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The Future of Healthcare Services Technology?

The NHS National Programme for Information Technology

Final Project for MBA 290T-1 – Innovation in Services and Business Models

12/10/2009

Gabor Foldes

Ushan Ganeshananthan

Jean Lu

Kieren Patel

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I. Introduction

The United Kingdom’s National Health Service (NHS) launched the largest civilian

information technology (IT) project to date: the National Programme for Information

Technology (NPfIT). Faced with antiquated, inefficient, and often incompatible IT systems, the

UK government launched the NPfIT in 2002 to revolutionize healthcare services. The NPfIT’s

central vision is to introduce electronic health care records for patients, facilitate online access to

patient records, and provide electronic booking and management services to all patients, and

physicians, clinicians and other healthcare professionals throughout the UK. NHS Connecting

for Health (NHS CFH), a directorate of the Department of Health, is in charge of managing and

implementing the NPfIT project as the “owner and service provider.” The vision behind the

project is to create efficiencies and increase quality in the delivery of healthcare to citizens of the

UK by making information more open, standardized, and accessible.

The stakes are high for a project of this magnitude. The NPfIT serves as the benchmark

not only for the UK but for the future of public healthcare IT worldwide. Initially budgeted to

cost £2.3bn with targeted completion by 2006, the program is now estimated to cost £20-30bn

with completion of many programs uncertain. With low user rates, enormous cost overruns, and

an increasingly dissatisfied public, the NPfIT provides an ambitious yet cautionary example of

services innovation at such a scale.

We analyze the major themes that underpin the NPfIT intiatives, based on tools and

frameworks discussed in the Innovation in Services and Business Models class. We highlight

specific initiatives and relate them to service innovation concepts. Then, we critique some of the

critical design and implementation decisions so far and provide recommendations for

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improvement. Lastly, we conclude with next steps for the program, including the boundary

conditions and lessons relevant to similar IT projects in the future.

II. The Many Pieces of the NPfIT

The NPfIT’s core is an integrated system called NHS Care Records Service. This consists

of two parts. The first part is a local detailed clinical patient record used by local service

providers where the patient receives most of her care. It is a comprehensive report that is usually

required by general practitioners (GPs), community clinics, and hospitals and includes

information such as test results, drugs administered in the patient’s past, and records of hospital

visits. The second part of the service is called the national summary care record, a snapshot of a

patient’s record that is accessible on a national level to facilitate emergency care for people away

from their own local service providers. There are 35 additional different systems and services

planned, ranging from the maintenance and transmission of medical records, to the secure access

for specialized NHS professionals, to e-booking for appointments (Fig. 1). We primarily focus

on the most novel service components of the NPfIT at the national level.

Holding the Pieces Together With the SPINE

The central IT component of the system is the “SPINE,” a set of IT solutions that provide

storage of and access to patient information.1 It serves as an aggregator of demographic

information about patients, their clinical records (such as allergies, adverse reactions to

medicine, treatment plans, etc.) and other data to create reports and statistics for research,

planning, and public health delivery. Once fully implemented, SPINE will allow for secure

access to summary information wherever and whenever a patient seeks care from the NHS. This

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aggregated data will help facilitate better care by providing doctors with higher quality patient

information and assistance in formulating a treatment plan (Fig. 2).

The SPINE also includes a set of security services to ensure the secure and controlled

access and transfer of confidential information. Security is a major issue surrounding electronic

health services and it is a point of great scrutiny for the NPfIT project.2 Private solutions in the

past have failed to reach economies of scale partly because of their inability to persuade enough

people that their personal data are safe. Safety and data protection proves to be one boundary

condition that can limit the openness of services in general.

The SPINE contracts with vendors who are leading IT providers to create the IT

infrastructure. This practice exhibits outside-in openness, although only to a limited extent.

