What’s in store for 2012?

On 14 December, eHealth Insider hosted a roundtable on the outlook for health IT in 2012 and beyond, sponsored by iSOFT, a CSC company.

The debate was held as NHS organisations in England started to reorganise themselves in line with the reforms first outlined in the ‘Liberating the NHS’ white paper, and as financial constraints on the health service started to bite.

Participants were also concerned about the impact of the wind-down of the National Programme for IT in the NHS. They agreed that both trusts and suppliers need certainty about the role of local and national organisations in order to move on from the “paralysis” created by the programme.

Looking at the wider e-health agenda, participants also agreed that patients must become more involved in their own care, but differed on how soon patients should be given access to their records.

The Big Picture

Christine Walters, the associate director of IM&T at Pennine Acute Hospitals NHS Foundation Trust, opened the discussion with an insight into the strategy adopted in Manchester for the procurement of essential IT.

Pennine Acute is working in a consortium of ten trusts for the joint procurement of picture archiving and communications systems and radiology information systems, when the contracts placed by the National Programme for IT in the NHS run out in 2013.

Walters said trusts were operating under significant financial constraints. Although the government has insisted that it has protected the NHS’ budget from wider public sector spending cuts, the health service must still deliver the ‘Nicholson challenge’.

This requires it to find efficiency savings of £20 billion over four years; a substantial amount of which will come from straightforward reductions in the NHS tariff.

However, Walters said that – in common with many trusts - Pennine Acute remains “very paper based” so there are big opportunities to “use technology to improve not just how the clinical side is delivered, but the non-clinical side.”

Walters said that delays to the national programme – which has particularly struggled to deliver ‘strategic’ systems to the North, Midlands and East - have contributed to the lag on removing paper.

While it has delivered some “great things”, such as the N3 network, she said, the programme has also left many trusts behind in terms of technology.

“Command and control has gone, but we haven’t got new rules,”

Christine Walters, associate director of IM&T, Pennine Acute Hospitals NHS Foundation Trust

“Command and control has gone, but we haven’t got new rules,” Walters said. Despite this uncertainty, a number of large acute trusts are now pushing ahead with electronic record system procurements.

“What do we do as organisations? Stand still and wait for the standards or push ahead?” she asked. “I say push ahead. I’m not going to stand back and wait for the centre to deliver standards. If you are making progress you have to keep pushing ahead.”

If Pennine Acute is pushing ahead, Jonathan Edwards, a managing director of The Advisory Board Company, said many NHS trusts were “pulling back” from their health informatics services because of “perceived issues with some of the service levels they have been getting” and re-evaluating their entire approach.

“Trusts are saying we need to start from scratch,” Edwards said. This clean slate approach created a lot of opportunity; but also massive challenges because the funding squeeze put pressure on trusts to have a strong business cases for any investment.

“IT remains something that trusts understand as being critical to quality improvement, but it seems to have become more of a long-term focus rather than a short-term, given the cost focus and disappointment of the national programme,” he added.

The role of the centre

Justin Whatling, the chief clinical officer at BT Health, predicted that there would be a move away from “technology thinking” towards “transformation thinking” in 2012.

For this to happen, though, he said the role of the “centre” needed to be clearly defined. Everybody needed to know their role in the system if the information market was to flourish; but at the moment there was “chaos.”

Whatling said the new NHS Commissioning Board that has just been established in Leeds should have a role in monitoring innovation, identifying barriers to innovation, and working out how to resolve them.

“We need to find a middle ground, we need the centre to tell us what it does - not telling how us how to do things - but allow things to flourish locally,”

Justin Whatling, chief clinical officer, BT Health

“We need to find a middle ground, we need the centre to tell us what it does - not telling how us how to do things - but allow things to flourish locally,” he explained.

All the round table participants agreed that the centre still has an important role to play in a successful health system, but they had different ideas about what this might entail.

