Life on Marsland on local solutions for local services

Iain Marsland has been around the healthcare IT scene for a long time, but his ideas are still evolving. Recently, he has been wondering if a more flexible relationship with IT suppliers might not deliver benefits for local health services.

Call it senility or cynicism, but increasingly I am challenging what I once believed to be fundamental truths in my NHS IT career.

This may be a problem for my current work, as I am often asked to provide a chief information officer’s (CIO’s) view of the world. I suspect that some of my renaissance views may not be shared with my erstwhile colleagues. 

However, anyone who has read my previous columns knows that I am a passionate supporter of clinical IT. At least that fundamental remains untouched.

Overly ruthless standardisation?

I was a late convert to the National Programme for IT in the NHS; being one of the last CIOs to be appointed by Richard Granger, the former director general of NHS IT.

Back then, the idea of centrally funded, comprehensive electronic patient and health records, being delivered through a structured programme, using best in class, tried and tested solutions was pretty exciting stuff for a West Country lad. 

The subsequent application of “ruthless standardisation” and delays in delivery has tempered that initial enthusiasm. I am now seeing sense in a range of ideas and solutions that I would previously have dismissed as either unsafe or anti-strategic. 

One such issue is how to build innovation into a software contract. Until now, I considered the Output Based Specification (OBS) as an immutable element of software procurements in the NHS; a formal specification of local requirements used to select and hold the supplier to account for delivery.  

I thought organisations needed to understand their needs and articulate them formally ahead of selection and procurement. But what if this is not possible, and the buyer actually wants someone to solve a problem through innovative IT?

In one trust with which I am currently working, clinicians have been reticent to be too prescriptive with their requirements; they do not want the supplier to limit the opportunities for the trust throughout their seven year contractual and service relationship.

Another has expressed his reservations at being able to adequately describe his needs for the next seven years. “If we were to write this [OBS] in three years’ time, with the benefit of hindsight, we would make a better job of it,” he argues.  A fair point, and surely true of most projects?

There is, of course, a danger in letting the supplier dictate what will be delivered; but this needs to be tempered where organisations are open and willing to embrace innovation and new ways of working.

Looking for innovation

A factor that may work against innovation for NHS customers is that Britain is a small island and the NHS is a relatively small health service. The £110 billion spent on the NHS is insignificant compared to £1.5 trillion spent on healthcare in the USA.

Similarly, our 8.9 per cent GDP health spend is less than many countries, including Germany, France and Canada. So why would a software house want to invest in this small and rather difficult market, a market that has been constrained by the national programme, and then write innovative software?

Another dimension of this issue is the fear of foreign products: the attitude that “it’s American, so it will never work here.” Somebody should badge the Microsoft product set “designed and made in America, used by the world.”

It’s true that the NHS, like most health systems, has practical and cultural differences from other territories and that these need to be addressed. The need to comply with standard data sets, Payment by Results, Choose and Book, and the 18 week waiting time initiative places significant additional demands on suppliers wishing to support and supply to our health service. 

However, we are in a privileged position in that the majority of health software is developed in English. It should also be remembered that some notable UK software houses have continued to develop their offers and are approaching the recently revived ‘interim’ NHS market with vigour, energy and new products.

Interestingly, whilst also working for the Irish Government, I have been in contact with a number of innovative Irish software companies. With an even smaller healthcare budget (7.5 per cent of GDP) and just over 50 hospitals, the Irish Republic appears to have a different approach to working with software companies.

Many of these companies exist by delivering solutions to specific problems and as a consequence have a different relationship with the healthcare system.

I know that procurement experts will be pulling their hair out with this non-structured approach. But that’s the challenge. With smarter procurements, it must be possible to purchase “solutions” rather than “systems” and to share both the risks and rewards of innovation.