to last August, indicate that medical staff are of the opinion that over £1 billion worth of computer and back-up systems are in use in the health service. I do not pretend that I know a great deal about computers. I do not. However, I know that the best computer is useless unless it is used correctly. At the end of the day you will not elicit the right answer unless the computer is operated by somebody who fully understands it and the correct information is put in.

Having studied in depth the auditor's report on the Wessex Regional Health Authority and the behaviour of some of the people involved in the computer business—not the regional health authority—I have no confidence that the health authority is getting a fair deal from the computer managers. I am worried in case the £1,000 billion of computer equipment may be seriously overvalued. The Government's policy is to increase the use of computers in the health service, and I do not disagree with that if that will improve the service. However, I do not want to see the health service become a milch cow for the computer manufacturers.

I have received a brief from the Royal College of Nursing, which has a vital interest because its members are affected. I should have thought that, if one expects medically trained staff also to become technicians, it may be necessary to consider a considerable restructuring of salary grades within the National Health Service. However, I shall say no more on that issue since I believe my noble friend Lord Cocks will deal with that aspect.

I was surprised by the sum of money involved in relation to one health authority because that is not the only case. Further instances are now coming to light of the misuse of computers resulting in financial loss to the National Health Service.

It may seem strange that somebody who comes from the North West should ask a Question about events 200 miles away, but I picked up my information from a small report in the Manchester Evening News. I have been in local government myself and I know what would have happened to me if, when I was leading it, my local authority had lost £46 million. I would not have been transferred anywhere else. I would have been dealt with summarily by the district auditor and might well have ended up in court and bankrupt.

I asked my Question on Monday, 26th October. I then found that a debate had taken place in another place on the previous Thursday in which the new Labour Member of Parliament for Southampton, Itchen—Mr. John Denham—had spoken for 10 minutes on the question of the Wessex computer scandal. The Minister who replied, Dr. Brian Mawhinney, was so concerned by the fact that the National Health Service in Wessex had lost £43 million that he said not a word about it. I find it strange that large sums of money have been spent unwisely yet the Minister replying to a debate in which the subject has been dealt with in some detail makes no comment at all.

I have mentioned the figure of £69 million. This morning it is reported that the BMA is deeply concerned that most of the trust hospitals are running out of funds and the health service may well grind to a standstill. No wonder, if that is the level of efficiency and the ministerial response. A few moments ago, the noble Lord, Lord Boyd-Carpenter, put his finger on the matter. He said that Ministers have responsibility. However, over the past few years the other place and this House have been transferring one responsibility after another from elected representatives to appointed bodies. We were told that the Secretary of State had the power to do this or to do that. A report published only last week showed that between 25 per cent. and 30 per cent. of the total sum of money spent in the public sector was now spent by appointed bodies. Without wanting to make a political point, perhaps I may point out that we all know where the appointees come from. Ninety per cent. of them come from Central Office. That is undeniable. One has only to see the posts held by former MPs who lost their seats in another place and Members of your Lordships' House; the majority are from the Government Benches.

I should like to take this opportunity to ask the Minister whether she cares to correct the answer which she gave to my Question on 26th October. I do not suggest for one moment that the Minister tried to mislead me or the House, but the way in which the information was supplied to her and the Answer was written can only be described as misleading. In answer to my Question the noble Baroness, Lady Cumberlege, said: The department was concerned. Although the scheme was very much a regional one and the region has taken responsibility for the mistakes that were made, the department on a number of occasions, through its regular review system, raised the issue with the region. The Secretary of State quickly appointed a new chairman, who in turn appointed a new regional general manager, whose first act was to call for an inquiry into the scheme and to abandon the project".—[Official Report, 26/10/92; col. 902.] That answer is not as accurate as it ought to be in the light of information that I have since obtained. I obtained a copy of the auditor's report on the Wessex situation. It was made clear in that report that the new chairman was appointed in 1988 and no action was taken to deal with the situation until 1990. He was in office for nearly 18 months before any action was taken. I understand—the issue is now in the public domain and I cite what is in the report; it was in one of the weekly magazines last week—that the chairman further exacerbated the situation by authorising an order for a computer worth £3.3 million without informing the remainder of the board of the regional authority. By the time the computer was commissioned, it had reduced in value to £1.3 million, a loss of a further £2 million.

