can you tell what it is yet?

With the awarding of the LSP contract for the south, the last piece of the national programme jigsaw is in place. Lyn Whitfield asks what the service will get for the money, but finds the answers hard to come by

Remember the first art installations, the ones that caused outrage back in the 1970s, before artists took to pickling sharks and sculpting their own body parts?

Well, NHS IT bears a passing resemblance to one. An awful lot of money has been spent. Curators say something terribly significant and exciting has been purchased. But there is still only a pile of bricks on the floor.

In the case of NHS IT, it is not even clear how many bricks there are or how much organisations will have to pay for their own little pile.

Which has made some people ask whether the bricks are really art at all - especially people who have spent a lot of time on their own work over the years, or frankly do not hold with all this newfangled nonsense.

First, however, a tour of what can be seen. In January, the national programme for NHS IT signed the last of its big service provider contracts, making Fujitsu local service provider for the south in a deal worth£896m over 10 years.

The national programme was set up in 2002, after ministers lost patience with slow progress towards the 1998 Information for Health strategy. It is charged with creating a new broadband network for the NHS (see box, top right) and making sure key applications, such as electronic booking, records and prescribing, run across it.

To do this, the programme has signed a national service provider contract for a 'data spine' and five local service provider contracts to sort out IT systems and implement what are now known as NHS care records services locally.

These contracts are worth rather more than£5.5bn over 10 years (see box, below left) - but it is not yet clear what is in them. The national programme eventually put the initial output-based specification for care records onto the web. But the final version, against which contracts were signed, has yet to be published.

One industry source says he has been asking for something simpler, a one-page summary of what is in the contracts, but has yet to receive it. 'We probably know more about what the intelligence services knew in Iraq than we do about what all this money has bought us, ' he jokes.

LSPs are starting to work on implementation plans with local NHS organisations and this may put more information into the public domain. In the meantime, briefing documents leaked from regional clusters into the national press indicate that records really are at the core of the contracts, and other systems that some people hoped might be included are 'extras'.

For example, NHS IT director general Richard Granger has told HSJ that picture archiving and communication systems will be an option - though he wants four vendors to work with LSPs and is currently involved in tough negotiations on price (see feature, pages 9-13).

It has also been clear for some time that local NHS organisations will have to find most of the money for implementation, training and change management.

Many IT directors remain unconvinced this will happen (e-novation, pages 2-3, 15 January).

However, there are signs managers are starting to engage. An NHS Confederation survey in January found 22 per cent of 158 responding organisations had conducted a survey of their readiness for electronic booking and NHS care records services, while 48 per cent planned to do so.

Policy manager Gary Fereday admits this means 30 per cent of the small sample that replied have no plans, or do not know what their plans are. But he says chairs and chief executives are talking about the national programme in a way they were not even a few months ago.

'People are a little bit concerned that they do not have all the details yet, but they are saying this is potentially one of the biggest things they will have to deal with over the next 12 months, ' he says.

'They are seeing this as a key risk, along with finance and the European working-time directive [which will apply to junior doctors in training from next summer and is likely to trigger big changes in how hospitals operate]. Last year, it would not have registered at all.'

One of the big issues for managers will be how to match up the NHS IT and modernisation agendas.

E-booking is an NHS plan commitment, intended to give patients more control over their treatment.

NHS care records should deliver clinical benefits, but they will also drive patient choice and support trends such as multidisciplinary team working and the 'networking' of hospitals and community facilities.

All this gives managers good reason to peer - however suspiciously - at the pile of bricks on the floor. It may not be such a draw for others.

A survey last month of more than 1,000 GPs found that only 35 per cent thought e-booking was a priority, and just 3 per cent listed it spontaneously as something they wanted to see implemented in the NHS.

More than 80 per cent of GPs were enthusiastic about electronic health records, and 75 per cent thought the IT-led modernisation of the NHS was a priority.

But they were more or less evenly divided on the merits of the national programme. Thirty-one per cent said it was a good use of£2.3bn [its initial three-year budget], 30 per cent said it was not and 39 per cent were unsure.

Perhaps it is not surprising that one of the big GP suppliers, Emis, has refused to subcontract with any of the LSPs (see box, below).

On the other hand, GP support for the programme may not be so bad, given that 26 per cent had never heard of it until the surveyors rang and 75 per cent had not been consulted.

The national programme has been slated month after month for lack of engagement, and things do not seem to be improving. Laurence Harrison, programme manager, healthcare, at industry body Intellect, says: 'Nothing has changed - there are still huge issues around communication.'

LSPs, he says, are doing their best, but there is 'a lot of confusion' in the NHS and among suppliers. For example, although Mr Granger has said legacy systems will not be ripped out unless it is impossible to integrate them with others, Intellect is worried trusts may expect to ditch existing suppliers.

