The NHS and Microsoft, is it really time to part company?


Since the NHS announcement of the cancellation of the NHS and Microsoft Enterprise Wide Licensing Agreement, on news forums such as eHealth Insider many in passing comment have been heralding this to be an opportunity for a change, suggesting it would be good for the NHS to break from the dominance of Microsoft as the primary technology provider.

Whilst the ending of the NHS and Microsoft agreement has created the opportunity to take stock, there are many strategic aspects not presently raised in discussions that should be considered before any organisations takes the plunge for change.

Of course nobody can fail to acknowledge that one of the key factors driving the agenda are the challenging targets for cost and efficiency savings to be made across the service, and arguably a primary reason behind the decision to cancel the agreement. Just as important however, patients, staff and the taxpayer will not be expecting responsible ministers and health service managers to be making short term gains, without ensuring these are not detrimental to the service in the medium to long term.

Microsoft is the dominant provider of software technology into the NHS, in fact this has been the case for more than 10 years, since organisations made the switch from technologies, for example Novell, Lotus, WordPerfect, that were then the predominant technology providers.

Yes, the NHS has undergone fairly significant technology change before. But it was not operating under the financial challenges faced by the NHS today. The migration from these technologies actually happened slowly over an almost 10 year time frame and critically, it also affected a much smaller number of end users than we are dealing with today.

Worth taking a step back for moment

One of the major factors that drove the change at that time was the Windows operating system with the easier use Windows interface, which delivered a radically different and far simpler way of working for both systems administrators and user alike, providing the means to more rapidly introduce computer solutions to new sections of the workforce at much less cost than could have been with the previous DOS based application environments.

A key factor in Microsoft’s early success was the fact that Windows and the early applications they released shipped with “Application Programming Interfaces” (Windows API) and “open systems architecture” (OSA) standards (noting that the OSA aspect did not necessarily employing then accepted industry standards defined by Open Systems Interconnect – OSI).

With the Windows API and OSA interfaces and the fact that Microsoft delivered then, and has continued to release, ever increasingly capable programming languages enabling simple utilisation of these technology layers, with an ability to incorporate functions and features from their “off-the-shelf” desktop and BackOffice technologies, Microsoft had delivered a rich and dynamic computing capability like no other.

A second and equally significant key to Microsoft’s success was the adoption of the Microsoft open standards and programming languages by the developer community worldwide. This coupled with the very successful partnering scheme which helped to established Microsoft’s becoming not only the most widely used and widely developed, but also the most widely supported technology, with thousands of technology service providers basing their business on the delivery and development of Windows based solutions.

The significance of what Microsoft has had a large hand in delivering, from a software engineering and development perspective cannot be understated. The ability to blend “commercial off-the-shelf” (COTS) technologies with new code to deliver new or custom applications has revolutionised software engineering. Enabling new “Agile” software engineering methodologies to come into existence which when applied correctly with COTS, delivers functionally rich applications at considerably less cost, time and most importantly risk than was achieved in the period predating Microsoft.

A IM&T Manager in a trust being asked to consider what investments in technology would deliver the most significant increases in efficiency savings over the next three years, could suggest:

Office automation and workflow, represents a means to deliver efficiencies and savings across a wide range of workforce activities. Importantly it is also a mechanism for delivering improvements in information quality to address gaps highlighted in the National Quality Board report recently published, which has identified 40% of health programme budget areas, representing £20bn of annual expenditure, is without any nationally collected quality information.

To deliver office automation and workflow a number of components are required:

– A messaging service to pass around workflow messages
– A business rules engine to manage events and actions
– A database engine to store metadata and structured data items
– Digital signature solution
– Forms tools, browser tools etc.

In considering the cost efficiency options for developing, implementing and supporting the office automation and workflow solutions they should be looking to utilise as much of our existing investment in technology as possible.

In acknowledging that not all of the components would already be available in my organisations, they should be looking to select technologies that had the best fit with those already deployed and with which my staff had been trained to use or are accustomed to.

In acknowledging that the trust would not have all the required skills readily available in house, then the choice of technologies would be influenced by selecting those that are supported the most in terms of third parties that could be called upon to help.

Another technical consideration, would be the ability to use as much commercial off the shelf software as possible, to limit the amount of software development (risk) to the minimum possible.

Top of the list for this would be Microsoft, with technologies addressing every aspect of the outline requirements listed above, with application programming interfaces to support development of any bespoke requirements, hundreds of technology partner specialist covering every aspect of the technologies above, thousands of developers to help at very competitive rates, and an unprecedented level of online resources available also.

Microsoft would clearly represents the lowest risk option for the iniative, given the majority of trusts already have:

MS Exchange Server (and Outlook Client), MS SQL Server for metadata storage, MS SharePoint for my document management and means through which presentation of workflow interfaces can be achieved, MS Office and Internet Explorer for my clients requirements that can be customised and tailored to deliver the most appropriate interface.

Trusts have digital signature capable technology in the NHS Smartcard, the only remaining missing link is Microsoft BizTalk to provide the business rules engine for the workflows.

In addition, there are also an extensive range of third-party Microsoft compatible third party components and bespoke solutions that address parts of the requirements that can be considered for purchase, to potentially further reduce production time and risk.

Alternative technology options for consideration

The alternative options to Microsoft at the same level of support and limitations of risk are not so easy to define, especially in terms of making a technology switch, Open Source being the option most widely promoted. Can Open Source truly provide the same complete range of “off-the-shelf” components with the integrated and standard programmatic interfaces and data integration / sharing capabilities comparable with that of Microsoft?

Even if the answer to this is yes, then the next consideration is the need for third party resources to help in the development, noting that the level of external support would initially be greater to address the unfamiliarity internally with the new technologies. How readily available are these, can they be obtained without any premium on the basis that they are less readily available?

But even before a trust could begin to consider the implementation of workflow development initiatives and commencement of securing efficiency savings and productivity gains, there would be the need for a migration project and switch of the organisation from the current set of technologies to the new, no small task in itself.


Very little exploration of the practicalities of making a technological switch of this significance is presented in the commentary I have seen to date, the focus very much on the assumption that moving to Open Source will reduces costs, and next to nothing has been offered in regards to the more strategic implications.

Open Source licences are free, but migration is not. There would be a requirement for investment to evaluate the implications of the technology switch (taking into account clinical applications exploiting the programmatic integration capabilities of Microsoft technologies), and then the investment in the projects to manage the transition.

Best estimate is that it would take a trust a minimum of six months to fully explore the implications and arrive at a plan for accomplishing the switch over, with another 6 months to accomplish the task fully.

An IM&T Manager instead could be looking to implement programme of work delivering office automation and workflow on an “agile” incremental basis, taking the least risk approach to produce the maximum return on investment at each stage.

In the same time frame as it would take to evaluate and plan a migration to alternative technologies, the trust could be delivered a range of cash releasing efficiency savings, with a plan and progress towards meeting requirements for Information on the Quality of Service, supporting the NHS strategic aim for Equity and Excellent: Liberating the NHS.

It would not take much to identify benefits and returns on investment that would easily justify the cost of procuring and maintaining investment in Microsoft licences.

Trust technology investments going forward need to align with the revised NHS national strategy of “connect all” rather than “replace all”. The NHS has tried revolution with only limited success, it now only has the resources for evolution.

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