Vendors were originally organized to provide expertise on different components of the NPfIT

and manage IT infrastructure on a regional basis (Fig. 3 and 4). For example, BT was awarded a

10-year, £620mm contract to establish the data storage facilities and the broadband

communication backbone. Another vendor, Atos Origin created the “Choose and Book”

scheduling system.3 As discussed later, this fragmented approach lacked coordination from the

outset and caused frustration and low adoption rates among doctors, as later discussed.

The SPINE is the first step in the establishment of an electronic healthcare ecosystem.

Each of the additional 35 services will touch the SPINE in some way. It will allow the

establishment of a multitude of applications that handle patients’ health records, transfer images,

and manage the development of NHS staff. In the future, the SPINE could become a major

source of inside-out openness as the aggregated data on patients and treatments will provide

opportunities for predictive care and further research. The ecosystem will undoubtedly need

outside companies to continue to innovate.

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An example of the ecosystem the SPINE helps to foster is the Blood Safety Tracking

service.4 Every year, around one million blood transfusions are carried out in the UK and a

significant risk is administering the wrong blood type during transfusions. The Blood Safety

Tracking service tracks blood from sampling to transfusion using a smart device. Blood bags are

tagged using active radio frequency identification (RFID) technology. At the time of transfusion,

staff will use hand-held readers to access the passive RFID chips embedded in each patient’s

wristband to confirm identification and blood type. In addition to increasing safety, the system

also provides more detailed data on the collection and usage of blood.

Accessing the NPfIT Services: Creating and Maintaining Knowledge via Platform

With a multitude of services offered at local and national levels, the central planners of

the NPfIT sought to centralize service delivery through a user-friendly interface. HealthSpace

(HS) is the personalized portal for the patient, giving her access and management tools for her

medical information. Patients can access Choose and Book, their Health and Medication details,

Summary Care Records, a Calendar function and personalized library of websites from the HS

portal. HS is a foundation for economies of scope. Through HS, the NPfIT can expand its

offerings to the patient seamlessly. Once patients use HS, the acquisition, marketing, and

distribution costs to deliver each new service is lower. There are also synergies between the

services; for example, a patient who schedules his appointments through Choose and Book will

likely also use the calendar functions. In this way, HS is a one-stop shop.

HealthSpace also enables co-creation between doctor and patient and increases the

utilization of knowledge through its use of platforms. Unique to HS is the patients’ ability to edit

their records for accuracy and healthcare providers’ access to these records. This is designed to

prevent medical mistakes and reduce multiple tests, such as X-rays, ultimately translating to

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lower healthcare costs. The power of this innovation is the indestructible nature of information.

For instance, if an allergy test requires assessment by a specialist, electronic test results can be

perpetuated across the entire system with better fidelity, thereby boosting the utilization of the

test.5 Furthermore, by placing the information on a platform accessible to both the patient and

provider, the health care record can improve the quality of care. Precious face-to-face meetings

can focus on tailoring a better treatment plan. Less time is devoted to a patient's mundane—and

possibly flawed—recounting about the other care she has received. Using co-creation is both

necessary to bring patients on-board and may prove useful if patients better comply with

recommended treatment plans.

Another example of one-stop shopping is eSpace, a portal devoted to healthcare

providers.6 It is an online portal available to all doctors and staff, full of updates and information

about various initiatives. As is the case with many IT projects, eSpace also allows for economies

of scale as the fixed setup costs are spread over an increasing number of users. By building this

platform, CFH makes each incremental initiative (e.g. a referral system for job hires) cheaper

too. Slotted under the "Capability & Capacity" initiative, eSpace can help doctors share the tacit

knowledge that is essential to their profession. eSpace offers a learning community for

practitioners so they can query colleagues and build relationships, expanding their networks

beyond those they regularly meet. A doctor can also access his peers to learn how to navigate the

complex changes and updates to the NPfIT. Thus, the doctor is co-creating his understanding of

medicine and experience, representing one of the most fundamental shifts in modern medicine.

