One size doesn't fit all

The idea has spread like wildfire. Within weeks of its conception, senior NHS officials were making speeches about IT with phrases such as 'ruthless standardisation' and 'expecting' organisations to use 'appropriate national systems'. Then came the flood of national procurements:

single systems with huge estimated budgets have been proposed for NHS Direct (£68m a year), booked admissions (£70£140m), payroll and human resources (£200m plus) and the shared services initiative (£500m).

You can see why the idea is attractive, and the centralists quote the same reasons every time they try it: economies of scale; mobility of workforce; do it once and get it right; reduce the number of bureaucratic NHS procurements; remove communication problems between systems.

It also means that local organisations can take major computerisation off their agenda and await the outcome of the national project. Chief executives being performance-managed for IT and responsible for delivering electronic health records will heave a sigh of relief.

This time around, one of the world's largest computer companies proposed the idea to the NHS on the basis that companies always standardise on single systems. But the argument falls short for the NHS.

First, the NHS is not like a computer company. Although the firm concerned is indeed one of the world's most valuable companies, it has a meagre 40,000 employees compared to the NHS's 1 million. Comparing a computer company to the NHS is like comparing booking outpatient appointments with booking seats on a plane.

Second, the NHS is far too large to treat as a single unit. It is made up of thousands of individual organisations. One size fits all could not possibly be appropriate for such a diverse organisation.

Third, large IT projects often require major organisational change and full involvement at a local level. Every time the NHS Executive tries imposing central IT solutions, it loses communities' support - often cited as a key reason for the failure of such projects. The local implementation strategy was created precisely to overcome this problem. It is odd to see this drive towards central control so soon after the creation of the local teams.

Fourth, much of healthcare computing is in its infancy.

Suppliers and clinicians are working together to develop the best solutions for care pathways, prescribing, hospital/GP links, patient confidentiality, electronic patient and health records and a host of other areas. This is a vibrant market, stimulated by competition between suppliers and their financial investment.

Every time the Executive pushes another batch of suppliers out of the market, it leaves another area of healthcare computing in tatters. No competition and no investment mean little or no progress. Once the suppliers are out of a market, their experience may be lost forever, and if the central projects fail, it may be difficult for others to pick up the pieces. Even talking about it causes a planning blight, as we have seen with Read codes.

Last but not least, large central IT projects carry extremely high risks compared to local projects conforming to a general strategy.

Complexity increases exponentially with size, and against a background of rapid technological advances the mix becomes impossible to manage.

Examples include the scrapping of the£77m immigration service system last month, the Inland Revenue's recent loss of five million tax records, the failure of the£110m Passport Office system in 1999 and - of course - the NHS's resource management, Read, HISS and Wessex fiascos.

Each new project admits the failures of the past ('not always made the best use of IT'). But central optimism wins. Reasons are given why things will be different this time .

Unfortunately for the taxpayers and those who suffer due to the introduction of failed systems, the benefit of hindsight usually validates the misgivings of those that warn against these projects.

Somehow they keep running into the same old wall.

In a major new initiative to prevent further disasters, the Treasury's office of government commerce launched its Gateway review process last week. This is a strict five-stage assessment for expensive high-risk projects, designed to prevent them from proceeding without potential problems being taken into account.

It is hoped this initiative will halt over-ambitious central schemes. If it doesn't, we should fight for local autonomy over the systems on which organisations and patients depend.

One can hardly recall a Budget which disappeared so quickly from the front pages.

Is that a good sign for Gordon Brown and his hopes of succeeding Tony Blair some time during the next parliament?

I am not so sure. I also wonder what Alan Milburn thinks in his quiet moments.

The papers have been full of extravagant claims for Iron Gordon, even those, like the Daily Mail, which fear and dislike him. 'The man whose time has come?' the paper asked this week, over a feature contrasting the chancellor's focused determination and austerity with the glitzy side of Tony Blair, not to mention his poor judgement over the Mandelson affair.

Admittedly it was the Hinduja passport affair which helped push the Budget into the shade. There again, it was a modest, holding kind of Budget - a bit here, a bit there, a bit for NHS recruitment and retention, but basically a bit more of the same.

'Another demonstration of our commitment to public expenditure, ' as my man on the Whitehall ambulance put it, though it could fairly be said that when the chancellor's aides spoke of an extra£1bn for the NHS, they were falling back into that bad habit of triple counting again.

In other words, It is£835m (for England, more for the Celts) over three years - welcome but modest when set against last year's promise of 6. 1 per cent growth in NHS spending for four straight years. 'Icing on the cake, but the cake arrived last year, ' as my man puts it.

It might also be contrasted, as Liberal Democrat Treasury spokesman Matthew Taylor did, with a£1. 9bn cut in motoring taxes - roughly what health and education get over three years. However, we can no longer ignore the price of these things in Europe - or the ease of smuggling, hence the decision not to clobber booze and fags with above-inflation tax increases (that will cost the NHS promised cash for cancer work).

But let's not be churlish. Mr Brown is shifting a lot of cash towards poor families and neglected regions, less covertly as his confidence grows. As minister Milburn was expected to tell MPs on Tuesday, there will be£150m (a year) for hospital improvements and equipment - money given direct to trusts in the same way that his education extra is going direct to head teachers.

That, I guess, is an implicit reproach to health/education authorities, to 'bureaucrats' in MP-speak. More eye-catching is the recruitment and retention money for nurses and GPs - a real problem while the economy thrives.

GPs who head for deprived areas can thus expect£5,000 'golden hellos'.

They will also be reassured that primary care is as important to the revived NHS as medicine in the more glamorous hospital end of the business. How else will the NHS achieve better screening for cancer, coronaries, blood pressure and the rest - or tackle the health inequalities which are a priority for Labour's second term?

Ministers are grimly aware how cross the British Medical Association is and how much damage its angry circulars can do to undermine Labour's upbeat mood as polling day looms. Their current tormentor, Dr John Chisholm, chair of the BMA's GPs' committee, is a good bloke, they say.

Mr Milburn even acknowledges the logic of the BMA's call for 10,000 extra GPs if the 48-hour appointment target is to be met. But 2,000 is the realistic target for now. Of course, it was Caution's cousin, Prudence, who helped build Gordon Brown's reputation.

Yet Budget 2001 confronts us with the fact that Mr Brown has raised Middle England's taxes by a hefty£28bn in varous crafty ways since 1997. He has only lowered Bottom England's. But as Matthew Taylor also points out, NHS spending is - so far - little higher than it was under the beastly Tories.

All right, we know it will get better. But that is only if the economy (ours and America's) holds up as Mr Brown, like Nigel Lawson before him, assumes it will.

That is why I wonder if this week's plaudits have been not the start of the Brown era - idealistic, redistributive, socialist even - but its peak. If the chancellor's star wanes, whose rises?

Mr Milburn must occasionally ask that himself.