The fortnightly newsletter that unpacks system leaders’ priorities for digital technology and the impact they are having on delivering health services. Contact Ben Heather in confidence here.

General practice has long been the pioneer for digital technology in the NHS.

GPs were designing electronic patient records when many hospitals were still working out how to plug in their first computer. GPs have been fully digitised for years while, even today, most NHS hospitals are not.

But with a new national contract with GP IT suppliers being hammered out, 2019 is a make or break year for the market.

NHS bosses, from health secretary down, are issuing blunt threats to the incumbent IT suppliers and restless digital newcomers are jockeying for a piece of the action.

Who blinks first, if anyone, will have a profound impact on the quality and range of digital tools available to both GPs and patients for years to come.

The two-horse town

If you’re a GP in England, nine times out of 10 you will be using either Emis’ Emis Web or TPP’s SystmOne software every day. There are two other suppliers (Microtest and INPS) that have small footholds, but the market is effectively a duopoly. 

Between them, Emis and TPP hold the GP records of most of the English population. Any company that wanted to build software that accesses any of that data, such as an appointment booking app, requires one (or ideally both) of these companies to allow them to plug into their system.

These systems are so far-reaching that minor errors can have a major impact. A glitch in TPP’s software, uncovered last year, had resulted in 150,000 patients having their records shared against their wishes. Emis was fined millions of pounds last year for lodging misleading reports about the reliability of its NHS service.

There are few, if any, other parts of the NHS where the IT crucial to the day-to-day running of the service is reliant on so few suppliers.

Conversely, both companies are heavily dependent on the NHS, which is by far their biggest customer. Last year, the Department of Health and Social Care paid them a combined £77m for primary care software alone, and both also have contracts with acute and community care trusts.

Fighting talk

Grumbling about the dominance of Emis and TPP has been growing louder in recent years and much of it is focused on difficulties accessing their massive databases of NHS patient information.

Connecting patient information across different systems (interoperability) to better support direct care in different care settings is sorely needed but it can’t happen without GP records.

The current national contract for GP IT signed in 2015 was meant to compel the major suppliers to share more patient data, including with potential competitors, but has had limited success. Whose fault this is depends on who you ask, but official pressure on all NHS IT suppliers not to hoard data has never been more intense.

NHS Digital said earlier this month that Emis’ and TPP’s software was not “highly interoperable” and the “lack of competition has resulted in a lower level of investment in technology and innovation than is required and protective supplier behaviours”. Health secretary Matt Hancock singled out the pair for criticism in December, stating that “the current market is dominated by two main providers, which slows down innovation and traps GP practices in long-term contracts with systems that are not suited to the digital age”.

For their part, TPP and Emis have repeatedly said they are, in fact, very open. Both companies have told HSJ they are ready and willing to embrace more competition and enhance their already strong offerings further.

Asked for his thoughts for this briefing, TPP founder Frank Hester said he too had been “frustrated with the progress in this area”.

“We have always been an advocate of open standards and interoperability,” he told HSJ.

High noon

Whatever the causes of GP IT’s maladies, changes are afoot.

After several delays, all suppliers must sign up to a new national contract, known as “GP IT Futures”, this year. Mr Hancock and NHS officials have been clear that the new contract is designed to break the current duopoly, bring new players to the market and force TPP and Emis (and everyone else) to sign up to data sharing standards, this time with harsh fines for non-compliance.

Much like the rest of NHS IT land, Mr Hancock has visions of GP patient data freed from the control of any one system, available to feed a bustling market of digital apps that GPs can pick up, plug in, and discard quickly and easily as their needs change.

Those suppliers that can’t (or won’t) embrace this brave new world have been threatened with being shut out of the NHS entirely. Such drastic steps have precedent with NHS Wales last year declining to renew its national contract with Emis, forcing about half the country’s GPs to switch systems.

Both Emis and TPP said they will sign up to both the standards and intent of the new contract. But if they don’t, or subsequently drag their heels, it is not clear whether the NHS would follow through on its threats.

Dropping either supplier would likely be deeply unpopular with the thousands of GPs forced to switch IT systems and would probably disrupt patient services. NHS Digital, which manages the central contract, says it has found at least one other major GP IT supplier from overseas to sign up to the new contract (and provide competitive pressure). But it would be a big call for a new player to scale up and replace either Emis or TPP.

Whatever deal is eventually struck between the NHS, the incumbent GP IT duo, and ambitious newcomers could easily lead to another four years of frustration and complaints about market failure. Or, it could lead to vastly improved digital services for GPs and patients alike.