When the Department of Health announced its intention to scrap England’s National Programme for IT in September 2011, there were few dissenting voices.
Over its nine-year course – it was launched in 2002, charged with the goal of revolutionising technology usage across the NHS – the initiative was mired in technical and contractual difficulties.
In a press release explaining its decision, the Department of Health said: "It is no longer appropriate for a centralised authority to make decisions on behalf of local organisations."
And so the floodgates of damning criticism opened. Last year, a report conducted by the Public Accounts Committee concluded that the project had been one of the "worst and most expensive contracting fiascos" in the history of the UK’s public sector, costing in the region of £9.8 billion.
Above all else, the project’s shortcomings have highlighted the NHS’s unsettled relationship with technology. While several pockets of the public sector have seemingly taken to technology with relative ease, the integration of IT amid the complex environs of healthcare appears to be an altogether different beast.
This has long raised question marks over whether the NHS is well suited to a centralised IT procurement model. The answer would seem to be a resounding ‘no’, and trusts are now set to follow more localised agendas as a means to better dealing with huge quantities of data.
A move away from central contracts
The ongoing upheaval will have an impact on radiology departments and the medical imaging community as a whole, particularly when it comes to picture archiving and communication systems (PACS), which, when added to the National Programme for IT in 2004, became one of its few successes.
When the programme was first developed, the concept of digital imaging was in its nascent stages; consequently, it demanded significant levels of training and support. This meant that, upon the programme’s launch, central contracts were limited to only a few established service providers with the adequate skills, resources and software to meet trusts’ IT demands.
This is no longer the case. Service provider numbers have multiplied steadily, creating a much more competitive marketplace. At the same time, a number of NHS trusts are firm in the belief that they have reached the end of the road with their initial service providers.
In fact, there are more than 100 NHS trusts across England currently looking to end vendor-specific contracts. The general consensus is that, with the necessary IT infrastructure having now been carried out, there is no longer a need to employ specialists to maintain their systems.
Moving away from central contracts would also afford trusts the possibility of retaining their pre-existing technology and data, if they should decide to switch suppliers. New contracts are expected to demand less expert input and financial expenditure.
Yet, while many have deemed the scrapping of central contracts as a case of good riddance, it is not necessarily a given that every trust will default to local solutions. Instead, they have the option to stick or twist when it comes to their service provider.
According to Aimie Chapple, Accenture’s managing director, UK health industry, and UK and Ireland client innovation, this will require some well-informed decision-making.
"In relation to medical imaging, the National Programme [for IT] actually did a good job, driving the digitisation of images across the NHS, and driving up service standards and quality," she says.
"The main challenge now is for trusts to take on more of a direct role in letting and managing contracts, as well as, in some cases, working directly with multiple suppliers."
It would seem that trusts are about to find themselves with far greater control and freedom concerning the way they manage their IT investments and balance budget constraints against big data. The ramifications for PACS solutions are considerable.
"Trusts have three main options," says Chapple. "One is to conduct a full new procurement exercise to move to a new solution and provider. They could also make a more continual extension to continue their current provider under the NHS Supply Chain framework.
Or, thirdly, they can continue with their current solution, but directly with the vendor, rather than as a managed service."
Challenges of implementing PACS and cloud-based solutions
According to Chapple, in the regions supported by Accenture, one of the National Programme’s largest contractors, "Most have chosen to extend tactically and maintain the current managed service."
These regions, known as ‘cluster areas’, include the East Midlands, Yorkshire and the Humber, and the north-east.
This sheds some light on the other side of the argument: trusts, while under pressure, shouldn’t be hasty in divesting themselves of the advantages of a proven provider – which, arguably, have allowed them to spend more time on end-to-end management and patient care.
What are the challenges of implementing PACS? First and foremost, the files transferred across the system are often very large (in excess of 2GB); CT studies have been known to be the cause of many a system grinding to a halt.
In the case of downtime, there has also been a general over-reliance – which many trusts are now looking to shed – on vendors and engineers.
Consequently, cloud has become an increasingly viable option for the successful running of PACS solutions. Chapple, for one, is under no doubt that we are set to see more and more health organisations making the leap in the coming years, bringing with it numerous associated benefits.
"Cloud is increasingly becoming an option for trusts – both for PACS and RIS [radiology information systems]," she says. "The key advantages include not having to manage all the hardware associated with traditional storage. This reduces costs and increases service consistency, resilience and reliability, as well as speed to fix in the event of failure.
"Cloud infrastructure and storage makes the sharing of images, out-of-hours support and general accessibility much easier, too."
But, in spite of its clear advantages for clinicians, the migration to cloud is still yet to take place in the UK. Does this concern Chapple? What are the barriers currently hampering progress?
"The challenge in implementing cloud-based solutions remains the speed of retrieval of images, but new streaming technologies, such as Agfa’s XERO [the internet browser-based medical imaging viewer deployed by Accenture], are making this less of a constraint.
"So, while there has been little uptake in the UK so far, compared with, say, the Nordic countries, which are leading the way, we at Accenture are confident that a cloud-based system represents the right answer for healthcare providers looking for a longer-term solution."
An open marketplace
Back to the present, and many local NHS trusts are in the process of window-shopping for potential new suppliers. According to a report conducted by EHI Intelligence, a market-leading data and analysis provider for NHS IT providers, trusts also have the option of linking up to procure systems by collaborative means, so as to share the financial burden.
"Trusts can either collaborate or tender independently, and this research suggests that the majority will choose to collaborate in some form," the report said. "Smaller trusts will look to work with larger neighbours to save money and support patient flows.
"This is likely to drive technological innovation, particularly when it comes to data storage and image sharing. However, trusts will still be looking for major savings on the cost of PACS and RIS delivered through the National Programme contracts."
While trusts contemplate the long game, suppliers will also be looking to capitalise on an open marketplace. Bidding will be predicated on creating more innovative and cost-efficient solutions, with smaller IT providers – previously excluded from the National Programme for IT – expected to enter the fray. This was also confirmed in the EHI Intelligence report.
"There is no doubt that the market will be very competitive and there will be room for smaller players to increase their market share and for new suppliers to enter the market," it said.
Given the amount of critical decision-making associated with IT procurement solutions, trusts will undoubtedly avail themselves of all the support they can. Notably, NHS Supply Chain, which provides supply chain services to organisations, last year held a PACS RIS exhibition, bringing together trusts and suppliers to discuss possible procurement solutions.
Likewise, trusts in London are receiving guidance from the Health & Social Care Information Centre’s (HSCIC’s) PACS division on contract negotiation. To avoid a potential scramble of trusts going to the marketplace at the same time, HSCIC has placed them in separate exit phases, to be potentially staggered beyond June 2015.
With local service provider contracts expiring simultaneously across the country’s different regions – when digital systems were first introduced, England was split into five cluster areas (three of which remain) – the coming months are sure to be a busy time.
As no trust is operated in exactly the same manner as any other, some are likely to form regional consortia, rather than go it alone. Whatever their decision, boards will be keeping a close eye on the decision-making process, based on the notion that procurement carries financial and clinical risks.
And, while the jump towards new vendor contracts may continue apace, the cloud looms somewhere in the near distance. This is something the NHS’s medical imaging community will be sure to monitor closely in the months ahead.