Nick Harte, iSOFT’s solutions director, said the centre’s role should be about incentivising useful initiatives. “[The interoperability toolkit] is a good example of the work we would encourage the centre to get involved in,” he said.

Edwards believed the centre should also provide guidance on some of the big issues that trusts are wrestling with, such as information governance, and on setting national standards for health information exchange.

He felt it might also do some national deals; for example reconstituting the Microsoft enterprise-wide agreement for the health service in England, the demise of which was “not a good thing for the NHS.”

The director of Health ICT Consulting, John Cruickshank, wrote a major report on NPfIT 18 months ago for the 2020 Health think-tank.

The report argued that NPfIT should not be scrapped, but that key bits of it should be retained, while elements that were not working should be “fixed.”

In line with this, he argued at the round table that it made sense for the Department of Health to continue to act as the manager for national infrastructure and the purchase of N3 and other national applications.

“The government has not been perhaps as robust as it needs to be in arguing the case for the benefits of making information available and enabling people to do things online for themselves,”

Joanne Shaw, chair of NHS Direct

He wanted the centre to continue to be the “guardian of joined-up care” - including standards, interoperability and records access. And where sensible, he argued that it should also procure systems at scale through frameworks.

On a different note, the chair of NHS Direct, Joanne Shaw identified the need for central government to sweep away public anxiety about sharing patient information.

She felt that the government was in danger of allowing small, noisy interest groups to spread fear and anxiety among the public about privacy and confidentiality.

“The government has not been perhaps as robust as it needs to be in arguing the case for the benefits of making information available and enabling people to do things online for themselves,” she said.

Self-care and patient records access

Discussions about what information should be made available to patients, and when, created the most lively debate of the round table event.

Shaw said there were two different eco-systems operating with regards to healthcare in Britain. One was the NHS and the other was self-care, so “how do we get them to come together in a useful way?”

She argued that giving patients access to their records was an essential building blocktowards helping people manage their own health. Unfortunately, she felt that some new systems served to further distance people from their own care.

“When you look about the NHS, there are real reasons to be concerned as you can see technology being implemented that actually cuts the patient off from the system rather than integrating the two,” said Shaw.

For example, the implementation of electronic hospital record systems meant the demise of paper charts hanging on the end of beds; essentially removing the only tangible source of information readily available to patients.

Shaw said it was imperative for technology to be used to enable people to make better decisions about their health and manage their care more effectively.

However, there were already examples of useful services being decommissioned and fears that new ones would not be commissioned in 2012, as the NHS “paused” for reform.

Cruickshank observed that giving patients access to records was “quite threatening to the clinical profession”, but said it was the patient’s information so it should be an “absolute right.”

He applauded the government’s announcement in its Autumn Statement that all patients would have access to their records by 2015. And he described the 3ML campaign to get telehealth systems into three million homes over five years as “a bold and positive step in the right direction.”

How well prepared are NHS trusts to make good use of information IT?

Before the NHS or patients can make good use of information, however, they need systems to deliver it. And for them they need good infrastructure.

For example, Walters said it was all very well to have great mobile technologies, but if the internet connection was not good enough to support them they were rendered useless.

Participants also agreed that clinical engagement was essential, as the most fantastic technology would not work if clinicians failed to embrace it.

Walters said that to achieve real transformation, trusts needed to bring in new technology and the skills to manage the transition to using it. She said this was not often done well in the NHS; while, in her experience, there was often cultural resistance to change.

“Most people go into the NHS for a career for life. That doesn’t happen in the commercial world, which is constant change, striving to improve and become more efficient,” she said. “The NHS knows it needs to change, but it doesn’t know how to make the transition from where it is to where it needs to be.”

“The NHS knows it needs to change, but it doesn’t know how to make the transition from where it is to where it needs to be,”

Christine Walters

However, she saw “green shoots” sprouting in some organisations. “You are going to have leaders and you can already see certain trusts leading the way, starting to do quite exciting things and once that happens that will spread,” she said. “You can see new suppliers moving into the marketplace, working alongside trusts.”

