Infrastructure 2015: part one Data centres Spend NHS trusts and boards spent a total of £62.6 million on data centres in 2015. More than half of this expenditure is accounted for by acute trusts, which spent a total of £37.8 million. Mental health trusts spent a total of £13.3 million. Spend on data centres was the second highest IT infrastructure spend for the NHS in 2015, right after desktop PCs. Data centre spend, by organisation type, 2015 £70 £0.2 £0.7 £60 £3.1 NI health and social care trusts £7.4 £50 English community trusts £13.3 Welsh local health boards £40 Scottish health boards £30 English mental health trusts English acute trusts £20 £37.8 NI health and social care trusts £10 £0 On-site and off-site As noted above, most trusts and boards run their own IT services; and in line with this most NHS data centres are located on-site. Almost three quarters (71%) of trusts and boards report that they have a data centre on-site, with an additional 18% of trusts and boards reporting that they have data centres both on and offsite. A minority of trusts and boards (8%) have decided to run all their data centres off-site. 51
Infrastructure 2015: part one On-site and off-site data centres, 2015 4% On-site data centres Both on-site and off-site Off-site data centres 8% Trust without a data centre 17% 71% Distribution and factors affecting the market Most of the NHS bodies that have data centres on site are English acute trusts (60% of the organisations reporting on-site data centres) or mental health trusts (25%); which is what would be expected from the response to the question about IT resources, which showed that almost all of these organisations run their own IT. Most of the NHS bodies that have data centres onsite and offsite are also English acute trusts (45% of the organisations reporting both onsite and offsite data centres) or mental health trusts (20%). This may be because some respondents included hosted systems within their returns. Some of the systems supplied to the NHS by the National Programme for IT were offered on a hosted basis. For example, the picture archiving and communications (digital imaging) systems supplied in London, and the RiO PAS deployed to mental health and community trusts in the capital, were hosted in the BT data centre. Digital imaging has been undergoing a refresh over the past couple of years as the national contracts have come to an end, and this has involved trusts in repatriating their PACS information from the data centre. Mental health and community trusts in the capital are working through a similar process, ahead of the data centre closing in October 2015. 52
Infrastructure 2015: part one Trusts can, however, opt to have these systems hosted by their supplier, and some have taken this route because of the complexity of the support required. Alternatively, the number of trusts reporting both on and offsite data centres may reflect significant investments by the organisations concerned. Trusts that are moving to new hospitals, or looking to deploy a major electronic patient record from a single supplier, may first invest in new data centres. Trusts looking to pursue ‘best of breed’ IT strategies have also made significant investments in data centres in order to improve uptime, resilience and data recovery; particularly when they have discovered that their existing infrastructure cannot support mobile working ambitions. North Bristol NHS Trust spent £5 million to build its own 10,000 sq ft data centre in 2009. North Bristol is one of the first NHS trusts in UK to commission its own bespoke site to house computer software. The trust said it was cheaper to pay for the new building rather than rent space outside the hospital. It subsequently deployed the Cerner Millennium electronic patient record . 21 Trusts that are looking to host applications and services for other local bodies have also made investments in the infrastructure necessary to do this. South Easter Health and Social Care Trust opened two performance optimised data centres or PODs from HP in January 2014. The significant investment in these data centres is to support an expected investment in IT triggered by Northern Ireland’s IT strategy and to enable the implementation of a virtual desktop from VMWare and a bring your own device policy managed by AirWatch . 22 21 - Bristol Post. Bristol hospital spends £5 million on computer building. http://www.bristolpost.co.uk/Hospital-spends-5-million-building/story-11288368-detail/story.html 22 - http://www.digitalhealth.net/news/29069/ 53
