Category Archives: e-health

BT earns £1.3bn extra from “dismantled” NHS IT scheme

By Tony Collins

The Department of Health paid BT £1.3bn more from the “dismantled” NHS IT contracts than the company first expected.

In 2004 BT expected £2.1bn from its contracts under the NHS IT scheme, the National Programme for IT. In fact BT’s payments totalled  £3.4bn to March 2013, according to information contained in a DH letter to the Public Accounts Committee.  The DH’s letter has gone unpublicised until now.

The size of the payments to BT, in the light of financial pressures elsewhere in the NHS, indicate that Connecting for Health, and its successor the Health and Social Care Information Centre,  regard BT’s data spine, the N3 broadband network,  and Cerner and Rio patient administration systems as indispensable.

The Public Accounts Committee has described the NHS IT scheme, the NPfIT,  as a “failed” programme.

Though important parts of BT’s work on the scheme have been successful, a national care records service in which an individual’s electronic patient record can be accessed across  the NHS, hasn’t materialised.

A cut-down version, the Summary Care Record, exists but the NHS and MPs regarded the creation of a detailed national electronic patient record as the main reason for the National Programme for IT.

Despite the extra money  is delivering far fewer Cerner Millennium systems to London’s acute trusts than originally intended, and none of the GP systems.

Payments to BT

After BT won three NPfIT contracts in 2003, the company said in its annual report of 2004 that the deals would be worth a total of £2.1 billion. The NHS deals were among “some of the largest BT has ever won”, said BT’s  2004 annual report. 

Now the DH’s letter to the Public Accounts Committee shows the amounts paid under NPfIT contracts to March 2013: 

  • N3 broadband network  - £937.7 m [BT]. Original contract value £533m.
  • Spine (including Secondary Uses Service)   £1.083.8m [BT]. Original contract value £620m.
  • Core contracts for local clinical systems in London (London Programme for IT, formerly part of the NPfIT ) –  £865.9m [BT]. Original contract value £996m. BT is delivering to far fewer trusts than it originally envisaged.
  •  Core contracts for the south of England – £586.3m. [BT]. No payments were due to BT for the south of England in the original contracts. BT replaced Fujitsu as the local service provider in the south. The DH spent a total of 737.3m on NPfIT contracts in the south of England to March 2013 but of this £151m had been paid to Fujitsu. The Fujitsu NPfIT local service provider contract is the subject of a protracted legal dispute between the company and the DH.

MP Richard Bacon, a member of the Public Accounts Committee, has criticised the size of some of the payments to BT.

Further payments are due to BT under the NPfIT contracts and it may also receive new payments for work under the Care.data project.

Comment

BT’s stunning financial success from the NHS IT scheme shows the value, from a supplier’s perspective, of getting a foot in the door. For some time it has been a monopoly supplier to the NHS. Its grip on the NHS, the HSCIC and the Department of Health, could be diminished if the HSCIC split up its work and awarded a set of new contracts. That is unlikely to happen. Indeed the signs are that some Whitehall officials would like to tie in the NHS to BT for the foreseeable future.

NHS database: is it a top IT priority?

By Tony Collins

It’s called the NHS database but the new “giant” medical records system is to be run by the Health and Social Care Information Centre, largely for the benefit of researchers.

Though it may help patients in the longer term, say by helping to identify what treatments work and don’t, it is arguably not the NHS’s most immediate IT priority.

I said on BBC R4′s Today programme this morning that a top NHS IT priority is providing secure links to health records so that patients with acute and chronic illnesses can be treated in one part of the NHS one week and another part of the health service the following week – perhaps in a different county – and have their updated records accessible wherever they go.

At present patients with multiple problems can end up being treated in different NHS or non-NHS centres without each organisation knowing what the other is doing.  This is dangerous for patients and gives the impression the NHS is technologically backwards.

Links can be made to existing medical records – there are millions of electronic records already in the NHS – without creating a big central database. The records can reside where they are at the moment, inside and outside the NHS, and be linked to securely by clinicians and nurses, subject to the patient’s specific consent.

Indeed patients should be able to look at their record online and correct any mistakes.

Research database

My comment on BBC R4 Today that a research database is a good idea has brought a mixed response – understandably, because are risks. We need some facts from the Health and Social Care Information Centre on who is going to run the database, and how information will be made genuinely anonymous.

The HSCIC concedes in its information material that some patient information on the database will be potentially identifiable, but it implies this is acceptable if the organisations using the data can be trusted.

Why must information be potentially identifiable? And to what extent can the HSCIC be trusted to run the database? It is, after all, managing contracts under the National Programme for IT, a scheme which Jeremy Hunt called a “huge disaster”.

How much extra will be paid to BT which runs the SUS database under the “dismantled” NPfIT? It is likely that BT’s Spine and SUS-related work will link into the new “NHS database”. Have any new contracts gone to open competitive tender?

Hospital group wins $106m settlement in Cerner dispute

By Tony Collins

 A US health organisation Trinity Medical Centre has won a $106m settlement in  a legal dispute with Cerner, which is one the main suppliers of patient record systems to NHS trusts in London and the south.

Under the NPfIT BT has installed Cerner at trusts that include the Royal Free, London, Barnet and Chase Farm Hospitals NHS Trust, Weston Area Health NHS Trust, Barts Health NHS Trust, North Bristol NHS Trust and more recently at Croydon Health Services NHS Trust.

The Wall St Journal says a clinical patient accounting program Trinity bought from Cerner in 2008 was defective and didn’t deliver the promised benefits, which Cerner disputed. Trinity sought about $240m in damages; Cerner estimated $4m.

The companies agreed to submit the dispute to arbitration which began in October 2013.

Cerner said it “strongly disagrees” with the award and believes the claim was based on unique circumstances. It called the award the only material judgment against Cerner in its 34-year history.

US lawyer Michael Dagley says his firm won a $106m settlement for North Dakota-based Trinity Medical Centre in an arbitration case against Cerner.

The firm says that Trinity alleged in 2012 that patient accounting software and other services purchased from Cerner were defective, producing thousands of billing errors.

“We think it’s tremendously significant because it represents the first major victory that we’re aware of by a health care provider against a software vendor,” Dagley said in a statement.

“Providers are under pressure to automate and vendors are under pressure to offer integrated products. Providers want one vendor for all their IT needs, so the vendors have this incentive to deliver software to the market as quickly as possible, and that can lead to products being introduced that are immature and defective, which in health care, can cause tremendous damage.”

Last year Cerner said it believed the chance of a material loss related to the matter was remote and it had 147 hospitals and 735 clinics using the patient accounting program.

Despite the settlement Cerner’s share price has held up well.

Trinity Medical Centre is a non-profit organisation with about 2,700 employees.

Dare anyone criticise this IT project – with the CEO as leader?

By Tony Collins

Croydon Health Services NHS Trust has had mixed success with its go-live of the Cerner Millennium system.

It is said to be a technical success but last week board members of the Croydon Clinical Commissioning Group expressed concerns about ongoing problems with the system.

Fouzia Harrington, director of quality and governance told the Croydon Advertiser: “The implementation [of Cerner] itself went well in technical terms, but there have been some implications about how it has been used by staff.

“It’s had far more impact in terms of the time it takes to book people in, for example. There have also been implications in terms of lost information about patients.

“There has been a lack of information about hospital activity, which has an impact on finances and, potentially,the quality of services patients are receiving…”

David Hughes, a lay member of the board, was not satisfied with that reassurance.

“You say that no harm has occurred,” he said,  “but while we’ve had no direct incident so far, patient care has definitely suffered.

“You talk about increased waiting times and there’s a risk that harm may occur because of the difficulty in getting in touch with clinicians who actually know what is going on with the patient.

“I’m very concerned from a quality point of view that our main provider has a serious problem with its information systems.”

