Beware of White Elephants

Image created by Rudy Chidiac. © Open Medical 2024. All Rights Reserved

In ancient Thai tradition, white elephants, owing to their rarity, were considered a valuable possession and often gifted to monarchs. But despite their prestige, these elephants were extremely costly to maintain and were more of a burden than an asset. Today, a ‘white elephant’ is a metaphorical term used to describe anything—an item, project, or business concept—that involves excessive cost disproportionate to its utility or value.

The public sector in the UK has seen a fair few white elephants over the years, particularly when it comes to major digital health projects—Horizon and the National Programme for IT (NPfIT) being the most high profile that immediately spring to mind.

NPfIT was the largest public-sector IT project ever taken on in the UK and initially budgeted around £6 billion. Its aim was to modernise NHS technology with integrated electronic patient records, online booking services, and digitised referral and prescription systems. But it didn’t pan out that way.

After ten years of setbacks and complications, the programme was scrapped, leaving taxpayers with an estimated bill of around £10 billion. Much of this investment went to large firms that had no grasp of the markets or ecosystems in which they operated. One just happened to have created and implemented some well-known post office software.

As the NHS struggles with mounting financial pressure and increasing demand, we need to be wary of these white elephants.

Spotting a white elephant shouldn’t be a challenge... Identify a large, top-down centrally mandated project with ambitious objectives that, in theory, sound very promising, but in reality, the implementation reveals a different story, with many such projects falling short due to a poorly aligned vision. This is especially true in the healthcare industry. If the technology's vision does not align with the needs of care providers on the ground, it will lack user engagement and, as a result, fail. This was precisely the case with the NPfIT.

Historically, the NHS has had more success with technologies developed by UK-based small and medium-sized enterprises. These smaller companies are often more agile, innovative, and have a nuanced understanding of the healthcare system, unlike larger corporations’ top-down approaches that often fail to address ground realities. By tailoring their technology to the specific needs and challenges of healthcare organisations, these smaller enterprises provide valuable, effective, and practical solutions.

Failed technological implementations within the NHS can almost always be traced back to a lack of value generation, but when it involves a tech project that will incur significant costs with a difficult removal process once deployed, the implications are considerably greater. So it’s absolutely essential to identify these projects early on, either to prevent them from turning into white elephants or to stop them altogether before it’s too late.

To prevent the occurrence of white elephants, there is a need to enforce stricter evaluations of technology procurement and implementation to make sure they offer clear, demonstrated benefits in the real world, which is especially important for the NHS.

Fortunately, there are indications that this may be happening already.

The Labour government recently made the decision to cancel £1.3 billion in funding for tech and AI projects that were apparently unfunded commitments. Some fear this may hinder the UK's growth and standing in the AI and tech sectors. But on the other hand, it could be a positive sign indicating a shift towards a more sustainable, long-term view, rethinking and refocusing to ensure a position that is best-suited to maximise benefits and avoid potential white elephants.

The NPfIT project shows that no matter how well-intended a project is, it will not succeed without clearly defined, measurable outcomes and an in-depth understanding of the healthcare context they are designed to serve. A balance must be struck between the potential of technologies and the realities of everyday healthcare delivery. With the NHS at a critical juncture facing significant challenges, it is more important than ever to place a greater emphasis on value-driven solutions. Technology projects must be grounded in practicality for daily healthcare provision and offer tangible benefits, making sure they become valuable tools that reduce the workload of NHS staff instead of complicating it.

Addressing these proverbial white elephants in the NHS is critical, and the focus has to be on solutions that deliver value to care providers and, most importantly, to patients.