NHS managers want change but see risk in centralising IT

The Government's ambitious plan to overhaul NHS IT may be the largest technology project ever seen in the UK but the question of...

The Government's ambitious plan to overhaul NHS IT may be the largest technology project ever seen in the UK but the question of who will control it is a controversial one. James Rogers found NHS IT managers wary of the risk of repeating past mistakes but focused upon the potential benefits.

The response from NHS IT managers to the service's new IT strategy, Delivering 21st Century Support for the NHS, has been mostly positive.

Under the terms of the plan, which was unveiled by health minister Lord Hunt last month, health service IT is likely to receive £5bn of much-needed government funding.

Primary projects include a national patient booking system, electronic health records and electronic reporting of laboratory results.

Crucially, however, key elements of the strategy, which is scheduled to start in April 2003, include setting stringent national standards for data and IT, and establishing a centralised procurement strategy. A national IT programme director, or IT tsar, will also be appointed to implement what has been described as "the IT challenge of the decade".

The main problem that the Government faces is how to implement a strategy so dependent on central control across an organisation as complex and devolved as the NHS. With more than a million employees and encompassing about 600 trusts, the UK's health service is a sprawling behemoth, with nothing comparable anywhere in the world.

This is at the heart of the worries raised by many of the IT managers interviewed. It appears that the sheer scale of the UK's health service is both its strength and its weakness.

Exploiting the colossal buying power of the NHS clearly makes sense but there is concern that local needs could be overwhelmed by the overall strategy.

For example, one head of IT in a medium-sized acute trust acknowledged that centralised procurement is the way forward but warned against disenfranchising local IT staff as a result of national strategies.

The NHS is no stranger to problems with centralised IT projects. In the early 1990s a centralised approach to IT delivery failed - the Hospital Information Systems initiative losing up to £103m and prompting criticism from the House of Commons Public Accounts Committee.

Experts, however, have warned that NHS IT managers should not get bogged down in a debate about centralisation. Terry Young, a professor at Brunel University's Department of Information Systems and Computing, said, "Instead of focusing on whether a system is centralised or decentralised the IT community needs to stand back and examine the role of information and communication in delivering better care."

Young believes that new datawarehousing and application service provider models are among the technologies that need to be researched.

This would improve the flow of information within the health service and support the development of new operational procedures and better service delivery, he said.

There can be little doubt that effective information and up-to-date IT are key to a 21st century health service but it appears that there are still long-term issues to be resolved among IT users.

The NHS IT managers who spoke to Computer Weekly asked not to be named because of the politically sensitive nature of NHS spending. They expressed views both for and against the issue of central control of the new IT strategy, which shows that issue will continue to be debated during the next few years.

Economies of scale could save millions
A straw poll of NHS IT managers revealed that the potential to use the NHS' purchasing muscle was the main plus-point in the argument for centralising IT delivery across the service.

  • "I think that this is probably a good thing because it may speed the procurement process up - and it may place an added emphasis on suppliers to provide solutions that the NHS requires, as opposed to other industry solutions that are then applied to health." An NHS IT performance director in a southern trust

  • "In some ways the idea of centralisation is right. What NHS IT has been lacking is any form of architectural overview." An information management and technology director in an NHS acute trust

  • "There are clear advantages in doing some procurement nationally - such as electronic health records - because there needs to be a common national system for cradle-to-grave records." A head of IT in a medium-sized acute trust

  • "The problem with claiming that we need local control over IT is that this strategy has not delivered in the past. Centralisation has already delivered the likes of NHSNet. Clinical managers and those managers directly responsible for patient services in the trust will benefit from centralisation. They just want services such as electronic health records and bookings systems - it doesn't matter where they come from." A head of IT in a north of England NHS trust

  • "The principle of increased centralisation and standardisation is long overdue and has to be welcomed. Centralisation is a way of avoiding funds being diverted to other, non-IT requirements, such as reducing waiting times." An NHS trust IT director

  • "Central procurement will help in terms of driving down cost but there needs to be some serious thought given to what types of deals you can get. For example, there is a lot of local interaction between software and hardware companies and trusts. Many smaller companies will have a lot to offer but may not be considered for national procurement strategies. This applies to both software and hardware." An IT systems designer in a specialist NHS trust

Local flexibility could be limited
According to IT managers the main problem with centralised control is that it may lack the flexibility required by local health systems that vary radically around the country - healthcare in Edale is hardly the same as in Elephant and Castle.

  • "Centralised procurement takes away trusts' flexibility but if the Government does this then clear standards need to be given and people need to receive some flexibility in terms of the packages offered. These packages will need to be clearly defined, with interfaces that work across the whole NHS. The Government also needs to take collaborative working across hospital groups into account." An NHS IT manager in a southern NHS trust

  • "The new NHS IT strategy critically lacks detail on how to deliver the vision. For example, there is a national programme director being appointed but there is no national ICT architect being appointed." An NHS information management and technology director in an acute trust

  • "There will be a number of instances where local needs and requirements must be satisfied. There must be leeway in the system to allow for that." An NHS trust IT director

  • "With regard to procurement, there needs to be a broad enough cadre of systems out there to cover the whole spectrum of healthcare so that the smaller clinical specialisms such as dermatology do not need to compromise." An NHS IT performance director in a southern trust

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