Hughes called for action. Although the trust may not be aware of an incident yet it may “come out through further investigation that there has been”.

Some waiting times have increased,  the CCG cannot be certain of exact levels of activity at the hospital, and missing information has made it difficult to commission some services.

The concerns were raised at a board meeting on Tuesday.

Dr Tony Brzezicki, chairman of the CCG, said new system would eventually lead to improvements.  “Hospital patients had five sets of notes before. That in itself posed a risk that Cerner will mitigate,” he said.

“However, there have been administrative delays which mean longer waiting times for patients.There are also issues for the service to primary care which is a significant risk. Some of the problems have been resolved though I am concerned at the time scale because they are certainly impacting on my practice.”

Success

John Goulston is the Croydon Health Services NHS Trust CEO. One of his previous jobs was as Programme Director of the London Programme for IT at NHS London. The LPfIT was formerly part of the National Programme for IT. 

As well as CEO, he chairs the trust’s Informatics Programme Board which has taken charge of bringing Cerner Millennium to Croydon’s community health services and the local University Hospital, formerly the Mayday.

Goulston reported to his board that the Cerner go-live - on 30 September and 1 October last year – was a success.

“Our partners Cerner, BT and Ideal have commented that the Trust has undertaken one of the most efficient roll-outs of the system they have worked on, with more users adopting the system more quickly and efficiently than other trusts … the success we have achieved to date is the result of the efforts of every single system user and all staff members,” said Goulston.

Goulston has said the trust deployed the “largest number of clinical applications in a single implementation in the NHS”. 

The Department of Health provided central funding, and the trust paid for implementation “overheads”.  The Health and Social Care Information Centre was the trust’s partner for the go-live.

The Croydon Advertiser asked Croydon Health Servicesa series of questions about Cerner, including its cost to the NHS, but was sent a short statement.

A spokesman told the Advertiser the system would improve patient administration and means that nurses have access to “quality, detailed information” when delivering care.

He added: “During the initial switch over of systems in September while staff were getting used to the system, some patients did need to wait slightly longer to check in for their clinic appointments.

“The trust has maintained and surpassed our 18 week referral to treatment targets from the initial roll out.”

Croydon’s response

Campaign4Change put some questions to the Croydon trust. These are the questions and its responses: .

Is the trust being completely open – taking seriously the duty of candour -  about problems arising from the Cerner Millennium go-live?

“The Trust takes its duty of candour on all issues very seriously; we believe that transparency is essential in running a modern NHS organisation. We are held to account by our board at public meetings, where the public are able to attend and question our senior management team, by our local health overview and scrutiny committee and our commissioners.

“Recent press coverage on CRS Millennium appeared in the local press when the system was discussed in a public meeting of our commissioners.”

As the CEO is leading the Cerner Millennium project, does this make it difficult for trust staff and trust directors to say anything even mildly critical about the implementation?

“Staff opinions on the implementation of CRS Millennium, both positive and negative, are welcomed by the Trust. Staff have given their frank opinions of the system directly to the Chief Executive both in our monthly all staff meetings and at the open staff engagement surgeries held by our Chief Executive and Chairman. All staff opinions are taken seriously and are acted upon appropriately.”

Given the CEO’s enthusiasm for the implementation is there a special onus on the press office to defend the implementation and play down problems? [I note that the Croydon Advertiser implied its questions had not been answered, and that the Trust gave a short statement instead.]

“The communications team respond to and facilitate a large number of external requests, including from the media, in a transparent, timely and appropriate manner. This same approach is followed on questions about CRS Millennium.

“CRS Millennium will bring about many improvements to patient care and Trust efficiency and we are enthusiastic about communicating these; it is unfortunate that recent press coverage did not consider these positive benefits in any depth.”

A comment on the Croydon Advertiser’s website says:

“When I checked in to out-patients I supplied all my personal details; however the post code I gave was declared invalid by the new system. That filled me with confidence. I also gave my contact as a mobile; however they tried to ring me using an old landline number.”

Comment

It’s generally accepted that having a high-level sponsor for an IT project is essential but when the lead is the CEO, does that make it difficult for people to challenge and constructively criticise?

A “good news” culture tends to prevail – as happened on Universal Credit, on the BBC’s Digital Media Initiative, and within the Department of Health on the NPfIT. Nobody dared to speak the whole truth to power. The truth tends to surface only when a new administration takes over or, in the case of Universal Credit, the minister obtained his own independent reports on project progress.

Campaign4Change put it to the Croydon trust that board directors see reports on the Cerner implementation only every two months and much can happen in the intervening period. This it did not deny.

Even if the trust’s directors met daily would they dare to challenge the CEO? And will the full facts  ever emerge? Things could be much better than CCG directors believe  - or much worse.

After nearly every major NPfIT implementation of the Cerner Millennium system in London and beyond (such as North Bristol) the facts were scarce, and reassurances that no patients had come to harm were plentiful. 

Here we go again?

**

Should lessons have been learned from these Cerner go-lives?

Barts and The London

Royal Free Hampstead

Weston Area Health Trust

Milton Keynes Hospital NHS Trust

Worthing and Southlands

Barnet and Chase Farm Hospitals NHS Trust

Nuffield Orthopaedic

North Bristol.

St George’s Healthcare NHS Trust

University Hospitals of Morecambe Bay NHS Foundation Trust

Birmingham Women’s Foundation Trust

NHS Bury

GPs asked to contact hundreds of patients who may have missed treatment after hospital’s cancer referrals blunder  - Pulse

London LMCs alert over Imperial cancer waits mix-up – Pulse.

GPs kept in the dark over hospital cancer blunder – Pulse

 IT system has increased waiting times and led to lost patient data.

Patient records go-live success – or NPfIT failure

When “life and death” NHS IT goes down

By Tony Collins

Almost unnoticed outside the NHS an email was circulated by health officials last weekend about a national “severity 1″ incident involving the Electronic Prescription Service, running on BT’s data Spine .

“The EPS [electronic prescriptions service] database is currently experiencing severe degradation of performance. … BT engineers [are] currently investigating with the database application support team,” said the email.

A severity 1 or 2 incident, which involves a temporary loss of, or disruption to, the Spine or other national NHS system,  is not unusual, according to a succession of emails forwarded to Campaign4Change.

The Department of Health defines a severity 1 incident as a  failure that has the potential to:

— have a significant adverse impact on the provision of the service to a large number of users; or

— have a significant adverse impact on the delivery of patient care to a large number of patients; or

— cause significant financial loss and/or disruption to NHS Connecting for Health [now the Health and Social Care Information Centre], or the NHS; or

— result in any material loss or corruption of health data, or in the provision of incorrect data to an end user.

The Health and Social Care Information Centre, which manages BT’s Spine and other former NPfIT contracts, reports that the spine availability is 99.9% or 100%. But the HSCIC’s emails tell a story of service outage or disruption that is almost routine.

If the spine and other national services  are really available 99.9% of the time, is that good enough for the NHS, especially when ministers and officials are increasingly expecting clinicians and nurses to depend on electronic patient records and electronic prescriptions?  In short, are national NHS IT systems up to the job?

NHS staff access the spine tens of millions of times every month, often to trace patients before accessing their electronic records.  The spine is pivotal to the use of patient records held on Rio and Cerner Millennium systems in London. It is critical to the operation of Choose and Book, the Summary Care Record, Electronic Prescription Service pharmacy systems, GP2GP, iPM/Lorenzo, and the Personal Demographics Service.

According to a Department of Health letter sent to the Public Accounts Committee, payments to BT for the Spine totalled £1.08bn by March 2013.

BT says on its website that its 10-year NHS Spine contract involves developing systems and software to support more than 899,000 registered NHS users. The HSCIC says the Spine is used and supported 24 hours a day, 365 days a day.

“There is a huge amount of industrial-strength robustness, availability, disaster recovery, that you cannot get someplace else,” said a BT executive when he appeared before MPs in May 2011.

