Jonathan Michael, a top NHS executive, had some good
words to say about Connecting for Health, an agency that is running
one of the world's largest civil IT programmes.
After pointing to a fundamental flaw in the NHS's IT-driven
modernisation, he told a healthcare symposium at London's City
University, "If that seems somewhat critical of Connecting for
Health, what we have to recognise is that CfH is evolving. It is in
a process ofﾉ refreshing its view and approach. But it is listening
and it is evolving."
The flaw Michael sees in the national programme for IT (NPfIT)
is its centralised, standardised approach at a time when the health
service is decentralising. The chief executive of Guy's and St
Thomas' NHS Foundation Trust, Michael wants IT support for the
specific ways people work in particular parts of his organisation,
such as the accident and emergency department.
"There is a fundamental flaw in terms of the business," he said.
"We are running a business in an increasingly decentralised
competitive healthcare market, rather than a centrally managed
healthcare market."
A rigidly standard approach "is not practical in a competitive
healthcare market where we may want to look at the business
processes within our organisation, be it in accident and emergency
or other areas, and to use our IT support systems to help us
improve efficiency".
Michael said the reality of the one-size-fits-all approach is
that it doesn't fit, or if it does, it constrains managers' ability
to run the business flexibly.
"The idea that the requirements for all hospitalsﾉ are the same
is, I think, simplistic. Flexibility is designed out of solutions
and out of the implementation process. So standardisation of IT
systems effectively dictates the standardisation of the business
model," he said.
Michael's speech about the NPfIT commanded the rapt attention of
his audience not simply because he is running one of the largest
NHS trusts in the UK but because it is rare for any senior health
service executive, especially one of Michael's standing, to
criticise openly the NPfIT.
After his speech, an IT manager in the audience said that
Michael had articulated "what many of us have been thinking for a
long time".
The speech also imposed on Mike Pringle, a professor of general
practice at the University of Nottingham and GP lead at Connecting
for Health.
Pringle, a strong supporter of the NPfIT, said, "It is very
interesting to hear Jonathan's perspective, a lot of whichﾉ I have
great sympathy with."
Michael's speech on 1 March was entitled "Information needs of a
large acute provider - can Connecting for Health deliver?" He said
of this choice, "I suppose you can see a degree of cynicism in the
title I gave this talk as to whether CfH can actually satisfy our
needs. CfH was conceived as a fairly centralised approach to IT
connectivity across the NHS at a time when the NHS was busy
decentralising, so there is a fundamental issue we need to
approach.
"The NHS is decentralising, not only across the four countries
in the UK but within England. And, of course, foundation trusts are
an example of that decentralisation and the change in status within
that decentralisation."
Michael's criticisms were aimed not at CfH but at the NHS IT
programme itself. It is expected to cost ｣6.2bn, mainly for
centrally-signed contracts with a small number of suppliers. But
the total sum could be up to ｣31bn once the costs of implementing
national systems locally are taken into account. Yet despite this
formidable investment by taxpayers, the programme shaped as it is
will not readily suit Guy's and St Thomas'.
"There are a number of things that we as an organisation are
looking for that are not currently available or are not available
in a timely fashion within CfH."
Caring for some cancer patients, for example, requires joint
decisions being made increasingly in multi-disciplinary teams.
Video conferencing is key to that, said Michael, but the original
plans for the NPfIT did not set aside money for video
conferencing.
Similarly, treating cancer patients sometimes requires complex
calculations of dosages. "Whether it is to do with chemotherapy or
radiotherapy, there are real risk management issues if you get that
wrong," said Michael. "You can say exactly the same thing regarding
a microdosage for babies. These are the sort of things that are
ideally suited to IT support." However, Michael said the national
programme was not due to deliver decision support systems such as
these soon.
As a user, Michael also needs flexible communications links
between different medical sites. "This comes back to the strategic
dilemmaﾉ about CfH being conceived as a centralised approach, where
the focus is on point-to-centre communication rather than
point-to-point communication."
In addition, he wants tailored systems to support patients and
clinicians in specialisms such as renal service, but he said, "The
original idea of having a standard system that would provide
support for all these different sub-specialities has some way to
go."
Michael also regretted that the programme would not now meet the
government's target of treating all patients within 18 weeks of
being referred to a consultant. The target for this is December
2008, but Michael said the functionality within CfH was not going
to be available until some time after this date, "So it is not
going to help us to meet that target."
Despite its size and complexity, the NPfIT cannot deliver
everything that trusts want. Still, Michael's comments touch on a
deep resentment in the medical and NHS IT community that the
national programme was set in motion in 2002 without widespread
consultation. In a mist of secrecy over the detail, the programme
was then, critics argue, presented to the NHS as a fait
accompli.
