Answers and questions

The end of the National Programme for IT in the NHS, at least in its current form, has provoked little surprise but many questions about what will happen next.

The instant reaction of Murray Bywater, managing director of Silicon Bridge Research, to the ministerial statement issued on Thursday was surprise that “the government has not done this before.”

The statement issued by health minister Simon Burns set out a number of changes to the programme. The national infrastructure and national applications that it has delivered will be retained.

However, they will cease to be managed as projects and become “IT services under the control of the NHS” that will “not be taken forward under the banner of NPfIT.”

The programme’s existing contracts will be honoured. However, CSC’s local service provider contract for the North, Midlands and East of England will be scaled back by another £200m and there will be “more locally-led procurement.”

The statement also says that a more modular approach will be taken to deployment, so that trusts can “connect all” rather than “replace” all their existing IT systems.

Bywater said he was pleased that national infrastructure would be retained. “There have been good things about the programme. The Spine is good. Infrastructure is far better now than it was ten years ago. It has raised the profile of NHS IT enormously.”

But he was wryly amused to hear that “new arrangements” would be made for the elements of the programme that still need to be nationally managed.

“We said two or three years ago that no government would ever announce the end of the programme, it would just let NHS Connecting for Health morph into the DH or something very like the old NHS Information Authority, and that is what seems to be happening,” he said.

Freedom but no money

Unsurprisingly, most reaction has centred on the decision to open up the NHS IT market to a “more plural system of suppliers”, as originally announced in the ‘Liberating the NHS’ white paper earlier this summer.

Jonathan Edwards, research vice president, healthcare providers at Gartner, said: “This seems like a confirmation of what has been clear for a long time.

“The government has endorsed local procurement of electronic patient records and free choice of suppliers; while not stating the obvious, that there will be no central funding.”

Edwards argued this would be good for trusts. “The announcement signals the official end of a centralised approach to electronic patient records that was never workable. The many years of planning blight while NHS trusts waited for ‘free’ national software can now come to an end.

“What is not clear is how the new approach will affect the contracts with [London’s local service provider] BT and CSC. I don’t understand how an open market can co-exist with contracts that maintain BT and CSC as regional monopoly suppliers.”

The question of how trusts will afford to invest in IT is another question that is already being raised, given that the NHS will be reorganised while being asked to make £20 billion of efficiency savings over the next four years.

Frances Blunden, who watches NHS IT for the NHS Confederation, said: “We are pleased there will be more flexibility and choice for local providers. That is consistent with other changes that are happening in the NHS, particularly the move to make all trusts foundation trusts, which already have these freedoms.

“Our big concern is that these changes will result in costs being shunted onto trusts in a very difficult financial climate. Trusts still need good IT, because all the indications are that is how you do modern, safe, effective heatlhcare. If NPfIT is going, the big question is how that IT will be funded.”

Bywater was more optimistic on the money front. The end of the programme, he argued, will take the NHS back to something closer to Frank Burns’ vision of the future of NHS IT as laid out in the 1998 information strategy, ‘Information for Health’, “which absolutely everybody agreed with.”

On top of which the present government is clear that it wants the NHS to make changes and to make them within its existing budget, and making loud noises that it will not tolerate failure to do that.

“That will be a big incentive for trusts to invest in IT. They will have to do it if they want to survive,” he said. “This government is deadly serious about saying ‘live or die’ to people.”

Matthew Swindells, who led an influential review of healthcare informatics for the DH and now heads the Chartered Institute for IT, felt there should also be a role for suppliers.

“If suppliers cannot show that implementing IT will mean better healthcare at lower cost, they should not be in business,” he said, bluntly. “Companies should be putting together good business cases and taking some of the risk themselves.”

Following recommendations

The present government has not been short of advice on what to do about healthcare IT. In opposition, the Conservatives commissioned an independent review of health and social care IT, led by Glyn Hayes.

This recommended something in line with yesterday’s announcement by calling for the effective bits of NPfIT to be preserved, while opening up the market for electronic patient records within a framework of standards to ensure interoperability.

Dr Hayes told E-Health Insider: “It is nice to see that the DH is following the guidance set out in my review. Local, modular, evolutionary progress is the right way forward.”

However, he raised more, critical questions. “What is not clear is how the local NHS will cope with purchasing systems when there is too little experience at local level,” he said. “This needs to be addressed if the new ideas are to work.

“There are centres of excellence where they will be able to cope, but much of the NHS does not have enough experienced health informatics staff to make the right decisions and also to stand up to senior management who tend not to understand the informatics issues.

“The other area of vital importance is getting the standards right to allow for adequate functionality and interoperability which the NHS needs. We must have central mechanisms for setting such standards and maintaining them.”

John Cruickshank, who wrote a more recent report on the way forward for NPfIT for the think-tank 2020Health, also commended the government for taking a course “consistent with [its] recommendations.”

However, in a statement, he asked how the government would be able to achieve its white paper vision of “an NHS that is less insular and fragmented and that works much better across boundaries” without setting out how ‘joined up IT’ would be secured and governed.

“The risk of a purely local approach to procurement is the return to the highly fragmented position in the 1990s,” he added. “Standards for interoperability have yet to reach the maturity level to ‘plug and play’.”

Swindells also felt this was important and the DH should not use the announcement as an excuse to “walk away” from IT or informatics. In particular, he said the DH would “need to drive interoperability in the systems the NHS is using.”

In time, he added, the new GP commissioning consortia should require providers to use IT systems that worked with each other and delivered the data that they wanted in the format they wanted it in.

Raising questions

Perhaps surprisingly, some of these concerns were echoed by the British Medical Association, an early and persistent critic of the programme that, until relatively recently, called for it to be scrapped on a regular basis.

Dr Chaand Nagpaul of the BMA’s GP Committee, said that while giving NHS organisations more choice over IT systems made sense, “we also need to be aware of the problems that could arise from a more localised approach.

“It is important that successful IT initiatives are not lost and that innovation is not stifled. There still needs to be some central accountability to ensure consistent and equitable delivery, mange local implementation, avoid wasteful duplication of effort and support local decision making.” For example, he said, “a nationally accredited list of systems would be helpful.”

Yesterday’s announcement paved the way for big changes in the way that healthcare IT is managed, bought and delivered in England, and ministers have big hopes for these.

In his statement, Burns said that allowing hospitals to use and develop the IT they already have, working with systems procured by the national programme or elsewhere, would make “practical sense” and “financial sense” since it would deliver savings for the inevitable “patient care.”

Yet, after eight turbulent years, significant changes to the programme that move it far from its original, top-down approach have generated little surprise, with many commentators already looking beyond it for more information about the future.