Life and death  

Sir David Nicholson spoke of the importance of the spine and other national NHS systems at a hearing of the Public Accounts Committee in 2011. He said they were

“providing services that literally mean life and death to patients today … So the Spine, and all those things, provides really, really important services for our patients…”

When Croydon Health Services NHS Trust went live with a Cerner Millennium patient records system at the end of September a “significant network downtime” – of BT’s N3 network – had an effect on patients.

A trust board paper, dated 25 November 2013 says:

“CRS Millennium (Cerner) Deployment -Network downtime – Week 1.  In particular, the significant network downtime in week 1 (BT N3 problem) led to no electronic access to Pathology and Radiology which resulted in longer waits for patients in the Emergency Department (ED) leading to a large number of breaches. This was a BT N3 problem which has been rectified with BT …”

Below are some of the emails passed to Campaign4Change in the past four months. Written by the Health and Social Care Information, the emails alert NHS users to outages or disruption to GP or national NHS IT systems.

Some HSCIC messages of disruption to service

October 2013

Severity 2
HSCIC
National
CQRS has not received a number of participation status messages.
Also affecting: GPES
USER IMPACT:
CQRS Users are not able to manually submit specific information, this will impact the users’ business process for entry of achievement data.
ACTION BEING TAKEN:
Following a configuration change by the GPES Business Unit a specific code has now been added to the GPET-Q Database. We are currently awaiting confirmation that the addition of the relevant code has been successful. Discussions are taking place regarding the re-submission of status messages. HSCIC conference calls are on-going.

[A severity 2 service failure is a failure [that] has the potential to:

- have a significant adverse impact on the provision of the service to a small or moderate number of service users; or

- have a moderate adverse impact on the delivery of patient care to a significant number of service users; or

- have a significant adverse impact on the delivery of patient care to a small or moderate number of patients; or

- have a moderate adverse impact on the delivery of patient care to a high number of patients; or

- cause a financial loss and/or disruption … which is more than trivial but less severe than the significant financial loss described in the definition of a Severity 1 service failure.]

**

Severity 2
HSCIC
BT Spine
National
Intermittent performance issues on TSPINE.
T-Spine
RESOLUTION:
BT Spine have confirmed that the incident has been resolved and users are able to perform routine business processes without delays.

November 2013

Severity 1
BT Spine
HSCIC
National
Users are unable to log into PDS.
USER IMPACT:
All sites are currently unable to access PDS, this is causing a delay to normal services.
ACTION BEING TAKEN:
BT Spine are working to restore service.

**

Severity 2
BT Spine
HSCIC
National EPS users.
Slow performance on reliable and unreliable messages for EPS.
USER IMPACT:
This is causing delays to routine business processes as some users may be experiencing slow performance with the EPS service.
BT investigating.

**

Severity 2
BT Spine
HSCIC
National
Slow performance on EPS Messaging.
USER IMPACT:
This is causing delays to routine business processes as some users may be experiencing slow performance with the EPS service.
ACTION BEING TAKEN:
BT moved the database to an alternate node following application server restarts. This temporarily restored normal message response times however performance has started to degrade again. BT Investigation continues.

**
Severity 1
Atos
HSCIC
National
Multiple users were unable to log in to the Choose & Book application.
ATOS made some network configuration changes overnight 19th/20th November which restored service. After a period of monitoring throughout the day yesterday the service has remained stable and at expected levels. Further activities and investigation will be carried out by several resolver teams which will be scheduled through change management.

**
Severity 2
BT Spine
HSCIC
National
Slow performance on EPS Messaging.
No further issues of slow response times with EPS messaging have occurred today. BT Spine to continue root cause investigation.

**

Severity 2
Cegedim RX
HSCIC
National
Cegedim RX – Users are experiencing slow performance in EPS 1 and EPS 2.
USER IMPACT:
Users are experiencing slow performance and delays to routine business processes when using EPS 1 and EPS 2.
ACTION BEING TAKEN:
Following a restart of application services, traffic has improved for all new EPS messages. However there is a backlog of EPS messages which may cause delays to routine business processes. Cegedim RX to continue to investigate.

**

December 2012

Severity 1
BT Spine
HSCIC
National
Performance issues have been detected with the transaction messaging system (TMS).
Also affecting: Choose and Book, GP2GP
USER IMPACT:
This may cause delays to routine business processes. This may have an effect on all Spine related systems. This includes PDS, Choose and Book, PSIS, SCR, ACF Services.
ACTION BEING TAKEN:
This has been resolved but BT are currently monitoring performance. Further investigation is required by BT into the root cause.

**

Severity 2
GDIT – CQRS
HSCIC
National
DTS has not processed a CQRS payment file.
CQRS
Also affecting: GPES
USER IMPACT:
This is causing delays to routine business processes.
ACTION BEING TAKEN:
GDIT are currently developing a fix which will be rolled out tomorrow evening, pending successful testing.

January 2014

Severity 1
BT Spine
HSCIC
National
TMS reliable messaging unavailable.
USER IMPACT:
TMS reliable messaging unavailable and users having to implement manual workarounds.
ACTION BEING TAKEN:
Issues experienced due to a planned change overrunning, BT Spine continue to implement the transition activity in order to restore service.

**

Severity 2
BT Spine
HSCIC
National
Users have experienced intermittent issues with the creation and cancellation of smartcards in CMS [Card Management Service for managing smartcards].
CMS
USER IMPACT:
This is intermittently causing delays to routine business processes as some users have been unable to create, cancel, cut or print cards in CMS.
ACTION BEING TAKEN
Users may experience issues with the creation and cancellation of cards in CMS. BT have identified a fix for the issue which is currently undergoing testing prior to deployment into the live environment.

**

Severity 2
BT Spine
HSCIC
National
The maternity browser was unavailable within NN4B.
RESOLUTION:
BT identified a problematic server which was recycled to restore system functionality.

**

Spine scheduled outage for essential maintenance activity.

During critical work to migrate to a new storage solution on Spine an issue was experienced on the Transaction Messaging Service (TMS) in September of this year. The issue resulted in BT failing over the TMS database from its usual site on Live B to Live A to restore service. The failover was completed well within the Service Level Agreement and no detrimental long term impacts to the service were incurred.

On the 15th January 2014 between approximately 22:00-23:30, HSCIC, in conjunction with BT, are planning to relocate the TMS database back to Live B, this is for several critical reasons:

  1. The issues experienced, which prompted the failover, are fully resolved and will not be experienced again as the storage migration work is now complete.
  2. The Spine service is designed to operate with all databases running on Live B so this work supports the optimum configuration for the service.
  3. Most critically the transition for all data on Spine to Spine2 has been designed to operate from a standby site with no live databases on it. Therefore to support the Spine2 transition this work is absolutely essential.

In order to facilitate a safe relocation of the database a 1.5 hour outage is required to TMS. The impact of this to Spine is significant and results in effectively an outage for Spine and its interfaces to connecting systems for that period. The time and date is aimed at the lowest times of utilisation for Spine, to minimise impact to end users, as well as not impacting critical batch processing and Choose & Book slot polls.

 

Date & Time

Change Start Change Finish Services Affected Outage Duration
15/01/2013 22:00 15/01/2013 23:30 Transaction Messaging Service (TMS) 1.5 hours
Service  Impact Description
Choose and Book The Choose and Book service will be available but functionality will be limited until the TMS database has switched over.Users of the web application will experience limited retrievals during the outage window.The system will not be able to create shared-secret for patients who have not been referred via Choose and Book before.Service Providers will be unable to:
  • Perform clinic re-structures and re-arrange appointments for patients for directly bookable services
  • Send DNA messages to Choose and Book.