Intellect also wants to make sure a new accreditation process is 'transparent' and that rejected suppliers are given clear reasons. Otherwise, Mr Harrison says, nonaccreditation could be seen as a black mark internationally.

A shake-up in the NHS supplier market has been expected for some time, but so far only one big merger has taken place, between iSOFT and Torex - and it is still subject to court action on competition issues.

However, Intellect has been advising companies to secure their futures until this summer, when the impact of LSPs will be clearer. After that, Mr Harrison's personal view is that more consolidation is inevitable.

So, the brick installation is causing quite a stir. The newspapers are interested and people are lining up for a closer look.What is not clear is whether history will judge it a collectors' item or one for storage in the basement. l Who has won the£5.5bn national programme contracts?

Schlumberger Sema won the£64.5m e-booking contract last autumn.Since then, the national service provider 'data spine' contract, worth£620m over 10 years, has gone to BT, which also became the local service provider for London in a deal worth£996m.

Accenture won the biggest LSP contract, the£1.1bn deal for the North East and Yorkshire, and picked up the contract for the North West and West Midlands, worth£973m.CSC won the Eastern LSP contract, worth£934m.

BT and Fujitsu are working with clinical systems provider IDX, while Accenture and CSC are working with iSOFT.

The other big clinical systems provider, Cerner, has been left with work on the e-booking programme.

Oracle: an enterprise-wide agreement

The national programme is also looking for 'enterprise-wide'agreements, similar to the NHS deal with Microsoft.The first of the new agreements was signed in January, with database supplier Oracle.

Oracle is already a big player in the NHS, since more than 70 per cent of trusts use its systems, and its database is part of the national strategic tracing service.

Oracle infrastructure will underpin iSOFT and IDX products and services and the e-booking programme.The national programme claims it will deliver big savings.

N3: the new IT infrastructure

BT has done particularly well from the national programme for IT.At the end of February, health minister John Hutton announced it had won the£530m seven-year contract to build a new broadband network for the NHS.

The new network, known as N3, will be radically different from NHSnet and, indeed, from traditional broadband services.BT will be required to act as an 'integrator'- working through public sector 'regional aggregation bodies' to buy connectivity from competing providers.

This approach is being driven by the government's Broadband Britain project, which wants the public sector to drive demand for high-speed, always-on connections, and use its muscle to put them into areas that are not commercially attractive to suppliers.

E-commerce minister Stephen Timms says 'Awarding the N3 contract is the first step in bringing an immensely influential pool of public sector broadband buying power to the market.Areas previously considered too remote or uneconomic for broadband will particularly benefit.'

The NHS should get a network that can deliver voice and video as well as data, and one that should drive the transfer of patient records, test results and other data-hungry applications.GPs are being promised connections of 512kbps and 1mbps, community hospitals connections of 10mbps and acute hospitals connections of 100mbps.

NHS IT director general Richard Granger says N3 will be more secure, crash less and be£900m cheaper than upgrading the old NHS intranet to deliver the same capacity.

Emis vs the local service providers

Emis, the largest supplier of computer systems to GP practices, became the first major firm to rebel against the national programme in January when it refused to subcontract to any of the local service providers.

The company told the E-health Insider e-mail service that it would not sign standard subcontractor contracts because they would result in 'a single, uniform system with insufficient focus on primary care'.

The company, which has 58 per cent of the GP market and a large and active national user group, said it would be unable to offer 'the same standard of service'.

So far, GPs appear to be backing the company.The user group has urged members to write to their MPs and NHS IT director general Richard Granger to complain.

Mr Granger has made less than effusive comments about the quality of primary care systems and their interoperability with the rest of the NHS.Strictly, the row is between Emis and the LSPs, which are the 'prime contractors' for the national programme.But it is a headache for Mr Granger, who does not want to be seen riding roughshod over the preferences of GPs, whose new contract offers practices a choice of IT systems and promises to pay for them.

Speaking to HSJ when the row blew up in January, he said: 'I want GPs to get the systems GPs want and I do not want any equivocation about that.'However, Emis's strategy is a high-risk one.On the face of it, the company will only win if it can apply enough political pressure to force the national programme to fund any system GPs choose, even if it comes from a supplier not signed up to an LSP.

But this would undermine the rationale for the national programme, which has been strongly supported by Department of Health officials and ministers.

A slightly less damaging alternative would be to allow GPs to choose systems from outside the national programme portfolio, but make them pay for these themselves. It would be interesting to see how long Emis retained its famously hard-nosed customers in such a scenario.

Mr Granger seems to think the row will be overtaken by the programme's momentum.