Infrastructure report - Oct15.indd

NHS IT infrastructure Part one: data centres, servers,computers, printers and the software that runs them. Independent research from Digital Health Intelligence November 2015



Infrastructure 2015: part one Contents NHS IT infrastructure: Part one: data centres, servers, computers, printers and the software that runs them. Introduction 7 Background 8 Methodology 11 Personal computers, laptops and computers on wheels Market size 12 Spend 13 Distribution 15 Personal computers Market size 16 Biggest users of PCs 18 Factors influencing the market 18 Spend 19 The impact of the Microsoft EwA 20 Market opportunities 21 Trust refresh policies 22 Scotland, Wales and Northern Ireland 24 Laptops Market size 25 Top ten users of laptops 26 Factors influencing the market 27 Spend 29 Market opportunities 29 3

Infrastructure report Contents Computers on wheels Market size and spend 30 Factors influencing the market 31 Market opportunities 33 Hardware providers (PCs and laptops) 33 Operating systems Market share 34 Factors influencing the market: Windows XP 34 Market opportunities 35 Spend 36 Office software Market share 37 Factors influencing the market 38 Market opportunities 38 Spend 39 Software as a service Market share 40 Factors influencing the market 40 Market opportunities 41 Printers Market share 43 Spend 44 Refresh policy 45 Printer providers 46 Managed print services 47 Managed print services providers 48 4

Infrastructure 2015: part one Contents IT resources 49 Data centres Spend 51 On-site and off-site 51 Distribution across trusts and factors affecting the market 52 Market opportunities 55 Data centre suppliers 57 Servers Market size and spend 58 Distribution 58 Server suppliers 60 Server operating systems 61 Market opportunities 63 Conclusion 64 5

NHS IT infrastructure Market size by volume 825,675 desktop PCs 189,534 laptops 1,000,000 licences for 203,470 Printers operating systems In 2014-15 £69.6m on £44.7m on desktop PCs laptops £55,8m on £36.9m operating systems on Printers

Infrastructure 2015: part one Introduction This report addresses the state of NHS IT infrastructure, covering data centres, servers, personal computers, laptops and computers on wheels, and the operating systems they use. It covers all 256 NHS trusts and health boards in England, Scotland, Wales and Northern Ireland, and is based on original data collection and a model for extrapolation that takes into account the number of staff employed by these organisations and their different patterns of IT use. The report indicates that trusts and boards have increased their expenditure on computers and the software that runs them since Digital Health Intelligence last examined the state of NHS infrastructure in 2013. Some of this expenditure has been linked to the NHS’ late migration away from the Microsoft products covered by the Enterprise-wide Agreement signed between the company and the health service in 2002, which expired in 2010. But some is linked to underlying trends, such as the need to complete the unfinished business of the National Programme for IT, to implement newer technologies that can support efficiency, quality, and research, and to adopt some of the mobile working that is already common in other sectors. These trends have been supported by the government’s ‘paperless’ drive and its technology funds; but will continue without them. This suggests there will be continued investment in infrastructure, computers and devices in coming years, and the market opportunities that this will generate for suppliers are highlighted throughout the report and discussed further in the conclusion. 7

Infrastructure 2015: part one Background Coverage of healthcare IT tends to focus on the software – and increasingly the apps and social media technologies – that NHS trusts and their clinicians use. Yet the best software will not perform well if it is not supported by adequate infrastructure and put onto appropriate devices. The NHS, with trusts that have multi-million pound budgets and a staff count in the thousands, might be expected to have a more modern IT infrastructure than it does; outside the handful of organisations that are known for their investment in technology. Given the mobile working patterns of many of its staff, it also might be expected to make significantly more use of mobile technology that it has done; at least until the past couple of years. One reason that it does not is the legacy of the National Programme for IT in the NHS, which was set up in 2002, to create a national IT infrastructure for England and to deploy electronic patient records to acute hospitals and healthcare communities. This encouraged many trusts to make significant investments in IT, so they would be ready to implement the new electronic patient record systems that its local service providers were contracted to deploy. The result was a burst of spending in the mid-2000s, which was not repeated in subsequent years, as the programme’s local service providers struggled to develop and deploy the promised ‘strategic’ systems. 8

Infrastructure 2015: part one The national programme also negotiated deals, or Enterprise-wide Agreements, with suppliers of security, database and office software, the most significant of which was with Microsoft. This deal, first signed in 2001, was allowed to expire in 2010, a few months after the company released Windows 7. Although the EwA covered this operating system, few trusts made the upgrade. In 2014, when Microsoft ended support for Windows XP, the Cabinet Office was forced to step in and negotiate a deal to continue support for the public sector. The deal only lasted for a year, and this report suggests it has had a significant impact. While the number of PCs and laptops in use across the NHS has increased slightly, the amount spent on them has increased significantly, suggesting that trusts have been forced to invest in higher specification machines. As the national programme has wound down, trusts have had to develop their own strategies for investing in modern administration and clinical software. Trusts that decide to consolidate services on a single site, to implement an EPR from a ‘single supplier’, or to move off a ‘burning platform’ that is no longer supported by its provider, are likely to first upgrade their infrastructure and hardware. This has contributed to the increase in PCs and laptops covered by this report. It is also likely to have contributed to investment in data centres and servers, spending on which has also been driven by the increasing amount of data that trusts need to handle; and by the pressure to go mobile from their staff. However, trusts that want to invest in IT must do so in an increasingly difficult financial climate, caused by a growing projected gap between flat funding, rapidly rising demand, and increasing costs. 9

Infrastructure 2015: part one In 2008, the English NHS was asked to meet the ‘Nicholson Challenge’ to deliver £20 billion of efficiency savings by 2015, using quality, innovation, productivity and prevention initiatives. In 2015, it was asked to make similar levels of savings through to 2020-21, using the new models of healthcare set out in the ‘Five Year Forward View’. The financial crisis will make it harder to make the case for investment in IT; but trusts will have to balance this against the quality and efficiency gains promised by new ways of working supported by modern IT systems. In addition, health secretary Jeremy Hunt has encouraged investment in NHS IT with his ‘paperless’ ambition and the creation of two technology funds to support investment in patient safety and information sharing technologies. Trusts that have won tech fund money have also made investments in infrastructure and hardware, and this report suggests that these have had a particular impact on the number of computers on wheels in use across acute and mental health trusts in England. The impact of the tech funds and other developments on mobile phones, tablets and digital assistants will be discussed in a companion report on mobile infrastructure. This report suggests that trusts and health boards have made significant investments in infrastructure and hardware over the past couple of years; but that best practice remains unevenly distributed, leaving significant opportunities for suppliers. 10