For directly bookable services the following functionality will be unavailable:

  • Booking appointments
  • Rearranging appointments
  • Creating new patient accounts

Choose & Book systems will need to queue the messages and resend to Spine once the TMS service is enabled.

Due to the timing of the outage slot polls will not be affected.

Summary Care Record application (SCRa) The SCRa application will be available but functionality will be limited until the TMS database has switched over. Simple traces can be completed on PDS data but users will be unable to perform any PSIS updates (e.g. GP summary updates)
DSA The DSA application will be available but functionality will be limited until the TMS database has switched over.Simple traces can be completed on PDS data but users will be unable to perform any PSIS updates (e.g. GP summary updates).
Electronic Prescription Service (EPS)Pharmacy Systems Reliable messaging will be unavailable for the duration of the switchover work as the TMS service will be suspended dual site. All messages received from EPS systems will be rejected and not go into retry.EPS systems will need to queue the messages and resend to Spine once the TMS service is enabled.
EPS Batch The PPA response for any “claim” messages will not be sent to PPA/PPD. However, EPS will send those response(s) again when the retry jobs are re-activated after the switchover exercise is over. Response for any “claim” messages will not be received until after the switchover. Retry jobs will resend the responses once the TMS service is enabled.
Existing Service Providers (ESPs) There will be varying impacts depending on the product, release version and Spine compliant modules of the solution.ESP systems will need to queue the messages and resend to Spine once the TMS service is enabled.
GP2GP GP2GP will be unavailable until the TMS database has switched over.GP2GP systems will need to queue the messages and resend to Spine once the TMS service is enabled.
GP Extraction Service (GPES) GPES functionality will be unavailable until the TMS database has switched over.Messages will be queued on Spine and processed once the TMS service is restored.
GP Systems Functionality for Choose & Book, EPS and GP2GP, SCR will be limited until the TMS database has switched over.For Choose & Book directly bookable services the following functionality will be unavailable:
  • Booking appointments
  • Rearranging appointments
  • Creating new patient accounts

Systems will need to queue the messages and resend to Spine once the TMS service is enabled.

iPM/Lorenzo The real-time connection to Spine will be unavailable during the TMS outage. However both systems can be disconnected from Spine and operate without synchronised PDS data.iPM/Lorenzo will need to queue the messages and resend to Spine once the TMS service is enabled.
Millennium An outage of PDS reliable messaging will impact Millennium users.Users will be unable to:
  • trace patients
  • register new patients on PDS
  • book or reschedule appointments

Millennium will need to queue the messages and resend to Spine once the TMS service is enabled.

NN4B Trusts will need to be aware that during the outage NHS numbers cannot be generated, new-births cannot be registered and blood-spot labels cannot be generated and should plan accordingly.All birth notifications will be queued and processed once the TMS service is enabled.
Personal Demographics Service (PDS) Simple traces can be completed on PDS data.PDS reliable messaging will be unavailable until the TMS database has switched over.
RiO Users will be unable to:
  • trace patients
  • register new patients
  • book or reschedule appointments

The RiO system will need to queue the messages and resend to Spine once the TMS service is enabled.

TMS Event Service (TES) The majority of TES functionality will be unavailable during the outage.Trusts will need to be aware EPS, Death notifications, and Patient Care Provision Notifications (change of pharmacy) will be queued and sent to the receiving systems once the TMS service is restored.Any impacted notifications will be queued and sent to the receiving systems once TMS is restored.
TMS Batch (DBS, CHRIS, ONS) DBS will be unavailable until the TMS database has switched over (DBS processing will be suspended for the duration of the exercise).As the TMS switchover will be scheduled to start at 22:00, CHRIS batch should complete before the outage starts (CHRIS batch runs at 20:00 nightly).ONS processing will start at 18:00 nightly. If it doesn’t complete before 22:00, the messages will be queued and processed once the TMS service is restored.

**

Severity 2
BT Spine
HSCIC
National
Users are unable to grant worklist items within UIM.
USER IMPACT:
This is causing delays to routine business processes as users are unable to complete their worklist items within the UIM application.
ACTION BEING TAKEN:
BT investigating.

**

Severity 1
BT Spine
HSCIC
National
The EPS database is currently experiencing severe degradation of performance.
USER IMPACT:
Delays to routine business processes.
ACTION BEING TAKEN:
BT engineers currently investigating with the database application support team.

Comment

David Nicholson is right. The NHS has become dependent on systems such as the Spine. But can doctors ever trust any aspect of the safety of patients to systems that are not available 24×7 as they need to be in a national health service?

It appears that BT and other suppliers have not been in breach of service level agreements, and the HSCIC has a good relationship with the companies.  But does the HSCIC have too great an interest in not finding fault with its suppliers or the contracts, for finding fault  could draw attention to any defects in a service for which the HSCIC is responsible?

Have national NHS IT suppliers a strong enough commercial or reputational interest  in avoiding  a disruption or loss of service, so long as they keep within their service level agreements? 

If nobody sees anything wrong with the reliability of existing national NHS IT services improvements are unlikely. Diane Vaughan’s book on the culture and organisation of NASA shows that experts in a big organisation can do everything right according to the rules  and procedures – and still have a disastrous outcome.

MP calls for candour after Cerner NPfIT go-live at Croydon

By Tony Collins

Richard Bacon, a long-standing member of the House of Commons’ Public Accounts Committee, has called on Croydon Health Services NHS Trust to be more open about problems it faces after deploying a Cerner Millennium patient records system at the end of September.

The installation was carried out by BT under the London Programme for IT – a branch of the NPfIT.  The Health and Social Care Information Centre, which has taken on BT and CSC contracts under the NPfIT, was the trust’s partner for the Cerner deployment.

Bacon has closely followed the NPfIT and written a chapter on it in his book, “Conundrum: Why every government gets things wrong and what we can do about it” which he co-wrote with Christopher Hope, the Telegraph’s senior political correspondent.

According to fragments of information in Croydon Health Services’ latest board papers, dated 25 November 2013, the trust has faced a series of problems after the NPfIT Cerner go-live.

They included:

-  N3 Network downtime and waiting time breaches.

- Excessive waits for patients in A&E

- Going over budget.

- Significant loss of income.

- A bid to recover Cerner costs.

- A need for HSCIC support for delays. 

-A need for extra investment in Cerner to “stabilise the operational position”

The trust has not published any specific report on the implementation’s problemsNow Bacon says it is “unacceptable for any trust not to disclose the problems it faces – and possibly patients face – after a major IT implementation such as Cerner”.

He adds:

“If these implementations go wrong they can affect the safety of patients.  We know this from some NPfIT deployments at other  trusts. For Croydon to say that board members have been kept informed of the potential risks of the Cerner implementation through the “Corporate Risk and Board Assurance Framework”  is not reassuring.

“This is putting a matter of importance in the small print. Indeed, for officials to brief board members on the potential risks, rather than actual events, is also of concern.

“Patients need to know that Croydon takes a duty of candour seriously. If the Trust cannot be open about its IT-related problems, how can we be sure it will be open about anything else to do with patient safety?”

Patient records go-live “success” – or a new NPfIT failure 

Patient records go-live “success” – or a new NPfIT failure?

By Tony Collins

John Goulston says the go-live of a new patient records system at his trust is a “success”.

He should know. He’s Chief Executive of Croydon Health Services NHS Trust. He’s also chair of the trust’s Informatics Programme Board which has taken charge of bringing Cerner Millennium to Croydon’s community health services and the local University Hospital, formerly the Mayday.

He was formerly Programme Director of the London Programme for IT at NHS London – a branch of the NPfIT.

In a report two weeks ago Goulston said the trust deployed the “largest number of clinical applications in a single implementation in the NHS”. Croydon went live with Cerner Millennium on 30 September and 1 October 2013.

