Tag Archives: npfit

IDS not quite as bullish on Universal Credit programme?

By Tony Collins

Iain Duncan Smith told the House of Commons in January 2013:

“Universal Credit is on track and on budget. The systems are not new or complex. After all, more than 60% of the total developed system is based on reusing existing IT. New developments will use tried and tested technology.

“The key difference between how this Government are doing things and how they were done before is that we have adopted commercial “agile” design principles to build the IT service for universal credit in four stages, each four months long.”

No longer does IDS say the Universal Credit programme is on time or on budget. Indeed in the House of Commons yesterday he was asked by Labour if the Treasury has approved the full business case for Universal Credit. His replies to MPs were not quite as bullish as they sometimes have been.

He spoke about the programme almost entirely in the future tense, and when he mentioned the present state of the programme he quoted someone else –  John Manzoni, the chief executive of the Cabinet Office’s Major Projects Authority.

Labour’s Nicholas Brown asked IDS when he expects the business case for Universal Credit to be fully signed off.

IDS: “I announced in December that Her Majesty’s Treasury has approved funding for the universal credit programme in 2013-14 and 2014-15. The final stage in Treasury approvals is sign-off of the full business case, which covers the full lifetime of the programme. We expect to agree that very shortly.”

Brown: The answer to a similar question two months ago was “very shortly”, but it is taking rather longer than the Secretary of State intended. What are the major outstanding issues between his Department and the Treasury, and where does universal credit now stand in the Cabinet Office’s traffic light system?

IDS: “… the reality is that we have agreed all the spending that is relevant to the plan that we set out at the end of last year. The final point relates to the full lifetime of that programme, which will take it all the way through, probably beyond all the years that anybody present will be in government. [MPs: 'Certainly you!'] …  That is now being agreed and the reality is that it has to be done very carefully. I genuinely believe, from my discussions, that it will be signed off very shortly. The result will be that the programme will be seen for what it is: a programme that will deliver hugely to those who have the toughest lives and need the most support and help.”

Labour’s Andrew Gwynne asked when the government is going to get a grip on a “chaotic shambles”.

IDS: “It is always nice to live in the past, but the reality is that if the hon. Gentleman waits he will see that this programme is running well and will be delivering, that this programme of universal credit will benefit everybody who needs the support they most need, and all the nonsense he is talking about will all go away.

Chris Bryant, Labour, said that IDS keeps telling MPs that the UC business case will be approved very shortly.  “What has gone wrong?” he asked IDS.

IDS: “There are no sticking points, but these matters need to be agreed carefully. This test-first-and-then-implement process is the way all future programmes will be implemented.

“I just want to quote Mr Manzoni, the new chief executive of the Major Projects Authority, who made it clear to the Public Accounts Committee in June that universal credit is stable and on track with the reset plan.”

Comment

The National Audit Office is re-investigating the UC programme and is expected to publish its second “progress” report on the state of the programme by December.

If IDS says anything unjustifiably positive about the programme now, MPs and the media will compare his comments today with what the NAO says in its new report. Is that why he refers to the programme only in the future tense? And who can say with certainty what will or will not happen in the future?

It may be worth mentioning that ministers and officials, some years into the NPfIT, referred to the state of the programme almost entirely in the future tense.

Has Fujitsu won £700m NHS legal dispute?

By Tony Collins

The Telegraph reports unconfirmed rumours that Fujitsu has thrown a party at the Savoy to celebrate the successful end of its long-running dispute with the NHS over a failed £896m NPfIT contract.

Government officials are being coy about the settlement which implies that Fujitsu has indeed won its legal dispute with the Department of Health, at a potential cost to taxpayers of hundreds of millions of pounds.

Fujitsu sued the DH for £700m after it was ejected from its NPfIT contract to deliver the Cerner Millennium system to NHS trusts in the south of England.

At one point a former ambassador to Japan was said to have been involved in trying to broker an out-of-court settlement with Fujitsu at UK and global level.

But the final cost of the settlement is much higher than any figure agreed, for the Department of Health paid tens, possibly hundreds of millions of pounds, more than market prices for BT to take over from Fujitsu support for NHS trusts in the south of England. The DH paid BT £546m to take over from Fujitsu which triggered a minor Parliamentary inquiry.