Finding a Doctor Through Markets and Networks

The “Choose and Book” (CaB) service, as mentioned before, is exemplary of a two-sided

market. CaB is an online booking service that allows patients to choose and book their hospital

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and clinical appointments. Previously, the GP would direct a patient to a specific hospital. Now

CaB functions as the platform, which connects patients, primary care clinicians, and secondary

care clinicians. Under the new system, the patient consults with the GP on which kind of

secondary care is appropriate. Then, GP provides the patient with an appointment request letter

with a unique booking reference number, NHS number, and a list of suitable hospital options.

The patient then chooses the provider and the time and date of his appointment. The platform

also provides crucial performance information regarding the quality of care to the patient. There

are cross-sided networks effects: the more patients there are in the system, the more hospitals

will use the platform and vice-versa.

As with all platform strategies, it is critical to persuade the distinct user groups to use the

system. Table 1 summaries the potential benefits offered by CaB to different users of its two-

sided market.7

Table 1: Benefits offered to different user groups of CaB

Patients Primary Care Providers Secondary Care Providers Choice regarding

healthcare service More convenience

regarding scheduling appointments

Less waiting time More transparency

Better referral and communication procedures with hospitals

Less administrative time on checking appointments

No paper trail Information at fingertips

Reduction of patient no-show ups

Better communication with GPs

Better management of clinical workload

Less paperwork Similar to how Intel faced resistance from its customers and the creators of the

components when it introduced the PCI bus as the cornerstone of its platform strategy, the NHS

also faced many GPs and hospitals that refused to adopt CaB. Despite their reluctance and

technical shortcomings of the system, 97% of the GP practices use CaB with over 16,000

bookings per day.8  

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Innovations in Data and Knowledge Utility

One of the intended consequences of using the NPfIT platforms to aggregate, organize,

and publish information is higher data utilization. The Secondary Uses Services (SUS)

exemplifies this by aggregating statistics about appointments and overall service and storing it

onto a central warehouse. The CFH recognizes that medical appointments generate much

information that "is of value for many other purposes to support healthcare."9 SUS collects the

data and provides a "dashboard" for providers to compare their progress to that of other

providers. This tool allows for the recycling or re-use of information by boosting utilization. This

system might provide statistics on how much time certain doctors spend with their patients, how

successful certain doctors are in treating diseases and other metrics related to success. Given that

the system aims to provide "health surveillance and monitoring,” doctors can compare practice

habits and performance levels, which may lead to better guidelines for the standardization and

improvement of medical procedure.10 A successful implementation of SUS would take

advantage of the R=G, N=1 paradigm mentioned by Prahalad and Krishnan.11 By casting a wide

net for resources such as care information, a doctor is better informed about how to treat the next

patient. Ultimately, informed decisions through higher utilization of data housed on a standard

platform will result.

Another interesting service tool is the The Map of Medicine, “a tool for achieving clinical

consensus throughout a healthcare community.”12 It collects and organizes best practices related

to treating about 400 different conditions, contextualizing facts into tacit knowledge. Doctors and

clinicians tend to operate in silos and some of their specialized knowledge is difficult to access.

The Map of Medicine attempts to create a consensus based on the current and evolving

knowledge of these specialists. The service currently details best practice procedures for

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accidents and emergencies and in fields such as cardiology, dermatology, elderly care, and

obstetrics. Similar to blueprints, the Map of Medicine is a visual tool that lays out the treatment

process from the patient’s perspective.

III. Criticisms and Recommendations

Despite its ambitious goals and small wins to date, the NPfIT has been mired by

numerous delays and is—by any measure—a financial black hole. Originally budgeted at £2.3bn,

the project is expected to cost £20-30bn and with a completion date in 2-5 years or beyond.

Furthermore, mismanagement on many levels has spurred two of the largest IT contractors—

Accenture and Fujitsu—to leave the project. A growing dissatisfaction among both patients and

doctors has lead to low user rates of the system. While there are numerous factors contributing to

this crisis—ranging from political to managerial to financial—we focus on flaws related to both

design and execution of the services. Each recommendation summarizes the current debate and

relates suggestions for improvement to service innovation concepts.