Friends of mine asked a lawyer—he has spent a lifetime in local government at senior level and now works in the health service—to provide a brief from the auditor's report. Out of courtesy I made a copy of the brief available to the Minister last week. A number of matters in the report need further examination. I shall not go into them today. However, I wish to put the facts right. According to the auditor's report and the brief that I have, the person who initiated the inquiry and called in the district auditor was the new general manager. Until he arrived, nothing had happened. I suggest that that situation could be dangerous.

I have spoken for some time because the subject is complex. Where is the equal society that the Prime Minister, Mr. John Major, tells us he is aiming for? I understand that last week in another place there were robust exchanges between the Labour and Government Benches after the reference by the Secretary of State, Mr. Michael Howard, to the situation in Lambeth.

As a former leader of a local government in one of the largest cities in the country, let me make my position clear. I hold no brief for officers or elected members in local government who do not behave themselves. Even if they behave badly through lack of knowledge, they are liable to surcharge if the ratepayers lose money. However, what happens to people appointed to such positions who (to say the least) prove inadequate and lack ability to carry out the functions with which they have been charged? In the final analysis, it is not the chairman of a regional health authority who is to blame. It is the Secretary of State. He or she has the power to deal with the situation and should start dealing with it in the same way that he or she would deal with local government.

Although such people to whom I have referred are appointed, in terms of public responsibility and the dispersal of public money they are bound by the same laws as local authorities. When people are found to be incompetent, with such sums of money to which I have referred being badly spent, surely it is time that the matter was considered. What is happening now? A Written Question was tabled in another place. The Answer stated that such information was not held centrally. Information referring to £69 million was not held centrally. The information had gone before it was known. No answer is given. The advice is, "Write to the regional chairman". If such advice is used by the government as a defence they ought to bring the regional chairmen to the Dispatch Box. Sometimes the answers from regional chairmen are couched in terms such as, "I am responsible only to the Secretary of State". That is not the most courteous way of dealing with the situation.

I have spoken for some time and have widened the debate from the Motion on the Order Paper. However, I believe that I have given Members on both sides of the Chamber enough information to make them anxious that matters are not as they ought to be. Mr. John Denham, the Member for Itchen, Southampton, is on record as asking that the Public Accounts Committee in another place should review the position. Nothing less than that will suffice. No oath of silence by a Minister of State in another place will close the subject because it is out in the open. What occurred in the South of England is out in the open only because of the pressure by local newspapers asking what is going on.

I express my appreciation to noble Lords who have awaited the debate. Computers are a technical subject. However, I hope that I have said enough to convince your Lordships that the situation requires a thorough examination in the interest of everyone, including that of the health service, so that money does not sweel away as it has in the past.

4.8 p.m.

Lord Cocks of Hartcliffe

My Lords, I should like to pay tribute to my noble friend for the tenacious way in which he has pursued the issue and has brought it yet again before your Lordships' House.

By coincidence, two days ago I talked to Mr. Ian Pope, a local estate agent for GA Property Services. He told me that he had installed a computer to try to match vendors to purchasers but had had to scrap it because it did not take into account the human element which is particularly important at that stage in the property market. We know that there are problems facing the National Health Service. Indeed, I noticed recently for the first time an advertisement in the local evening paper by a firm of solicitors inviting people who thought that they had cases of alleged malpractice to contact them to see whether a case could be worked out. Only last weekend a firm of solicitors advertised locally inviting people who thought that they had been victims of passive smoking to contact them with the same objective.

We hear complaints about lack of specialists in the service. Yet with the creeping plethora of potential litigation copying the United States, is it any wonder that people are reluctant to go into the specialisms of obstetrics and gynaecology?

