Insider View: Jon Hoeksma

As details of BT’s new deal for London emerge, it is becoming clear that the NHS has given up on its goal of creating integrated, shared electronic records. The editor of E-Health Insider asks if what’s left represents value for money.

Having originally signed a £1.1 billion contract to become local service provider for London in 2003, BT has just signed a new deal with the Department of Health that will deliver savings of £112m.

In return, the capital will get fewer deliverables. Crucially, the London Programme for IT has ceased to be universal. It no longer covers all of the health service in London, and it has abandoned the strategic goal of integrated care records.

As a letter from NHS London chief executive Ruth Carnall makes clear, fewer acute trusts will get Cerner Millennium, fewer community trusts will get RiO, there will be no new ambulance system, no GP systems, no London-specific record sharing system and no Map of Medicine from the end of the year.

"Although the contract reset with BT can be declared a success, its scope will only cover one half of the London acute trusts,” points out John Cruickshank of health think-tank 2020 Healthcare. “A careful review of the small print is needed to assess whether it is value for money.”

Value for money?

So does the deal, which focuses on the more flexible delivery of Cerner to a relatively small number of hospital trusts, represent a bad deal?

Certainly this is the view of Conservative health spokesman Stephen O’Brien, who told E-Health Insider: “The government’s volte-face on the NHS IT programme satisfies no-one, not the patient, not the doctor, not the taxpayer and not public confidence at large.

“There is a real, burning, question whether they have achieved increased value for money with this Memorandum of Understanding with BT; or whether by getting a lot less for a relatively minor discount, the taxpayer has a right to be angry at the poor use of their money.”

He added: "Our ideal, should we form the next government, has been clearly set out in my independent review: but with the contracts and discussions still locked behind closed doors in Richmond House, there is little to be done until 7 May."

The independent review that the Conservatives commissioned from Dr Glyn Hayes reported last year and recommended a major recasting of the National Programme for IT in the NHS. However, the Conservatives have always been clear that their room for manoeuvre will depend on its multi-billion pound contracts.

Yet while O’Brien may yet get a chance to review the as yet unsigned CSC deal for the North Midlands and East, the MOU for London [known as Contract Change Control Notice 3] is a done deal and legally binding.

"Although the contract reset with BT can be declared a success, its scope will only cover one half of the London acute trusts,” said John Cruickshank of health thinktank 2020 Healthcare. “A careful review of the small print is needed to assess whether it is value for money.”

Drivers for change

Change is an inevitability in a ten year IT deal; and this is the third version of the contract. But CCN3 does not appear to reflect the new priorities of a primary care-led NHS, in which polyclinics and a choice of providers features heavily, and a wave of acute trust mergers is expected after the General Election on 6 May.

Instead, it is rooted in attempting to avoid a repeat of the disastrous 2008 implementations of Cerner Millennium at Royal Free and Barts and the London NHS Trusts. These decisively tilted the scale towards a more flexible and far more expensive delivery model, based on Cerner’s core methodology.

The problem was that LPfIT was priced on a vanilla model. So even before the 2008 banking crisis and November 2009 Treasury demand that NPfIT provide £600m in savings, it was clear that there was not enough money in the pot to fund everyone getting the ‘New Cerner Delivery Model’.

It is also rooted in other realities. For instance, BT stopped providing new GP systems some time ago. Vast swathes of London were EMIS bastions, and BT always struggled to convince practices to switch to INPS. The telecoms giant also ran into problems with hosting locked down configurations of the GP software.

The ditching of an integrated London-wide solution goes back even further; to 2006, when BT officially switched from IDX to Cerner as its major sub-contractor, and announced its ‘de-risked best-of-breed strategy’ for London based on Millennium, RIO and INPS with a BT provided integration layer.

Over time, the BT glue failed to appear and was replaced by the idea of a London summary care record. Even this has now been dropped, with the latest plan to use the national Summary Care Record to exchange patient information, together with some use of NHS Connecting for Health’s integration toolkit.

End of a dream – start of what?

It is the abandonment of an integrated solution, of whatever stripe, that is probably the biggest loss as a result of CCN3. And this begs the question of what the purpose of CfH and the LSPs has been. Where have they added value?

Some, but not all, of the NHS in London will get a series of stand-alone acute and community EPRs, but they could almost certainly have bought these systems off-the-shelf more cost effectively.

Meanwhile, for the hospital trusts, primary care trusts and practices now excluded, the past decade has essentially been a lost opportunity, since the only real benefits they will have seen is national infrastructure. Left to their own devices, a significant number of NHS organisations would undoubtedly have been better off had they been able to pursue their own local strategies.

Given that the deal is signed, however, the challenge ahead is to make the best of the situation. Those trusts that will get Cerner have the best prospect yet of getting a solution that will serve them and their patients well.

However, given that the trend in London since 2003 has been delivering less to fewer NHS trusts, who would bet against the prospect of further descoping in a CCN4 yet to come?