Recommendation 1: Embrace Openness in the NPfIT Design

One of the most fervent debates surrounding the NPfIT is whether a centralized SPINE

service is needed at all. The imposition of a monolithic central database and record service has

created great friction between GPs and the government as well as great anxiety among patients.

From the GPs’ point of view, the central SPINE database mandated that they adopt new

platforms that often had limited functionality, to the potential detriment of patient care.13 The

designers of the SPINE system overlooked the fact that GPs were nearly 100% computerized by

time SPINE came into effect (Fig. 5). Before the SPINE system was implemented, many GPs

took the time to engineer their own systems, to determine what was possible, and to implement

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what was best for their practices. The needs of doctors working at University Hospital in London

are fundamentally different than those of a clinic operating in rural Scotland.14 In an effort for

mass standardization, the NPfIT planners disregarded the tacit knowledge reflected in the

customization of lead users in the GP community who had built and developed their own IT

office systems with functioning tools. From the patients’ perspective, there is a strong and

persistent public fear that centrally stored data, away from local hospitals and clinics, is

unprotected and susceptible to privacy invasion. Electronic medical records present major issues

for security which have been addressed in part but have yet to earn public trust.15

Given the spiraling costs and GPs’ resistance to adopt SPINE-based systems, we

recommend that the central system should be scaled down in favor of an open and modular

system that relies on interoperable local systems. In this new arrangement, all records are created

and stored locally at the hospitals and clinics where patients receive care. This change would

keep records closer to the doctor-patient relationship and in the immediate future, allay concerns

about security.

To provide the ability to access records anywhere in the UK, the government must lead

the establishment of standards and protocols that facilitate interoperability and communication.

Standards for functionality and data are required to be set centrally to ensure that local systems

can communicate with one another. Rather than punish non-adopters, the government could

instead offer rewards through a national accreditation system, encouraging IT providers to

innovate and design systems for local customers. Accredited systems can be listed in a catalogue,

including prices previously negotiated and set with the government. Public funds should be

directed only to suppliers who meet these standards. An accreditation process would ensure that

systems last for a sufficient period of time and remain flexible to future technologies,. Local

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hospitals would maintain the option to customize their systems to suit a range of idiosyncratic

needs.

This model would reflect a fundamental change in strategic design of the NPfIT. Rather

than a top-down centralized system focused on control, this bottom-up approach based on open

innovation principles involves doctors, patients, the government and third party IT developers.

By opening up the system, GPs, doctors and hospitals can choose which system is best for them.

This open “complex adaptive system” would then become a mix of customization to address

local needs and standardization to satisfy the communication needs of a larger network.

Furthermore, local communities, hospitals and doctors do not face the prohibitive cost of

replacing legacy systems that were sufficient. The government should now act as a coordinator

of standards, negotiator of prices, and administrator of accreditation, leveraging the knowledge

used to customize and maintain current systems.16

Recommendation 2: Refocus on the Patient

The NPfIT requires a system overhaul for simplification and consolidation. There are too

many components and systems to manage effectively at this point of the NPfIT. In order for

patients and doctors to benefit from healthcare IT solutions, there must be a change in the way

that IT is viewed from an institutional standpoint.

To examine the shortcomings of the NPfIT, we laid out two simple “business models,”

per Osterwalder.17 In the current design, the value proposition centers on creating large-scale

centralized databases (Fig. 6). This approach where systems that collect data yet bears little

direct relevance to patient care should be abandoned or assigned lower priority. Instead, the

NPfIT systems must deliver clear benefits to the care of the patient and the care provider (Fig. 7).

Given this burden of proof, it is not clear that the benefits conferred by a program such as SUS

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outweigh the complexity it adds to the healthcare service process and frustration it causes

doctors. From a practical standpoint, the time it takes for a doctor to record minutiae related to

each appointment or summarize the treatment outcomes of her patients might interfere with

patient care. In the worst case, the fixed cost related to the doctor’s operations may be

underutilized, as she sees fewer patients resulting from more administrative tasks or directs time

to “gaming the system” with her SUS reports. Thus, the NPfIT should conduct a thorough and

independent review of all the service components and retain only those that have an immediate

impact on patient care. Perhaps in the future, with better IT automation for data collection or

other innovations, services such as SUS will become more cost-effective and thus impactful.

