Global digital exemplars – redefining the healthcare IT market?

Matthew Swindells, NHS England’s director of operations and information, has given an interview in which he indicates that he wants trusts in England to buy most of their IT via the global digital exemplars. Lyn Whitfield, Highland Marketing’s director of strategy and content, looks at the evolution of the GDE programme, and what it might mean for the healthcare IT market.

Remind me of the background? In November 2015, health secretary Jeremy Hunt asked US ‘digital doctor’ Professor Robert Wachter to conduct a review of NHS IT.

Hunt had already set the NHS in England the challenge of going ‘paperless’ – initially by 2018, in a speech to the Policy Exchange think-tank, and then by 2020, in the IT strategy, Personalised Health and Care 2020.

As work started on the challenge, Hunt said he wanted to learn lessons from the National Programme for IT’s failure to roll-out electronic patient records in England and the HITECH Act’s partial success in digitising US hospitals.

The Wachter Review: Wachter reported in August 2016 and came up with ten findings and ten recommendations. One of these was to make best use of the £4.2 billion the Treasury had allocated to NHS IT in the previous year’s budget.

Wachter argued this would not be enough to “enable digital implementation and optimisation at all NHS trusts” so money should be directed to trusts “that are already digitised and ready to reach even higher phases of digital maturity” and to “trusts that are prepared to digitise”.

Everybody else would have to wait. Wachter recommended that the date at which “it would be reasonable for all trusts to have reached a high degree of digital maturity” – for which read, go paperless – should be pushed back again, to 2023.

CDEs become GDEs: While Wachter’s review was held up by EU referendum ‘purdah’, NHS England invited 26 of the “most digitally advanced trusts in the country” to bid for a £100 million pot of funding to make further investments and share their expertise.

Once the review was published, eleven of them – plus Royal Liverpool and Broadgreen University Hospitals NHS Foundation Trust, which hadn’t been on the original list – were announced as global digital exemplars. A further four acute GDEs were announced in this year’s Next Steps on the Five Year Forward View, alongside seven mental health exemplars.

Two further sets of exemplars, covering ambulance services and ‘place-based’ projects, will be announced this autumn. The latter will show off integrated care/information sharing work – local digital exemplars, if you will.

So, how do you get to be a GDE? On its website, NHS England says trusts were invited to bid if they had high digital maturity assessment scores, were involved in digital health initiatives, represented a range of different solution types, and had no regulatory problems.

However, many commentators have noted that the majority of the chosen trusts are running systems from large, US suppliers. Roughly half are using Cerner Millennium, while Epic, Meditech and Allscripts are all represented. InterSystems will have a GDE when Royal Liverpool and Broadgreen finalises its contract for TrakCare as part of a city-wide deployment.

Having said that, other GDE trusts are working with IMS Maxims, System C, and Emis Health. A further trust, University Hospitals of Birmingham, has built its own EPR, PLICS, and a final trust, Luton and Dunstable University Hospital, has focused on electronic document management.

And what do you get for being one? The acute GDEs have all been promised £10 million from central funds to build on their existing digital achievements and to reach Level 7 of the HIMSS electronic medical adoption model, EMRAM.

The GDEs are also being asked to nominate ‘fast follower’ trusts. These will be expected to reach EMRAM Level 5 and to develop ‘blueprints’ for the third wave of trusts to work with.

At a Westminster Forum earlier this year, Will Smart, NHS England’s chief information officer, said the idea was to take the “secret sauce” from the GDEs and to spread it around the system.

“Our absolute imperative is that we end up with blueprints or maps so that, as we move out of this phase, if you are Coventry and you need to replace your EPR you can look around and say: ‘Which trust do we want to operate like?’”

So, the GDEs were always going to change the healthcare IT market? Indeed. As soon as the exemplar idea was announced it was clear that companies that wanted to play in the English PAS and EPR market would need to secure a GDE, because the fast follower and third wave trusts would line up behind them and, mostly likely, buy the same systems.