The question of the National Health Service is overlain by the exponential growth in the cost and sophistication of new treatments. Only yesterday in the Observer I read an article entitled, GPs face writs if hospitals refuse patients". That trend needs to be considered seriously. That is why I welcome my noble friend's debate, because the sums involved in computerisation are enormous. Very often we tend to forget the pace of technological change. The first time that I saw a television set was at my dentist uncle's place when I was 18. It was a broadcast of the Fifth Test at the Oval in 1948. I remind noble Lords that England was all out for 52. Perhaps the events in Calcutta may be regarded in the same perspective.

We do not like to admit that new techniques are very hard for adults to grasp. Nobody likes to say: "I do not understand it. I know you have explained it to me, but I still don't quite see it".

I should like to give an example which was sufficiently long ago not to offend colleagues in another place. The noble Lord, Lord Orr-Ewing, was chairman of the Metrication Board, which was set up to prepare the British people for the change from the old coinage to the decimal currency. On the first day when the new decimal currency was operative, I sat in the Tea Room in another place and watched a queue of my colleagues lining up to order their coffee, tea, bun, etc., holding out a handful of change to the lady behind the counter, allowing her to sort out what they had to pay. I am quite willing to take a submission that people in another place are below average intelligence. Nevertheless, the point is that they were totally bereft of any understanding of the new coinage.

The same goes for computer literacy. I believe we have all had the humiliation of having our video recorders set to record a piece in the future, at another time, possibly on another date, and having it done by a child of nine or 10 who is totally at home in this new medium. Certainly, for myself, I am almost bereft.

We have to remember that the people serving on the boards and holding the positions are quite frankly too old to master the new techniques. It is very difficult, if one is sitting on a board listening to people making a computer presentation to say to them after perhaps an hour or a couple of hours: "Would you mind going through it all again. I did not really follow you after the first five or 10 minutes". Today's opinion-formers and decision-makers are from a previous generation. They are being asked to make decisions. They are in the hands of experts who present the knowledge. Very often the experts themselves have substantial vested interests in the decisions made and there are vast sums involved, as my noble friend has pointed out. That is one of the roots of the problem which has been described.

My noble friend mentioned the question of the Wessex authority and the difficulties there. I was surprised when I read the debate in another place about the National Health. Service on 26th January that this problem had been largely ignored. Nevertheless, there was a mention of it and it was brought up by the honourable Member for Birmingham, Northfield. He said: Qa Business Services, the computer division of the regional health authority, was sold off and went bust within 18 months. Millions of pounds have been spent on a value-for-money exercise that saves no money. We see HealthTrac, a new all-singing, all-dancing supply system that has to be investigated by the Audit Commission. That is what is happening under the new-look national health service". [Official Report, Commons, 26/1/93; col. 953.] Opening the debate, the Shadow Secretary of State said: Right through the summer and autumn, the West Midlands regional health authority was nothing less than a fiasco—millions of pounds wasted on privatisation and consultancies, audit reports, National Audit Office reports, but no action, a refusal to take any steps [etc.]" [col. 892.] So it was mentioned, but not to the extent that I would have expected, given the sums which were involved and the difficulties exposed by the audit report.

The Minister may recall that at Question Time on 16th November, I asked whether we were absolutely sure that all these advances were in the best interests of patient care. I was conceited enough to draw to the attention of the House the fact that I serviced the entire captain's office on HMS "Siskin" with an old Imperial, a Gestetner and a few filing cabinets. I know that we have to progress, but the "Caring Systems" handbook which is the subject of my noble friend's Question today says: in the rush to meet Resource Management timetables, systems are sometimes being installed without proper consideration of objectives ... some hospitals have a computerised care planning system which restricts the extent to which plans can be individualized". The Minister will be well aware that the report of the National Audit Office which my noble friend mentioned has a number of appendices at the back which are almost embarrassing to read. The North-East Thames project summary mentions: no feasibility study or investment appraisal; inadequate user consultation; inadequate planning; weak project management; and poor financial monitoring. The North-Western all-districts summary mentions: no feasibility study or investment appraisal; no review of pilots before roll-out.

It would weary your Lordships to go through the report. There is a common theme running through it. It is that the matter has not been properly thought out and has not been properly handled.

