EHI acute survey: grim, with a few bright spots

After two years of anxious speculation about the scale of the financial challenge facing the NHS and the impact of the Lansley reforms, trusts are starting to get a handle on the policy and business challenges ahead of them.

That, at least, is the impression given by eHealth Insider’s second annual survey of IT directors and others working in and with acute sector IT.

Last year’s survey found large numbers of respondents expecting their trusts to have to make very large savings of 20% or even 30% of their income – and to shed very large numbers of staff in response.

This year’s survey, while hardly cheering, suggests most trusts are looking for smaller, if hardly insignificant, savings of around 5-10%.

Encouragingly, it also suggests that trust boards are taking an increasing interest in IT strategies and that as many trusts are planning to preserve or even raise their IT budgets as are planning to cut them.

A lot of that money, it is clear, is going on “keeping the lights on.” Yet some trusts, at least, are planning big investments. Last year, just 8% of respondents said their trust was planning to go out to tender for an EPR. This year, 20% said the same.

Facing up to the finances

EHI ran its first, annual acute survey in March last year. It ran the second survey this summer, attracting 120 responses from IT directors (7%), managers (36%) and staff (14%), analysts and clinicians (18%) working at trusts or IT services across the UK.

The two surveys therefore span the first year of the ‘Nicholson challenge’ for trusts to find £20 billion of ‘efficiency savings’ over four years, by adopting quality, innovation, productivity and prevention initiatives.

As the NHS works through the second year of the challenge, there is no doubt that finances remain tight; but some of the panic about the health service’s financial position seems to have subsided.

This year, 17% of respondents said their trust was looking for savings of more than 20% of its total income, down from 37.2% last year, while 27% said their trust was looking for savings of more than 10%, down from 39%.

Having said that, these are still significant savings; and more than nine out of ten respondents said their trust’s budget was flat or that it was looking for savings of some kind, with most (30%) saying it was looking for savings of around 5%, in line with national targets.

Unsurprisingly, the pressure on finances is translating into pressure on jobs, with 50% of respondents saying their trust expected to lose at least some staff; and a further 42% saying “we don’t know what is happening yet.”

Gallows humour

The general impression that while things are tough they are less terrible than last year in most places, and a bit better in some, was reflected in responses to a new question, asking respondents whether they felt more or less optimistic about meeting the challenges they face this year.

There was plenty of woe. One respondent said simply that they were “planning to leave asap” while another said: “Depressingly, pretty much everything seems to be about money saving schemes” and another added: “We will certainly not meet all our challenges this year – we don’t have the resource.”

There was some Dunkirk spirit. One respondent wrote: “We muddle through” while, in a similar vein, another said: “We have managed in the past, this will be no harder.”

But some were chipper. “We now have a very committed team and senior support,” said one correspondent, while another said: “We have a new, excellent chief information officer who is an IT professional, and on the board for the first time in 15 years. This shows board commitment to technology enabled change.”

Boards take charge

A new interest in IT from boards that need to get hold of their business came through in various sections of the survey. Until recently trusts were, in theory at least, expected to look towards the National Programme for IT in the NHS for solutions to their IT problems, particularly when it came to PAS and EPR implementations.

Now, of course, the programme is winding down, with just a few trusts in the North, Midlands and East still to decide whether to commit to CSC’s Lorenzo, and a larger number of trusts in the South to discover whether they will get anything from the latest round of system procurements.

Although 10% of respondents (many of them from Scotland and Wales) said they were still ‘mainly influenced’ by national bodies when it came to forming IT strategies, most (44%) said they were influenced by the trust board.

In the same vein, just 16% of respondents said individual departments and clinicians were the main influence on their strategy; down from 38% last year. And just 15% of respondents said their strategies were influenced by clinical commissioners, even though they are supposed to be the shapers of the new NHS.

Keeping the lights on

The NHS’ major auditors have calculated that the health service is meeting its savings targets at the moment – indeed, it recently announced that it finished the financial year with a surplus of £4 billion.

However, there is concern that some trusts are in severe trouble, and that even those trusts that are on top of their business agendas are finding it difficult to shift their attention from the ‘productivity p’ of QIPP to the ‘innovation i’.

To make savings on the scale demanded, reconfiguration and the imaginative use of new technologies, from digital records to telehealth, will be needed. Again, the survey provides tentative support for the idea that this message is getting through.

Admittedly, a quarter (26%) of respondents said their budgets would be flat this year, and 42% said they would be cut. And freetext comments reflected the misery this can cause.

“We need to hang on to what we have got, simply to survive,” one wrote. “There is no protection for IT, we are just expected to do more with less,” said another.

However, the expectation of huge cuts to IT budgets has subsided, with just 7% of respondents saying they expected their budget to be cut by more than 20%, down from 27% last year; and 8% saying it would increase.

“Our trust is emerging from turnaround and is investing heavily in IT to support frontline productivity,” wrote one correspondent. And another added: “My trust has decided to invest heavily in IT in order to deliver key projects and, ultimately, an electronic patient record.”

Still, getting the point, and doing something about it are different things, with respondents noting that it is “difficult to get the money” and, again, that board level backing is all important.

“We need to replace our PAS and we want an EPR. We failed to replace during one procurement process and are trying again. We are looking for our fourth chief executive in two years,” wrote one respondent, quite possibly in despair.

In the market for EPRs

In line with the other findings, when they were asked about their department’s main priority for the year ahead, almost half of respondents said their focus would be on running or maintaining infrastructure.

However, far fewer respondents this year than last year said that their department’s main priority was just to “reduce costs even if this means a poorer service” (10% down from 26%) or just to “keep our systems up and running” (14% down from 27%).

And more indicated that there would be room for some investment, or that their department’s main priority would be to “deliver a major PAS/EPR upgrade” (25%, up from 14%).

In terms of the NPfIT, and where PAS and EPR replacements are likely to come from, 14% of respondents said they had received an EPR system NPfIT and didn’t need one.

A further 23% said they had a non-NPfIT EPR and didn’t need one, 6% said they would wait for the remains of the programme to get to them, and 20% said they would be going out to tender. The ‘best of breed’ route of linking up existing systems and adding a portal was picked as the way forward for 27% of trusts.

Other technologies attracting significant interest included e-prescribing (although a number of respondents said their trust had canned e-prescribing implementations because of cost), document and asset tracking systems, clinical correspondence and patient communications, such as texted appointment reminders.

Reforms; bad but not terrible?

There was even some suggestion that people may be feeling better about the reforms forms. True, just 15% of respondents thought they would deliver any kind of benefit; but that was up from 5% last year; with most of the difference apparently made up of people who had decided “they will make no difference.”

As one respondent put it: “The NHS is highly resistant to change, and it’s the usual suspects who will be in charge. It’s rearranging the deckchairs once again.”

But rather fewer people thought they would be disastrous, with a comparatively small proportion of respondents (26%) saying “more providers and tighter budgets will lead to lower quality” (against the 42% who picked this option last year).