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Information and communications technology is evolving so rapidly that we cannot realistically plan systems implementation more than 24 months ahead. Maybe this was the thinking behind the magic figure of two years and nine months originally announced at HC2002 as the timescale for the implementation of what is now known as the National Programme for IT in the NHS in England (NPfIT)?1 In practice, timescales have stretched progressively from five to eight or even 10 years, depending on how one chooses to read the Connecting for Health (CfH) media releases.2 So how did this happen, and what are the implications? More importantly, who will pick up the pieces?
Distinguishing ICT from business process
There is a clear distinction between ICT itself and business process change. The two are related, but fundamentally different in nature. One evolves at exponential speed, is available instantly anywhere in the world immediately it is released — and is lots of fun for geeks to play with. The other evolves much more slowly, is dependent on local cultural issues — and generally causes lots of pain and anguish along the way.
No wonder, then, that tensions exist between the over-optimistic prophets of unfettered IT and a growing army of NHS employees struggling to deliver customer care in a post-modernisation setting. This is not necessarily anyone’s fault, but rather a simple fact of life that seems to have been lost in the grand design of the NPfIT.
Demise of existing systems
From the outset, CfH made it clear that specialist UK healthcare suppliers had seriously let down NHS customers with inadequate existing or ‘legacy’ systems. Suppliers failing to meet to stringent new CfH requirements would be banished for ever into outer darkness — or be encouraged to export their failed wares to unsuspecting foreign markets. But, it takes two parties to tango, and there is little evidence of any specific suppliers making significant money from persuading NHS organisations (not necessarily users) to buy anything against their own express wishes.
Anyway, as the putative NPfIT pounds rack up relentlessly from thousands to millions to billions, who is now to say the NHS has not been getting value for money from its long-serving existing systems? The indications are they will still be required for some considerable time, so let’s hope all the original suppliers have not yet gone away.
Role of ICT in healthcare
There is no question that healthcare has generally failed to take full advantage of available IT, and that the NHS needs to speculate first in order to accumulate significant benefit. Undoubtedly, relative levels of expenditure on IT in healthcare are low — it’s the same all over the world and certainly not a problem peculiar to the NHS.3
Why is this and what are the common causes of failure to invest in healthcare IT? The answers could have been determined by CfH, if their advisors had asked anyone with real hands-on experience of implementing healthcare systems. They would have learned very quickly that we can’t yet do ‘fly by wire’ in healthcare and, therefore, still have to rely on clinical users to help make IT systems work in practice. A primary cause is the ongoing crisis in healthcare service delivery. This is a worldwide healthcare issue, and won’t be solved solely by IT — or even by the NHS on its own.
Until we can achieve significantly higher levels of standardisation in clinical process, it will continue to be tough to apply IT effectively on the same scale as in other service sectors. In the meantime, there are a number of things we can do to accelerate the transition process and help ensure that at least the most basic NHS IT needs are met effectively. Pending arrival of a new generation of point-of-care clinical systems, life has to go on and NHS managers have to take responsibility for ensuring continuity of their core business processes.
Balancing local and central initiatives
So the major issue is not IT itself, but its application to basic business processes. This can only be addressed effectively at local level; not just trying to implement unproven central solutions based on impractical system concepts. Indications are that the NHS Executive is beginning to appreciate this point, but is finding it hard to admit the scale on which the original aspirations were misjudged.
But it would be a great mistake to dismiss the NPfIT as a totally worthless concept. There is much to be admired, particularly in the approach to central infrastructure support.4 If CfH can successfully complete even the basic elements, other European countries will surely benefit from the learning experience.
Local implementation priorities
Realisation of local NPfIT business objectives will now depend on continuing support and development of the much-maligned existing systems. This has already been recognised for GP systems and a similar situation is now emerging for hospital systems. The idea of a clean sweep with standard NHS PAS-replacement systems was never going to work in practice, and new systems will have to coexist with old for some time to come.
