PACS rollout in U.K. encounters financial, logistical, and legal woes

A U.K. government-led effort to wire 150 English hospitals into the digital age was promoted as one of the biggest PACS efforts in the world. But 10 months after announcements of five successful tender offers to vendors for their PACS, two key contracts have yet to be signed. Questions have arisen about whether the installation of these PACS will deliver the kind of cost savings the project promised.

Digital radiology is regarded as a key part of the National Program for IT (NPfIT), an ambitious scheme to bring IT to English hospitals, clinics, and primary-care centers (called GP surgeries). The U.K. government has committed to cutting to 18 weeks the time required from GP referral to treatment. Its ability to meet this pledge would be greatly aided if digital workflow could speed up efficiency in radiology departments. This was, in fact, the rationale for a centralized procurement program to bring PACS to as many U.K. hospitals as possible.

(Wales and Scotland have not been included under the NPfIT's remit. They remain free to negotiate deals with whichever PACS supplier they choose. Officials in Northern Ireland, who are also contemplating a mass PACS rollout, reportedly turned down an invitation to join the NPfIT procurement process.)

Centralized procurement of PACS was to provide U.K. officials as much leverage with vendors as possible. The bigger the deal, the bigger the discount, went the thinking.

To implement this plan, the government divided England into five separate regions, or "clusters." Five designated local service providers (LSPs) then subcontracted PACS deals to appropriate third parties. Following this plan, government officials claimed to have won price reductions of up to 57% on diagnostic workstations, 65% on computed radiography, 71% on disk storage, and 82% on PACS servers.

But the road to these cost savings has been rougher than expected. Hospitals were instructed to purchase PACS through the centralized route or not at all, and two of the five clusters have chosen the latter. Contract negotiations in these two, the North East and Eastern clusters, are on hold owing to a legal dispute, leaving radiologists in limbo.

The problem has been the selection of a PACS supplier. A government announcement in May 2004 that GE Healthcare had won both tenders was premature. Agfa Healthcare has since stepped in as a likely alternative, although no contract has yet been signed.

DI SCAN now has learned that another PACS provider is seeking a review of the NPfIT PACS procurement process in the U.K. High Court. The company lodged its application for review in December 2004. A decision as to whether this judicial review will go ahead should be made by the end of March, according to a High Court official.

The implications of this review for the PACS procurement process are not known. In the meantime, NPfIT officials are expressing optimism that this latest hiccup can be worked out sooner rather than later.

"The NPfIT is aware that an application for judicial review has been made, and we wait to hear whether leave for the judicial review has been granted," said an NPfIT spokesperson. "Precise terms for the delivery of PACS in the North East and Eastern clusters are yet to be finalized between the LSPs and the NPfIT, but we remain hopeful that this can be achieved in the near future."

Impatient radiologists have been advised to get in touch with suppliers for the three clusters that have signed contracts. These are GE Healthcare (Southern), Philips Medical Systems (London), and Kodak and ComMedica (North West and West Midlands).

"In the interim period, trusts with urgent requirements for a PACS can obtain it from other LSPs to ensure they realize its benefits and have a compliant system," the NPfIT spokesperson said.

The attractiveness of this option will likely depend on how long the legal wrangling takes. Some radiologists are now desperate to get on with the process, having decided months ago to go filmless. Others, however, are still struggling to make the figures add up, even with the promised discounts. They remain frustrated that the government is not pushing the project forward.

The early process underlying the project was a harbinger of things to come. Initially, PACS and RIS were both excluded from NPfIT's list of essential and centrally funded "core services." A statement issued in September 2004 reversed this decision for PACS but not for RIS. Then last month government officials promised to fund regional archives centrally and to provide £132 million ($245 million) over three years to assist with capital deployment costs. These concessions, however, have failed to completely allay fears over the proportion of the bill to be footed by hospitals themselves, even for the core PACS technology.

Well aware of its critics, the U.K. government has appointed a go-between to smooth rocky relations between disgruntled radiologists in England and officials responsible for PACS implementation. Dr. Erika Denton, consultant radiologist at Norfolk and Norwich University National Health Service (NHS) Trust, has been charged with working towards a timely nationwide PACS rollout. Denton's own hospital is spared any engagement with the NPfIT procurement, having purchased a PACS of its own choosing under a private finance initiative in 2001.

"The NPfIT has had a bumpy ride so far, but I think this is inevitable given the enormity of the project," Denton said. "I hope that I will be able to act as a conduit between the Department of Health and the hospital trusts, and therefore with clinical radiologists."

The pace will need to pick up dramatically if suppliers are to meet NPfIT targets on PACS installation. Just 25 of the country's 178 acute hospital trusts have a PACS at present. All of them are slated to go digital under the U.K. initiative. Government officials had originally slated the PACS rollout to begin in summer 2004, with 80% of installations completed by the end of 2005. The remaining 20% were to be up and running a year later.

Although this end-point now appears to have crept back at least to March 2007, some progress has been made. PACS implementation activity at 10 early adopter sites - four in the Southern cluster, four in London, and two in the North West and West Midlands cluster - has begun, according to an NPfIT spokesperson. The first activity undertaken is a site survey, which reviews, among other things, network infrastructure, current radiography setup, and general readiness to implement.