Insider view: Lyn Whitfield

In his recently published memoirs, Tony Blair recalls how he once met Bill Gates, to the acute embarrassment of a young David Miliband.

“I got all my terminology muddled up and, to the horror of David and the ‘beautiful people’ in the office asked Bill how his mainframe was or something like that, a question that produced… a curious gulping sound from Bill.”

Well, it would. Yet the meeting probably helped to get a commitment to get a grip on healthcare computing into New Labour’s 1997 manifesto. And a later seminar at Downing Street certainly helped to create the National Programme for IT in the NHS.

In 1998, the government published the ‘Information for Health’ strategy that created the NHS Information Authority. It was supposed to develop a national infrastructure for the health service, run demonstrator projects, and develop standards against which trusts could procure their own IT systems.

By 2002, it was obvious that most of IfH’s targets were going to be missed. Technical issues, lack of money and the difficult procurement process caused by a fragmented NHS IT market were identified as key causes of failure.

When Gates came back to London for the launch of Windows XP, that Downing Street seminar mulled over a different idea: a programme to replace local procurement with national contracts and “ruthless standardisation.”

In the autumn of 2002, the first director general of NHS IT, Richard Granger was appointed. By 2004, the programme’s multi-million pound national and local service provider contracts were in place. And a decade of public controversy about electronic health records was well underway.

Or, to put it another way, the man who says in his memoirs that he had “heard the term mainframe somewhere or another” was instrumental in the decision to spend £12.7 billion on healthcare computing – with decidedly mixed results.

Successes, we’ve had a few

Plenty of commentators will argue that “the NHS supercomputer” has been an unmitigated disaster; but it has had positives to report.

BT rolled out the N3 broadband network on time and to budget, and it has since been upgraded to carry voice calls (although there have been persistent complaints about its capacity and speed).

Picture archiving and communications systems, which were added to the programme after its launch, were successfully installed in English hospitals (although there have been persistent complaints about the cost of the PACS programme and its lack of integration with other systems).

The Choose and Book electronic booking system is in place (although usage has stalled at around 50%) and the Electronic Prescription Service Release 2 is finally rolling out (albeit many years late).

This morning’s ministerial statement says that the national infrastructure and applications that NPfIT has delivered will be retained, but “they no longer need to be managed as projects” and can instead become “IT services under the control of the NHS.”

Somewhat surprisingly, given its flirtation with commercial personal health records in the run up to the election, the coalition government also seems committed to the Summary Care Record – although a separate review of both its content and consent model are underway that should report “by the end of September”.

Where the programme has really struggled has been with the other part of the National Care Records Service; getting detailed records into acute trusts and other healthcare providers.

But then again…

This part of the programme proved beyond two local service providers; Accenture, which exited the East and North East in 2006, and Fujitsu, which left the South in 2008.

In May last year, Christine Connelly, who became NHS chief information officer six months after Granger’s departure in January 2008, set deadlines for the two remaining LSPs to show they were making “significant progress.”

BT was told to get Cerner Millennium moving again in London, after a long halt caused by two disastrous go-lives at Bart’s and the London and the Royal Free NHS trusts.

CSC was told to get iSoft Lorenzo into a trust by November and an acute trust by March. BT met its target. CSC hit one target with a go-live at NHS Bury, but missed the second. University Hospitals of Morecambe Bay NHS Trust went live with Lorenzo Regional Care Release 1.9 only in June.

By then, a general election had taken place. In the run up to it, the Conservatives endorsed the findings of an independent review of health and social care IT that called for the national programme to be radically rewritten and the LSP contracts to be “halted and re-negotiated.”

In the white paper, ‘Liberating the NHS’, health secretary Andrew Lansley said that NHS organisations would be able to choose from “a more plural system of IT and other suppliers.” This morning’s announcement follows this direction of travel.

It says that in future, “a more locally led system of procurement should operate”, alongside a “more modular approach” to IT development that will allow NHS organisations to “introduce smaller, more manageable change” and build on the best of the systems they already have.

Some issues to mention

The government seems to have given many critics what they wanted; a new regime in which trusts will be able to choose systems that meet them from a range of suppliers, as long as these interoperate and allow information to be exchanged across healthcare communities.

There is no danger of the new regime failing because trusts divert ‘ring-fenced’ IT money to other priorities, as they did in the days of IfH. But only because there will be no ‘ring-fenced’ money.

Trusts will have to find their own funds for IT investment; against another reorganisation of the health service and a demand to find £20 billion of efficiency savings over four years.

Some may decide that IT is not a priority for investment; even though there is a compelling argument to be made that a cheaper, higher quality and more consuming health service cannot be delivered without it.

Nor is money the only challenge for trusts that accept the argument – or that just need to replace ageing legacy systems. As the programme has palpably stalled over the past couple of years, a handful of trusts have gone outside it for one reason or another.

Some (such as Newcastle and Royal Berkshire) have tried procuring national programme systems by other means. Others (such as The Rotherham) have turned to alternative suppliers for full-on EPR systems. Still others (such as Blackpool) have tried adding ‘high end’ functionality to existing PASs.

None of these approaches has been without its problems. So, while it’s hard to imagine that many tears will be shed over the demise of the national programme, it’s effective death does not mean that all will be easy from now on.

Challenges remain with getting the successors to “mainframes” into the NHS. It’s just that in future the challenges will be different.

NPfIT timeline

This timeline comes from a review of the National Care Records Service led by researchers from the University of Edinburgh that was recently published in the British Medical Journal.