Recommendation 3: Redesign Change Management Strategy to Increase Usage

One of the major reasons underlying barriers to adoption for most physicians is

difficulties with technology, interdependent updates and support, and electronic data exchange.

The complexity of the systems increased physicians’ initial time investment and reduced the

financial and quality-of-care benefits, leading to apathy and outright dislike of the NPfIT

systems.18

In a 2008 poll commissioned by the House of Commons, most respondents considered

highly regarded, industry-leading electronic medical records to be challenging because of the

poor interface design.19 The complexity of joining these multiple systems resulted in a vast

number of screens, options, and navigational aids. A service blueprint for a hypothetical patient

consult highlights the complexity imposed by the current NPfIT intitiatives (Fig. 8). The

“Onstage Contact” row now refers to the “onstage” NPfIT initiative, instead of an employee with

whom the customer interacts. The row is populated with over seven different interfaces for a

doctor, each requiring a change in his behavior. These substantial time costs and insufficient

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training by the government prevent doctors from obtaining benefits, ultimately lowering the

potential for improvement in the quality of care.

In addition to overburdening doctors, the central managers of the NPfIT project

blundered by ignoring the lessons of change management. Early in the process, the NPfIT

planners aimed for speed, spending billions of pounds in procurement contracts in less than a

year without first consulting doctors, clinicians and hospital administrators. Planners did not

fully appreciate the time needed to: 1) persuade and educate all users of a need for a redesign and

2) develop and deploy fully functioning IT systems.

There was a fundamental disregard and inability to formulate a coherent strategy for

change management in implementing these new systems. Planners ignored the opportunity posed

by co-creation, to invite doctors to actively participate in the design, procurement and

implementation. This fundamental error has led to the inability of central planners to get doctors

to take ownership of the NPfIT services that were funded for their use. Though change

management consultants were hired, the overarching strategy of service delivery without

listening to the customer limited their effectiveness. Professor John Kotter, a leading thinker on

change management, wrote:

The change process goes through a series of phases that, in total usually require considerable length of time. Skipping steps creates only the illusion of speed and never produces a satisfying result. A second very general lesson is that critical mistakes in of the phases can have a devastating impact, slowing momentum and negating hard-won gains.20

As a result of this flaw, skepticism, confusion and disappointment ensued. Excluded from

the original design phase and entrenched in their previous behaviors, potential users naturally

became skeptical of these new systems. Many hospitals and clinics had little idea about what

services they were to receive from the NPfIT. Furthermore, many expectations were not met by

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the delivered systems, contributing to delays as the vendors scrambled to change systems to suit

customer needs. The inefficiency in this development process contributed to the friction and

frustration between IT vendors and the NPfIT planners, eventually leading to the departure of

Fujitsu and Accenture.

Going forward, the NPfIT needs a clear and thoughtful change management strategy that

engages doctors and clinicians on all levels of service. Additionally, the NPfIT planners must

make a greater concerted effort to persuade doctors and end users that change is needed. This

change must involve end users on the local level with the support of local leaders and suppliers

who agree to accommodate and adapt to the needs of users on the front line. The complex

relationships between suppliers, central planners, doctors, and change management consultants

precluded early interactions with the doctors. The correct management structures facilitate direct

contact between suppliers and end users and allow them adequate time to develop operational

systems.21 Using tools such as service blueprints could improve understanding of each user

group’s needs and motivate the disparate vendors to work cross-functionally. The NPfIT should

also consider studying various customer segments (by specialty, age, geography and role in the

care delivery process) in their “natural habitats.” This would not only improve the service design

but also provide honest feedback about already launched systems.

IV. Summary and Conclusions

The NPfIT is an ambitious project that attempts to advance one of today’s hardest service

innovation problems—the efficient use of IT in the healthcare sector. The system exhibits central

concepts in service innovation, such as:

Standardization: the main reason for this project was the need to create standards for the

digitization of the healthcare industry.