Said Goulston in his report:

“Administrative functions do not engage clinicians; providing them with a suite of clinical functionality has been justified as each weekday approx. 1,000 staff are logged on and using the system. CHS [Croydon Health Services] has in Phase 1 deployed, in addition to patient administration, the largest number of clinical applications in a single implementation in the NHS England.”

BT helped install Millennium at Croydon under the National Programme for IT.  The trust’s spokesman says the Department of Health provided central funding, and the trust paid for implementation “overheads”.  The Health and Social Care Information Centre was the trust’s partner for the go-live.

The Centre is the successor for Connecting for Health. It has taken on CfH’s officials who continue to help run the NPfIT contracts with BT and  CSC.

Goulston said that Cerner and BT have paid tribute to the trust which installed Millennium in A&E, outpatients, secretarial support and cancer services, and elsewhere.

“Our partners Cerner, BT and Ideal have commented that the Trust has undertaken one of the most efficient roll-outs of the system they have worked on, with more users adopting the system more quickly and efficiently than other trusts … the success we have achieved to date is the result of the efforts of every single system user and all staff members,” said Goulston.

Best Cerner implementation yet?

Optimistic remarks about their launch of Cerner Millennium were also made in 2012 by executives at the Royal Berkshire NHS Foundation Trust.  Their optimism proved ill-judged.

Of the Millennium go-live at Royal Berkshire, trust executives said that it “had been considered to be the best implementation of Cerner Millennium yet and that despite staff misgivings, the project was progressing well”.   This positive message should be disseminated, they said.

Months later they told the Reading Chronicle of patient safety issues and a financial crisis arising from the Millennium implementation.

A Royal Berkshire governors Rebecca Corre was quoted as saying: “There is a patient safety issue when staff write down observations and then there is an hour before they can get it onto the computer. If it is an experienced nurse, they may pick up a problem, but others may not.”

Ed Donald, Chief Executive of Royal Berkshire was quoted as saying:

“Unfortunately, implementing the EPR [electronic patient record] system has at times been a difficult process and we acknowledge that we did not fully appreciate the challenges and resources required in a number of areas.”

Are executives and managers at Croydon Health Services NHS Trust  now similarly afflicted with an unjustified optimism about the success of their Cerner go-live?  

Past consequences of NPfIT go-lives hidden?

The Department of Health has claimed benefits for the NPfIT of £3.7bn to March 2012 but there have been trust-wide failures: thousands of patients have had their appointments, care or treatment delayed by difficulties arising from past implementations of patient record systems under the NPfIT.  For thousands of patients waiting time standards have been exceeded or “breached” because of disruption arising from troubled go-lives.

In nearly every case trusts made it difficult for the facts to come out publicly. Vague or unexplained fragments of information about the consequences of the NPfIT implementation appeared  in different board papers over several months. The facts only emerged after a journalistic investigation that required scrutiny of many board papers and follow-up questions to the trust’s press office.

So Campaign4Change investigated Croydon Health’s implementation of Cerner Millennium to see if the Francis report’s call for a “duty of candour” over mistakes and problems in the NHS have made any difference to the traditional fragmentation of facts after NPfIT go-lives of patient record systems.

The Francis report called for “openness, transparency and candour“.  Trusts were told not to hide sub-standard practices under the carpet. The health secretary Jeremy Hunt said it can be “disastrous” when bad news does not emerge quickly and the public are kept in the dark about poor care.

To my questions about the Cerner Millennium implementation Croydon trust’s spokesman always responded promptly and tried to be helpful. But it appears that trust executives have given him limited information about consequences of the go-live, and have preferred to indulge the “good news” NHS culture that Jeremy Hunt warned about.

On being asked what problems the trust has faced since the go-live the spokesman gave various answers that made no mention of the problems.

“All of our staff received training on the system, and we are continuing to offer our teams support as it is embedded.”

What of the problems arising from the implementation, and has the board been fully informed?

“Millennium has featured regularly on the Corporate Risk Register presented to each Part 1 Board meeting.   In addition, implementation has received detailed confidential consideration at Part 2 of Board meetings, (which is why you won’t find it in our public board papers).”

Given Francis’s call for duty of candour,  should the trust be more open about its problems?

“The initial roll out for CRS Millennium was introduced over three days at the Trust, with a phased approach.  We did this to ensure the system was working in each department, before introducing it in another area.

“We are monitoring waiting time performance and records management so we can identify any issues if they emerge. The system is still being introduced in some services and when this is completed we will be able to assess the overall programme,” said the spokesman.

Does Croydon’s unwillingness to give in its statements to me any details of problems indicate that the culture of a lack of transparency in the NHS will be hard to change, no matter how many times Jeremy Hunt talks about the need for candour when things go wrong?

The spokesman:

“I’d like to be clear about the Trust’s approach:

  • The Trust board has been cited on the roll out of CRS Millennium and any potential risks throughout the process.  As I previously noted, the board received an update in September.  The board meeting, which will take place on Monday of next week, will receive a further update from the Chief Executive.  The papers from this meeting will be published on our website and the meeting takes place in public;
  • A meeting chaired by the Chief Operating Officer has reviewed any operational matters arising on a daily basis.  This is an internal meeting for clinicians and managers which has informed the implementation process;
  • Patients and visitors to the hospital have been kept fully appraised of the introduction of the system and were made aware that they may experience some delays to the check-in process while staff became familiar with the new computer system;

“These actions would suggest that the Trust has been transparent in its approach.  You are welcome to review the board papers when they are published.”

Serious problems now emerge

Croydon did indeed publish its board papers on 25 November 2013 – which is to its credit because not all NHS trusts publish timely board papers.

But it’s mostly in the small print of various board papers that details emerge of Millennium-related problems. The shortcomings are mentioned as individual items rather than in a single, detailed Cerner Millennium deployment report.  This leaves one to question whether trust directors have an overview of the seriousness of the difficulties arising from its implementation of a new patient records system.

These are some excerpts from deep inside Croydon’s latest board papers:

Breaches in waiting time standards

- “CRS Millennium (Cerner) Deployment -Network downtime – Week 1.  In particular, the significant network downtime in week 1 (BT N3 problem) led to no electronic access to Pathology and Radiology which resulted in longer waits for patients in the Emergency Department (ED) leading to a large number of breaches. This was a BT N3 problem which has been rectified with BT providing CHS with the required scale of N3 access (>600 concurrent users and >1,600 users on any day – which is the largest network usage of any trust in England).”

- • “Hospital Based Pathways: The deployment of CRS Millennium was a particular challenge in the month across the multiple service areas within the Directorate of A&E, Surgery and Maternity.

• “Cancer & Core Functions: With the implementation of CRS Millennium, the open pathways part of RTT [referral to treatment – patient waiting times) may fail the standard – validation will be completed after the narrative for this report... “

Excessive waits in A&E

- “The main drivers adversely affecting the performance in the month [October 2013) for A&E were the deployment of CRS Millennium and the commencement of winter pressures due to the seasonality change.  A&E  4-Hour Total Time in Department Target: 95.00%. Actual: 91.57%.”

Over budget

“The Trust position as at October is an adverse variance of £4.1m. This is a significant deterioration on the Month 6 position. The movement is mainly due to a significant reduction in income mainly as a result of operating issues caused by the Cerner deployment (£0.9m)...  Actual £14.8 (£14.8)m; Budget £10.7m; Variance £4.1m.”

“Cerner Millennium: Plan YTD [year-to-date] £245,000; Actual YTD  £621,000;

Significant loss in income

“… A new patient administration system was deployed in the Trust on the 30th September and 1st October (Cerner Millennium). The deployment has resulted in significant loss in income in September and October £ 1.1m. Trust performance on Activity Planning Assumptions and Key Performance Indicators is substantially worse than plan …”

Extra costs

“Medical £412k and admin £148k agency levels continue to be high due to cover for vacancies, annual leave, sickness and release of staff for Cerner training. The Trust has also incurred additional costs associated with the Cerner deployment (£600k) including overtime payments to administration staff and training costs.”