Infrastructure 2015: part one Methodology This report covers 256 NHS trusts and health boards within the UK. Of these, 230 are located in England (154 acute trusts, 56 mental trusts and 20 community trusts), 14 in Scotland, seven in Wales and five in Northern Ireland. The report does not cover ambulance services or specialist and administrative organisations, such as English clinical commissioning groups. All 256 trusts and boards were sent a Freedom of Information Act request asking them to detail the infrastructure and hardware that they use, and how much they spend on it. The volume, spend and distribution figures in this report are based on their responses. To account for organisations that did not respond, final figures were calculated using an extrapolation model based on employee headcount and type of trust. In general, the model assumes that the more employees a trust has, the more PCs and other machines it will have. However, it also assumes that acute trusts will have a different distribution of machines to mental health or community trusts, and adjusts the extrapolated figures accordingly. This means that a distribution per 100 employees can also be calculated, and this is given at some points in the report. The employee figures were taken from the Digital Health Intelligence Database and compared against headcount data from the Health and Social Care Information Centre on the date of the research. In September 2013, Digital Health Intelligence (formerly EHI Intelligence) published a similar report on ‘NHS IT infrastructure’, discussing “UK market size and opportunities for servers, networks, hardware, devices and operating systems.” In order to show progress in the last two years, the final figures for 2015 are compared with the figures in the 2013 report where comparison can be made. 11

Infrastructure 2015: part one Personal computers, laptops and computers on wheels Market size Digital Health Intelligence calculates that there are 1,037,945 computers in use across the NHS, of which 80% are PCs (825,675 units), 18% laptops (189,534 units) and 2% computers on wheels (22,735 units). Statistics from the Health and Social Care Information Centre, combined with data held by Digital Health Intelligence, indicate that there are 1,349,261 staff (headcount) employed by the 256 NHS trusts and boards covered by this report; giving an average of 61 PCs, 14 laptops and two COWs for every 100 members of staff. Since Digital Health Intelligence published its last infrastructure report in 2013 , the total number of computers in use in the NHS has increased by nearly 9.9% (or 93,864 units, from 944,081 units). The number of PCs increased by just 3.0%, while the number of laptops jumped by 44.7%, and COWs by 105.2%. 900,000 Market size for PCs, laptops and COWs 2013 and 2015 800,000 700,000 600,000 2013 500,000 2015 400,000 300,000 200,000 100,000 0 12

Infrastructure 2015: part one Spend In 2015, NHS expenditure on PCs, laptops and COWs was £126 million; of which £69.6 million (55% of the total) was on PCs; £44.7 million (36%) was on laptops, and £11.8 million (9%) was on COWs. Since 2013, spending on PCs, laptops and COWs has risen faster than the number of machines in use, in percentage terms. PC spend has increased by 39.4% in two years, rising from a total of £49.9 million in 2013 to a total of £69.6million in 2015. Spending on laptops and COWs increased at an even higher rate, rising by 138.3% and 152.4% respectively. Laptop spend rose from £18.8 million to £44.7 million and COW spend increased from £4.7 million to £11.8 million. £80 Spend on PCs, laptops and COWs 2013 and 2015 £70 £60 £50 2013 £40 2015 £30 £20 £10 0 1 - Digital Health Intelligence. NHS IT Infrastructure. http://www.digitalhealth.net/intelligence/reports/detail.cfm?report_id=81 13

Infrastructure 2015: part one Volume and spending compared There are still far more PCs in use in the NHS than other kinds of computer (80%). However, they now account for only just over half of NHS trust and board spending (55%). Laptops now account for 18% of the computers in use in the NHS, but 36% of total spending; suggesting that trusts and boards are making significant investments in these computers. Similarly, although COWs accounted for just 2% of the computers in use in 2015, they accounted for 9% of total spending suggesting there has been a particular uptick in spending on these devices. Type of computer, Desktop PCs Spend by type Desktop PCs 2015 Laptops of computer, 2015 Laptops 2% COWS 9% COWS 18% 55% 80% 36% 14

Infrastructure 2015: part one Distribution Overall, the English acute sector has the largest number of computers; as would be expected, given that it is the largest sector covered by this report. However, it has more PCs (84% of the total number of computers in use) than might be expected, given the mobile nature of many of its clinical staff, who need to work across wards and treatment areas. Mental health and community trusts are more invested in laptops. A third (33%) of the total number of computers in use in mental health trusts, and 35% of the total number of computers in use in community trusts are laptops. Of the devolved nations, Scotland has the largest volume of computers, as the largest service. Scotland, Wales and Northern Ireland are all heavily invested in PCs, in comparison to laptops. Distibution of PCs, laptops and COWs Distribution of expenditure on PCs, by type of organisation, 2015 laptops and COWs by type of organisation, 2015 600,000 £60 Desktop PCs Desktop PCs 500,000 Laptops £50 Laptops COWs COWs 400,000 £40 300,000 £30 200,000 £20 100,000 £10 0 £0 NI health and social care trusts NI health and social care trusts 15

Infrastructure 2015: part one When it comes to spending, the English acute sector is investing some money in laptops. But mental health and community trusts are, proportionately, investing much more. While laptops made up 33% of the total number of computers in use in mental health trusts in 2015, they accounted for around 49% of their spending. Similarly, while laptops were 35% of the computers in use at community trusts, they accounted for 66% of their spending on computers; the largest proportional spend of all trusts and boards. Among the devolved nations, Welsh health boards are making similar investments in laptops over the past year. While laptops accounted for 17% of their total number of computers in use at Welsh health boards, they accounted for 42% of the spending, the largest proportional spend within the devolved nations. English acute trusts are also making a significant investment in COWs, which now account for 3% of the total number of computers in use and 18% of their spending. Again, this suggests that where there has been investment in computers over the past two years, it has tended to go on laptops and, in acute trusts, COWs. The factors driving this are discussed in more detail in the sections that follow. Personal computers Market size Digital Health Intelligence data and calculations show there are 825,675 PCs in use across the NHS, with 60% of these in use in the acute sector. This is an increase of 3% on 2013, when there were 802,000 PCs in use across the NHS. 16

Infrastructure 2015: part one PCs by NHS organisation type, 2015 4% 4% English acute trusts 4% English mental health trusts Scottish health boards English community trusts 12% Welsh health boards NI health and social care trusts 16% 60% Across NHS trusts and health boards, there are 61 computers per 100 employees; which would be low for a sector in which most staff work behind a desk, but is higher than might be expected for an organisation like the health service, in which many clinical staff are mobile. Number of Number of PCs per 100 PC volume Market size Desktop PCs trusts employees staff, 2015 2015 2015 English acute foundation trusts 100 513,046 58 297,786 £22,380,889 English acute trusts 54 316,527 61 193,641 £10,763,519 English community trusts 20 64,874 57 36,726 £3,967,207 English mental health foundation 42 163,675 62 101,992 £16,511,649 trusts English mental health trusts 14 41,181 76 31,244 £518,138 NI health and social care trusts 5 51,810 62 32,075 £3,867,381 Scottish health boards 14 129,551 74 96,369 £7,758,787 Welsh health boards 7 68,597 52 35,844 £3,790,269 Total 256 1,349,261 61 825,675 £69,557,839 17