Why is that so serious? My noble friend Lord Desai pointed out from the Front Bench on 16th November that all the mismanagement of computer systems means that money is lost which could be spent on other things within the health service. My noble friend Lord Ennals drew attention to the fact that loss in Wessex led to the closure of 20 beds in St. Martin's Hospital. That could be repeated. In the Dorset Echo the chief executive of the Dorset Health Authority said that the loss on the computers meant that up to 600 people in the county had not received treatment. That was when the loss was estimated at £20 million. But my noble friend has shown that it is in fact over three times as much as that.

I mentioned at the time that the sums involved would have provided in my former constituency of Bristol, South the hospital for which my friends have been waiting for so long. But I have often thought that we should look at the matter in terms of what could be done with the money. The Bournemouth Echo of 24th July pointed out how many hip replacement operations could have been done at a cost of £4,000 each; that 900 heart transplants could have been done at £23,000 each (that is on the £20 million figure); and that 1,000 kidney transplants could have been provided at up to £20,000 each. It would have paid for 30,000 full days of treatment in intensive care. So the issue is one of great seriousness.

My last quotation is from yesterday's Sunday Times. An article by Peter Kellner is headed, Terminal case of truth haunts NHS". He says that with all the reforms that have gone on, with the introduction of all the extremely expensive computer equipment, nobody knows what is happening in the National Health Service. I do not make a party point about that. I want to be as even-handed as he was. He concludes: I have a simple proposal. Mrs. Bottomley and Mr. Blunkett should declare a moratorium on statements that the recent NHS reforms have been either a stunning success or a ghastly failure and jointly admit that, in all honesty, they haven't a clue. I would not expect the Minister to embrace that concept, but I believe that, for a service which is so important to so many of our citizens, we should sit down and have a good look at just what is going on. The health service journal quotes the director of European Marketing Associates as saying that the National Health Service spending on computers is actually three times what its leaders believe. That figure is quoted in a Royal College of Nursing brief which fortuitously arrived this morning. It would perhaps be fair to use a summary from the brief which structures the remarks in a much better way than I could. It states that with any computerised system, patient confidentiality must be protected". I am sure that we would all embrace that. It goes on to point out that computer strategy has significant resource implications because of the enormous sums involved, and states that, without the full support and involvement of nurses, no patient care system could work effectively". It is therefore necessary to introduce the training schemes to which my noble friend Lord Dean referred.

I am sure that people would have a much better grasp much sooner than the Members of the other place had on decimalisation. However, it is difficult for people to admit that they do not grasp the concept. Thorough training is required and such is the cost of the new systems that it is essential that the best value for money is obtained. I shall not digress to other government departments but I believe, for example, that the Foreign Office has had computer problems which have caused losses of some millions of pounds. It is not a party point. If we are pouring resources into information services it is in everybody's interests that they work effectively.

Finally, once again I thank my noble friend Lord Dean for drawing the matter to the attention of the House.

4.22 p.m.

Lord Rea

My Lords, my noble friend Lord Dean of Beswick has done us all a service by drawing our attention, in the widest possible sense, to the matters discussed in the handbook. On first reading it is an innocent enough document and in fact will be helpful to nurse managers. It gives guidance based on a wide inquiry of how they should set up and operate good management systems to maximise their effectiveness while minimising their interference with "hands-on" patient care—what most of us believe to be their real job.

It is becoming the tradition of the Audit Commission to put forward realistic suggestions about overcoming problems and not merely to uncover bad or wasteful practices. Reading between the lines of the handbook it is possible to discern a sad state of affairs brought about by the excessive zeal of managers to use computer technology to solve almost every problem.