A case that couldn’t go to court?

The FT reported in 2011 that Fujitsu and the Department of Health had been unable to resolve their dispute in arbitration and a court case was “almost inevitable”.

But the FT article did not take account of the fact that major government departments do not take large IT suppliers to an open courtroom. Though there have been many legal disputes between IT suppliers and Whitehall they have only once reached an open courtroom [HP versus National Air Traffic Services] – and the case collapsed hours before a senior civil servant was due to take the witness stand.

Nightmare for taxpayers

Now the Telegraph says:

“Unconfirmed reports circulating in the industry suggest that a long-running dispute over the Japan-based Fujitsu’s claim against the NHS for the cancellation of an £896 million contract has finally been settled – in favour of Fujitsu.”

It adds:

“Both Fujitsu and the Cabinet Office, which took over negotiations on the contract from the Department of Health, are refusing to comment. The case went to arbitration after the two sides failed to reach agreement on Fujitsu’s claim for £700 million compensation. Such a pay-out would be the biggest in the 60-year history of the NHS – and a nightmare for taxpayers.”

The government’s legal costs alone were £31.45m by the end of 2012 in the Fujitsu case.

Francis Maude, Cabinet Office minister, is likely to be aware that his officials will face Parliamentary criticisms for keeping quiet about the settlement. The Cabinet Office is supposed to be the home of open government.

Earlier this week the National Audit Office reported that Capgemini and Fujitsu are due to collect a combined profit of about £1.2bn from the “Aspire” outsourcing contract with HM Revenue and Customs.

Richard Bacon, a Conservative member of the Public Accounts Committee is quoted in the Telegraph as saying the settlement with Fujitsu has implications across the public sector. “It should be plain to anyone that we are witnessing systemic failure in the government’s ability to contract.”

What went wrong?

The Department of Health and Fujitsu signed a deal in January 2004 in good faith, but before either side had a clear idea of how difficult it would be to install arguably over-specified systems in hospitals where staff had little time to meet the demands of new technology.

Both sides later tried to renegotiate the contract but talks failed.

In 2008 Fujitsu Services withdrew from the talks because the terms set down by the health service were unaffordable, a director disclosed to MPs.

Fujitsu’s withdrawal prompted the Department of Health to terminate the company’s contract under the NHS’s National Programme for IT (NPfIT).

Fujitsu’s direct losses on the contract at that time – which was in part for the supply and installation of the Cerner “Millennium” system – were understood to be about £340m.

At a hearing of the Public Accounts Committee into the NPfIT,  Peter Hutchinson, Fujitsu’s then group director for UK public services, said that his company had been willing to continue with its original NPfIT contract – even when talks over the contract “re-set” had failed.

“We withdrew from the re-set negotiations. We were still perfectly willing and able to deliver to the original contract,” he said.

Asked by committee MP Richard Bacon why Fujitsu had withdrawn Hutchinson said, “We had tried for a very long period of time to re-set the contract to match what everybody agreed was what the NHS really needed in terms of the contractual format.

“In the end the terms the NHS were willing to agree to we could not have afforded. Whilst we have been very committed to this programme and have put a lot of our time, energy and money behind it we have other stakeholders we have to worry about including our shareholders, our pension funds, our pensioners and the staff who work in the company. There was a limit beyond which we could not go.”

The termination of Fujitsu’s contract left the NHS with a “gaping hole,” said the then chairman of the Public Accounts Committee Edward Leigh.

Thank you to campaigner Dave Orr for drawing my attention to the Telegraph article.

Comment 

In an era on open government it is probably not right for officials and ministers at the Cabinet Office and the Department of Heath to be allowed to secretly plunge their hands into public coffers to pay Fujitsu for a massive failure that officialdom is too embarrassed to talk about.

Why did the DH in 2008 end Fujitsu’s contract rather than renegotiate its own unrealistic gold-plated contract specifications? Should those who ended the contract be held accountable today for the settlement?

