Moves to centralise NHS IT deals could stunt progress

Many NHS trusts have made many excellent deals for their own IT services. Could government plans to centralise IT purchasing in...

Many NHS trusts have made many excellent deals for their own IT services. Could government plans to centralise IT purchasing in the name of rationalisation and economies of scale jeopardise this progress and fail to engage staff? asks Tony Collins

Susan Aston knows how NHS computers can make a difference to the lives of patients. When she found she needed to see a consultant about a cataract, she expected a long wait: typically it would take six weeks for a GP's practice to write to consultants and wait for them to prioritise the case before sending out an appointment letter.

In fact Aston's appointment was booked electronically the day after she saw her GP for a referral.

A local booking system, linked from the surgery to the hospital, showed that an appointment had become free the next day. "I saw the consultant incredibly quickly. Electronic booking is amazing," said Aston, a retired health visitor.

Her GP, Gordon Turner, belongs to one of 21 surgeries in the Bournemouth area that are using electronic systems to book appointments.

Bournemouth is among a group of GP practices using promising patient-booking systems in Wales, Birmingham, Yorkshire and London.

In other areas, such as the Wirral, GPs and hospitals are making a success of using electronic patient records, which are less likely than paper-based files to go missing or drift out of date.

Specialists say that the Department of Health's (DoH) IT plans, published in 1998, which set targets for electronic patient records and giving people choice by having an agreed date for an appointment, are beginning to pay off.

But as enthusiastic as some specialists are about the slow but successful implementations of new systems in the NHS, they are concerned that the 1998 plans are taking a new turn.

In an attempt to speed up the pace of change the government is using £2.3bn of new money earmarked specifically for IT to take control of almost everything to do with new technology in the health service, in the name of "ruthless standardisation".

Contracts worth hundreds of millions of pounds may be awarded in the next few months, under the NHSnational IT programme. The deals will go to a few consortia of service providers, which will deliver what tender documents describe as an "end-to-end service coverage across a designated locality".

To manage the national programme, the director-general of IT in the NHS, Richard Granger, is setting up a new central bureaucracy of about 200 people, including about 50 private management consultants and other specialists.

In a speech at Aston University, Birmingham, in June last year, health minister Lord Hunt accepted that a national approach "flies in the face of our efforts to devolve responsibility and funding for services to primary care trusts and [NHS hospital] trusts".

But he was "also aware that no other national or corporate organisation would approach IT planning and implementation in a fragmented or piecemeal manner", he said.

"It is time we accept that IT is one of those core functions that should be managed and undertaken centrally and get on with it," he said.

Particular supporters of the national IT programme are large suppliers which stand to make tens of millions of pounds in gross profits from the strategy. They say it represents a challenge, and there is a risk of failure, but they believe the targets are achievable.

The national programme comprises four major projects: infrastructure; prescriptions; appointment booking; and electronic health records. But it goes well beyond these, and could engulf most, if not all key local systems, such as the successful, locally-supported technology that enabled Aston's GP to book a quick appointment for her.

With several large consortia due to be appointed this spring - IBM is already said by some NHS specialists to have been chosen unofficially for a contract to run London systems - NHS trust directors say they have been asked to provide clauses in new contracts with IT suppliers which allow the deal to be "novated". This means that the customer's name on the contract would change from the trust to a local service provider.

Existing contracts, as well as new ones, could be novated in this way, the DoH has confirmed. One possible result, however, is that trusts and GPs could lose control of their IT contracts to large companies that may not have experience of the NHS.

"Novating pending and new contracts is normal practice for large organisations such as the NHS that will need to rationalise its IT base," said a DoH statement to Computer Weekly. "At the appropriate point in the future, the need to migrate existing contracts and the migration paths will be considered."

One trust IT manager in London said he fully expects "local service providers to be appointed over my head whether I like it or not".

A year ago, local clinicians and IT specialists were able to buy IT systems within their allocated budgets. Now they will largely lose this direct control. Instead the department said local specialists will be able to express preferences which will be given "full consideration".

The scale of the integration, migration and rationalisation will be enormous. The National Audit Office estimates that in the 1990s at least £200m was spent on IT each year. This spend rose to £850m annually by 2001 and excludes the £2.3bn of extra money allocated to the national IT programme.

So there are at least £2bn worth of legacy systems in local use, much of which could be phased out and replaced, or migrated into the national programme.

Granger says the benefits of a centralised policy include savings of hundreds of millions of pounds, as local buying is aggregated, where possible, centrally or regionally. Rationalising IT, and introducing much tighter control on contracts with suppliers, will achieve further savings.

But the published results of local trials of booking systems, for example, show that booked appointments were often cancelled because beds, equipment or staff were not available. Trials also found that systems failed to take account of consultants taking sick leave, being absent to attend work-related events or court cases.

And in the case of integrated care records services, the chief executive of a trust in the north of England said Whitehall officials have underestimated the project's complexities.

"Integrating healthcare records over the lifetime of an individual, through a whole series of ill-health events involving a combination of agencies and dozens of healthcare professionals is complex and requires excellent technical solutions and vast degrees of cultural and organisational change," he said.

"To suggest that you can build that and roll it out in the same way as a supermarket checkout system displays, to me, incredible naivety that would make you seriously concerned about their understanding of their complexity of healthcare."

This raises questions about whether national systems can achieve adequate buy-in from local clinicians. The Commons Public Accounts Committee, in a report on the lessons learnt from a range of IT disasters, including those in the NHS, said, "The commitment of clinicians is crucial to the success of such [large IT projects]."

In response, the DoH said clinicians will be involved in national buying decisions. But this will involve only a group of clinicians close to the DoH.

The move to engage clinicians locally will happen as national procurement is finalised, Granger said in a recent interview. This creates major risks for the success of the national programme. The PAC said in a report in January 2000 that if end-users were irritated at the way a system works they would not use it as planned or would revert to parallel clerical systems.

IT specialists and clinicians in the NHS strongly welcome the £2.3bn of new money for systems, but some question whether the DoH is wise to spend so much of it with a few large consortia.

Those who are sceptical about the national programme would prefer that the systems developed under plans announced in 1998 for patient records and booking systems be given a chance to flourish, as some already are; and the extra money be allocated for systems bought locally from accredited suppliers, leaving the DoH to set rigorous national technical standards and ensure that business change accompanies the new technology.

This combination, the sceptics say, would be more likely to bring about the reforms the NHS desperately needs, without risking huge losses to the taxpayer and sidelining local IT systems and specialists.

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