Insider view: Jon Hoeksma

In an editorial opinion piece, E-Health Insider editor Jon Hoeksma reads between the lines of the Operating Framework for clues to the future of the National Programme for IT in the NHS.

When a row blew up over whether the National Programme for IT in the NHS was “grinding to a halt” this autumn, the new chief information officer for health, Christine Connelly, promised a review and clarity by the end of the year.

E-Health Insider understands that her plans, like the detailed implementation plans promised for the Health Informatics Review, have been delayed until 2009. The latest delays are symptomatic of the problems October’s row highlighted – and the mire the national programme has become stuck in.

Although Connelly is said to be conducting a no holds barred review, with a particular focus on where the two remaining local service providers add value, it is hardly mentioned once in the Operating Framework for the NHS in England 2009-10 that was issued this week, or the supporting Informatics Planning 2009-10.

It looks as if NHS Connecting for Health is being sidelined by the Department of Health. In part, this is the intended outcome of the NPfIT Local Ownership Programme. But principally it is a consequence of the programme’s comprehensive failure to deliver on its core objective: to provide detailed, integrated shared electronic records to the NHS in England.

Recently, the exit of Fujitsu as local service provider for the South, has shown CfH to be at the mercy of events, rather than in control of them. It has proved unwilling or unable to extricate the NHS from the fundamentally flawed contracts it signed with local service providers almost five years ago. And it has failed to give trusts access to viable alternative systems; be they legacy, interim or provisional.

Less interim by the minute

While the national programme has clearly had some notable successes, this central failure has become a dangerous clot blocking progress on health informatics. The DH’s Operating Framework and informatics planning guidance basically says bypass surgery is an acceptable treatment.

The Health Informatics Review, published shortly after the Darzi report in July, spoke of the need for interim solutions. The new DH documents are much more explicit. They instruct local health communities to develop plans that incorporate “components from NPfIT and other solutions.”

They also instruct them to achieve the Clinical 5 for secondary care “as soon as possible” and to plan to integrate acute, community and other services. Yet there is little advice on how local health communities or trusts should plan, resource, fund and install such systems. It represents a gaping hole in the guidance.

Despite being published in May, the Additional Supply Capability and Capacity framework, and Lot 2 clinical systems, has yet to be used or funded.

National contracts a huge block

Meanwhile, the LSP contracts continue to prove almost impossible to unpick without incurring huge costs. Some close to the programme estimate the cost of terminating the two remaining LSP contracts with BT and CSC at £2 billion. Although it had its contract terminated in May, by September Fujitsu was reported to be preparing a legal claim of £700m against the NHS. It now has an interim deal through to May 2009.

There is almost no prospect of a replacement local service provider being appointed for the South; but there is also no sign of a coherent alternative plan. Instead, the region appears to be fragmenting as iSoft and Cerner ramp up direct sales efforts.

There are strong arguments in favour of LSPs providing expertise, rigour and a corpus of technical and implementation experience, but they need to clearly demonstrate where they add value rather than cost.

In London, the challenge is to put out the flames at Barts and the London NHS Trust and Royal Free Hampstead NHS Trust, before any further implementations of Cerner Millennium can occur.

While that happens, the whole approach of a standardised solution appears to have been jettisoned in favour of locally configured implementations. This is a huge shift, which will require a lot more money be found from somewhere.

Already there are indications that the London Programme for IT and BT are pondering robbing Peter to pay Paul; ditching the requirement for primary care and scrapping the integrated record the programme is meant to deliver in its later stages, in order to deliver some workable local Cerner installations.

This may make sense from where they are now, but it is a far cry from where the programme began. And the cost difference between a nationally procured, standardised solution and bespoke configurations, requiring very heavy local implementation costs, is huge.

Sources indicate that Newcastle, a foundation trust that has independently purchased Cerner Millennium, is budgeting in the region of £18-20m for the full project. There are 23 acute trusts in the capital and 43 in the South.

The picture is even more opaque in the North, Midlands and East of England, where CfH’s contract renegotiations with Computer Sciences Corporation continue to drag on. While the news of two, small Lorenzo pilot sites is welcome, it may be years before the full product is robust enough for large-scale implementations.

Are trusts really supposed to just carry on waiting? Some areas like Yorkshire and Humber are already going their own way, developing a common care record using SystmOne. Areas of the North West are also showing a more flexible approach.

Some trusts on legacy systems such as McKesson are likely to have support contracts extended again, but for others this is not an option. 

Getting out of the mire

In her letter to the Financial Times, Connelly promised both clarity and direction. CfH must provide both to regain credibility and become relevent to the wider NHS. And one priority must be finally supporting trusts with a wider range of suppliers; specifically making acute systems of choice a reality not just a hollow framework deal.

CfH should also make a virtue of necessity by recasting its new mission as supporting all informatics efforts, regardless of supplier or systems, across the health service. While there are no obviously easy options, finding a safe path out of the swamp surely makes more sense than continuing to trudge through the ever more treacherous mire.