Bid to recover Cerner costs?

“… The Trust is currently forecasting a deficit position of £17.8m, which is £3.3m off the plan submitted to the NHS Trust Development Authority. This is a £3m movement from the month 6 forecast and is as a result of operational issues caused by the Cerner deployment. The current projected impact is an additional costs £1.7m and a loss in activity £1.1m . An application is to be made to recover the additional cost/losses relating to the Cerner deployment [of £2.9m] …”

HSCIC support for delays

“Cerner Millennium – Revised implementation date to Sept 2013 (achieved) ,with resultant additional costs including additional PC requirements of £146k, specialist support services £300k, procurement costs £91k, data cleansing costs £200k.

“Health& Social Care Information Centre (HSCIC) has confirmed support for the delayed implementation will be provided, accounting treatment of support to be confirmed with Department of Health.”

More money to stabilise operational position?

“As a result of operational issues caused by the Cerner deployment , Income is significantly reduced in October. The forecast assumes that the Trust will resume normal operating levels from November and that an element of the income lost will be will be recovered in the latter part of the year. A business case is being submitted to the Trust Board for additional investment in Cerner to stabilise the operational position.

“If there are further operational issues due to the Cerner deployment then this will significantly impact on the year end forecast…”

Over-optimism?

Principal risk -reporting output from Cerner is not accurate or timely. Officer in charge: CEO. Before go-live risk scores: June 2013 – 16; July – 16; Aug  – 10; Sept – 10. After go-live risk score (for Oct): 20 [high risk of likelihood and consequences]

Principal risk – operational readiness following the implementation of Cerner. Officer in charge: COO.  Before go-live risk score 15. Post go-live: 20. Risk rating before go-live – Green. After go-live – Red.

Red risks

Corporate Risk Assurance Framework

Nine risks are reported as Red [two of which relate directly to Millennium]:

“… Reporting output from Cerner is not accurate or timely. Data migration was successful. However reliance on external provider as internal knowledge has not yet been fully gained. A data quality dashboard with exception reporting is in place.

“… Operational readiness following the implementation of Cerner CRS Millennium impact conveyed to Trust Development Authority e.g. ED [Emergency Department] reporting and cost overruns

Risk scores

- Failure of CRS millennium to deliver anticipated benefits – 12. Officer in charge: CEO

- Reporting output from Cerner is not accurate or timely – 20. Officer in charge: CEO

- Operational readiness following the implementation of Cerner – 20. Officer in charge: COO

Croydon’s trust’s response to problems

Said John Goulston, Croydon’s CEO, in his latest [November 2013] report to the board of directors:

“The issues being encountered now with CRS Millennium are not due to any lack of integration testing with legacy applications or testing of workflow. They can be attributed to changing from a 25 year old Patient Administration System (Patient Centre) which did not require working in real time, was simple and intuitive to use, easily configurable and flexible to our needs.

“CRS Millennium’s patient administration functions are almost the complete opposite and the language used is new for our staff i.e. conversations, encounters etc. For our staff it has been a big ask for them to step into and up to such a complex application.”

He added: “The benefits of the new system are that each patient will have a single accurate electronic record that can be viewed and kept up-to-date by hospital and community clinical staff. This will eventually mean less time searching for patient notes, missing documentation and duplicating patient information…

“As with any massive change, there are still some challenges to tackle in making the system work effectively for every single user, in a diverse and complex organisation.

“However the success we have achieved to date is the result of the efforts of every single system user and all staff members. I would like to thank all our staff for their hard work in getting the Trust to this important stage.”

The trust spokesman gave me this statement on the problems:

“The Trust board has been given regular reports on the roll out of CRS Millennium and any potential risks throughout the process, not least through its regular reviews of the Corporate Risk and Board Assurance Frameworks.  As I previously noted, the board received a specific update in September.

“As you already know, November’s board meeting received a further update from the Chief Executive.  The papers from this meeting were published and the meeting takes place in public;  Those attending are invited to put forward questions.

“A meeting chaired by the Chief Operating Officer continues to review operational matters.  This is an internal meeting for clinicians and managers which has informed the implementation process;

“Patients and visitors to the hospital have been kept fully appraised of the introduction of the system and were made aware that they may experience some delays to the check-in process while staff became familiar with the new computer system;

“As you highlight from the board report, Cerner & BT noted that ‘the Trust has undertaken one of the most efficient roll-outs of the system they have worked on’   The papers also note some operational challenges as the system was rolled out.  These have been addressed as part of the daily meetings I reference above – these are mainly concerned with users familiarising themselves with the system and have been addressed through the support and training staff received.

“In terms of the costs, the introduction of CRS Millennium has been supported by central funding from the Department of Health with the Trust paying the implementation overheads.   These costs are a matter of public record and the Trust publishes annual Accounts as part of its Annual Report.”

Comment

When you go into hospital it’s reassuring to know the directors will be well informed and open about problems that could affect you.

The approach of Croydon Health Services NHS Trust to openness about its problems is not reassuring. It is no better or worse than other trusts that have implemented Cerner’s Millennium. In fact the timely publication of its board papers means it is more open than some.

But it should not require a time-consuming journalistic investigation to establish the consequences for patients of an NPfIT go-live. It has required just such an investigation after the go-live of Millennium at Croydon.

Board directors will not have the time to dig for, and piece together, information about internal problems that could delay patient appointments, treatment and care. They need the unpalatable facts in one place. Croydon Health Services has failed to make it easy for patients or board directors to see what has gone wrong.

NPfIT deployments at other trusts have led, cumulatively, to thousands of patients having appointments that were disrupted, or who had to wait longer to be seen than necessary, or whose records were not available, or who were seen with another patient’s records.

In shying away from telling the whole truth trusts take their cue from the top: the Department of Health has always made it hard to establish facts about anything to do with the NPfIT.  Said the Public Accounts Committee in its report The National Programme for IT in the NHS: an update on the delivery of detailed care records systems in July 2011:

 “It is unacceptable that the Department [of Health] has neglected its duty to provide timely and reliable information to make possible Parliament’s scrutiny of this project.

“Basic information provided by the Department to the National Audit Office was late, inconsistent and contradictory.”

Unanswered questions

Croydon has questions to answer, such as how many breaches of waiting time standards it has had, and may still be having, due to problems arising from the go-live. Other unanswered questions:

- What does a “a large number of breaches” in the Emergency Department mean? Have each the patients affected been told?

- Why are the risks related to the implementation much higher after go-live than before, given that the trust has had years to prepare for the go-live, and the many lessons it could have learned from other trusts?

- Exactly what problems are still affecting patients?

In a post-Francis NHS, Jeremy Hunt has demanded openness about mistakes and problems. There is an agreed need for change – but how can Hunt change an NHS culture – indeed a public sector culture – in which senior executives, in troubled IT implementations, will always emphasise the good news over the bad, perhaps hoping the bad will always remain hidden?

Trust spends £16.6m on consultants for Cerner EPR

By Tony Collins

Reading-based Royal Berkshire NHS Foundation Trust says in an FOI response that its spending on “computer consultants since the inception of the EPR system is £16.6m”.

The Trust’s total spend on the Cerner Millennium system was said to have been £30m by October 2012.

NHS IT suppliers have told me that the typical cost of a Trust-wide EPR [electronic patient record] system, including support for five years, is about £6m-£8m, which suggests that the Royal Berkshire has spent £22m more than necessary on new patient record IT.

Jonathan Isaby, Taxpayers’ Alliance political director, said: “This is an astonishing amount of taxpayers’ money to have squandered on a system which is evidently failing to deliver results.

“Every pound lost to this project is a pound less available for frontline medical care. Those who were responsible for the failure must be held to account for their actions as this kind of waste cannot go unchecked.”

