Is more centralisation really the way forward? Jane Dudman encounters mixed feelings over the NHS's updated IT strategy

The eagerly anticipated, updated NHS IT strategy signals a big push towards more central procurement. National projects have been commissioned for digital TV and smartcards. A 'national solution' will be developed for electronic booking systems, based on local pilots. And more mature projects, such as electronic patient records, will have to meet national and international standards.

The targets set out in Building The Information Core - implementing the NHS plan are ambitious. By March 2002, all NHS clinical staff should have access to basic e-mail, browsing and directory services; the new national payroll and human resources system should be in place by March 2004 and the NHS should finally be working with electronic patient records by 2005.

On the other hand, the strategy sets out a clearer vision of how the patient should benefit. 'Integrating IT with the NHS plan is important, because it has always previously been seen as something of an addon, ' says Ann Harding, associate director at healthcare software supplier iSOFT. As to the specifics: 'It is not beyond the wit ofman to deliver on the target for access to e-mail and browsing. But I am slightly more worried about the targets for online reporting and appointment booking. '

While she welcomes the document's 'clarity', she says there can be too much emphasis within the NHS on trying to get every aspect of IT projects right, rather than rolling them out and modifying them as they go along. This could affect electronic health records: 'do not let's look for the holy grail, let's do something now, based on the right formats and the right standards, and let's learn by doing it. '

Paul Brown, director of the centre for the advancement of electronic health records at Chepstow, Monmouthshire, welcomes the new strategy. 'The document seems to outline the right sort of objectives and to be a bit more realistic, but it is actions, not words, that count. '

And this is the worry of some observers, who feel actions being taken by senior managers within the NHS Executive and the NHS Information Authority could undermine much of the progress so far.

In particular, they are concerned about the imposition of large, centralised systems across the health service. 'The NHS is far too big to run centralised IT projects, ' comments Markus Bolton, managing director of System C. 'Every time it is tried, it has been a disaster. 'He says the two-year-old Information for Health strategy set an overall framework but was designed to enable local groups and trusts to evolve their own implementation, according to local needs.

'Now we seem to be driving away from all that, ' he says. Although local implementation strategies are still seen as the way to deliver IT into specific areas, the central setting of standards and systems has become more important. This, he believes, is inappropriate at a time when local staff and managers are more computer-literate and aware of how technology systems can help them.

Others disagree. Peter Dyke, head of marketing at BT Health, welcomes standardised frameworks. 'It is perhaps the best and easiest way of moving the agenda forward without losing vast sums of money to fragmented and inconsistent systems, ' says Mr Dyke. The NHS needs the firm hand of centralised management to implement IT systems effectively, he believes. 'It took five or six years to make NHSnet work, ' he says. 'There was consulting all over the place and people got side-tracked by multiple interest groups, until the decision was taken to pay for the network centrally. That is the model they are leaning towards. '

Mr Dyke fears there may not be enough strong-willed project managers within the NHS to drive forward new centralised initiatives, in the same way as Bob Grindrod drove forward NHSnet until last year, when he joined a private consultancy. 'There are some people within the NHS Information Authority who can run these projects, but we need to bring people forward into these roles, ' says Mr Dyke. 'The technology itself is a doddle. '

There is a shift from seeing IT as purely a technical issue, to be implemented by IT specialists, towards placing greater responsibility at the door of NHS operational managers responsible for care delivery.

There are 60 online booking pilots in place around the UK. If only one is chosen as a national model, that will have a huge impact on the others.

Mike Kingswood, UK managing director of McKesson HBOC, says the extra funding from the Department of Health for these IT initiatives is 'positive', but in reality, local implementation strategies already show large shortfalls in the investment required to deliver all the Information for Health targets. So once again, the NHS may be looking to see where the money is coming from.