Infrastructure 2015: part one Biggest users of PCs As expected, NHS Greater Glasgow and Clyde has the highest number of computers because it has the highest number of employees of any organisation covered by this report. This trust also spent the most on PCs and other computers of any NHS organisation in 2015. Number of PC’s per 100 NHS Organisation PCs staff NHS Greater Glasgow and Clyde 24,600 68 Belfast Health and Social Care Trust 10,392 59 Nottinghamshire Healthcare NHS Foundation Trust 7,000 78 Oxford University Hospitals NHS Trust 7,000 71 NHS Ayrshire and Arran 6,864 76 NHS Highland 6,000 82 Southern Health and Social Care Trust 5,694 70 Western Health and Social Care Trust 5,538 66 Pennine Acute Hospitals NHS Trust 5,507 67 Northern Health and Social Care Trust 5,487 57 NHS Greater Glasgow and Clyde spent the most on hardware of any trust covered by this report, spending £2.3 million on PCs, £1million on laptops and £42,147 on COWs. The trust undertook very high capital spending on ICT in 2012-13 of £7.4 million, as it prepared to open a new, £842 million ‘super hos- pital’ and to implement an InterSystems’ TrakCare patient adminis- tration system . Its expenditure then fell by 50% in 2013-14 and 2014-15. Factors influencing the market The heavy reliance on PCs by the NHS in general and the acute sector in particular is a legacy of the National Programme for IT in the NHS. The programme, which was set up in 2002, encouraged trusts to invest in IT to prepare for the implementation of ‘strategic’ electronic patient record systems. 18

Infrastructure 2015: part one This led to a burst of spending that many trusts have not repeated. However, the number of PCs in use across the NHS has risen slightly over recent years, as some trusts have finally implemented NPfIT systems, others have made their own investments in EPRs, and others have upgraded their machines to more modern operating systems with the end of Microsoft support for Windows XP (discussed in more detail below). Spend Total expenditure on PCs in 2015 was £69.6 million for 825,675 PCs, giving an average expenditure of £60 per employee. PC spend has increased by nearly 40% in two years, from a total of £49.9 million in 2013. The acute sector, as the largest sector by employee number, was the heaviest spender on PCs. Acute trusts spent just over £33.1 million on personal computers in 2015, while mental health trusts spent £17 million and community trusts just below £4 million. Desktop PC spend, by type of organisation, 2015 NI health and social care trusts Welsh local health boards £80 English community trusts £70 Scottish united health boards £3.9 £3.8 English mental health trusts £60 £4.0 English acute trusts £7.8 £50 £40 £17.0 £30 £20 £33.1 NI health and social care trusts £10 0 2 - Digital Health Intelligence. Super hospital “catalyst” for paperless. http://www.digitalhealth.net/infrastructure/29887/ super-hospital- 19

Infrastructure 2015: part one The impact of the Microsoft EwA There has been a small increase in the number of PCs in use across the NHS over the past two years, but a much bigger increase in the amount of money spent on them. One reason for this is another legacy of the national programme. NHS Connecting for Health, the agency that ran the programme, negotiated deals with the major suppliers of database, security and office software, known as Enterprise-wide Agreements. The biggest of these deals was with Microsoft. Signed in 2001, this gave NHS organisations access to perpetual licenses for server and desktop operating systems and the Office productivity suite . The deal was 3 allowed to lapse in 2010, shortly after Microsoft released Windows 7. Although NHS organisations could have upgraded their machines to Windows 7, relatively few did; partly because of the general lack of investment in hardware (outlined above), partly because of the training implications, and partly because many national and local applications were written specifically for XP. This meant that when Microsoft announced it was going to end support for XP on 8 April 2014, eight out of ten NHS trusts and boards were still using an OS that had been released in 2001. The Cabinet Office stepped in to negotiate a year-long support deal for the public sector with the company. The increase in spending on PCs indicates that significant numbers of organisations have finally been undertaking migrations, and spending more on both licenses and higher specification machines in the process (the impact on the operating systems is discussed below). The implementation of modern electronic patient record systems also tends to be preceded by major upgrades to infrastructure and hardware. 20

Infrastructure 2015: part one Cambridge University Hospitals NHS Foundation Trust has been working on a £200 million eHospital project, ahead of the move to a new campus. The centrepiece is the first installation of the Epic electronic patient record in the UK . Despite 4 this, the greater part of the funding (£140 million) has been spent with HP, which won the contract to upgrade the trust’s infrastructure and roll-out new machines. 5 Market opportunities With two thirds of trusts having now migrated away from Windows XP, Microsoft’s decision to end support for this operating system should have far less impact in future years. Despite this, the NHS is likely to continue to invest in its PC estate. Trusts that are moving to new buildings, or implementing major electronic patient record systems, tend to upgrade their PCs first; and many trusts still need to complete the work of the National Programme for IT and get new administrative and clinical systems in place. In addition, trusts that are adopting ‘best of breed’ strategies are finding that they need to invest in higher-specification machines to run new systems. Therefore, while the number of PCs in use across the NHS may not continue to increase significantly, suppliers should find opportunities to renew and upgrade the PC estate. 3 - Microsoft in Health. Licensing guidance for the NHS. http://www.microsoft.com/health/en-gb/buy/Pages/Licensing- guidance-for-the-NHS.aspx 4 - Digital Health Intelligence. Cambridge University Hospitals NHS Foundation Trust. http://www.digitalhealth.net/docu- ment-library/11/Routes%20to%20EPR%20profile%20-%20June%202013.pdf 5 - HP. HP Helping Cambridge University Hospitals Transform to Digital Hospital. http://www8.hp.com/uk/en/hp-news/ press-release.html?id=1393859 21

Infrastructure 2015: part one Trust refresh policy One of the reasons that trusts are overly reliant on PCs is that many spent heavily in the early 2000s in anticipation of receiving ‘strategic’ systems from the National Programme for IT, and have not made similar investments since. Relatively few trusts have policies in place to refresh their hardware on a rolling basis, and instead make significant investments only when they ‘have’ to, for example because they are planning a significant clinical soft- ware upgrade, or there is a trigger such as the end of support for Micro- soft XP. Digital Health Intelligence found that just 3% of trusts and boards refresh their PCs and laptops every three years, while just under half (47%) aim for every five years and 11% every four years. Almost one in five (17%) of trusts and boards do not have any strategy for refreshing their hardware, and 16% said they were not aware of any such policy. Trust refresh policy cycles for desktop PCs and laptops, 2015 16% 1% Every five years 2% No policy Every four years Every three years 3% Every six years 3% Every seven years 11% Every eight years Other 47% 17% 22