 The £16.6m consultancy figure was uncovered this week through a Freedom of Information request made by The Reading Chronicle. It had asked for the spend on consultants working on the Cerner Millennium EPR [which went live later than expected in June 2012].

The Trust replied: “Further to your request for information the costs spent on computer consultants since the inception of the EPR system is £16.6m.”

The Chronicle says that the system is “meant to retrieve patient details in seconds, linking them to the availability of surgeons, beds or therapies, but has forced staff to spend up to 15 minutes navigating through multiple screens to book one routine appointment, leading to backlogs on wards and outpatient clinics”.

Royal Berkshire’s chief executive Edward Donald had said the Cerner Millennium go live was successful.  A trust board paper said:

 “The Chief Executive emphasised that, despite these challenges, the ‘go-live’ at the Trust had been more successful than in other Cerner Millennium sites.”

A similar, stronger message had appeared was in a separate board paper which was released under FOI.  Royal Berkshire’s EPR [electronic patient record] Executive Governance Committee minutes said:

“… the Committee noted that the Trust’s launch had been considered to be the best implementation of Cerner Millennium yet and that despite staff misgivings, the project was progressing well. This positive message should also be disseminated…”

Comment

Royal Berkshire went outside the NPfIT. But its costs are even higher than the breathtakingly high costs to the taxpayer of NPfIT Cerner and Lorenzo implementations.

As senior officials at the Department of Health have been so careless with public funds over NHS IT – and have spent millions on the same sets of consultants – they are in no position to admonish Royal Berkshire.

So who can criticise Royal Berkshire and should its chief executive be held accountable?

When it’s official policy to spend tens of millions on EPRs that may or may not make things better for hospitals and patients – and could make things much worse – how can accountability play any part in the purchase of the systems and consultants?

The enormously costly Cerner and Lorenzo EPR implementations go on – in an NHS IT world that is largely without credible supervision, control, accountability or regulation.

Cash squandered on IT help

Trust loses £18m on IT system

The best implementation of Cerner Millennium yet?

Firecontrol disaster and NPfIT – two of a kind?

By Tony Collins

Today’s report of the Public Account Committee on the Firecontrol project could, in many ways, be a report on the consequences of the failure of the National Programme for IT in the NHS in a few years time.

The Firecontrol project was built along similar lines to the NPfIT but on a smaller scale.

With Firecontrol, Whitehall officials wanted to persuade England’s semi-autonomous 46 local fire authorities to take a centrally-bought  IT system while simplifying and unifying their local working practices to adapt to the new technology.

NPfIT followed the same principle on a bigger scale: Whitehall officials wanted to persuade thousands of semi-autonomous NHS organisations to adopt centrally-bought technologies. But persuasion didn’t work, in either the fire services or the NHS.

More similarities

The Department for Communities and Local Government told
the PAC that the Firecontrol control was “over-specified” – that it was unnecessary to have back-up to an incident from a fire authority from the other side of the country.

Many in the NHS said that NPfIT was over-specified. The gold-plated trimmings, and elaborate attempts at standardisation,  made the patient record systems unnecessarily complicated and costly – and too difficult to deliver in practice.

As with the NPfIT, the Firecontrol system was delayed and local staff  had little or no confidence it would ever work, just as the NHS had little or no faith that NPfIT systems would ever work.

Both projects failed. Firecontrol wasted at least £482m. The Department of Communities and Local Government cancelled it in 2010. The Department of Health announced in 2011 that the NPfIT was being dismantled but the contracts with CSC and BT could not be cancelled and the programme is dragging on.

Now the NHS is buying its own local systems that may or may not be interoperable. [Particularly for the long-term sick, especially those who have to go to different specialist centres, it's important that full and up-to-date medical records go wherever the patients are treated and don't at the moment, which increases the risks of mistakes.]

Today’s Firecontrol report expresses concern about a new – local – approach to fire services IT. Will the local fire authorities now end up with a multitude of risky local systems, some of which don’t work properly, and are all incompatible, in other words don’t talk to each other?

This may be exactly the concern of a post-2015 government about NHS IT. With the NPfIT slowly dying NHS trusts are buying their own systems. The coalition wants them to interoperate, but will they?  

Could a post-2015 government introduce a new (and probably disastrous) national NHS IT project – son of NPfIT – and justify it by drawing attention to how very different it is to the original NPfIT eg that this time the programme has the buy-in of clinicians?

The warning signs are there, in the PAC’s report on Firecontrol. The report says there are delays on some local IT projects being implemented in fire authorities, and the systems may not be interoperable. The PAC has 

” serious concerns that there are insufficient skills across all fire authorities to ensure that 22 separate local projects can be procured and delivered efficiently in so far as they involve new IT systems”.

National to local – but one extreme to the other?

The PAC report continues

“There are risks to value for money from multiple local projects. Each of the 22 local projects is now procuring the services and systems they need separately.

“Local teams need to have the right skills to get good deals from suppliers and to monitor contracts effectively. We were sceptical that all the teams had the appropriate procurement and IT skills to secure good value for money.

“National support and coordination can help ensure systems are compatible and fire and rescue authorities learn from each other, but the Department has largely devolved these roles to the individual fire and rescue authorities.

“There is a risk that the Department has swung from an overly prescriptive national approach to one that provides insufficient national oversight and coordination and fails to meet national needs or achieve economies of scale. 

Comment

PAC reports are meant to be critical but perhaps the report on Firecontrol could have been a little more positive about the new local approach that has the overwhelming support of the individual fire and rescue authorities.  

Indeed the PAC quotes fire service officials as saying that the local approach is “producing more capability than was expected from the original FiReControl project”. And at a fraction of the cost of Firecontrol.

But the PAC’s Firecontrol Update Report expresses concern that

- projected savings from the local approach are now less than originally predicted

- seven of the 22 projects are running late and two of these projects have slipped by 12 months

- “We have repeatedly seen failures in project management and are concerned that the skills needed for IT procurement may not be present within the individual fire and rescue authorities, some of which have small management teams,” says the PAC.

On the other hand …

The shortfall in projected savings is small – £124m against £126m and all the local programmes are expected to be delivered by March 2015, only three months later than originally planned.

And, as the PAC says, the Department for Communities and Local Government has told MPs that a central peer review team is in place to help share good practice – mainly made up of members of fire and rescue authorities themselves.

In addition, part of the £82m of grant funding to local fire services has been used by some authorities to buy in procurement expertise.

Whether it is absolutely necessary – and worth the expense – for IT in fire services to link up is open to question, perhaps only necessary in a national emergency.

In the NHS it is absolutely necessary for the medical records of the chronically sick to link up – but that does not justify a son-of-NPfIT programme. Linking can be done cheaply by using existing records and having, say, regional servers pull together records from individual hospitals and other sites.

Perhaps the key lesson from the Firecontrol and the NPfIT projects is that large private companies can force their staff to use unified IT systems whereas Whitehall cannot force semi-autonomous public sector organisations to use whatever IT is bought centrally.

It’s right that the fire services are buying local IT and it’s right that the NHS is now too. If the will is there to do it cheaply, linking up the IT in the NHS can be done without huge central administrative edifices.

Lessons from FireControl (and NPfIT?) 

The National Audit Office identifies these main lessons from the failure of Firecontrol:

- Imposing a single national approach on locally accountable fire and rescue authorities that were reluctant to change how they operated

-  Launching the programme too quickly without applying basic project approval checks and balances

- Over optimism on the deliverability of the IT solution.

- Issues with project management including consultants who made up half of the management team and were not effectively managed

MP Margaret Hodge, chair of the Public Accounts Committee, today sums up the state of Firecontrol

“The original FiReControl project was one of the worst cases of project failure we have seen and wasted at least £482 million of taxpayers’ money.