Paragraph 18, on page 8 of the handbook under the heading "Letting the tail wag the dog", states, A number of the hospitals studied had started from the presumption that a computerised nursing system was needed. Only then was consideration given to possible uses. The resulting systems constrain rather than facilitate changes that nurses subsequently wish to make to the organisation and quality of care … Once implemented, it is harder to change a computerised system than to amend manual procedures". The rationale behind the enthusiasm of managers for computers is not always easy to ascertain. Paragraph 21 states: Computerised products are constantly evolving. Many have only a very short track record by which purchasers can be guided. The number of additional facilities offered or promised, apparent ease of use and quality of report presentation can therefore assume inordinate importance when a system is chosen". Often there has been disappointment in the quality of support and advice from some system suppliers. One wonders whether some managers have been hood-winked—my noble friend suggested perhaps even less honourable reasons. The Wessex overspend, referred to by both my noble friends, has been made public and discussed. The handbook implies that many other smaller computer systems throughout the country have also been unwisely chosen. It will be difficult, if not impossible, to calculate how many and which systems are performing well and saving money, and how many have failed in their object and may be wasting the time of the clinical and nursing staff who are trying to operate them.

In the brief mentioned by my noble friend Lord Cocks the Royal College of Nursing states that, thousands of nurses across the country … have been forced to struggle with computer technology with inadequate training". There are areas of nursing which are not at all suited to computerisation—individual care plans for patients being the most obvious. At page 20 of the handbook a case study is given of computer-assisted care planning. It states, On one medical ward studied, the complete care plan of a patient staying for five or six weeks could amount to a pile of computer printout six inches thick … Any written individualisation [care] was thus effectively lost the following day. A separate written continuation record of care was therefore necessary and all important information on the patient was held in this. The weight of the care plans precluded their use for handover between nurses. One side-room was completely filled with back care-plans … Clinicians' views of the usefulness of nursing care plans were understandably scathing". The team which compiled the handbook also visited the United States and France. In the best "Magnet Care" hospitals in the United States—the creme de la creme hospitals—individual patient care was handled manually. They had given up trying to do it by computer; it was not appropriate. That is not to say that modern information systems should play no part in organising and managing hospital nursing activities. But the aims and needs of each segment of work—care planning in the case of nursing; workload assessment or rostering; who is on duty over the weeks and months—must be carefully thought through before a decision is taken to buy an expensive computerised system. Our anxiety is that the zeal of managers has taken over and that too much money may be being spent.

The computer industry may be aware that the new National Health Service is a seller's market and may be taking advantage of managers' wishes to desperately find quick solutions to new and formidable problems. That is of crucial importance when, as my noble friend pointed out, throughout the country hospitals are being forced to curtail admissions for routine surgery due to lack of money. A two-tier service between the patients of fundholders and non-fundholding GPs has clearly emerged. As an aside, I may add that a contributory factor for the two-tier service is that the money for fundholders has been subtracted from that available to district health authorities to pay for the routine operations that they are now being forced to curtail.

I wish now to turn to questions notice of which, I understand, was given to the noble Baroness by telephone. They follow some of those put by my noble friends. Can the Minister give us an up-to-date figure on expenditure on computers by the Department of Health and by the regions of the National Health Service over recent years?

My noble friend Lord Cocks has mentioned the brief from the Royal College of Nursing. That quotes two figures similar to those given by my noble friend Lord Dean. The most recent figure given by the Department of Health is £300 million. But the figure amounts to £990 million according to a survey by the European Marketing Association. When the noble Baroness comes to answer the question I wonder whether she will tell us how the figures she gives have been derived.

Is there much variation between the regions? For example, can she tell us which region is spending the most and which the least on computers? Can she give us the latest figures for the numbers of managers and clerical or administrative staff in the National Health Service as a whole over recent years? What proportion of the total cost of the National Health Service is formed by expenditure on administration? The NHS has up to now been rather proud of the fact that its administrative percentage has been very low—something like 6 per cent.—whereas on the other side of the Atlantic administration costs amount to 20 to 22 per cent. of a much higher total health bill. What has been the trend in the United Kingdom over recent years?

The report of the Audit Commission published in April 1992 states: Whilst spending on IT is increasing auditors have found little evidence that it is well managed and well controlled. Auditors have drawn attention to these matters but it seems evident that improvements may take some time to implement and computing expenditure will continue to rise during this period". My noble friends have made some cogent points to emphasise this. I believe that it is the function of an opposition to keep a government on their toes. I hope that the noble Baroness can satisfy us that effective action is being taken to address our concerns and those of the Audit Commission.