Infrastructure 2015: part one In an IM&T strategy issued in July 2014, Somerset Partnership NHS Foundation trust noted that it had not ring-fenced funding for replacing PCs at the end of their life. Almost two thirds (59%) of its machines were over five years old and 43% were using Windows XP, for which Microsoft support had ended in May. The trust was seeking to replace 3,300 machines in the first three years of the strategy, and to have completely refreshed its hardware estate by the end of 2019, by which time it hoped that 90% of its equipment would be less than five years old. 6 Despite this, there are signs of growing interest in moving towards a more regular replacement of hardware. Just under six in ten (59%) of the trusts and boards who said they replaced their IT every five or four years said they would be running planned, yearly refreshment cycles in the future. Milton Keynes University Hospital NHS Foundation Trust told Digital Health Intelligence in the response to the research for this report that it is planning to refresh 25% of its total computer estate every year. The trust has signed a ten-year, £23 million deal to implement a range of Cerner’s clinical modules over the next two to three years, including e-prescribing, building towards a full electronic patient record and the refresh will support this significant investment in EPR technology. 7 This suggests there is an opportunity for the providers of managed services who can convince trusts of the financial and efficiency benefits of such a move. Additionally, several trusts are adopting a mixed device policy as part of an outsourcing or managed service deal, and the chance to adopt appropriate hardware on a managed basis can be an argument by firms capable of delivering such a service. 6 - IM&T Strategy. Somerset Partnership NHS foundation Trust.. http://www.sompar.nhs.uk/con- tent/26210/27900/98116/Enclosure_N_IMT_Strategy_-_June_2014_V6.pdf 23

Infrastructure 2015: part one Scotland, Wales and Northern Ireland Scottish health boards have the highest ratio of PCs to employees of any of the organisations covered by this report (74 PCs per 100 employees), and the highest spend among the devolved nations (£7.6 million). In part, this is a function of the size of some of the boards. However, Scotland’s approach to healthcare IT has also been a factor. Scotland does not have England’s internal market in health, with its split between commissioning and providing organisations. In consequence, it sets more policy nationally. NHS Scotland’s IT strategy is based around nationally-procured infrastructure, the roll-out of a single electronic patient record system to all health boards (InterSystems’ TrakCare), and framework contracts for other core systems. The roll-out of these systems has led to a significant investment in the infrastructure needed to operate and access them effectively. The situation is similar in Wales, where the NHS Wales Informatics Service has 8 been driving a digitisation policy based on the implementation of an in-house PAS (Myrddin) and clinical portal, alongside national contracts for pathology, digital imaging, and other core systems. The policy is mature, and Welsh health boards had the lowest spend on PCs in 2015 (£3 million) as well as the lowest volume of PCs (35,844 units, or 52 PCs for every 100 members of staff). Northern Ireland is in the early stages of an IT strategy that bears similarities to those pursued by the health services of the other devolved nations. In 2015, Northern Irish health and social care trusts spent a total of £3.9million of PCs, and had an average of 62 PCs per 100 employees. Health and social care trusts are large organisations that, as their name implies, span health and social care. Northern Irish trusts have a desktop- 9 based IT infrastructure investing on centralised systems. Four of the five total trusts in the province feature in the top ten users of PCs: Belfast Health and Social Care Trust, Southern Health and Social Care Trust, Western Health and Social Care Trust and Northern Health and Social Care Trust. 7 - Digital Health Intelligence. Milton Keynes to stick with Cerner. http://www.digitalhealth.net/news/29910/ 8 - Digital Health Intelligence. http://www.digitalhealth.net/news/29164/ 9 - http://www.computing.co.uk/ctg/interview/2389324/joined-up-healthcare-in-belfast-an-interview-with-nhs-bh- sct-director-of-it-paul-duffy 24

Infrastructure 2015: part one Market opportunities Scotland, Wales and Northern Ireland do not have England’s internal market in healthcare, and far more policy and funding is determined centrally. All three devolved nations have established IT strategies that are supported by centrally-placed contracts for major administrative and clinical systems, or framework contracts for supporting infrastructure and management. As a result, there are relatively few opportunities for suppliers outside these contracts and tenders; although securing a win or place on a framework can deliver a significant amount of business. Laptops Market size The total number of laptops in use across the NHS has increased by 44.7% in two years, from 131,000 laptops in 2013 to 189,534 laptops in 2015. The majority of these laptops are in English acute and mental health trusts. Laptops by NHS organisation type, 2015 2% 4% English acute trusts 8% English mental health trusts 40% English community trusts Scottish health boards 11% Welsh health boards NI health and social care trusts 35% Across the NHS, there is an average of 14 laptops per 100 employees; however this ratio varies by type of trust. Underlining the relatively high investment in mobility made by mental health trusts (outlined above), Digital Health Intelligence calculates that they have more laptops per 100 employees than organisations in the acute sector. 25

Infrastructure 2015: part one There are 38 laptops per 100 employees working in mental health foundation trusts and 31 per 100 employees working in mental health trusts; and just (11 laptops per 100 employees in acute foundation trusts and eight per 100 employees in NHS trusts. Community trusts also have a relatively high proportion of laptops to employees – 31 per 100 staff. Laptop per Number of Number of Laptop Market size Laptops 100 trusts employees volume 2015 2015 staff, 2015 English acute foundation trusts 100 513,046 8 42,030 £6,585,829 English acute trusts 54 316,527 11 33,357 £5,335,516 English community trusts 20 64,874 31 20,271 £8,207,042 English mental health foundation 42 163,675 31 51,247 £16,398,981 trusts English mental health trusts 14 41,181 38 15,684 £865,994 NI health and social care trusts 5 51,810 9 4,518 £551,818 Scottish health boards 14 129,551 11 14,814 £3,651,120 Welsh health boards 7 68,597 11 7,613 £3,099,169 Total 256 1,349,261 61 189,534 £44,695,468 Top ten users of laptops Many of the ten organisations with the most laptops in use are English mental health or community trusts, with the single largest user Southern Health NHS Foundation Trust; an enormous organisation that provides community, mental health and learning disability services across the South from a base in Southampton. Number of Laptops per NHS Organisation laptops 100 staff Southern Health NHS Foundation Trust 3,892 47 Northamptonshire Healthcare NHS Foundation Trust 2,366 71 Tees, Esk and Wear Valleys NHS Foundation Trust 2,300 55 Kent and Medway NHS and Social Care Partnership Trust 2,200 52 Oxford Health NHS Foundation Trust 2,172 54 Kent Community Health NHS Foundation Trust 2,143 53 NHS Greater Glasgow and Clyde 2,100 68 Lancashire Care NHS Foundation Trust 1,902 54 Rotherham Doncaster & South Humber NHS Foundation Trust 1,701 65 South Staffordshire and Shropshire Healthcare NHS Fouundation Trust 1,602 27 26

Infrastructure 2015: part one In 2013, Southern Health NHS Foundation Trust deployed 1,596 laptops to staff through a mobile working project, to give its 6,500 staff better ac- 10 cess to the electronic patient record, RiO which had deployed as part of the National Programme for IT, and which it signed a direct contract with the company in 2014 as the national contract came to an end . 11 Factors influencing the market The greater use of laptops in mental health and community trusts can be linked to the greater mobility of their clinical staff, who frequently need to work from a number of clinics, or from community settings, including patients’ homes. However, it can also be linked to the roll-out of electronic patient records by the National Programme for IT. Mental health and community trusts in London and the South deployed the RiO EPR from CSE Healthcare, while trusts in the North, Midlands and East deployed a variety of ‘interim’ systems, including TPP’s SystmOne. With these systems in place, trusts looked at using laptops to enable staff to access these records and administrative systems, such as worklists and timesheets, on the move. The more recent, ongoing investment in laptops can be linked to CSE Healthcare and other companies developing mobile versions of their EPR systems. 10 - http://www.southernhealth.nhs.uk/knowledge/rio-community/rio-and-mobile-working-survey/ 11 - Digital Health Intelligence. Southern Health takes RiO EPR. http://www.digitalhealth.net/news/EHI/9401/southern- health-takes-rio-epr/ 27

