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After nearly a year of delays, the NHS has again picked a small group of suppliers to lead the digitisation of NHS trusts.

On Monday, the new central tech strategy unit NHSX named eight electronic patient record suppliers as being able to provide solutions which met a “high-quality bar”. The eight have been placed on an NHS England framework that has now adopted by NHSX. The aim is clearly partly to control who gets access to the NHS provider IT market.

Despite the health secretary Matt Hancock’s sabre-rattling at incumbent IT suppliers and flirtation with disruptive SMEs over the past year, the chosen suppliers are largely the usual suspects, minus one or two. It is a list that suggests those hoping for radical change to NHS IT market under NHSX, should lower their expectations.

The framework

The health system support framework was conceived in 2017 as a “one-stop-shop” for providers and commissioners to help them select consultancy services and digital technology needed for regional integration.

It was very much a Matthew Swindells’ project and came during the time the NHS England number two was effectively in charge of NHS IT strategy. The idea was to push trusts towards clinical IT systems road-tested by “global digital exemplar” trusts, a cadre of providers picked and funded by NHSE to show the rest how digital is done.

While the consultancy parts of the framework have been live since August 2018, the lot covering clinical IT has been delayed until now. In December last year, industry sources told HSJ that process had been poorly handled and skewed to favour incumbents.

The approach of favouring relatively few supplies would, on the face it, be anathema to the health secretary’s tech vision, which aims to “break the supplier-capture” and promoted niche products. Until now NHSX has also been quietly stepping away from much Swindells-era IT policy.

So, why this decision on EPR vendors? One explanation could be that the framework is too advanced to be abandoned and/or is deemed to be irrelevant. One supplier source whose company is on the framework told HSJ the EPR list was “daft” and would be little used. A well-placed NHSX source told HSJ in June the unit was cool on the whole idea of frameworks.

But other suppliers, including IMS Maxims and Allscripts, told HSJ this was not just another framework among many. On Monday, NHSX chief executive Matthew Gould called it a “key part” of delivering better NHS digital services, including only “ most capable bidders” that had met a “high-quality bar”. A significant statement from the man who now has the power to block or approve major trust IT projects throughout England.

The chosen suppliers

Suppliers of “enterprise-wide electronic patient record” for community and acute trusts on the framework are:

  • Allscripts Healthcare
  • Cerner
  • DXC Technology
  • Meditech
  • Nervecentre Software
  • System C Healthcare
  • TPP

In addition, Allscripts, DXC, and TPP appear on the framework for mental health trust EPRs.

Of these, five (Allscripts, Cerner, IMS Maxims, Meditech, System C) are all core suppliers to global digital exemplar trusts (or several in Cerner’s case) and have a vast (Cerner) to middling (IMS Maxims) presence in the NHS. DXC has one of biggest, if not the biggest, IT footprints in the NHS, largely left over from National Programme for IT,  including the Lorenzo EPR. TPP is the second-largest supplier of IT systems to GPs in England and has been pushing into the acute and community market.

With the exception of Nervecentre, which launched its first EPR last year, the list is largely incumbent suppliers.

There are three big names missing, although all three told HSJ this is because they did not apply to join the framework.

Epic, the massive American health software company, is the most notable. Its system was installed at great expensive (and disruption) at Cambridge University Hospitals Foundation Trust about five years ago. Three other trusts have since picked Epic but, although it is often credited with helping make Cambridge the country’s most digitally advanced trust, HSJ has been told its sheer cost has put off central policymakers. Epic told HSJ it had not applied to be on the EPR list, saying it values “success of our NHS customers over the pace of our expansion”.

Intersystems is another big American supplier not on the list. The company was picked as a preferred supplier for one GDE trust in Liverpool and used in a handful of South West trusts. Although it is included elsewhere on the framework, HSJ understands the company chose not to apply for inclusion as an EPR supplier.

Emis, the biggest IT supplier to English GPs, is another notable exception. Like its main competitor TPP, the company had been pushing into the community and acute market. The company told HSJ it had not sought inclusion on the EPR list as it believed its business was covered elsewhere.

The rest

If the central NHS framework for digitising trusts has just eight suppliers on it - all but one an established player - where does this leave the disruptive innovators, for whom the health secretary promised to fight “vested interests” in his first month on the job?

NHSX has said all eight suppliers had to show they met “interoperability” standards - that their software can connect to other, even competing, software. This is important for smaller niche software suppliers, allowing them to plug into incumbent IT systems. It also makes it harder for incumbent suppliers to block competitor’s access to their systems or even extract a fee for the privilege.

Despite many incumbent suppliers’ protestations to the contrary, most NHS IT systems in use today are not interoperable, stifling innovation, creating a poor user experience and blocking the flow of patient information. HSJ asked NHSX and NHSE what interoperable standards these eight suppliers met, but did not receive a response before publication.

Secondly NHSX said the eight suppliers had to demonstrate their products are modular - that parts can be swapped and changed easily, sometimes with competing products. Once again this should open the door to smaller niche companies. Trusts only have to buy the parts of a big EPR they need and can more easily dump pieces that are not working without having to replace everything. Many of the incumbent suppliers already have a shortlist of SMEs with which they partner to provide alternative products or fill gaps.

Without rigorous enforcement of interoperbaility and the ability to ‘swap out’ aspects of their services, there is a high risk that the eight suppliers become, if they are not already, gatekeepers to the NHS IT market for smaller companies.

At the moment the “one-stop-shop” IT framework has no space for small innovative companies unless they shelter beneath the wing of an incumbent. However, one industry source suggested NHSX will seek to carve out a bigger space for SMEs.

But for now, the framework supports a vision of NHS IT that entrenches, rather challenges, many of the biggest IT suppliers. Mr Hancock’s tech vision included creating “market conditions that drive innovation, in an ecosystem where developers and vendors continuously compete on quality to fill each niche, rather than capturing users”.

NHSX’s first framework for digitising NHS trusts does little to support that aim.

An earlier version of this story stated that Intersystems supplies a GDE trust in Liverpool. This has been now changed to reflect that while Intersystems is a preferred supplier, it has not yet signed a contract with the trust.

The HSJ Digital Transformation Summit, taking place at the Crowne Plaza, Stratford-upon-Avon from 12-13 February 2020, unites 120+ senior leaders from across the provider, commissioning and STP landscape with those who have leveraged technology to drive tangible improvements across other industries, to discuss how to realise your digital visions in a cash-limited environment and scale up innovations to improve quality and outcomes for your local population.

Held under the Chatham House Rule, attendees will quiz NHSX and other national figures on general policy direction and co-develop solutions to their local challenges with innovators from across the country. The Summit is free to attend for senior NHS digital leaders – register your interest here