Infrastructure 2015: part one St Helen’s and Knowsley Health Informatics Service offers IT support, managed and web services to local health service organisations. To do this, it has invested in two data centres, on two sites, and in state of the art monitoring and support software to ensure uptime of 99% . 23 Almost all of the NHS bodies that report only having data centres off site are mental health trusts (55% of the NHS organisations reporting offsite data centres only) or community trusts (35%); which is what would be expected from the responses to the question about IT outsourcing. Health organisations in Scotland and Wales tend to have data centres onsite; and all of Northern Ireland’s health and social care trusts report having a data centre onsite. Distribution of off-site and on-site data centres, by organisation type, 2015 100% 90% 80% 70% Welsh health boards 60% Scottish health boards 50% NI health and social care trusts English community trusts 40% English mental health trusts 30% English acute trusts 20% 10% 0% Trusts with Trusts with Trusts with off-site on-site and on-site NI health and social care trusts data centres off-site data centres data centres 23 - http://www.his.sthk.nhs.uk/Pages/Data-Centre-Services.aspx 54
Infrastructure 2015: part one Market opportunities Across the NHS, the pattern is for trusts and health boards to run their own data centres. As with so much relating to healthcare IT, the reasons for this are historical: the patient administration and core clinical systems available to trusts before the National Programme for IT was set up in England had to be run out of local data centres. Although some trusts – and particularly mental health and community trusts - were offered hosted systems in the later stages of the programme, those trusts – and particularly acute trusts - that waited for it to deliver ‘strategic’ electronic patient records have continued to run these systems. This, plus the general lack of investment in IT across the NHS, and its late adoption of mobile working, gave trusts relatively little incentive to make significant investments in their data centres. However, this has changed over the past few years. Trusts that have adopted new, electronic patient records have first tended to make significant investments in the data centres, infrastructure, and devices required to run and access them, while trusts adopting ‘best of breed’ strategies, or the technologies promoted by the tech funds, have been pushed into investing in their data centres in order to run them effectively. Further investments can be expected as the NHS looks to complete the work started by the national programme, while adopting newer technologies with clinical and efficiency benefits, and to prepare for the ‘big data’ and genomics revolutions that are now on the near-horizon (and discussed further below). Further investments can also be expected as the NHS comes under pressure for better IT from its staff and patients. Already, young clinicians will complain publicly if they cannot access apps that promise to make their day-to-day work easier, and run them on the device of their choice. 55
Infrastructure 2015: part one Staff increasingly expect to access at work the kind of banking, shopping and social applications that they use at home. And patients expect to use their own devices while they are in hospital. Trusts have often tried to manage these demands by limiting access to their networks and picking the devices that can be used on them. However, these strategies are looking less and less sustainable. More software and higher expectations from staff and patients must be met by greater investment in infrastructure; including the software and services required to manage identity and security effectively. The big question facing is whether this demand, in combination with other factors, will be enough to break the historic pattern of data centre provision in the NHS and encourage trusts to look at other options, such as outsourcing their management to specialists, or looking at hosted and ‘as a service’ models. As discussed above, there are reasons to think that we are looking at the beginning of the end of the days of healthcare organisations trying to run 400 applications; with knock-on effects for data centres and servers. Other factors that may drive change are those that have affected other industries; data centres require expensive computers, racking and refrigeration – even after the considerable investment that has been made in virtualisation over the past decade. They require sophisticated management software, back-up and expertise that may be in short supply – not least because industry standards have risen to the point where significant periods of downtime or data loss are considered unacceptable. Data centres also require land that, in the NHS, is increasingly expensive to occupy, and which policy is demanding for other uses – from raising funds to building key-worker housing. And they require power and capital investment that is in increasingly short supply. 56
Infrastructure 2015: part one As server infrastructures become old, inefficient and slow, and need replacing, trusts may have to look for ways to shift their costs into revenue. New finan- cial packing is required; and hosted services, cloud computing, and as a service models provide options. Full-blown outsourcing is a long way off, but increasingly trusts will need to decide what can be delivered internally and what externally for a given benefit, and over time this will bring about significant changes in the market. Data centre suppliers Cisco is the largest data centre supplier to NHS trusts and boards, followed by HP, NetApp (a storage provider that works with Cisco under the FlexPod brand) and Dell. 24 Data centre suppliers, 2015 23% 20% HP NetApp Cisco In-house 13% Dell Other 15% 8% 21% 24 - http://www.vohkus.com/netapp-data-centre-solutions/ 57