Infrastructure 1: Hardware Northumberland, Tyne and Wear NHS Foundation Trust, is one of the largest mental health trusts in England. It employs more than 6,000 staff across 100 sites to cover a population of 1.4 million. It issued staff with laptops with 3G connectivity back in 2013 to give them access to its EPR, RiO, and to enable them to update records in real-time. 12 The increase in number of laptops in acute trusts also reflects the imperative to introduce mobile working (a subject that will be explored in more detail in Digital Health Intelligence’s second report on infrastructure and hardware, which will deal with wireless and mobile devices). Although trusts often deploy tablets and iDevices to board members and to staff who need to look up information, some have found that these are not good data entry devices; and that laptops are preferable. The two technology funds set up to support health secretary Jeremy Hunt’s ambition for a ‘paperless’ NHS by 2018 are therefore likely to have driven investment in laptops. In particular, the first or ‘Safer Hospitals, Safer Wards: Technology Fund’ report gave out considerable sums for the implementation of electronic patient records, e-prescribing and other technologies with a patient safety or efficiency focus. Staffordshire and Stoke on Trent Partnership NHS Trust received £1mil- lion funding in 2014 from the first round of the nursing technology fund, for a remote working solution including laptops, clinical tablets and smart- phones . 13 The funding will provide the community nursing staff, health visitors and adult social care workers with equipment to enable easy access to the clinical and corporate systems they need while out of the office; including recording, access information, order equipment and prescriptions. 12 - Digital Health Intelligence. Mental health maintenance. http://www.digitalhealth.net/insight/analysis/1118/men- tal-health-maintenance/ 13 - NHS England. Nursing Technology Fund. Second Round Prospectus. http://www.england.nhs.uk/wp-content/up- loads/2014/11/ntf-rd2-prospectus.pdf 28

Infrastructure 2015: part one Spend Mental health trusts spend more money on laptops than any other sector covered by this report. In 2015, their total spending on laptops was £17.2 million. The second biggest spending sector was acute trusts with (£11.9 million) and the third community trusts (£8.2million). Laptop spend, by type of organisation, 2015 £50 NI health and social care trusts £45 £0.6 Welsh local health boards £40 £3.1 Scottish health boards £3.7 £35 English community trusts £8.2 £30 English acute trusts English mental health trusts £25 £11.9 £20 £15 £10 £17.3 NI health and social care trusts £5 £0 Market opportunities As with PCs, when acute trusts invest in electronic patient records and other efficiency and quality technologies, they are first likely to update their infrastructure and devices, and this will create opportunities for the suppliers of laptops. There will be more opportunities if the government decides to run further technology or other challenge funds to support its ‘paperless’ agenda, and the latest NHS IT strategy, ‘Personalised Health and Care 2020’. Tablets, mobile devices tethered to specific software systems, and the slow spread of ‘bring your own device’ initiatives may also present challenges to laptops (an issue that will be discussed further in Digital Health Intelligence’s companion report on mobile infrastructure and devices). 29

Infrastructure 2015: part one In mental health, the picture is slightly different, because of their more mobile workforces, the technology refresh triggered by the end of national programme contracts, and the relatively recent development of mobile- friendly administrative and clinical systems. Mental health and community trusts are likely to offer significant opportunities for suppliers who can offer them effective mobile working solutions. Computers on wheels COWs are used as a way of giving staff access to IT systems on wards and in other treatment areas, and are particularly associated with specific functions, such as clerking, clinical noting and e-prescribing. To support the latter, some carts come with drawers for storing medications. Market size and spend There are a total of 22,735 COWs in use across the NHS, and their number has increased by 105.2% since 2013 when there were 11,081 units. COWs volume account for only 2% of the total hardware market covered by this report (22,735 units), but 9% of the total hardware spend (£11.8 million). This reflects the cost of the custom carts, as well as the computers that are mounted on them. COWs by NHS organisation type, 2015 1% 1% 4% English acute trusts 5% Scottish health boards 9% English mental health trusts Welsh health boards English community trusts NI health and social care trusts 80% 30

Infrastructure 2015: part one There is now an average of 85 COWs per trust or health board although, of course, their distribution varies greatly by type of organisation. There are virtually no COWs in use in community and mental health trusts, which have relatively few wards, and considerably more in use in the acute sector (where there are three and two cows for every 100 employees for acute and foundation trusts respectively). COWs per Number of Number of COWs Market size COWs 100 trusts employees volume 2015 2015 staff, 2015 English acute foundation trusts 100 513,046 2 10,101 £3,138,392 English acute trusts 54 316,527 3 8,005 £6,496,919 English community trusts 20 64,874 0.4 255 £316,073 English mental health foundation trusts 42 163,675 0.4 695 £668,481 English mental health trusts 14 41,181 1 506 £282,704 NI health and social care trusts 5 51,810 0.4 228 £224,840 Scottish health boards 14 129,551 2 2,101 £162,016 Welsh health boards 7 68,597 1 843 £470,912 Total 256 1,349,261 2 22,735 £11,760,336 Factors influencing the market The two technology funds set up to support the government’s ‘paperless’ ambitions put a significant focus on the roll-out of electronic patient record systems and technologies with a proven impact on patient safety. The first, or ‘Safer Hospitals, Safer Wards: Technology Fund’ was initially billed as an e-prescribing fund. And although it eventually funded a range of EPR and other technology projects, in 2014 it allocated £44.4 million to 54 e-prescribing projects at 53 trusts. The University Hospital of South Manchester NHS Foundation Trust was given funds for two projects; but Papworth Hospital NHS Foundation Trust received the single largest investment in e-prescribing when it was allocated £4.3 million as part of what was then a joint eHospital programme with Cambridge University Hospitals NHS Foundation Trust. 14 Since COWs are particularly associated with the roll-out of electronic prescribing and medicines administration systems, the tech funds are likely to have had a significant impact on the number in use across the health service. 31

