Eight years ago, I started working as a software developer for a doctor who, frustrated with the limitations and inefficiencies of the software used in his department, decided to do something about it by writing his own.
This is not an unusual story for a healthcare IT company - you might have to be a little crazy to start one purely for financial gain or the technical challenge!
The software was a big success. The project was small, free from bureaucracy, and we knew most of the users by name, visiting them regularly. We learned a lot when they picked up the phone to share a problem with us – and we would make the necessary changes within days.
Despite the success on the ground, we were losing a political battle. The trust saw us as competitors to the National Programme for IT in the NHS / Connecting for Health solution that would be shortly coming along and so there was minimal investment. In fact, the project was almost entirely funded by us.
Then the trust commissioned a different software house to develop a separate system from scratch. Both our business and the trust have moved on since then. Our story illustrates ournaive belief that we could build a business just by creating better software.
Not an easy place for vendors
For as long as I can remember, there has been a perception that IT vendors overcharge and under-deliver. However, I don’t think people realise how difficult it is to develop a sustainable business developing software for the NHS.
Unsurprisingly, most trusts are very risk averse when it comes to procurement. Procurement processes tend to filter out companies which don’t have £X million turnovers and software deployed in lots of trusts (immediately disqualifying most start-ups!) before any discussion about whether the product is any good.
For small companies, this essentially means that you need to find a partner company to sell through – sometimes doing nothing other than putting their name on the contract and taking up to a 40% cut of the revenue.
Assuming you can get past that, there is often a set of backwards-looking tender requirements. It’s common to see something like “software must work on a Windows XP machine running IE6 with 256MB RAM”. But I have never seen anything along the lines of “software continually be updated to support the three most popular web browsers on all Microsoft desktop operating systems still in support.”
It’s rare for purchasers to request support for the common user interface, provide guarantees about future interoperability with NHS standards, or get into how we should approach more abstract requirements such as performance and usability.
I’m not, of course, saying that vendors don’t do these things. We do them because we want to have the best product, but we accept that there is little commercial incentive.
Too focused on price
Many companies will submit a tender response saying they can meet the requirements (you can always negotiate your way out of it later, right?) and so price is likely to be the deciding factor in the tender.
Some vendors are almost giving their software away, forcing a price war, so there is almost no money to be made up-front. Money has to be recouped somewhere, which is why you sometimes find vendors charging silly amounts to make trivial changes. It’s no wonder that this model creates tension between vendors and customers. One can look around and see examples where both sides seem to push each other towards an adversarial relationship.
We end up doing a lot of work at no charge, from things like out-of-hours support to consultancy around data debt, interoperability and process change – issues which frequently arise during initial implementation but NHS staff have not necessarily had to deal with before. We feel we have to do it to ensure success of the projects and act in the trust’s interest over issues like data debt.
Vendors are in a fantastic position to promote best practice and knowledge sharing between customers (in fact, this was one of the recommendations of the BCS paper ‘Preparing the NHS for an information revolution’).
We see trusts trying to solve the same problems again and again. We have the clinical and process change expertise to advise but, disappointingly, this is often seen as outside of our remit. There is a lot of process variation between trusts trying to achieve the same goals and we are in a position to recognise that and get them to talk to each other.
Despite our struggles, I’m optimistic. There are lots of talented and passionate people working towards improved IT in the NHS. There is recognition from that a different approach is needed.
Events like the NHS Hack Day and on-going open source initiatives provide a fantastic platform for innovation and anything that brings developers, designers and users closer together is good news. My hope is that the NHS, free from its CfH shackles, will see the value in promoting these relationships and that there is fantastic value to be had by looking outside the big vendors for solutions.
About the author: After graduating from the University of Bristol with anMEng in Computer Science in 2004, Will joinedBluewire Technologies as a founding employee. For the last 8 years he has been one of the principal developers of the Epro Clinical Toolkit and is passionate about software development,user experience and innovation.
When not developing software he can usually be found playing trombone in various local orchestras, climbing a rock face or enjoying the surf in North Devon.He can be found on twitter as @wilhol and github at https://github.com/willholley/.
