Insider View: Jon Hoeksma

E-Health Insider editor Jon Hoeksma looks back over a week of confusion for the National Programme for IT in the NHS, and considers what the turmoil says about the chances of a fast and successful procurement being run in the South.

‘It’s off, it’s over’, then ‘err, no its not’; the NHS IT programme reaches the end of the week with just with a few bits to be lopped off. But it could have been very much worse.

In a week of financial gloom, in which the Pre-Budget Report made it very clear that there is no prospect of jam for years to come, the fact that the National Programme for IT in the NHS has not been axed is an achievement. On Sunday, it sounded like Alistair Darling was about to switch off its life support.

The Chancellor’s announcement on The Andrew Marr Show that NPfIT was “quite expensive” and “not essential for the frontline” or “something we need to go ahead with just now” clearly caught everyone on the hop, from suppliers to the Department of Health.

E-Health Insider understands that negotiations have been underway for some time between the DH and local service providers BT and CSC to scale back the scope of delivery and cut costs. That the Treasury jumped the gun shows just how firmly it is now in the driving seat. Expect that trend to continue.

Health secretary Andy Burnham was left to make an emergency statement in the House of Commons, restating the government’s commitment to the programme, while saying £600m will be trimmed from it.

In the process, he indicated that in future the programme will be based on more local choice and re-focused on the priorities set by clinicians. Some of its ‘all singing, all dancing’ functions will go. NPfIT development of GP systems will be one casualty, but there will be others.

“There is scope to pare back the scheme,” Burnham said, while later adding “where systems are working we will be pressing on.”

Pressing on, with what?

Burnham’s emphasis on building on what already works suggests it may actually be the hospital sector that sees the biggest reductions in functionality.

Unfortunately, it is in the hospital sector that the more advanced systems and most sophisticated clinical functionality have yet to be widely delivered; as a result, it is where the biggest potential savings are to be made.

Some key functionality will be prioritised; expect a focus on the Clinical 5 set out in the 2008 Health Informatics Review. Burnham singled out e-prescribing as a priority, and the thing clinicians most want.

But delivering such functionality is now expected to happen, where feasible, in the context of building on what hospitals already have in place, rather than more grandiose replacement schemes. As ever, this involves contract re-negotiations with suppliers – which have more or less been a constant since NPfIT began.

In a strong defence of the programme, Burnham said that although there are savings to be had, health IT on the scale being attempted by the NHS costs money. “It is about delivering a system that is workable and we will not do it on the cheap,” he said.

He added that wishful thoughts about a white knight riding to the rescue of a Conservative government in the form of Google offering to do medical records on the cheap were a fantasy.

So a robust defence of NHS IT and the national programme from the cabinet. What response can we expect from DH and its informatics directorate?

Tough times for procurement

For the South at least, the answer is another procurement exercise – three years after the first Additional Supply Capability and Capacity (ASCC) exercise was begun. ASCC 2 is to begin formally in January.

All the indications are that DH CIO Christine Connelly is absolutely serious about this. She has revved up suppliers and NHS IT leads to jump through improbable hoops. The imperative is to complete the new procurements by the end of the NHS financial year, strongly suggesting no money will be available after 2009-10.

Yet the obvious question is: why bother? Why run another big regional procurement exercise, particularly for hospitals, when the last ones delivered such mixed results? Is it realistic to expect a better or even a different result this time around?

EHI understands that the procurements will be region-wide, awarded for community, mental health and acute, with each contract split between more than one supplier.

Spine compliance and CfH accreditation requirements will be the key hurdles that a supplier will have to clear. The cost of Spine compliance is said to exceed £500,000; and that’s after you’ve managed to get into the CfH compliance centre.

In practice, then, the procurement will freeze out anyone who is not already NPfIT compliant. So why bother asking NHS organisations what they want and then re-trawling the market, if the requirements set almost guarantee the conclusions to be reached?

Community, for instance, would most likely go to CSE Health and TPP. But then, why run a procurement for community systems at all when, in April, BT was awarded a £500m deal for the South that involved deploying Cerner to four acute sites and RiO to 25 community and mental health sites? Will ASCC 2 overturn this earlier deal?

A more pragmatic approach would be to open any procurement to suppliers willing to commit to becoming Spine and CfH compliant over a period of time.

Show us the money

Crucially, it also remains unclear whether contracts will be awarded with money behind them. The indications are less than encouraging.

Two weeks ago, Connelly told suppliers she had about £9 billion to play with. On Monday, her Secretary of State appeared to take a different view, making clear much of the NPfIT budget has already been spent. Asked how much, he said: “40-50% has been paid out so far.”

Given the current state of public finances, will the Treasury really countenance the award of new IT contracts running into hundreds of millions?

Finally, even if all the concerns above were to be unfounded – the NHS agrees on what it wants; the suppliers can be found; the commercials get sorted; the money is found; and the Treasury signs off – is there enough time to do it?

To be in with any chance, the schedule has to run flawlessly – in the dog days of what feels like the fag end of a government that will be facing a general election in less than six months. It will need stores of good will, good organisation and good fortune, some of which have been in short supply this week.