Infrastructure 2015: part one Servers Market size and spend In 2015, there were 30,767 servers in use by NHS trusts and boards, an in- crease of 23% from 2013. While there has been an increase in the number of servers in use, spending on them has increased dramatically over the past two years; increasing by 115% (from £19.1 million in 2013 to £41.0 million in 2015). 35,000 Market size, servers, £45 Server spend, 2013 and 2015 2013 and 2015 £40 30,000 £35 25,000 £30 20,000 £25 2013 2015 £20 2013 15,000 2015 £15 10,000 £10 5,000 £5 £0 0 Distribution The English acute sector has the largest number of servers (21,740), as would be expected as it is the largest sector covered by this report, and the one with the most dedicated, onsite data centres. Logically, the English acute sector also spent the most on servers in 2015; £26.3 million. 58
Infrastructure 2015: part one Servers per Number of Number of Market size Servers 100 staff, Volume 2015 trusts employees 2015 2015 English community trusts 154 829,573 3 21,740 £26,268,646 English acute trusts 20 64,874 2 1,312 £1,564,653 English mental health foundation 56 198,221 1 2,849 £4,325,603 trusts NI health and social care trusts 5 51,810 1 508 £2,540,009 Scottish health boards 14 129,551 3 3,286 £4,319,375 Welsh health boards 7 68,597 2 1,073 £1,981,105 Total 256 1,342,626 2 30,767 £40,999,391 Investment in servers is being driven by the factors driving investment in NHS infrastructure generally; the need to implement new electronic patient record systems, ‘paperless’ working, and the shift to mobile. In addition, one factor that has encouraged large, tertiary trusts to invest over the past two years is the demand for the increased data storage and signifi- cantly faster analysis tools required to handle the unprecedented volumes of data that are now being generated by digital imaging and electronic patient record systems. Academic health science networks and large university trusts, in particular, have been preparing for new research opportunities for the genomics revolu- tion that is on the near horizon. Such investments are often made across a number of NHS and academic bodies, benefiting suppliers that can also deliver distributed access, while also maintaining high levels of control over security and information governance. 59
Infrastructure 2015: part one In 2014, South London and Maudsley NHS Foundation Trust decided to deploy a more powerful infrastructure because its existing server and storage environment was taking too long to process the volumes of data being generated by the trust, which is now handling large quantities of neuroimaging data and DNA sequencing information. The trust, which is now part of Kings Health Partners Academic Health Sciences Centre, improved its processing speeds by up to 400% with the high capacity computing and storage infrastructure . 25 Server spend, by type of organisation 2015 £45 £40 £1.6 English community trust £2.0 £35 £2.5 Welsh local health boards £4.3 NI health and social care trusts £30 £4.3 Scottish united health boards £25 English mental health trusts £20 English acute trusts £15 £26.3 £10 NI health and social care trusts £5 £0 Server suppliers Dell and HP dominate the NHS server market, with 4,734 and 4,706 respectively; or a 41% market share each. IBM and Cisco are the third and the fourth largest server suppliers to NHS trusts and boards, with 7% and 3% market shares respectively. 25 - OCLS – Case Study: HP Server solution. http://www.ocsl.co.uk/media/185343/OCSL-South-London-Maudsley- Foundation-Case-Study-Web-.pdf 60
Infrastructure 2015: part one Server suppliers, 2015 8% 41% 3% Dell 7% HP IBM Cisco Other 41% Cisco is still fairly new to the server space, having only entered the market with UCS (Unified Computing and Servers) a few years back. However, Cisco has been the fourth largest server supplier to NHS trusts and boards since 2013. Server operating systems Microsoft is the market leader in operating systems for servers in use at NHS trusts and boards. All but 6% of the servers in use in 2015 were running some version of its Windows Server operating system, with half (50%) running Windows Server 2008. The biggest change since 2003 has been in the proportion of trusts using Windows Server 2003, which has dropped markedly, from 50% in 2013 to 29% in 2015. 61
