From the Beginning
Established in 1948, the National Health Service is now the largest health-care organization in Europe and has been recognized as one of the best health services in the world by the World Health Organization. Controlled by the British government, it is also a vast bureaucracy, employing more than 1 million workers and providing a full range of health-care services to the country's 50 million-plus citizens.
Organizationally, the NHS is managed at the top by the Department of Health, under Health Secretary Patricia Hewitt. The Department of Health oversees 10 so-called Strategic Health Authorities (SHAs), which provide supervision to:
The inspiration to digitize this far-flung bureaucracy first surfaced in late 2001, when Microsoft's Bill Gates paid a visit to British Prime Minister Tony Blair at No. 10 Downing St. The subject of the meeting, as reported by The Guardian, was what could be done to improve the National Health Service. At the time, much of the service was paper-based and severely lagging in its use of technology. A long-term review of NHS funding that was issued just before the Blair-Gates meeting had concluded: "The U.K. health service has a poor record on the use of information and communications technologythe result of many years of serious under-investment."
Coming off a landslide victory in the 2001 general election, Blair was eager to move Britain's health services out of technology's dark ages. Gates, who had come to England to tell the CEOs of the NHS trusts how to develop integrated systems that could enhance health care, was happy to point the way. "Blair was dazzled by what he saw as the success of Microsoft," says Black Sheep Research's Brampton. Their meeting gave rise to what would become the NPfIT.
At the time the NPfIT was conceived, no one could possibly have imagined that it would balloon into such an ambitious and complex effort. "It was initially a procurement exercise," notes a health-care IT strategist who was involved with the NHS for years and who agreed to talk to our sister publication Baseline on the condition that his name not be used.
"Procurement, and specifically cutting down on the cost and the bureaucracy of buying computer systems, was always a major objective of the program," adds author Brennan.
Brennan, who has held senior-level IT positions with the NHS and in 2002 launched Clinical Matrix Ltd., a technology and strategic consulting company, says that when the NPfIT was conceived in 2001, hospitals throughout the U.K. were dealing with multiple vendors, many of them small to midsize U.K. systems and software houses. Several major U.S. firms had gone after the U.K. market, only to withdraw because of the red tape and expense involved.
"Vendors would spend as much as $100,000 in marketing a system to a single trust," Brennan says. "Every hospital typically bought a collection of systems and paid up front rather than waiting till implementation was complete."
The predictable results: a hodgepodge of systems throughout the NHS, many of them incompatible; and excess costs. The June NAO report summarized the situation thusly: "In the past, procurement and development of Information Technology within the NHS has been haphazard, with individual NHS organizations procuring and maintaining their own IT systems, leading to thousands of different IT systems and configurations being in use in the NHS. These are provided by hundreds of different suppliers, with differing levels of functionality in use across the country. The large number of different and incompatible systems has meant that the NHS's IT system infrastructures have been built up to create silos of information, which are not shared or even shareable."
After a February 2002 meeting at 10 Downing St. chaired by Blair and attended by U.K. health-care and Treasury officials as well as Microsoft executives, the NPfIT program was launched.
In quick order, a unit was established to purchase and deliver IT systems centrally. To run the entire show, NHS tapped Richard Granger, a former Deloitte and Andersen management consultant. Granger signed on in October 2002 at close to $500,000 a year, making him the highest-paid civil servant in the U.K., according to The Guardian.
In one of his first acts, Granger commissioned the management consulting company McKinsey to do a study of the massive health-care system in England. Though the study was never published, it concluded, according to The Guardian, that no single existing vendor was big enough to act as prime contractor on the countrywide, multibillion-dollar initiative the NHS was proposing. Still, Granger wanted to attract global players to the project, which meant he needed to offer up sizable pieces of the overall effort as incentives. The result: He divided England into five regionsLondon; Eastern; Northeast; Northwest with West Midlands; and Southerneach with a population of about 10 million.
Each of the five areas would be serviced by a prime information-technology vendor, known as a Local Service Provider (LSP).
The process for selecting vendors began in the late fall of 2002. It was centralized and standardized, and was conducted, Brennan and others say, in great secrecy. To avoid negative publicity, NHS insisted that contractors not reveal any details about contracts, a May 2005 story in ComputerWeekly noted. As a byproduct of these hush-hush negotiations, front-line clinicians, except at the most senior levels, were largely excluded from the selection and early planning process, according to Brennan.
"We would challenge the assertion that there has been secrecy," the CfH told Baseline in an e-mail. "There has been a great deal of engagement with key stakeholders."
NHS offered 10-year service contracts to the LSPs for the five regions, worth slightly less than $2 billion each. According to the CfH Web site, the LSPs "are responsible for delivering services at a local level and supporting local organizations in delivering the benefits from these. They ensure the integration of existing local systems while maintaining common standards."
In conjunction with the software suppliers they select, they are also responsible for implementing clinical and administrative applications, which support the delivery of patient care and enable acute-care trusts and PCTs to exchange data with the National Spine. In addition, the LSPs provide the data centers to run the applications.