Michael referred to these early days of the national programme
when he said that Derek Wanless, in advising the government on the
future of NHS IT, had emphasised the importance of having common
standards for information and communications technologies. But
Wanless's call for common standards across NHS IT somehow
transmogrified into "ruthless standardisation".
On this, Michael said, "Our view is that wider use of available
application software from diverse suppliers would be beneficial and
allow us to deal with some of the lack of timeliness in the
processes."
He also alluded to the dual irritation for trust executives of
having to countenance delays in the delivery of core systems from
local service providers while being restricted from buying IT from
suppliers other than those appointed by CfH.
"I see the absolute critical nature of effective IT systems and
informatics in its wider sense in allowing us to deliver
high-quality, efficient patient care. So the need is as great as
ever. Solutions, however, are needed sooner rather than later,
preferably today, if not yesterday.
"There are a number of software communications technology
solutions already available to meet most of the needs. Our view is
that it would be helpful to have a slightly more flexible approach
by CfH, utilising these solutions to deliverﾉ more flexible
solutions at a faster pace than is currently envisaged."
A potential sticking point is that if CfH allows trusts to buy
what they want - even if to a common standard - this could
jeopardise the contracts the health secretary has signed with local
and national service providers. These deals commit the NHS to buy a
minimum volume of services and systems from the local service
providers, though details of the contracts are being kept
secret.
Even so, Michael said it was possible for some trusts to buy
systems that are not offered by their local service provider. "I
believe that some of the providers of CfH are recognising the need
for a greater degree of flexibility. Maybe within the contractual
framework there exists the opportunity for greater flexibility," he
said.
Picking up on the point, Pringle, CfH's GP lead, confirmed later
at the same event that there was flexibility in the contracts.
"It would have been foolish for CfH to have negotiated without a
plan B, and you will know there have been changes in software
providers, and that has happened without disaster."
Another speaker at the symposium, Robin Guenier, former head of
the Central Computer and Telecommunications Agency, from which the
Office of Government Commerce sprung, suggested that the NPfIT
would benefit from appointing one full-time senior responsible
owner to take charge of the entire programme.
But Michael said Guenier's proposal highlighted a fundamental
flaw in the NPfIT: it is too big and complex for one person to
oversee.
Indeed, Guenier's proposal gave Michael a chance to identify
what, for many, is the reason that numerous GPs and other
clinicians are struggling to give their support to the NPfIT is
being implemented.
"That [idea of a single senior responsible owner] fundamentally
demonstrates a strategic flaw of CfHﾉ The NHS is not a single
organisation. No person sat in the centre can dictate what goes on
in a whole series of autonomous organisations within a framework of
the NHS."
He added, "What people have been trying to do is to dictate to a
whole series of organisations what they should do, when actually it
is not what they want to do."
What is the problem with the national programme for IT?
In his speech to the City University, Jonathan Michael, chief
executive of Guy's and St Thomas' NHS Foundation Trust, questioned
none of the main objectives of the NHS's IT plan, which includes
establishing an electronic patient record. His criticism was of the
way the national programme is being implemented.
He questioned, for example, the wisdom of appointing a small
number of suppliers, known as local service providers, to deliver a
ruthless standardisation of systems.
Under the national programme for IT, contracts were signed in
late 2003 and early 2004 with four local service providers: BT,
Accenture, CSC and Fujitsu. The idea was that these suppliers would
provide what NHS trusts needed in new technology, including
electronic patient records, electronic prescriptions and systems to
book hospital appointments, known today as Choose and Book.
But some trusts are discouraged from buying core IT systems from
any company other than the local service provider.
Michael said, "From [the trust's] point of view, the constraints
of standardisation are that effectively all other IT investments
hitherto become legacy needing to be replaced. You end up having to
develop software through a small group of providers, even
effectively new software, even though there may be off-the-shelf
systems available, but available from somebody else, So where the
marketplace already has solutions they are not available to us
under Connecting for Health."
About Jonathan Michael
As a user, Jonathan Michael, chief executive of the Guy's and St
Thomas', speaks with great authority. He was knighted last year for
his services to the health service.
Guy's and St Thomas' Hospital in London is one of the UK's
largest NHS trusts. It has 1,200 beds, an annual turnover of ｣650m
and 9,000 staff. The trust provides specialist medical services to
south east London as well as nationally and internationally.
Michael was also a consultant in kidney disease at Queen
Elizabeth Hospital in Birmingham, where he established the largest
kidney unit in the country.