Infrastructure 2015: part one Server operating systems, by Windows Server Server operating systems, by Windows Server number of licences, 2013 2003 number of licences, 2015 2008 5% Windows Server 4% Windows Server 2003 2008 1% Windows Server 3% 2% Windows Server 2012 2012 Other 4% Windows Server 2000 Windows Server 2008 R2 8% VMware Other 50% 50% 44% 29% The use of Windows Server 2003 was encouraged by the Enterprise-wide Agreement between Microsoft and the NHS that has already been discussed above. Trusts were able to obtain licences for Windows Server 2008 under the agreement, but migration was delayed because a lot of NHS applications would not run on the new 64-bit architecture and because of the difficulty in finding staff with the skills to carry out the work. As a result, the major factor driving the shift from Windows Server 2003 to Windows Server 2008 has been Microsoft’s decision to end support for Windows Server 2003 on 14 July 2015. Despite this, 90 organisations, which have 4,700 licenses, are still using the older software to manage their servers and networks. Five trusts are now using VMware (ESXi) as a server operating system, with 383 licenses between them. VMware Server is a virtualisation platform that supports a range of operating systems and hardware; and allows users to run both Windows and Linux on the same PC, without rebooting . 26 62
Infrastructure 2015: part one Other operating systems used by trusts and boards include the open source OS Linux, which is used by ten trusts that have 210 licenses between them; and Unix, which is used by seven trusts and with 158 licenses. Market opportunities Less than 10% of the server licences in the NHS are for the most up to date version of Windows Server, Windows Server 2012. This is likely to be because of the cost of the licenses to cover this software and its associated applications (such as Exchange, SharePoint and Lync) and because of the ongoing issue of getting some NHS applications to work on it. Many trusts are likely to stop at Windows Server 2008 R2. Despite this, other suppliers look likely to find it hard to break Microsoft’s dominance of the server OS market, except in specific cases where the IT industry generally is adopting other solutions, including open source solutions. In a response to the research for this report, Moorfields Eye Hospital NHS Foundation Trust said it had already bout 29 Windows Server 2012 R2 licenses; but an additional 94 licenses for Windows Server 2008 R2. Buckinghamshire Healthcare NHS Trust and Royal Devon and Exeter NHS Foundation Trust also started migrating to the latter reporting 250 licenses and 89 licenses respectively. 26 - VMware Server 2. http://www.vmware.com/files/pdf/server_datasheet.pdf 63
Infrastructure 2015: part one Conclusion The NHS is facing one of its pivotal periods. On the IT front, it needs to complete the work of the National Programme for IT in the NHS. While this successfully delivered a number of national infrastructure programmes, it largely failed to deliver ‘strategic’ administrative and clinical systems to trusts in England. These organisations will now need to find their own route to implementing effective electronic patient records, while simultaneously addressing at least three technology demands that did not exist when NPfIT was set up in 2002. The first is demand for access to administrative and clinical systems on mobile devices that had barely been heard of at the turn of the last century; including laptops (invented in the 1980s, but widely available from the mid 1990s) and tablet computers (popularised by the Apple iPad launched in 2010, and the subject of a companion report on mobile infrastructure). The second is adding in newer technologies with a proven efficiency or safety benefit, such as ‘closed loop e-prescribing’ and blood transfusion, in which every step of the process is scanned and monitored using barcode technology. And the third is handling quantities of data that was unimaginable when the programme was set up. Some of this will be imaging data unleashed by one of the more successful parts of the national programme, the National PACS Programme. More of it will be ‘big data’ and information generated by the genomics revolution that is now on the near horizon. Trusts will need to address these demands while facing up to two new challenges. The first is a financial crisis that may be unprecedented, since the NHS has already lived through five years of ‘Nicholson Challenge’ demands for efficiency savings, and the present government looks unwilling to make substantial increases in funding. 64
Infrastructure 2015: part one The second is the policy responses that are being generated to respond to the crisis. Since NHS England published the ‘Five Year Forward View’ in October 2014, a raft of initiatives have been launched that look set to change the way healthcare is funded, run, and integrated with other services. These include ‘vanguards’ to explore joint planning, funding and delivery models, ‘chains’ to take over struggling smaller hospitals and to deliver specialist services from many sites across a wide area, and ‘integrated’ health and social care. Over the two years since Digital Health Intelligence last reported on infrastructure, some trusts have looked to move ahead on the first set of demands; moving to new build hospitals, implementing their own single supplier electronic patient records, or investing in ‘best of breed’ strategies. Meanwhile, some of those already ahead have been looking to build on their basic administrative and clinical investments and to deploy more advanced technologies, particularly where these can deliver demonstrable efficiency or safety gains. This has triggered expenditure on infrastructure. As detailed in this report, there has been an increase in investment in centres and considerable expenditure on servers to support more complex software, mobile working, and data handling demands. There has also been investment in PCs, laptops and COWs to give staff better access to IT systems; with COWs, in particular, supported by the e-prescribing focus of the two technology funds created by the government t support its paperless ambitions. These drivers for investment in infrastructure and devices are likely to continue; both because there is still so much of the NPfIT agenda to complete, and because there is evidence that trusts increasingly want to be seen as offering leading edge IT to their clinical and research staff. 65
Infrastructure 2015: part one The upshot will be continued opportunities for suppliers. However, some trusts will genuinely struggle with affordability. Therefore will be earlier and more widespread opportunities if the government decides to revive the technology funds or to run IT challenge funds for specific projects. This will make the Chancellor’s announcement of the outcome of the current spending review in November 2015 of interest to trusts and suppliers alike. Over the past two years, the Department of Health’s decision to end the Enterprise-wide Agreement with Microsoft, and Microsoft’s decision to end support for some of the software that it covered, has had a significant impact on health service spending on servers, computers, and the software that run them. With the majority of trusts now migrated away from Windows Server 2003, Windows XP, and Office 2003, the impact of the EwA is likely to reduce substantially; although there may be opportunities for the suppliers of alternatives to Microsoft systems if they can persuade trusts they can do as good a job for significantly less cost. However, broader trends – including the need to complete the work of the National Programme for IT, to adopt newer technologies with a clinical safety or efficiency benefit, and to support mobile working - will continue, and therefore the underlying drivers for investment in infrastructure and devices will continue; generating further opportunities for suppliers. Because affordability will be an issue for some trusts, there is no doubt that additional technology or challenge funding will lead to faster and more even progress. However, neither trusts nor suppliers should take their eyes off the bigger picture. The two newer challenges will have a less predictable impact. A real and continuing squeeze on finance may make some trusts more willing to look at the experience of other industries when it comes to finding cost effective ways of working. 66
Infrastructure 2015: part one In the IT space, this may encourage interest in non-trust based ways of planning for, implementing, and supporting IT; including outsourcing, hosting, cloud delivery and software as a service. Vanguards and chains may have a similar effect. While most acute and mental health trusts continue to run – and invest in – their own data centres, some mental health and community trusts already rely on larger organisations for their IT. It is fairly easy to imagine that the bigger and more successful vanguards may take on the IT of their new sites and, down the line, at least consider outsourcing its hosting and management to specialists so they can concentrate on their core activities. More specialist chains will also need distributed IT to support their distributed services. The potential downside, for suppliers, is that this could reduce the size of the overall market; so they will need to be able to spot the innovators and respond rapidly to their demands. While big trends will drive further investment in infrastructure and devices, the growing NHS financial crisis and the policy response to it may lead to some disruption in how that is delivered. The NHS in England could start to look more like other industry sectors that make use of specialists to run data centres and host specialist IT systems, that turn to outsources to provide technical support, and to software as a service to run applications at a predictable cost. If this happens, suppliers are likely to benefit from the new opportunities created. However, they are also likely to find themselves operating in a market that is growing in size but has fewer customers. Most industries facing the kind of challenges that the NHS faces first consolidate their operations and then look to rationalise them, while introducing technology that can drive productivity. The NHS may just be at the start of this process, which will favour infrastructure and technology providers adept at supporting this direction of travel. 67
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