NHS plan is evolving but one-size-fits-all is a fundamental flaw, says hospital chief

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.

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.

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