4.32 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, I should like to thank the noble Lord, Lord Dean of Beswick, for bringing this matter to the attention of your Lordships' House. Little did I think that it would be quite so wide ranging. It included not only computers but cricket, litigation, decimal coinage and the speed of change. As the noble Lord, Lord Cocks, presumed, I will not confess to not having a clue about the National Health Service; rather, I shall address my remarks to the subject on the Order Paper today which concerns the Government's response to the recent report of the Audit Commission, Caring Systems: A Handbook for Managers of Nursing and Project Managers. Towards the end of my speech I shall address the points that have been raised in particular about the Wessex computer system and some of the relevant figures.

I welcome the handbook which the Audit Commission has produced. As ever, it has been conscientious in exercising its role as the public's watchdog. Your Lordships will, I know, join with me in acknowledging the valuable part the commission plays in ensuring that we get not only good health services but value for money. These are aims which we all share.

The handbook, published in December of last year, outlined a number of concerns about the way the health service was managing information systems for nurses. It focused particularly on some cases where there was a lack of planning prior to the installation of systems. The report also pointed to a need to improve nurse education and training in order to maximise the benefit of these systems to patients. In doing so it confirms that the action which the Department of Health is taking is the right action. I shall come later to how the Government's strategy, launched in the week before the handbook, is addressing the points which the Audit Commission raises.

Computers are becoming an important tool in the effective management of the hospital ward. I know that some of your Lordships have a healthy scepticism about the information technology revolution. The noble Lord, Lord Cocks of Hartcliffe, is right to point out that it is the human element which is most important, especially in health care, and that nurses must not become slaves to data-hungry machines. It is fair to say that in the past many NHS computers have been used solely to produce statistics and their clinical application has been of limited value. But the Government have set out to transform the old centralised and monolithic NHS.

Nursing, midwifery and health visiting are professions which are changing rapidly in the 1990s. An ageing population, increased patient expectations and the rising costs of applying technological innovations have all stretched finite resources. Purchasers and providers of health care are faced with ever-increasing demands for improved quality and greater volumes of service. The incentive to use resources more efficiently has never been greater.

It is interesting that in its handbook for ward sisters the Audit Commission found no evidence of a systematic relationship between the quantity of resources available in wards and the quality of patient care. It went on to say: What distinguishes the wards that are succeeding is that they manage to use all their resources to release nursing time for patients". Information systems can help the NHS to face the challenges and seize the opportunities that all these changes have brought. They can harness the skills of the workforce to greater effect; they can help improve care, increase efficiency and raise effectiveness. By allowing different people to pool information these systems can transform the ways in which the NHS delivers compassionate services.

The new technology can also improve the working day (and indeed working night) of the great army of nurses, midwives and health visitors who commit themselves to the care of the most vulnerable members of our society. Information technology can be a highly effective tool to add to their exceptional skills and commitment. For example, it can give staff the information they need about a patient at the press of a button instead of waiting for hours for a file to be unearthed and delivered. A computerised system put in to handle nurse rostering can both develop and simultaneously accurately cost a roster, allowing the ward sister to manage her budget more efficiently.

The Audit Commission's handbook recognises the benefits that computers can bring to the work of health professionals. The Government welcome this. It also adds a note of caution about some of the problems which new technology can bring, many of which were highlighted this afternoon in your Lordships' debate. Unfortunately the report is based on a survey that started in 1991. Much of the evidence gathered relates to the resource management pilot sites set up by the management executive in 1988. These were established to ensure that the management executive dealt with any teething troubles before it began wider investment across the NHS, so it is perhaps not surprising that the commission came across some of these problems. The Audit Commission's survey will have missed much of the good work that is now going on as a result of that learning process.

For example, in Bishop Auckland nurses are reporting benefits from their nursing system in the recording of activity and therefore the planning of patient care. Their system has been implemented very recently, but they are already using workload information to match nursing resources with patient needs. Contrary to the views of some of the nurses mentioned by the noble Lord, Lord Rea, these nurses see the new system as a very useful tool and will not now want to be without it.

