Breaking chainKingsley Manning 

From the very beginning there has been a degree of disconnect between the Connecting for Health (CfH) programme and the development of NHS policy. But now, after the publication at the end of January of the ‘Our health, our care, our say’ hite paper, the gap appears to be widening.

For anyone with an interest in healthcare IT, the first point of note is that in more than 200 pages there is only passing reference to CfH. This in a white paper which sets out the government’s ambition to achieve a fundamental shift in the delivery of healthcare services, moving services away from acute hospitals and into community and primary care settings.

Empowering patients, providing supportive information, and introducing an increasingly diverse range of provider organisations are all strategies that should be powered by modern and comprehensive IT systems. But CfH and the integral, critical role that healthcare IT could or should make to the achievement to this strategy barely rate a mention in the white paper.


It may well be that the authors of the white paper, cognisant of the programme’s delays, felt that placing any emphasis on the contribution that the £6 billion CfH programme would perhaps be unwise – particularly given that in key areas like primary care so little seems to have changed over the last three years of the National Programme for IT (NPfIT).

Choose and Book appears to be slipping into 2007 while the market for GP systems is effectively returning to where it was in 2002. There has been progress, particularly with community and child health systems, but even here the systems now being implemented are existing systems that were readily available before the launch of NPfIT.

Primary and community care systems have historically been a poor relation in the development of NHS IT. Their client base is diverse (particularly in the case of community-based care) and strong-minded (particularly the independent GPs). Meanwhile, the average value of each system sale is small. In addition the data involved are very complex, and current system suppliers are well-embedded.

As a result, focusing on the large acute hospital system and its large, reliable and competent base of IT suppliers would always have been more attractive, even if the approach ran contrary to the fundamental dynamics of choice and decentralisation underpinning the planned future of healthcare delivery in the NHS.

With the publication of the new white paper, though, the position has become even more challenging. The government is intent on moving activity and resources out of the acute sector to promote much greater integration with social care and to introduce new providers into both primary and community services. It is also committed to using new technologies and approaches to deliver increasingly sophisticated clinical care to patients in the high street, the work place and the home.

This is a bold vision but one which is entirely consistent with changing public attitudes, developments in clinical and pharmaceutical technologies, and the overwhelming need for improvements in productivity across the healthcare system. Healthcare IT needs to play a key role in helping to achieve this vision.

Shared record

To support the integration of health and social care, the white paper commits to having a shared health and social care record by 2010. By that date all users are to be offered personal, integrated health and social care plans.

Even before 2010, much of the care in primary and community settings could come from an increasingly diverse range of suppliers. GP practices are to be offered a range of incentives to expand, to open at more convenient hours and to widen the range of services they offer. At the same time the NHS will run a national procurement exercise for new providers of GP services, which will result in a national list of accredited providers.

Some of these providers may be existing GP- or nurse-led practices, but others will be come from the voluntary and the private sectors. Initially, procurement will focus on under-serviced areas – communities that don’t have enough GPs – but primary care trusts will also have the power to bring in new providers when they believe that local GP services are unsatisfactory or when they want to develop new services.

Greater plurality of provision will create new challenges for primary care IT. New providers will bring with them a range of new systems and applications, raising issues of inter-operability, data standards, confidentiality and information integration.

In response, CfH will have to clearly develop a very different approach to primary and community care. One intriguing question likely to be asked is how any procurement can be entirely fair when one set of potential private providers, the GPs, are having all their IT costs met by the NHS and have privileged access to NHS IT systems.

While there is no requirement for PCTs to divest themselves of their in-house community service providers, from 2007 they will have to undertake a formal and rigorous review of these providers’ performance. If that performance is found wanting, PCTs are encouraged to go out to tender for the services they require from any willing provider. At the same time, the white paper opens up the possibility of moving NHS community service providers into new forms of ownership, with the ‘social enterprise’ structure put forward as one option.

For existing community service providers, increasingly sophisticated IT systems for managing complex care pathways and chronic disease should become a priority if they are to compete successfully with the unfettered new entrants. But given the shortage of resources and the enormous pressures that the current NHS reforms will generate, it’s not clear how many NHS community providers will be able to respond.

Finally, if the government is successful in its aims. the impact of the latest reforms on acute hospitals will be extremely significant. They face the prospect of little or no growth in resources, while capacity is expected to fall – the white paper gives tacit recognition that ‘service reconfiguration’ will become a dominant issue. Under these pressures, improving productivity and service quality by investing in new IT systems should be a priority, but it could also be a powerful excuse for delaying that new PAS implementation for just another couple of years.

To deliver the vision of health and social care that the white paper describes requires modern healthcare IT systems as never before. It will be interesting to see how CfH responds.

The complete version of this article, summarising and analysing the white paper, is available at

Kingsley Manning
Chief Executive, Newchurch