Gesundheit – NHS NPfIT not to be Sneezed at

29th January 2010

Peter Kruger

Bearing in mind the international media attention the NHS National Programme for IT (NPfIT) attracted when it launched it has got off relatively lightly now it is staggering to a halt. Even when accusing the NHS of being a member of the Healthcare Axis of Evil, Sarah Palin failed to identify NPfIT as a weapon of mass destruction. All this may change over the next few months as the German government puts the brakes on its own healthcare IT project – the Gematik health ID card. The project has been plagued by the usual problems that beset large IT programs; it is late, there have been problems associated with backing up data and, like the NPfIT, doctors resisted deployment. It would be convenient to draw parallels between the Gematik health ID card and the NHS NPfIT and conclude that big healthcare IT projects do not work – especially convenient if like, FDP Minister of Health Philipp Rösler, you are taking a slash and burn approach to healthcare IT.

In Britain, if anyone stood up and suggested combining NPfIT with the UK Electronic ID card, the room would take on the appearance of a H M Bateman cartoon with people screaming and running for the exits. In true British tradition many people in the UK couldn’t give a damn about identification and already carry a wide range of personal information – mostly on ID cards masquerading and retail loyalty cards. However, those who do have concerns express them with a vengeance and one of the websites dedicated to getting the UK ID card scheme scrapped also campaigns against the NPfIT patient database. Unlike in Britain, everyone in Germany is already compelled by law to carry some form of identification and a majority of the population seem comfortable with the health ID card concept.

The Gematik health ID card, if deployed, should reduce the administrative overheads associated with processing prescriptions and also cut data entry costs. But, for now, Philipp Rösler is concentrating on getting people to pay more for healthcare through increased National Insurance contributions. And pay more they will have to as Rösler is also clipping the wings of IQWiG (Germany’s equivalent NICE), which evaluates the efficacy and cost effectiveness of new drugs – and stands between the pharmaceutical industry and its customers.

To the outsider Rösler’s position as Minister of Health is a strange one. His party, the Liberal FDP, is a junior partner in an alliance dominated by the right wing CDU (think Lembit Opik as Minister of Defence in a Conservative dominated government.) The FDP calls itself a liberal party but its members are not the fluffy, irritable Guardian readers you tend to run into in wholefood shops – their UK equivalents would be very well heeled Daily Mail readers and the closest you would get to them is waiting in a traffic queue behind a double parked Waitrose delivery van. Many FDP members have private medical insurance and, as the increase in National Insurance contributions is per capita, even FDP members without private schemes can swallow the extra cost.

The CDU/FDP (Black and Yellow) alliance has made the German political landscape claustrophobic for the opposition party, the SPD (similar to the UK Labour Party). Rather like riding on a crowded subway train the SPD can moan and complain and, occasionally, dig their elbows in. Criticism of Rösler’s strategy by the SPD’s health expert, Carola Reimann, carries additional weight as she is also chairman of the parliamentary health committee. However even this criticism falls short of the roasting Rösler receives in the German press. For the SPD conditions are not conducive to drawing up long-term healthcare reforms, and dreaming up hypothetical applications for information technology in healthcare is rather pointless.

Rösler’s pummelling of the German healthcare sector is even giving some in the CDU pause for thought and has left him looking rather like a schoolboy who, after joining a big gang and finding he can punch above his weight, is showing off by picking fights across the playground. Pointing to the NPfIT and claiming it has been a complete failure might be an easy way to slap down German healthcare IT providers, but would it be a fair assessment of the NHS programme?

Attempting to brand the NPfIT a success would see you running out of lipstick before you run of pigs. But then how many IT projects in the private sector, let alone the public sector are actually are completed within budget, on time and meet the initial specification? Come to that, how many people, when purchasing their first PC, discover it needs a bundle of extra software and hours on configuration before it meets their expectations?

Of course the big IT vendors should have known better than to become involved in a project over which they had only partial control and which stretched over more than two electoral cycles. Some vendors did walk away. IBM folded its cards and decided to play on another table, Denmark, where it used its WebSphere platform to build a health portal based on the patient owned medical record model. Other vendors, however, feared if they were not part of the NPfIT competitors would use the contracts to win the bulk of other government contracts on offer. These vendors pushed on despite their inability to put in place the new working practises on which the system relied. In this sense the partnership between the UK Government Department of Health and IT vendors was rather like a marriage. The woman realised that her future husband had faults but believed she could change him. The man thought his future wife was the best girl on the block – and, in ten years time, still would be. Ultimately both parties were disappointed.

When the NPfIT was first proposed some suggested it should confine itself to creating a set of standards. This would have enabled the army of healthcare IT vendors already supplying the NHS to build systems that were compatible with each other and accessed a common database of patient information. At that time some hospitals had up to 14 different, and mostly incompatible, IT systems - it was obvious something had to be done. Throughout the duration of the NPfIT any new IT systems installed, old ones being updated and procedures being redesigned had to conform to standards defined within the programme. Over time this convergence on a set of standards has simplified the NHS’s IT infrastructure.

At £15 Billion doing something has proved expensive but doing nothing to improve the IT infrastructure of an organisation that consumes £100 billion of public each year would also have proved expensive.

Ten years ago features such as networked PACS, tagged onto the end of the NPfIT, were already commonplace within parts of the German healthcare. It this, and many other respects, the NPfIT was ambitious considering the then existing state of the NHS IT infrastructure.

If healthcare IT programmes, be they in Germany or the UK, had focussed on standard creation rather than implementation then many small ehealth vendors would have had an easier decade. The hope always was that, come the end, or abandonment, of these large programmes the bare bones of an IT platform would exist and funds would start flowing to ehealth vendors again, rekindling the healthcare innovation that was commonplace a decade ago. Now, to see those funds flow into the coffers of pharmaceutical companies is, to say the least, disappointing.

Rösler is not alone in being overfriendly to big pharma. In the UK the Conservative Party, thought to be frontrunners to form the next government, say they will reform the system that sees NICE evaluate medications. The idea that healthcare providers cannot be freed from the strangle hold of big pharma seems to have become ingrained in the thinking of health ministers and betrays a lack of strategic thinking on the part of government health departments. This is strange since even big pharma realises it is vulnerable to technological change – that is why it pays such close attention to what is happening in markets such as e-prescribing.