Last December, the NHS Management Executive launched its information management and technology strategy. In a press release the Royal College of Nursing welcomed it and was particularly pleased to see that nurses had been consulted throughout the planning period and had had special advice booklets published for them. Without the full support and involvement of nurses no patient care system can work effectively.

The information management and technology strategy tackles all of the main problems that the Audit Commission has highlighted. First, it addresses the problem of making sure that nurses understand the benefits of the systems and are happy with using the new equipment. One of the keys to successful implementation is positive involvement, consulting staff about the system and discussing it with them. I read in Nursing Standard last month about one site which held a party involving the patients and relatives on every ward as the system went live. The site involved all the staff in explaining to patients why computerisation was useful and specifically how it would improve their care. The system went in smoothly and in much less time than at some other sites. But I agree with the noble Lord, Lord Cocks of Hartcliffe, that even with imaginative approaches such as this, if the system is not user friendly enthusiasm rapidly wanes. A common complaint is that the language which computers use is not the language which is used on wards. It is not surprising that people are daunted by the jargon: a glance at the glossary at the back of the commission's handbook reveals a mystery world of "PENFROs" and "TDS7000s".

An important part of the management executive's strategy is to develop a language for computers which is based on the words which nurses and their professional colleagues actually use. This project is in no way intended to constrain the language of the nursing profession. Rather, it is intended to capture and codify it as a foundation for the development of new systems. Its development is being guided by the Strategic Advisory Group for Nursing Information Systems which was established in December 1991. Its remit is to advise the management executive on the pace and direction of information systems and the overall development for information technology. Its members include representatives from the Royal College of Nursing, the Royal College of Midwives and the Health Visitors' Association.

The noble Lords, Lord Dean of Beswick, Lord Cocks of Hartcliffe and Lord Rea, raised the issue of training. I am very pleased to tell your Lordships that the strategy is also supported by work to improve training and education for nurses who are working with computers on the ward. It recognises the need for people to be fully trained to apply these systems imaginatively and effectively. The advisory group is examining how training in the use of information systems can be brought into the mainstream of education for the nursing professions.

A nursing workforce capable of using information technology to manage both clinical care and nursing resources is a must for the NHS as we move towards the next century. This has considerable implications for nurse training. Manchester University has now accredited a course in this area and Oxford Regional Health Authority has developed an excellent resource management course with the Royal College of Nursing. The Strategic Advisory Group has set up a working party to take forward this important area of work with purchasers and providers of education.

As the handbook makes clear, it is important to make sure that the right equipment is installed. Maximising value for money is a central feature of our strategy and it provides a framework to ensure that the NHS gets the best possible value from expenditure on computer systems. Most hospitals which have bought nursing systems through the Resource Management Programme are reaching the period for evaluation which is a requirement of this programme and we look forward to those results with interest.

In setting policies and standards for information management and technology, the NHS Management Executive is providing a national lead. Purchasing and implementation, however, remain local issues, but those wishing to invest in IT will have to produce a convincing business case, meeting the points highlighted by the National Audit Office's 1990 report which your Lordships have drawn to my attention this afternoon. The management executive is also working with suppliers to set quality standards for new systems. It intends to introduce a procurement questionnaire by April 1994. Suppliers will then have to clarify that they will comply with national standards at the time of procurement. In this way we will ensure that suppliers develop quality products which are appropriate to the NHS and its needs and overcome some of the weaknesses of the past.

To support the Government's overall strategy, the management executive, working with colleagues in the regions and in individual hospitals, consultancies and academic institutions, has produced a wealth of guidance. Much of this has been referenced in the Audit Commission's handbook, but Tom Keighly, the regional nursing officer for Yorkshire RHA, has said that the handbook does not recognise the success of the management executive's guidance. For example, in Yorkshire over 1,000 copies of the learning programme Using information to manage the Nursing Resource are in use. Nurses are benefiting considerably from this programme run in several districts in conjunction with colleagues of higher education.