Pending availability of a full National Care Records Service (whatever this turns out to be), GPs and hospitals must either implement their own local electronic patient record (EPR) systems or continue to operate with manual paper records. This situation will become increasingly difficult to support without using interim local document-management systems. It is no surprise, then, that the hottest new application forecast by European hospitals is medical document management — but apparently not yet in the UK.5
Strategic challenge for LSPs
The challenge for the NPfIT's local service providers (LSPs) is to step into this breach and carry a new, more pragmatic, message to NHS trusts and clinical users. Some may have been under the impression that their NPfIT contracts represented ‘bankable’ business, but in practice this is far from the case. NHS trusts, already strapped for cash, need convincing of the scale of local resources and funding needed simply to secure current business processes and prepare for essential changes for the patient choice agenda. LSPs and their NHS clients are still heavily dependent on specialist support from existing system suppliers during the transition to the NPfIT's aims and objectives. The available pool of experienced healthcare-IT staff was never large enough to meet realistic demands. It was further depleted during the market stagnation that followed Information for health and has continued under the NPfIT.
Using large-scale service suppliers as prime contractors is an effective way to channel more skilled resources into the NHS market; this is how the USA market has operated for the past 20 years.6 The big mistake was to force LSPs to adopt limited-choice solutions selected by CfH with little reference to user needs at operating level. Even worse was the decision to demand major modifications to standard product specifications in the mistaken belief that CfH knows more about healthcare-IT system needs than major suppliers. Worst of all was the mistaken assumption that the choice agenda does not extend to individual NHS trusts in their selection of strategic IT systems.
Market forces bite back
So now market forces are beginning to reassert themselves; in the long run they always do. It was naive to assume that even an organisation the size of the NHS could unilaterally dictate the future direction of healthcare IT. The resultant UK market perturbation has merely accelerated a consolidation process that was already under way long before the NPfIT appeared on the scene.
The big surprise has been the ability of small specialist healthcare-system suppliers to adapt and reinvent themselves for a new market environment. There have been a significant number of mergers and acquisitions, and several companies have successfully floated on the stock market. Existing-system suppliers are playing an increasingly important role as subcontractors to LSPs, and many of them are seeing a significant upturn in their levels of business.
But the suppliers likely to gain most from the NPfIT are technology companies providing servers, desktops, commodity software, telecoms and diagnostic devices. Significant discounts are now on offer to NHS purchasers through national agreements but, as a result, major technology suppliers have had to reduce their costs of sale to the NHS. This means fewer supplier staff dealing directly with third-party healthcare system builders and NHS end users, plus closer and more direct marketing links with the NHS at government and strategic levels.
Medical devices and diagnostic companies are a major exception to this rule. They, too, are forging closer high-level links, but also maintaining and increasing clinical-level contacts in the NHS. These organisations can be expected to have an increasing impact on the future evolution of healthcare-IT and service delivery. It is surprising they didn’t figure more prominently in original NPfIT thinking.
Managing NPfIT expectations
As the Government moves to the next stage of NHS modernisation, there will be new requirements: for foundation trusts, payment by results, integration with social services and support for private-sector clinical services. Each of these offers major business opportunities for innovative suppliers, inside or outside the NPfIT, who can address the healthcare market from a position of strength and experience.
The priority for CfH must now be to manage expectations for the NPfIT in such a way as to secure effective completion of the essential basic infrastructure components as originally conceived by the NHS Information Authority — without throwing the baby out with the bath water. At the same time, local NHS organisations need all the help they can get from LSPs to manage the long and difficult transition from paper-based systems to electronic healthcare records. For all the NHS users and commercial suppliers involved, the risks of failure are too great to contemplate.
References
1. Government agrees four IM&T priorities for next “two years and nine months” of NHS reforms, backed by substantial funding. News. Br J Healthcare Comput Info Manage 2002; 19(4): 2.
2. NHS Connecting for Health. Business plan 2005/2006. Leeds: NHS Connecting for Health, 2005 (September). www.connectingforhealth.nhs.uk/publications/
3. Wanless D. Securing our future: taking a long-term view. London: HM Treasury, April 2002.
4. Silicon Bridge Research. Understanding the market for eHealth. Summary report for DTI. Basingstoke: Silicon Bridge Research, March 2002.
5. Silicon Bridge Research. European hospital market metrics — 2004 British Isles. Version 1.3. Basingstoke: Silicon Bridge Research, 2004.
6. Silicon Bridge Research and University of Sussex. Presentation to DTI Advisory Group on complex product systems approach to managing eHealth delivery. Basingstoke: Silicon Bridge Research, July 2001.
First published in BJHC&IM, April 2006
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