Published: 15/01/2004, Volume II4, No. 5888 Page 2 3

As the structure of the national programme for It is electronic records contracts is finally revealed, those holding the NHS's purse strings are getting nervous, says Lyn Whitfield

After weeks of waiting, the national programme for NHS IT was finally able to take the wraps off its big electronic records contracts in the run up to Christmas.

Celebrations, no doubt, in Richmond House, where national programme staff worked all hours to get the deals signed.

But elsewhere, the announcement fell just a little flat.

Health secretary John Reid said that by 2010, all 50 million patients in England will have their own NHS care record, which will summarise details of their care and make it available to 30,000 GPs and 270 acute, community and mental health trusts.

But this generated almost no coverage in national papers distracted by British Medical Association predictions that teenagers could be the fattest, least fertile and most depressed in history.

Mr Reid also laid out details of the first two local service provider contracts. And promptly faced a barrage of questions about where the money would come from.

Funding has been emerging as a big issue for some time. The national programme was set up in 2002, with£2.3bn to spend over three years. Director general of NHS IT Richard Granger seems confident that this level of investment will be maintained until the end of the current, five-year settlement for the NHS. 'The formalities have not been gone through, but the political will is there, ' said Mr Reid.

However, most forecasters are predicting a squeeze on public sector spending from next year - or after the next general election.What happens to ten-year contracts if the NHS emerges from its five-year deal into a much harsher spending environment?

Meanwhile, more money will have to be found to implement the programme locally.Mr Granger wants to see IT spending increase from an average of 1.8 per cent of total expenditure to 3-4 per cent, in line with the Wanless report (HSJ news, page 3, 11 December 2003; and news focus, pages 14-15, 17 December 2003).

But one IT director told e-novation that his trust would have to find another£4m to increase its IT spend from 1.8 per cent to 4 per cent of total expenditure.

'If our trust executive could get his hands on£4m, would he really spend it on [records] rather than waiting lists, star-ratings, clinical governance and the rest?' he asks.

Mr Granger says the national programme will deliver 'performance and efficiency savings' that will make a 4 per cent investment in IT 'a satisfactory position to adopt.'He also says managers should think of IT as a way of achieving waiting list and other targets, rather than as an extra.

However, the 1998 IT strategy, Information for Health, failed, in part, because money 'earmarked' and then 'ring-fenced' for implementation was spent on other priorities.

Carol Clarke, chief executive of Solihull primary care trust and head of the NHS chief executive's information forum, believes things will be different this time, because of the spectacular success, to date, of national procurement.

'Wanless was very clear that spending needed to rise from about 2 per cent to 4 per cent, with 1 per cent coming from the national programme, ' she says. 'We do not think we will see 0.25 per cent top-sliced for this over the next four years, but my PCT is quite clear that we will need to find that. And the fact that the deals have been pulled off gives us the confidence to do it.'

Mr Granger says LSPs will act as prime contractors, leading consortia of hardware and software firms, whose first job will be to 'build interfaces' between existing systems.

If organisations need new systems, they will work with strategic health authorities to define their requirements. LSPs will then procure a system that meets their requirements and the output-based specification developed by the national programme.

A persistent criticism of the national programme has been that its approach may not deliver systems that are sufficiently flexible to meet local demands or win clinician support.

Indeed, Ray Ison, professor of systems at the Open University, says it displays many features of public sector IT procurements that have ended in failure.

Public services, he says, are complex, adaptive systems with many different stakeholders and it is necessary to spend time getting stakeholders to hold the same mental model of what they want to achieve. Professor Ison is worried that the national programme has only just started communicating with senior managers and clinicians, but says its outcomes will depend on contractors.

'Will they just supply something, or will they become co-developers with managers and staff?'

The IT director quoted above has no doubt. 'If you are a big LSP, covering hundreds of hospitals, that level of configurability will not be cost effective, ' he says.

Ms Clarke is convinced that managers will support the national programme, even if they find themselves working in devolved organisations like foundation trusts. 'Care records will be the one thing that are common across the sector, and it will be absolutely vital for them to work, ' she says. 'As a chief executive, you have a duty to work for your organisation, but you also have a duty to the wider NHS.'

And there are other optimists. Simon Gill, electronic patient record project director for Gloucestershire health community, says IT managers will now be free to concentrate on implementation.

'Of course it is a large and complex project, and the crunch will come when it comes to engaging clinicians, ' he says.

'But from an IT perspective, people should be saying 'great' because IT is finally being driven forward at a good pace - and that has been missing in the past.'