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Aggregation: the system at its core is a very large scale collection of data.

Economies of scale: the creation of standards for medical records requires resources and

participation on a scale that the private sector has so far failed to achieve. The UK

government stepped in to correct this “market failure,” rolling out a system so that IT and

human resources are used efficiently and information collected reaches a critical mass.

Economies of scope and one-stop shopping: many of the systems are designed so that

they provide access to multiple related services.

Increasing utilization: the electronic records enable the re-use of information. One benefit

is that the data is available with no delay, which prevents the need to recreate data. Also,

the existing data can be used in new ways for better diagnoses and treatments.

Co-creation: patients can choose what goes on their health records and doctors can

collaborate with them to establish best treatment plans.

Platforms and two-sided markets: the system provides many ways to connect patients

with doctors and GPs with specialists.

Fostering an ecosystem: the design of the NPfIT aims to create an ecosystem of services

around a centralized database though the implementation fell short.

While the NPfIT implemented many of these concepts at the service level, it failed to

apply them on the whole system. The system includes many platforms, such as HealthSpace and

eSpace, and created too many standards. The system itself is disjoint and requires a great deal of

customization. Similarly, even though many of the individual initiatives were designed to

enhance co-creation with the user, the system was designed top-down without meaningful input

from the doctors or patients. This led to the biggest fault of all: the attempt to innovate in a

closed system instead of embracing open innovation. Many care providers had already

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implemented systems prior to the NPfIT. Given the lead users in the industry, it was a mistake to

impose a new system instead of designing one that would incorporate already successful

innovations. A natural extension of allowing for outside-in openness would be to allow for

inside-out openness. Going forward, the NPfIT should work on providing a secure framework

for private enterprises to build services and find new ways to utilize health data. This could result

in new innovations, advancements in medical research and predictive forecasts (e.g. early

discovery of pending pandemics).

Even though it currently does not meet expectations, the NPfIT underscores many

important lessons for services innovation:

Customer primacy as a design principle: whenever you design a complex innovative

service, study, understand, educate and co-create with the customer.

Focus on the core services: get the most important services right, then tackle the

remainders.

Implementation focus: have great service ideas, but even better implementation.

Involve all stakeholders: platform strategies touch a lot of different players; they have to

be won over to make the platform work.

Also, national IT services for healthcare pose interesting challenges to the lessons from private

industry. Some boundary conditions where such a program in the public domain would not

succeed include:

Short-term benefits to end users do not compensate for large initial investment, because

long-term benefits are difficult to measure and communicate.

Data protection and security concerns limit openness.

Inability to win over users and other stakeholders.

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Inability to build an ecosystem; no one wants to build the complements.

Failure to set up standard that are both clear to promote innovation and yet flexible for

local needs.

The successful implementation of the NPfIT program would be the proof of concept for

standardizing healthcare IT records and building ancillary services. If it succeeds, a global wave

of innovative IT healthcare services and the large-scale adoption of unified healthcare records

should follow. If it fails, more resources will be wasted, hampering other nations from launching

similar systems. We hope that the NPfIT is able to deliver value to its patients, healthcare

professionals, and the overall public in a timely and cost-effective way.

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Figure 1: Service Components of the NPfIT

Source: Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.45.

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Figure 2. The SPINE of the NPfIT

Source: Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.14

Figure 3. Regional Division of IT Vendor Services

Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. Pg.16

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Figure 4: Contracted vendor assigned to select NPfIT initiatives

Source: O’Brien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 40.

Figure 5: The Growth of GP Systems

Source: O’Brien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 68.

