Executive Summary
1.1 Background
Since the creation of the £12billion National Programme for Information Technology in 2002, the subject of NHS IT in England has been much commented on, not least because of its ambition, delivery record and cost. A new Government would need to assess how to gain the best from IT investment in the NHS and what should be done with the centrally run Programme. There is a risk of a hiatus around NHS IT after the Election.
In response, 2020health believed it would be helpful if we undertook a short, independent research project to map out an action plan for NHS IT, with a particular focus on the Programme, to assist policy makers determine the way forward.
1.2 Key Drivers
The NHS is shifting more and more to a complex, federated system and away from a centralised hierarchical model. This has profound implications for IT.
As the plurality of providers grows, IT becomes a vital prerequisite to enable patient-centric, joined up healthcare services. As care becomes more personalised, patients increasingly want access to their own health records, have control over who has access to them, and exercise informed choice over their care.
A new Government must work IT planning intrinsically into its policy and strategy (not treat IT as a cost - it is an asset). A constant dialogue is needed on strategy, refreshed at least yearly, linking business / policy plans to IT investment priorities, governance, processes and capabilities that the NHS needs.
The perception that IT projects can be axed, or made successful simply by renegotiating contracts, is entirely false. Unless a new Government genuinely recognises that they must deliver massive change in the way health and care are provided, supported by IT, they will fail again. Localising / fragmenting the existing problems will only make things worse.
1.3 The Programme in Overview
The Programme was conceived to address the problems of a highly fragmented IT situation across England. Its central feature is the NHS Care Records Service, with a central core (the NHS Spine, a national database of key information about patients’ health and care) supported by a national infrastructure. The two remaining Local Service Providers are responsible for the delivery of local care records solutions, which connect into the Spine.
In retrospect it is clear that the Programme tried to do too much, too quickly, with a limited focus on early winners to gain credibility and acceptance with the NHS. There was a collective failure to get the Programme positioned as an enabler for transforming healthcare services, and gain full clinical engagement and local ownership.
While the delivery of the overall vision remains 5 or more years away, the Programme has had some success, especially in delivering infrastructure, defining standards and some local care records.
1.4 Local Service Providers
The Programme’s most significant failure lies in acute hospitals where centrally provided solutions have been very late because the NHS does not conform to a ‘one size fits all’ model, and for a mixture of contractual, software delivery and deployment reasons.
There have been successive attempts to make the Local Service Providers model work better over the years through several contract resets, with some improvement. Both contractors are now in further contract resets, due for conclusion by 31March. As a starting point, a new Government must test the contractual arrangements and baseline plans against key criteria that we set out in the main body of the report.
Without sight or knowledge of the commercial situation or current state of negotiations, we do not know how close the revised arrangements are to meeting these criteria.
Irrespective, there are elements of the local solutions that work well (e.g. infrastructure; shared care records in primary and community care; secure data centres) and these should continue in one form or another. In the hospital area, much has been invested in time and money, some sites are operational and we are told that both solutions are close to being fully ready.
In the event that the new Local Service Provider arrangements do not meet the criteria, the acute solutions should be exposed to competition with the small number of other viable solutions, through becoming part of an acute systems procurement catalogue. Local health communities could call-off what they need based on their own capability, maturity, starting point and plans.
The catalogue should be created and coordinated centrally, but be accountable to the NHS. To incentivise Trusts to use the catalogue, partial central funding should be available. Suppliers must show clear adherence to well defined interoperability standards.
This would also allow fairness in those parts of the NHS which already fall outside the preserve of Local Service Providers (principally the South). A process is underway to provide local solutions here but there is a risk that contracts may be rushed through, resulting in a sub-optimal solution for the NHS.
Adherence to standards here is a critical element but there is as yet no ‘magic bullet’. There is a vibrant community internationally, in which the centre participates on behalf of the NHS. Here we recommend that the centre take a more practical but informed approach, and follow international/ EU standards unless there is an overwhelming case otherwise.
1.5 Under-exploited Opportunities beyond the Programme
A new Government needs to consider carefully the potential of:
- telemedicine (to provide remote access to specialised care, extending the reach of clinicians into the domestic care setting, improving service and overall efficiency);
- collaboration services (network technology, enabling productivity & mobility, as a platform for improving working practices);
- electronic document records management (scanned paper medical records).
In each case pilots have taken place and there is a need to define a national strategy based on best practice in the UK and elsewhere, including both technology and process change aspects. Where appropriate, enabling national infrastructure would need to be procured and/or establish call-off catalogue arrangements as required.
Although the Programme is helping to address the matter of improving the prescribing value chain (i.e. the electronic linkage of patients, prescribers, dispensers and the reimbursement agency), a review is needed to secure clinical and administrative benefits in a timelier manner than the current plans.
Finally, the nature of the current provision at local NHS IT level is highly-fragmented, with limited resilience against failure. If the NHS is to get value out of IT, local IT services need to be transformed to a scale and quality well ahead of where many are now. Over time, the NHS should therefore address consolidation opportunities, such as rationalising NHS data centres into either large-scale off-site facilities or a “cloud-based” provision, once established and safe.
Furthermore, where feasible, IT staff should be organised into shared services aligned to the natural health communities that they serve. i.e. county or metropolitan level, to deliver more critical mass and offer career progression. Going forward these local organisations should take responsibility for strategy, integration with national programmes and play a leading role in the selection and implementation of front-line systems.
1.6 National/Local IT Services
Our view is a national approach to IT should only be taken when one or more of three principles can be met:
- to avoid redundant variation for infrastructure and back-office solutions on a once and once only basis;
- to provide economies of scale, associated with using NHS purchasing power;
- to meet the ‘national’ nature of NHS patient care, through essential central coordination or regulation, e.g. standards, security.
A new Government would wish to do an urgent stock-take of NHS IT projects, assets and organisation against these principles and we set out specific recommendations in Figure 1.1. It shows our recommended plan for action for NHS IT for the new administration’s first 12 months in office. The timetable is explicitly tight, since long drawn out reviews are not what is required. We do not have access to accurate costing information, but believe the recommendations in totality will save more than £1bn and accelerate improvements to patient outcomes.
National IT organisation(s) would be needed to deliver relevant services in support of these principles. The presumption is that they should have a limited remit and be performance managed by the NHS. They need to exhibit a culture of transparency, pragmatism, and learning / promulgating lessons to support NHS-wide IT-enabled change. A small, linked organisation is also needed to interpret policy as a bridge with the Department of Health and set a national direction for IT.
Beyond this, and respecting any nationally agreed contracts already in place, localNHS organisations should be free to set their own strategy to take advantage of national assets, with far greater emphasis on local choice of front-line systems. A single IT strategymust be set at the local health community level (i.e. tomatch the scope of the local IT organisation - e.g. county-based), as opposed to a free-for-all which would be impractical. Foundation Trusts would not be mandated to participate but would be encouraged, in order to meet the local healthcare strategy.
The totality of IT provision must support the delivery of joined-up care. The emphasis must be on technology-enabled service improvement aligned to the core process of delivering care to improve patient outcomes, as opposed to an over-emphasis on technology.
The complete article (PDF) can be found online at 2020Health.org (2MB).