Walters gave the example of Pennine Acute working with iSOFT, a CSC company, to deploy e-prescribing as an example of a genuine partnership between the NHS and private sector.

Cruickshank suggested that while some NHS organisations were capable of responding to the IT agenda, others were not.

“The risk is that IT is purely regarded as a cost, rather than as a potential asset or as something that can make a transformational difference to clinical and business outcomes,” he said.

“We’ve been living in a world where the centre has been driving the IT agenda in terms of the national programme.

“There’s lots of sensible noises about local devolvement and decision-making. But what concerns me is that the pendulum seems to be flying very quickly here and, potentially, some of the very good things that have come about through national approaches may get jettisoned.”

“…potentially, some of the very good things that have come about through national approaches may get jettisoned,”

John Cruickshank, director, Health ICT Consulting

Whatling argued that before thinking about new technologies, trusts should work on diffusing existing technologies with clear efficiency savings as an alternative to cutting staff. “We need to make the most of what we have now and demonstrate the value,” he said.

He identified a number of easy mobile technologies that the NHS had not yet widely adopted, such as audio conferencing to facilitate discharges or video conferencing to get specialists into the community.

Predictions for 2012

Despite the structural turmoil in the NHS, the financial constraints on it, and the challenges posed by the run-down of NPfIT, Paul Smith was optimistic in his outlook for 2012.

The head of research for EHI Intelligence said that EHI’s 2011 NHS IT Market Forecast Report showed that acute and mental health trusts in England were likely to increase their IT spending, because of the policy and financial challenges on them.

He told the round table that 2012 will present plenty of opportunities as people in the NHS and the IT industry “really want to make things happen.”

Smith was also enthusiastic about the success of the EHI CCIO Campaign, which has been calling for every NHS provider organisation to appoint a chief clinical information officer to lead on IT and information issues, and which is about to become a clinical leaders’ network to support these ideas in the future.

“[The campaign] is doing what the leaders in the market are already doing, talking about information not technology,” he argued. “At the heart of it, the NHS is about clinical information and if we can get people more engaged in the clinical process we can use information to get people better faster.”

Walters said she already had good clinical engagement at her trust. She said it had capital available for IT projects if a sound business case could be made, and that it had a sound strategy for IT procurement. She predicted that the more able trusts would be OK; but was not positive about the outlook for others.

Harte was cautiously optimistic for the coming year. He said there was enormous pent-up demand in the NHS for a number of services offered by iSOFT, a CSC company, so there was reason to look forward to the coming year.

But he had some concerns about how quickly the NHS could get over the “inevitable decisional hiatus” caused by the latest reform. Harte also argued that trusts should be more creative about funding IT investments.

For example, he argued acute trusts might look to pharmaceutical companies for funding for IT projects that would benefit them, while generating data for research and trials.

“That would advance the agenda of getting all hospitals involved in research. I think patients would like to see their doctors involved in modern research and feel they will benefit from it,” he said.

In contrast, Shaw was not hopeful of seeing transformational change in 2012. She suggested it would be user-owned technologies that would transform the way people interacted with the health system, rather than changes within the system itself.

“I expect to see increasing divergence between what patients do themselves for their health and their use of technology and what the NHS is offering,” she said; adding that 2012 might be too short a time-frame for significant change in this respect.

"I expect to see increasing divergence between what patients do themselves for their health and their use of technology and what the NHS is offering,”

Joanne Shaw, chair of NHS Direct

Shaw also felt that primary care was in desperate need of clinical engagement about the benefits that technology could bring to patients.

“The scale of change in primary care and clinical commissioning groups makes that a real challenge over the next 12 months. It’s hard to see in many places how that will move forward.”

“Some [CCGs] probably have some idea of how IT will support them, but for many it will be very, very low on their agenda. That’s one area where we may not see much progress in 2012,” she concluded.

 

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