The Government have made no secret of their concerns about the weaknesses of the Wessex RISP scheme. As your Lordships have indicated this afternoon, this was a very large project which was mismanaged. The auditors have diagnosed several underlying problems: insufficient financial controls; unrealistic cost estimates; insufficient information to members of the regional health authority; and lack of proper control systems. Wessex has now put the basics right. It has revised its financial procedures and instructions and trained all staff in them; it has renegotiated two major computer contracts so that it now gets a better service at a much lower cost; it has taken independent legal advice on the scope for redress on all aspects of the project and reached a satisfactory settlement with one of the companies involved.

The noble Lord, Lord Dean of Beswick, referred to a decision to purchase a computer at a cost of £3.3 million. Your Lordships will understand that I cannot say much in detail about this now as it is still the subject of legal action which is now being vigorously pursued by the authority. The district auditor concluded that the decision to purchase the computer was premature and based on an unrealistic development plan. The underlying problem was lack of independent advice to those making the decision, including the regional chairman. That has now been put right. The computer has been installed and is operating successfully.

Lord Dean of Beswick

My Lords, I am grateful to the Minister for giving way. The point I was making is that the district auditor's report makes a specific observation that the computer was purchased solely on the initiative of the chairman and that the other members of the board were not aware of this and were not informed. That point was made by the district auditor, not me.

Baroness Cumberlege

My Lords, I thank the noble Lord for that clarification.

I shall now address the questions of the noble Lord, Lord Rea. I thank him for giving me notice of them. The noble Lord asked whether the department has any figures on expenditure on computers centrally and for each region and what changes there have been in expenditure on computers over recent years. Total expenditure on computers for hospital and community health services including their maintenance and contract services was £253.8 million for 1990–91. On a regional basis for the same year revenue expenditure ranged from £5.2 million for Oxford to £11.9 million for South-East Thames. Capital expenditure ranged from £3.6 million in the Northern region to £17 million for the North-West Thames region. Changes in expenditure over the preceding two years show a rise in revenue expenditure from £67.2 million to £134.6 million and in capital expenditure from £62.5 million to £119.2 million.

The noble Lord also asked what was the number of NHS staff involved in administration. The number for administrative and clerical staff employed in September 1991 was 127,370. He also asked how this compared with clinical staff for previous years. I have not been able to get those figures this afternoon but I should like to point out to your Lordships that the NHS is the largest employer in Europe. It is essential that we have strong and effective management in place. That is a view shared by the BMA, which in past times has made it plain that it believes that the NHS needs not only better management but more management.

The management has been deliberately strengthened in order to ensure that it has both the quality and quantity of managers to run a £27 billion organisation. More than 75 per cent. of all NHS staff are involved in direct patient care. The NHS has a larger turnover than British Airways, ICI, Shell, Glaxo and IBM combined. I believe that we manage the NHS on a shoestring.

In conclusion, your Lordships will be pleased to know that the department and the Audit Commission see eye to eye on information systems which nurses need, and our strategy reflects this. It would have been marvellous if its survey some 18 months ago could have picked up on more of the good practice that is now becoming commonplace. But what is clear is that we have common aims. We are both working to ensure computer systems for a modern and efficient NHS; systems that are centred on the patient, easy to use, cost-effective and, above all, of benefit to both staff and patients alike. I am confident that with careful management and sustained investment we can build those systems to take us forward into the next century.

Lord Sefton of Garston

My Lords, before the noble Baroness sits down perhaps I may point out that my noble friend Lord Dean of Beswick said that if these surprisingly vast amounts of money occurred in local government there would be a very good chance that local government officers and management would be surcharged and would lose their right to sit on a local government body. Does the same law apply to these appointed bodies? If not, why not? If that law does not apply, do the Government intend to make these bodies subject to the same rules and regulations?

Baroness Cumberlege

My Lords, the chairmen of health authorities at regional and district level, or chairmen of trusts, cannot be surcharged. But they are accountable to the Secretary of State. Your Lordships will be aware of many recent changes of the chairmanship of regional health authorities in the past year or so.

Lord Sefton of Garston

My Lords, the second part of my question was: do the Government intend to do anything about that and make sure that the bodies are responsible?

Baroness Cumberlege

My Lords, I was trying to point out that the Government do take action. That is why we have had resignations in the past year.