Personal View: John Cruickshank

The general election

John Cruickshank 2020Health.co.uk

Whichever party forms the next government, it must take crucial decisions about the National Programme for IT in the NHS.

With NHS chief executive Sir David Nicholson warning that £15-£20 billion must be saved from NHS budgets by 2014, NHS IT will rightly be scrutinised.

Sadly, even before the election campaign got underway, much of the political debate around NPfIT has been conducted at the sound-bite level.

So whichever minister takes office on 7 May, they will have a steep learning curve getting to grips with the nuances of NHS IT. He or she will find a mixed picture.

More or less encouraging:

Published in March, our report “Fixing NHS IT – a plan of action for a new Government” set out a dispassionate analysis.

It looked at NPfIT’s successes and failures, making some 30 recommendations for action in the new administration’s first 12 months.

In the report, we argued that any perception that NHS IT can be ‘fixed’ just by axing projects or renegotiating contracts, is false. And adopting a localised-only approach to IT will lead to fragmentation and a worse position.

Our new government must emphasise technology-enabled service transformation to improve patient outcomes. So what are the immediate actions needed in the first 100 days?

The starting point must, of course, be an urgent stock-take of key projects, assets and organisations, consistent with the principle that future national IT approaches should only be done in limited circumstances.

Those circumstances are to avoid redundant variation in infrastructure and back office systems; or to provide economies of scale; or for essential national coordination or regulation, such as standards or security.

To exploit sunk investment, and to act as a platform for the future, we also advocate retaining and restating a commitment to key national infrastructure, such as N3, NHSmail, PACS, and elements of the Spine.

Less or more worrying:

Three key projects are worthy of an early, intensive review:

1. The Summary Care Record: while the SCR could usefully serve as a national ‘urgent care record’, its worth beyond that needs testing.

Now that its roll-out has been halted, a review is needed around its clinical effectiveness; its architecture and security; its fit to the many local shared care records initiatives (which we support); and its overall business case.

2. LSP contracts: in reaching ‘contract reset’ agreement in London, a more pragmatic and realistic deployment approach was agreed, at a saving of £100m. However, was value for money secured, given that BT’s contract now covers only one half of London’s acute trusts?

The position with CSC’s contract for the North, Midlands and East is more serious, in large part due to the repeated delays around the Lorenzo solution and its first large scale implementation at University Hospitals of Morecambe Bay NHS Trust.

Mindful of the fall-out from the Fujitsu exit in the South two years ago, the absence here of a worked-up NHS contingency plan is worrying.

If it appears that the LSP arrangements would fail against the ten success criteria our report identifies, the existing arrangements need safely deconstructing. We need to keep the elements that work well – for example in primary and community care.

But acute hospitals in the NME need a proper choice of alternate suppliers to fit their own needs, while meeting clear interoperability standards, and with equity around central funding support.

3. The Southern ASCC procurements: having announced that LSP replacement systems would be procured by early 2010, as yet trusts outside the Cerner club have nothing to see. The effectiveness of the procurements needs testing – we question whether they will deliver optimal, integrated solutions.

Moving forward from here

In due course, and depending on the outcome of the reviews, we believe the central IT organisation needs a radical downsizing and reorientation to be more transparent and accountable to the NHS.

But this needs aligning to a programme to strengthen IT provision at the local level, with consolidation promoted through much greater adoption of shared service models.

And to enable interoperability and more local choice of systems, the new government will need to ensure a practical, informed and transparent approach to standards, adopting international / EU ones unless there is an overwhelming case to do otherwise.

Finally, and perhaps most importantly, immediate ways to accelerate the benefits from IT need to be established to deliver some early successes from the new regime. For example, we see scope in the following areas:

• Our NHS currently under-exploits telemedicine and collaborative technology. Why are we so far behind other countries?
• The Electronic Prescription Service could release major savings through reductions in fraud, drug wastage and back-office costs, as well as delivering significant patient safety benefits. Why are technology and cultural barriers allowed to slow down these vital improvements in the prescribing value chain?
• Many patients already benefit from on-line access to their local GP system for booking appointments and ordering repeat medications. But free software exists to do so much more, allowing patients fuller access to their primary care record. Why not actively encourage this?