“Three years after the project was cancelled, the DCLG still hasn’t decided what it is going to do with many of the specially designed, high-specification facilities and buildings which had been built. Four of the nine regional control centres are still empty and look likely to remain so.

“The Department has now provided fire and rescue authorities with an additional £82 million to implement a new approach based on 22 separate and locally-led projects.

“The new programme has already slipped by three months and projected savings are now less than originally predicted. Seven of the 22 projects are reportedly running late and two have been delayed by 12 months. We are therefore sceptical that projected savings, benefits and timescales will be achieved.

“Relying on multiple local projects risks value for money. We are not confident that local teams have the right IT and procurement skills to get good deals from suppliers and to monitor contracts effectively.

“There is a risk that the DCLG has swung from an overly prescriptive national approach to one that does not provide enough national oversight and coordination and fails to meet national needs or achieve economies of scale.

 “We want the Department to explain to us how individual fire and rescue authorities with varied degrees of local engagement and collaboration can provide the needed level of interoperability and resilience.

“Devolving decision-making and delivery to local bodies does not remove the duty on the Department to account for value for money. It needs to ensure that national objectives, such as the collaboration needed between fire authorities to deal with national disasters and challenges, are achieved.”

Why weren’t NPfIT projects cancelled?

 NPfIT contracts included commitments that the Department of Health and the NHS allegedly did not keep, which weakened their legal position; and some DH officials did not really want to cancel the NPfIT contracts (indeed senior officials at NHS England seem to be trying to keep NPfIT projects alive through the Health and Social Care Information Centre which is responsible for the local service provider contracts with BT and CSC).

PAC report on Firecontrol

What Firecontrol and the NPfIT have in common (2011)

How to cost-justify the NPfIT disaster – forecast benefits a decade away

By Tony Collins

To Jeremy Hunt, the Health Secretary, the NPfIT was a failure. In an interview with the FT, reported on 2 June 2013, Hunt said of the NPfIT

“It was a huge disaster . . . It was a project that was so huge in its conception but it got more and more specified and over-specified and in the end became impossible to deliver … But we musn’t let that blind us to the opportunities of technology and I think one of my jobs as health secretary is to say, look, we must learn from that and move on but we must not be scared of technology as a result.”

Now Hunt has a different approach.  “I’m not signing any big contracts from behind [my] desk; I am encouraging hospitals and clinical commissioning groups and GP practices to make their own investments in technology at the grassroots level.”

Hunt’s indictment of the NPfIT has never been accepted by some senior officials at the DH, particularly the outgoing chief executive of the NHS Sir David Nicholson. Indeed the DH is now making strenuous attempts to cost justify the NPfIT, in part by forecasting benefits for aspects of the programme to 2024.

The DH has not published its statement which attempts to cost justify the NPfIT. But the National Audit Office yesterday published its analysis of the unpublished DH statement. The NAO’s analysis “Review of the final benefits statement for programmes previously managed under the National Programme for IT in the NHS” is written for the Public Accounts Committee which meets next week to question officials on the NPfIT. 

A 22 year programme?

When Tony Blair gave the NPfIT a provisional go-ahead at a meeting in Downing Street in 2002, the programme was due to last less than three years. It was due to finish by the time of the general election of 2005. Now the NPfIT  turns out to be a programme lasting up to 22 years.

Yesterday’s NAO report says the end-of-life of the North, Midlands and East of England part of the NPfIT is 2024. Says the NAO

“There is, however, very considerable uncertainty around whether the forecast benefits will be realised, not least because the end-of-life dates for the various systems extend many years into the future, to 2024 in the case of the North, Midlands and East Programme for IT.”

The DH puts the benefits of the NPfIT at £3.7bn to March 2012 – against costs of £7.3bn to March 2012.

Never mind: the DH has estimated the forecast benefits to the end-of-life of the systems at £10.7bn. This is against forecast costs of £9.8bn to the end-of-life of the systems.

The forecast end-of-life dates are between 2016 and 2024. The estimated costs of the NPfIT do not include any settlement with Fujitsu over its £700m claim against NHS Connecting for Health. The forecast costs (and potential benefits) also exclude the patient administration system Lorenzo because of uncertainties over the CSC contract.

The NAO’s auditors raise their eyebrows at forecasting of benefits so far into the future. Says the NAO report

“It is clear there is very considerable uncertainty around the benefits figures reported in the benefits statement. This arises largely because most of the benefits relate to future periods and have not yet been realised. Overall £7bn (65 per cent) of the total estimated benefits are forecast to arise after March 2012, and the proportion varies considerably across the individual programmes depending on their maturity.

“For three programmes, nearly all (98 per cent) of the total estimated benefits were still to be realised at March 2012, and for a fourth programme 86 per cent of benefits remained to be realised.

There are considerable potential risks to the realisation of future benefits, for example systems may not be deployed as planned, meaning that benefits may be realised later than expected or may not be realised at all…”

NPfIT is not dead

The report also reveals that the DH considers the NPfIT to be far from dead. Says the NAO

“From April 2013, the Department [of Health] appointed a full-time senior responsible owner accountable for the delivery of the [the NPfIT] local service provider contracts for care records systems in London, the South and the North, Midlands and East, and for planning and managing the major change programme that will result from these contracts ending.

“The senior responsible owner is supported by a local service provider programme director in the Health and Social Care Information Centre.

“In addition, from April 2013, chief executives of NHS trusts and NHS foundation trusts became responsible for the realisation and reporting of benefits on the ground. They will also be responsible for developing local business cases for the procurement of replacement systems ready for when the local service provider contracts end.”

The NAO has allowed the DH to include as a benefit of the NPfIT parts of the programme that were not included in the original programme such as PACS x-ray systems.

Officials have also assumed as a benefit quicker diagnosis from the Summary Care Record and text reminders using NHSmail which the DH says reduces the number of people who did not attend their appointment by between 30 and 50 per cent.

Comment

One of the most remarkable things about the NPfIT is the way benefits have always been – and still are – referred to in the future tense. Since the NPfIT was announced in 2002, numerous ministerial statements, DH press releases and conference announcements have all referred to what will happen with the NPfIT.

Back in June 2002, the document that launched the NPfIT, Delivering 21st Century IT for the NHS, said:

“We will quickly develop the infrastructure …”

“In 2002/03 we will seek to accelerate the pace of development …

“Phase 1 – April 2003 to December 2005 …Full National Health Record Service implemented, and accessible nationally for out of hours reference.”

In terms of the language used little has changed. Yesterday’s NAO report is evidence that the DH is still saying that the bulk of the benefits will come in future.

Next week (12 June) NHS chief Sir David Nicholson is due to appear before the Public Accounts Committee to answer questions on the NPfIT. One thing is not in doubt: he will not concede that the programme has been a failure.

Neither will he concede that a fraction of the £7.3bn spent on the programme up to March 2012 would have been needed to join up existing health records for the untold benefit of patients, especially those with complex and long-term conditions.

Isn’t it time MPs called the DH to account for living in cloud cuckoo land? Perhaps those at the DH who are still predicting the benefits of the NPfIT into the distant future should be named.

They might just as well have predicted, with no less credibility, that in 2022 the bulk of the NPfIT’s benefits would be delivered by the Flower Fairies.

It is a nonsense that the DH is permitted to waste time on this latest cost justification of the NPfIT. Indeed it is a continued waste of money for chief executives of NHS trusts and NHS foundation trusts to have been made responsible, as of April 2013, for reporting the benefits of the NPfIT.

Jeremy Hunt sums up the NPfIT when he says it has been a huge disaster. It is the UK’s biggest-ever IT disaster. Why does officialdom not accept this?

Instead of wasting more money on delving into the haystack for benefits of the NPfIT, it would be more sensible to allocate money and people to spreading the word within Whitehall and to the wider public sector on the losses of the NPfIT and the lessons that must be learnt to discourage any future administrations from embarking on a multi-billion pound folly.