Infrastructure 2015: part one The Somerset Partnership NHS Foundation Trust was successful in bidding for £1.1 million of ‘Safer Hospitals, Safer Wards: Technology Fund’ money, in order to roll-out the use of RiO across its ten community hospital sites. Some of this funding was used to acquire COWs for clinical staff. 15 The different approach taken in Scotland, Wales and Northern Ireland, which all have national health IT strategies, but which have not put the same emphasis on e-prescribing or on challenge funding for specific technologies may account for the relatively lower take-up of the infrastructure and devices associated with this. Just 7% of the total spend on COWs across the NHS is spent in the devolved nations (with Scottish boards spending £162,016 on COWs in 2015, Welsh boards £470,912, and Northern Irish trusts £224,840). COWs spend by organisation type, 2015 £14 £12 £0.2 £0.2 Scottish health boards NI health and social care trusts £0.3 £0.5 £10 £1.0 English community trusts Welsh local health boards £8 English acute trusts £6 English mental health trusts £9.6 £4 NI health and social care trusts £2 £0 14 - Digital Health Intelligence. Trusts win up to £8.2m in ‘tech fund 1’. http://www.digitalhealth.net/news/29318/ 15 - The Somerset Partnership, NHS Technology Fund. http://www.sompar.nhs.uk/about_us/nhs_technology_fund 32

Infrastructure 2015: part one Market opportunities The government significantly scaled back its second, or ‘Integrated Digital Care Technology Fund’, releasing just over £40 million of the promised £240 million. This was a significant disappointment for e-prescribing suppliers; and the government has not promised to reinstate this or other challenge funding. Given the link between e-prescribing and investment in CoWs, there will be more opportunities for suppliers of CoWs if the technology funds are reinstated. However, even if this does not happen, there should be slower investment in e-prescribing in coming years, as trusts are encouraged to take up a technology with proven clinical safety benefits, and younger clinicians demand access to decision support technologies. Further opportunities may arise with the deployment of other technologies that require mobile computing in conjunction with other devices and equipment; such as the roll-out of ‘vein to vein’ blood tracking, or the widespread adoption of the scanning technology for consumables that is currently being trialled by ten trusts interested in more closely aligning their treatment activities to financial and clinical outcomes. Hardware suppliers Dell and HP dominate the market for PCs and laptops, with an 83% market share. Brands such as Lenovo, Fujitsu and Toshiba have consid- erably smaller market shares. Hardware suppliers, PCs and laptops, 2015 9% 3% Dell 5% HP Lenovo Fujitsu Other 48% 35% 33

Infrastructure 2015: part one Operating systems Market share Digital Health Intelligence calculates that the trusts and boards covered by this report have 1 million operating system licenses for all computers. This suggests that 98.8% of all computers have an operating system license and 12,007 machines do not have a licence; most probably because of under- licensing. Microsoft is overwhelmingly dominant company in the market. All trusts are running some form of Windows operating system on their machines and only 11 trusts also use operating systems from other suppliers on some of their machines. This means the big issue to be tackled by trusts since the 2013 report has been migration away from Windows XP, which has led to a big increase in the use of Windows 7, which now runs more than half (65%) of machines in the NHS. Operating systems for desktop Operating systems for desktop PCs, by number of licences, 2013 Windows XP PCs, by number of licences, 2015 Windows XP Windows 8 Windows 8 1% Windows 7 3% Windows 7 14% Windows Vista 2% Windows Vista 30% 85% 65% Factors influencing the market: Windows XP When Digital Health Intelligence published its last report on NHS infrastructure and hardware in 2013, Microsoft was within a few months of ending support for Windows XP, which was still used to run eight out of ten computers in the NHS (for reasons discussed above). 34

Infrastructure 2015: part one The Cabinet Office stepped in to secure a one-year extension of support with the company, and since then the percentage of NHS machines running XP has now dropped dramatically, to just 30%. Two thirds (65%) of NHS machines are now using Windows 7. When the research for this report was conducted, just 2% were using Windows 8; which forced users to master the ‘Metro’ tiled user interface. A further 3% of NHS machines are using other operating systems; of which Apple is the most dominant in laptops, and Linux, the best known open-source operating system, the most dominant in PCs. Market opportunities Although the number of PCs and laptops running XP has dropped dramatically, a worrying third of machines remain reliant on it. When the research for this report was conducted, 11% of trusts still running on XP reported that they had migration plans underway or in place. This suggests there are still some immediate opportunities for suppliers as this work is completed, even if the impact of the EwA and the end of support for XP should now decline as factors influencing the market for operating systems in the NHS. Digital Health Intelligence’s research suggests limited opportunities among those trusts that have moved away from Windows XP. Just 10% of trusts and boards that answered a question on their future plans said they were planning to move on to Windows 8, while 52% said that they planned to stick with Windows 7. Trusts' refresh policy cycles for operating systems, 2015 5% 8% Completed migration to Windows 7 10% Stay with Microsoft Migration to Windows 7 in progress Move to Windows 8 52% Assess each OS individually 11% No policy 14% 35

Infrastructure 2015: part one However, it is possible that their plans may have been affected by the release of Windows 8.1 and then the launch of Windows 10; both of which have made a feature of reintroducing some of the more familiar and popular features of Windows 7. Just 8% of trusts told Digital Health Intelligence that they are open to using alternatives, such as open source operating systems. However, the government has supported open source, with the Cabinet Office publishing an Open Source Procurement Toolkit and supporting information document to encourage public bodies to consider this option. NHS England is also running an Open Source Programme (although this is more focused on encouraging the suppliers and developers of clinical software to share and develop code) . 16 This may stimulate further interest, as may technical developments. VMware, for example, has released VMware Workstation; a virtual machine that is capable of running multiple x86-based operating systems simultaneously (meaning, for instance, that Windows and Linux can be used on the same PC). Spend Trust and board expenditure on operating system licenses was £55.8 million in 2015. Of this, £21.5 million was spent by acute trusts, while mental health trusts spent £17.7 million and community trusts £1.2 million. In the devolved nations, Scottish health boards spent £9.7 million; Welsh health boards £3.2 million and Northern Irish health and social care trusts £2.5 million. Operating system spend, by organisation type, 2015 £60 £1.2 £2.5 £50 £3.3 Scottish health boards NI health and social care trusts £9.8 £40 English community trusts Welsh local health boards £30 £17.7 English acute trusts English mental health trusts £20 NI health and social care trusts £10 £21.5 £0 16 - Department of Health. Digital strategy, 2012. https://www.gov.uk/government/uploads/system/uploads/attach- ment_data/file/213222/final-report1.pdf 36

Infrastructure 2015: part one Office software Market share NHS trusts and boards hold 983,398 licenses for office productivity software, suggesting that 94.8% of all computers hold an office license. Microsoft is again the dominant supplier, with 99% of the market. As with operating systems, the big change since 2013 has been in the kind of Microsoft Office in use. In 2013, a quarter of NHS PCs and laptops (26%) were running Microsoft Office 2003 and a fifth (20%) were running Microsoft Office 2007, while a further fifth (22%) were running the most up to date version then available, Microsoft Office 2010. Now, Office 2010 has become the preferred system, running on 73% of NHS machines. MS Office 2010 MS Office 2010 Microsoft Office on desktop PCs, MS Office 2007 Microsoft Office on desktop PCs MS Office 2007 by number of licences, 2013 MS Office 2003 by number of licences, 2015 MS Office 2003 MS Office XP MS Office 2013 Other 1% Other 30% 3% 22% 6% 17% 2% 20% 73% 26% 37