Where does Matthew Swindells come in? As the Wachter review was being conducted, NHS England announced the appointment of Matthew Swindells as national director for commissioning operations and information.

Swindells started his career as a graduate trainee, went on to become a trust chief executive, left the NHS to advise health secretary Virginia Bottomley, then returned to the NHS briefly as its first chief information officer, where he came up with the idea of the ‘Clinical 5’.

After that, he spent some years at Cerner. Which has raised eyebrows. NHS England insisted when he was appointed to his current job that “he will divest himself of any financial interests in his current employer, and recuse himself from any official dealings with them for the subsequent 12 months after taking up his post.”

What has Swindells said about GDEs? He’s consistently drawn attention to their potential to reshape the market and has not been shy about drawing the further conclusion that all but a handful of suppliers will leave it.

In July, digitalhealth.net reported that he told the annual iLinks conference that, if the GDE programme worked, trusts would “run an evaluation and decide who they want to partner with” and “nobody will run procurements to buy IT systems again.”

In an interview with the Health Service Journal this week, he went a step further and said that GDEs and their suppliers would be put onto a new procurement framework, from which trusts would be expected to buy if they wanted central support.

“If you go: ‘I’ve just seen the latest fantastic system in Turkey and I’d like to bring it to the NHS’ then we will say: ‘You can do that, but you are on your own. That’s not our recommendation’. Our recommendation is build what works and spread it, and at the end of that we will end up with half a dozen systems running across the NHS.”

Yikes: Swindells has never been afraid of telling the NHS managers or suppliers what he thinks of them.

What are the issues with the GDE model? When Hunt announced the first tranche of GDEs, he unwisely compared them to the American ‘ivy league’ of flash universities; which didn’t go down well with trusts that weren’t invited to join.

It’s still not clear whether trusts that have sunk considerable sums into ‘best of breed’ strategies will be able to pursue them in the longer term, or how ‘third phase’ trusts will get with the programme. Many of these trusts are financially and clinically challenged as well as digitally immature, so the GDE programme risks entrenching a digital postcode lottery.

So it’s a bad idea? If you agree with Wachter that no English trust is truly world-leading and that a few trusts should be more ambitious than they have been, then an exemplar / fast follower programme is a logical response.

However, demonstrator projects have failed to make much of an impression on the technology used by most trusts in the past. The National Programme was a response to that; but it also failed. So aiming for a kind-of hybrid solution, in which the GDEs both show what can be done and help to shape the market so that more trusts can play in it, also has a logic.

If the outcome is that ‘third phase’ trusts can buy from a smaller range of better understood systems, that come with good deployment support, and a ‘start here’ pack of pathways that align with current policy and business imperatives, that might well look like success.

That’s a lot of ‘ifs’. It is. And the NHS in England has a terrible habit of giving up on national IT approaches after a couple of years.

Still not good news for suppliers, is it? The GDE programme has already shut out some small suppliers and, if Swindells’ comments are to be taken at face value, it could shake-out some of the companies that have GDE slots at the moment.

The emerging procurement framework idea has been accused of being anti-competitive and could choke-out innovation. However, there’s a lot we don’t know yet. Will the framework just cover PAS and EPR systems, or other core systems such as digital imaging or electronic document management?

Will companies that do well out of the GDEs be required to open up their systems to innovative mobile and app providers, as the GP system suppliers have been forced to do?

There’s plenty of healthcare IT work that’s not PAS or EPR related, and it should be possible to build a vibrant market around large vendor systems in which small companies and innovators can play; albeit in a different way.

Take aways: The GDE programme is not about creating a few, ‘beacon’ trusts. Matthew Swindells’ interview with HSJ this week underlines that it has the potential to reshape the healthcare IT market.

Suppliers and others wanting to work with the NHS need to be alive to this potential change, and be ready to adjust their sales and marketing strategies accordingly.