The Download: How many flowers should bloom?

In the wake of the National Programme for IT, there was a prevailing view that local NHS organisations were best left to do their own digital thing.

But, like the National Programme for IT, this “thousand flowers bloom” approach, as it was later called, has left its own troubled legacy, namely a tangled mess of bespoke IT systems of variable quality. 

In the past few years, the NHS has started swinging back towards a more nationally coordinated approach and bringing some semblance of order to the IT garden. HSJ reported last week, for instance, that NHS England is now considering building a nationally available electronic patient record, a feat not attempted even during the most grandiose National Programme for IT years.

NHS central digital folk argue this is not a return to the bad old National Programme for IT days. Local NHS organisations may face increasing central scrutiny over which IT solutions they pick, they say, but they will still be free to choose, (sometimes, and preferably from an approved list).

But as power moves from local decision-makers into central bureaucracy, the cost of such a shift deserves closer examination.

Seeds from the centre

First, it is worth noting that many national NHS IT services set-up during the National Programme for IT never went anywhere while others have been expanded since. NHS Digital still runs a national electronic referral service, electronic prescribing, and patient summary care record system. Most of the NHS still uses a single email system, NHSmail, managed through a central contract. Last year, GPs were threatened with non-payment by the NHS unless they started using the national e-referral system.

In the wake of WannaCry, NHS internet flows are also more heavily monitored than ever by NHS Digital’s central cybersecurity unit. The body is currently consulting industry on how this unit could be strengthened further, with “100 per cent visibility” of all NHS network traffic.

Under the long-term plan, this centralisation of IT services will expand further, primarily in digital patient services.

NHS Digital has now built both a national NHS patient log-in and a patient opt-out. All NHS organisations and IT suppliers will be expected to use these products by the end of next year to verify a patient’s identity online and let them modify their record sharing preferences.

Over the next five years, local NHS organisations, starting with GPs, will also be expected to plug into the national NHS app. This, according to the plan, will become the nationally-mandated “gateway” for patients wanting to access digital health services, such as an online consultation.

Even when the centre is not providing an IT service, it is often involved in picking digital winners and encouraging others, with carrot and stick, to follow their lead (see global digital exemplar programme).

The advantage of the central solution is obvious. They provide a consistent experience, they are scalable, and they are often cheaper.

But they can also be vulnerable.

Putting all your flowers in one bed

When the NHSmail system crashed in November, hundreds of thousands of NHS staff across England and Scotland lost access. Parts of the NHS, such as Oxfordshire, that have opted to run their own email service were unaffected.

In July last year, a software glitch in TPP’s SystmOne software meant 150,000 patients’ confidential records were shared contrary to their explicit wishes. TPP is one of two suppliers that between them provide the primary clinical IT system to 95 per cent of NHS GP practices.

Central systems centralise risk in the event of failure.

Imagine a future in which the NHS app crashes and millions of patients can’t book GP appointments, order a repeat prescription, or attend an online consultation.

An argument can also be made that a heavy reliance of central systems, or a highly restricted pool of approved suppliers, can also stifle innovation.

The Download has been told that when NHS England strongly recommended local NHS organisations pick the Pathways software (developed by NHS Digital) to power NHS 111 online services last year, the market for competing suppliers, some of which had been invited by NHS England to pilot their product in the NHS, collapsed.

There are concerns among some suppliers that the NHS app could have a similar impact on the dozens of digital companies that already have contracts with local NHS organisations to provide digital patient services. 

Such concerns can spook new IT suppliers, with the NHS potentially missing out on beneficial innovation. It can also discourage local innovation developed from within the NHS. 

Weeding

A contrary argument would be that letting IT suppliers do their own thing is precisely what’s led to the current predicament, with local NHS organisations with poor digital know-how paying too much for IT that’s not fit for purpose.

Here is where the second and perhaps more promising element of an increasingly interventionist digital centre comes into play; the mandating of standards for IT suppliers to participate in the NHS.

This is not so much handing out seeds as specifying the type of plants we let into the NHS garden in the first place.

These standards are mostly common sense – using the NHS number, basic data security and ensuring systems are interoperable (ie: talk to one another) – but plenty of NHS IT does not currently meet them. The standards will, however, be increasingly baked into NHS IT frameworks and they already have strong central backing.

The NHS has tried to improve the behaviour of incumbent IT suppliers, especially around interoperability, before with limited success, but that doesn’t mean it can’t be done.

As the centre takes more control of NHS IT strategy, one solution is to replace recalcitrant IT suppliers with new central systems. But the other is to support a diverse market of alternative suppliers, all of whom can be ripped out by the roots if they fail to help the NHS flourish. The NHS probably needs a balance of both.