Infrastructure 2015: part one Factors influencing the market The Enterprise-wide Agreement that the NHS signed with Microsoft in 2004 gave trusts access to perpetual licenses for the most up-to-date Office software available. Trusts were keener to follow the upgrade path from Office 2003 to Office 2007 and then Office 2010 than they were to move from XP to Windows 7, since Office 2007 offered some significant improvements on earlier versions of the software; such as the introduction of the ‘ribbon’ to access commonly used features. The EwA probably discouraged trusts from exploring alternative productivity suites; not least because it enabled staff to buy the software at a huge discount, which encouraged them to become familiar with it. Market opportunities Some 55% of the trusts that have already completed the migration to Office 2010 do not plan to make further upgrades. This is not surprising in light of the end of the EwA and NHS funding constraints; it would take a big improvement in the software and its impact on productivity to make it worth trusts’ while to pay for new licences. However, the same funding constraints may now encourage trusts to look at alternatives, including open source options, particularly for staff who only need to perform a few tasks and rarely, if ever, use Office’s full capability. Oxford University Hospitals NHS Trust estimated in its IM&T Strategy to 2017 , that the future cost of Microsoft Office Professional would be 17 about £220 for every new PC. As a result, it decided to standardise on OpenOffice as its default office suite for new machines; only installing Microsoft Office where staff have a real need for it. The trust argued that the financial benefit of installing the open source option outweighed disadvantages, such as training costs and reduced software consistency. 17 - IM&T Strategy 2012 – 2017. Oxford University Hospitals NHS Trust. Version 1.0. http://www.ouh.nhs.uk/about/trust- board/2012/july/documents/TB201264ii-IMT-2017.pdf 38

Infrastructure 2015: part one Office software spend, by organisation type, 2015 £25 £0.5 £0.2 £20 £1.1 NI health and social care trusts £2.1 English community trusts Welsh local health boards £15 £7.1 Scottish health boards English mental health trusts £10 English acute trusts £10.9 £5 NI health and social care trusts £0 Spend The total spend on office software by NHS trusts and boards in 2015 was £20.6 million. Acute trusts account for the biggest slice of this, at £13.5million, while mental health trusts spent £2.5 million and community trusts £1.4 million. Welsh and Scottish health boards spent £1.7 million and £1.1 million respectively; and Northern Irish health and social care trusts just £390,937. 39

Infrastructure 2015: part one Software as a service Market share To date, 27% of NHS trusts and boards (69) are using software as a service. Of these, 90% are located in England, 45% are acute trusts, 24% community trusts and 21% mental health trusts. Factors driving the market The single biggest supplier of software as a service to NHS trusts is AirWatch, a provider of enterprise mobility management services that was acquired by VMware in February 2014. Otherwise, software as a service is primarily used for back office systems, which helps to account for its presence in English trusts which have to operate in an ‘internal market’ that puts a significant emphasis on contracting that is absent from the devolved nations (which either abolished the internal market or, in Northern Ireland, never implemented it). The second biggest supplier of software as a service to the NHS is Capita, whose Integra Financials package is used by trusts for business accounting, and the third is McKesson, another provider of business software that, at the time the research for this report was conducted, also ran the NHS Electronic Staff Record for trusts in England. Similarly, Allocate Software is a provider of workforce management and compliance tools that has recently moved into discharge management and care co-ordination. The NHS also uses software as a service to help manage aspects of its IT. BrightCloud is a provider of application hosting and internet access services, while Flexera is a provider of software asset management systems, and Service Now and Zen Desk are providers of infrastructure management, service desk, and support and ticketing systems. 40

Infrastructure 2015: part one SaaS suppliers, 2015 AirWatch 23% Bytes 27% ServiceNow BrightCloud Vodafone QES 4% Flexera Integra Financials 7% McKesson 4% VMware 3% Microsoft 4% 4% Allocate Software 4% 4% Zendesk 4% Others 4% 4% 4% What the NHS doesn’t seem to be using is software as a service for its patient administration and clinical software; except in some very specific circumstances. QES, for instance, provides software to run screening and early intervention programmes, such as condom distribution. Even though some large providers have SaaS offers - IMS Maxims has had a fully hosted, software as a service version of its Maxims EPR since 2011, while Cerner launched a software as a service version of its Millennium electronic patient record in June 2014 – trusts still prefer to tender and contract for systems that are then hosted by their supplier or in their own data centres (an issue discussed further below). Market opportunities Although the NHS is making limited use of software as a service at the moment, it is clear that an increasing number of trusts are willing to adopt this model for back-end applications, and this is likely to open up the healthcare market to further ‘as a service’ offers. 41

Infrastructure 2015: part one Over the next five years, IT departments are likely to be asked to deliver their share of the £22 billion efficiency savings demanded by the ‘Five Year Forward View’, and software as a service may be one way for them to do this. With more applications being run on a SaaS basis, staffing can be reduced, or staff redeployed to other, more strategic and high-value roles. As this happens, there is likely to be a knock-on effect on data centres and servers, with the requirement for trusts to continue to run ever-larger data centres reducing. This could open the door for more managed data centres and infrastructure as a service. While the NHS is clearly at the start of the process, the days of healthcare organisations running 400 applications may be coming to an end. The government has strongly backed this direction of travel. The Cabinet Office’s Crown Commercial Service has set up the G-Cloud framework to make it easier for public sector organisations to buy cloud services, and its latest iteration, G-Cloud 6, has four lots covering infrastructure as a service, platforms as a service, software as a service, and specialist cloud services . 18 The big shift will come as and when trusts use the G-Cloud or other frameworks to adopt software as a service for their major administrative and clinical systems. Trusts have already made a shift to hosted services in some areas, such as digital imaging, where the sheer size and complexity of the systems involved can make asking expert suppliers to run them an attractive option. In addition, some community and mental health trusts already run hosted patient administration systems. As more trusts follow, it can only be a matter of time before some seriously consider the software as a service option; and (as noted above) suppliers are moving to make it available. The drive for more integration between different health organisations, and between health and social care, triggered by the ‘Five Year Forward View’, which sees this a key way to reduce waste and so improve efficiency in the NHS, is also likely to drive this agenda. Trusts that emerge as the leaders of ‘chains’ of district general hospitals or specialist services are likely to want distributed IT to support their distributed services; while moving to a software or platform as a service model will shift the requirement for in-house teams to sort out the point to point integration involved in health to health and health to social care integration projects onto suppliers and their partners. 42