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Figure 6: Current business model for NPfIT endorses top-down planning

Large-scale centralized and

accessible health data

Value Proposition

SPINE, mandatory adoption

Distribution Channels

Key Activities

Develop a plethora of services to

exploit opportunities provided by a central health

databasePartner Network

Outside IT vendors

Key Resources

IT developers, experience with NHS practices

Cost Structure

Paid for by taxpayer, major cost overrun

N/A

Revenue Flows

Top-down planning, co-

creation in using services but not

in design

Client Relationship

Primary care providers (doctors),

secondary care providers (clinics and hospitals),

patients (taxpayers)

Client Segments

Figure 7: Proposed business model for NPfIT facilitates co-creation through flexible standards

Organize health and social care

information

Value Proposition

Selective adoption of

services

Distribution Channels

Key Activities

Provide standards and a unified

platform to create services built

around electronic heath data

Partner Network

Outside IT vendors,

doctors, clinics, hospitals

Key Resources

IT developers, experience with NHS practices,

access to doctors/patients

Cost Structure

Paid for by taxpayer N/A

Revenue Flows

Co-creation in design, focus on patients, provide

platform for doctors to use

customized systems

Client Relationship

Primary care providers (doctors),

secondary care providers (clinics and hospitals),

patients (taxpayers)

Client Segments

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Figure 8: Blueprint for the NPfIT Initiatives: Aiding doctor through hypothetical consult

Source: http://www.connectingforhealth.nhs.uk/systemsandservices

Notes: Because Connecting for Health is mainly a system of IT platforms, we amended the service blueprint in the following ways: • Physical evidence is accessed through a "one-stop shop" of the NHS Portal. While different programs may use another specific software package or an intranet, we abstract these programs to one term to maintain simplicity. • Customer action is the action from the perspective of the doctor, a general practitioner in this case. • Onstage Contact to be the specific NHS CFH initiative used for the doctor's action. • Backstage Contact was amended to mean the out-of-sight or overarching CFH programs needed for the action. • Support processes are other people or "actors" needed to finish the service to the patient. Again, the initiative is IT-focused so we place the IT functions in the foreground and the other actions in the background. One could, of course, blueprint these services for the other actors (e.g. patients booking appointments).

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                                                            1 www.connectingforhealth.nhs.uk/systemsandservices/spine 2 en.wikipedia.org/wiki/NHS_National_Programme_for_IT#The_Spine_.28including_PDS_.26_PSIS.29 3 www.connectingforhealth.nhs.uk/industry/suppliers/ 4 www.connectingforhealth.nhs.uk/systemsandservices/bloodpilot/about 5 www.webmd.com/allergies/allergy-tests/ 6 www.espace.connectingforhealth.nhs.uk/content/frequently-asked-questions/ 7 www.chooseandbook.nhs.uk/staff/overview/impact/primary/ 8 Department of Health: The National Programme for IT in the NHS. House of Commons, Twentieth Report of Session 2006-2007, p.112 9 www.connectingforhealth.nhs.uk/systemsandservices/sus/background/ 10 www.connectingforhealth.nhs.uk/systemsandservices/sus/background/whysus/ 11 C.K. Prahalad and M.S. Krishnan, “Processes: Enablers of Innovation,” Chapter 2 in The New Age of Innovation, pg. 45-79. 12 www.connectingforhealth.nhs.uk/systemsandservices/mapmed/ 13 O’Brien Stephen and Hayes, Glyn. Independent Review of NHS and Social Care IT. House Commons Audit Commitee, August 2009, pg 9. 14 Department of Health: The National Programme for IT in the NHS. House of Commons Committee of Public Accounts. Session 2006-7. pg. 20 15 Ibid. pg 111 16 O’Brien Stephen and Hayes, Glyn. pg. 131 17 business-model-design.blogspot.com/2005/11/what-is-business-model.html 18 O’Brien Stephen and Hayes, Glyn. pg. 79 19 Robert H. Miller and Ida Sim. Physicians’ Use Of Electronic Medical Records: Barriers And Solutions Health Affairs, 23, no. 2 (2004): pg. 116-126 20 John P Kotter, "Leading Change: Why Transformation Efforts Fail," Harvard Business Review (March/April 1995), pp. 5967 21 O’Brien Stephen and Hayes, Glyn. pg. 158-159