Infrastructure 2015: part one Attempting to sort out point to point integration, to open up the application programming interfaces of proprietary services to add the functionality required for new ways of working, and to sort out the security and information governance issues involved in doing so, have proved to be a major stumbling blocks to integration projects. Whole new NHS IT structures have been created in pioneer areas to overcome them. Suppliers that can do the job for healthcare communities are likely to find themselves in a large and potentially lucrative new space. Printers Market share In 2015, there were 203,470 printers in use by NHS trusts and boards. This is around a fifth of the total number of PCs and laptops, and 15 printers per every 100 members of staff. Printers per Number of Number of Printer Market size Printers 100 staff, trusts employees volume 2015 2015 2015 English acute foundation trusts 100 513,046 15 78,201 £11,694,393 English acute trusts 54 316,527 13 40,880 £11,521,730 English community trusts 20 64,874 11 7,323 £1,066,354 English mental health foundation trusts 42 163,675 17 28,549 £7,273,378 English mental health trusts 14 41,181 18 7,325 £1,311,138 NI health and social care trusts 5 51,810 17 9,051 £306,295 Scottish health boards 14 129,551 22 28,512 £1,982,872 Welsh health boards 7 68,597 5 3,720 £1,696,558 Total 256 1,349,261 15 203,470 £36,852,717 18 - http://ccs-agreements.cabinetoffice.gov.uk/contracts/rm1557vi 43

Infrastructure 2015: part one The majority of these printers (58%) are in the English acute sector, where 60% of PCs and laptops are also located. In acute trusts, there are 119,081 printers distributed across 154 acute and foundation trusts; suggesting an average of six PCs and laptops per printer. Printers by organisation type, 2015 2% 4% English acute trusts 4% English mental health trusts Scottish health boards NI health and social care trusts 14% English community trusts Welsh health boards 58% 18% Mental health trusts, which account for 18% of the printers in use across the NHS, have 35,783 devices distributed across 56 organisations; suggesting an average of five computers per printer. Scottish health boards have 28,512 printers (14% of the total), suggesting four computers per printer. Spend Total NHS expenditure on printers is £36.9 million, around one third of the total spend on PCs and laptops. Acute trusts spend most in total (£23.2 million) but Welsh local health boards, which spent £1.7 million in total in 2015, have the highest expenditure per printer (£456 per unit). Northern Irish health and social care trusts have the lowest expenditure per printer (£34 per unit) and a total spend of £306,295. 44

Infrastructure 2015: part one Printer spend by organisation type, 2015 £40 NI health and social care trusts £0.3 £35 £1.1 Scottish health boards £1.7 £2.0 English community trusts £30 Welsh local health boards £8.6 £25 English mental health trusts English acute trusts £20 £15 £23.2 £10 NI health and social care trusts £5 £0 Refresh policy Trust and boards printer refresh policies mirror replacement policies for other kinds of hardware, such as PCs and laptops. Just under a third (27%) said they refresh printers on a five year basis, 19% do not have a policy and 18% change their printers only as and when required. 45

Infrastructure 2015: part one Trust printer upgrade policies, 2015 16% Every five years 1% 27% No policy 4% As and when required Every three years Rolling contract 6% Every four years Every seven years 9% Other 19% 18% Printer providers HP currently holds the largest market share (34%). As discussed above, the company won one of the largest infrastructure, hardware and device contracts in the NHS in recent years, when it secured a deal with Cambridge University Hospitals NHS Foundation Trust in April 2013, ahead of its implementation of Epic . 19 Ricoh is another market leader in the printer industry, and has a 12% share of the NHS market, while Canon is in fourth place, with 8%. Zebra in third place, is a more specialist provider of thermal printing solutions, and is used to print wristbands, specimen and pharmacy labels that carry barcodes in the NHS. 19 - HP. HP Helping Cambridge University Hospitals Transform to Digital Hospital. http://www8.hp.com/uk/en/hp-news/ press-release.html?id=1393859 46

Infrastructure 2015: part one Printer suppliers' market share by number of printers, 2015 9% 2% HP 3% Ricoh 3% 34% Zebra Canon Brother 4% Xerox Kyocera 5% Konica Minolta Lexmark 5% Epsom Samsung 6% Other 12% 8% 9% Managed print services Nearly two thirds of all trusts and boards have a managed print service; or in other words use an external provider to manage their printing requirements. However, there is some variation across the UK. While 75% of Northern Irish trusts and 55% of Scottish boards do not use a print managed service, 70% of English acute trusts and 60% of Welsh health boards do. Generally, trusts turn to managed print services for cost reasons; managed print services can streamline printing, cut print volumes, and remove the direct costs of maintenance and peripherals. The financial squeeze on the NHS is therefore likely to increase interest in managed print services. 20 - Kable. Blackpool trust’s print strategy drives cost savings. http://cloud.governmentcomputing.com/news/blackpool- trusts-print-strategy-drives-cost-savings-4274682 47

Infrastructure 2015: part one In May 2014, Blackpool Teaching Hospitals NHS Foundation Trust com- pleted the first stage of an implementation of a Canon managed print services solution, reporting that it has managed to reduce print volume by 15% and to save £27,000 a year . 20 In addition, as more trusts implement electronic patient records and move towards ‘paperless’ working, they will need to gain control of their legacy records through electronic document management, and tightly control ad- hoc printing to avoid key patient information being left outside EPR and EDM systems. Again, this points towards print management solutions becoming the norm. Managed print services providers Danwood and Canon are the most used providers of managed print services, having nearly 50% of the market between them. HP and Xerox are well-known hardware devices suppliers, who also provide print managed services, but their market share for this service is only 3% each. Vision is gaining share; it is a strategic partner of technology giant Samsung. Printer suppliers' market share by number of printers, 2015 10% 3% Danwood Canon 3% Ricoh 3% 24% Konica Minolta Altodigital HP 3% Vision Xerox 6% XMA Other 8% 23% 17% 48

Infrastructure 2015: part one IT resources The NHS tends to run its own data centres and systems, and to employ the staff required to do this. Digital Health Intelligence calculates that almost three quarters (70%) of trusts and boards manages and supports its own IT functions in house, with another 16% reporting that they have both in-house and outsourced IT resource management. IT resources: in-house and outsourced, 2015 16% In-house and outsourced In-house 14% Outsourced 70% 49

Infrastructure 2015: part one Just 37 trusts said they outsourced their IT entirely or partially. Most of these organisations outsourced their IT to Health Informatics Service or what amounts to the modern equivalent, a commissioning support unit. For example, Staffordshire and Shropshire Health Informatics Service manages some or all the IT for trusts in the area covered by the NHS East Staffordshire Clinical Commissioning Group, including Burton Hospitals NHS Foundation Trust, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, and Staffordshire and Stoke on Trent Partnership NHS Trust. The Greater East Midlands Commissioning Support Unit also manages IT for three trusts: Derbyshire Community Health Services NHS Trust, Derbyshire Healthcare NHS Foundation Trust and Lincolnshire Community Health Services NHS Trust. Some large acute trusts also run the IT for local mental and community trusts. For example, 2gether NHS Foundation Trust and Gloucestershire Care Services NHS Trust are supported by Gloucestershire Hospitals NHS Foundation Trust. Top five outsourcing organisations mentioned in Number of trusts research, 2015 covered Staffordshire and Shropshire Health Informatics Service 3 Greater East Midlands Commissioning Support Unit 3 Kent and Medway Health Informatics Service 2 North West Commissioning Support Unit 2 Gloucestershire Hospitals NHS Foundation Trust 2 50