The answer is nobody is accountable in part because the terms of the dispute aren’t known. Nobody knows each side’s arguments. Nobody even knows for certain who has won and who has lost. Possibly the government has paid out hundreds of millions of pounds to Fujitsu on the quiet, for no benefit to taxpayers.

Is this in the spirit of government of the people, by the people, for the people?

50,000 on waiting list and cancer test delays after NPfIT go-live

By Tony Collins

Croydon hospitals have built up a waiting list of 50,000 patients since a Cerner electronic patient record system go-live last October, according the trust’s latest board papers.

And, since the go-live, more than 2,200 patients have waited at least 6 weeks for diagnostic tests, of which 160 have been identified as “urgent suspected cancer and urgent patients”.  This backlog may take until the end of August to clear, say the board papers of the Croydon Health Services NHS Trust which includes Croydon’s Mayday Hospital, now the University Hospital.

The trust has declared a “serious incident” as a result of the diagnostics backlog. An SI can be reported when there is possibility of unexpected or avoidable death or severe harm to one or more patients.

“No harm”

The trust concedes that its waiting times pose a “potential clinical risk” but the board papers say several times that there is no evidence any patient has come to harm.  This assurance has been questioned by some trust board members. The trust continues to investigate.

Croydon is the latest in a long line of trusts to have had serious disruption after a Cerner go-live under the NPfIT, with BT as the installation partner.

The trust has kept the implications for patients confidential. This may contravene the NHS’s “duty of candour” – to report publicly on things that go wrong. The duty has come about in the wake of the suffering of hundreds of people in the care of Mid Staffordshire NHS Trust.

Croydon Health Services NHS Trust has decided not to publish its “Cerner Deep Dive” or Cerner “Lessons Learnt” reports, and discussions on the reports have been in Part 2 confidential sections of board meetings.

The trust defended its “Part 2″ approach in its statement (below).

Meanwhile the Health and Social Care Information Centre, which runs the NPfIT local service provider contracts, including BT’s agreement to supply Cerner to hospitals in London,  has commissioned Cerner to capture the benefits nationally of Cerner installations.

Q&A

My questions and points to the trust, and its responses are below.

From me to the trust:

Croydon had good reasons to go live with Cerner, and DH funding was a further incentive but the trust does not appear to have been in a position to go live – at any stage – with a Big Bang Cerner implementation. The 7 aborted official go-live dates might have been a sign of why.  It would have been a brave decision to cancel the implementation, especially as:

-  the trust had spent 2 years preparing for it

- DH, BT and Cerner had put a lot of work into it

- there was DH pressure to go live especially after all the missed go-live dates.

The latest board papers say 6 or more times in different places that there has been no harm to patients as a result of the delays and waits.  Some members have raised questions on this and there is the matter of whether the trust is commissioning its own assessments (marking its own work).

On this:

- 50,000 on waiting list

- Cerner deep dive not published

- Lessons Learnt not published (concealment of failures, against the spirit of duty of candour called for by Robert Francis QC and Jeremy Hunt?)

- Diagnostics – an SI reported. The trust has considered the contributing issues which related to Cerner implementation but has not published details of the discussion. Again a concealment of failures?

- An accumulation of over 2,200 patients that were waiting over 6 weeks for diagnostics. Out of that number 160 patients were identified as urgent suspected cancer (USC) and urgent patients.  Can the trust – and patients – be sure there has been no harm?

- “… external assurance through an external clinician will provide the assurance that no patients have suffered harm as a result of the length of the waiting times”. Bringing in an external clinician to provide an assurance no patients have been harmed seems to pre-judge the outcome.  The trust appears to be marking its own work, especially as the backlog of patients awaiting diagnostics may not be cleared until the end of August.

- Managing public and GP perceptions? “Members agreed that GP interactions should be held off until the investigations had produced definite findings. However the Communications Department are on standby to publish information to GPs if required, and the Trust is ready to react to other enquiries. The Trust will in any event publish the incident report after the investigation has been completed.”

- “… the implementation of Cerner in October 2013 had an impact on activity levels and the delivery of RTT standards”. Again no report on this published.

- “An independent assessor would re-check all patients to assure that no harm has resulted. The Committee noted the progress report and requested that this is referred to a Part 2 meeting of the Trust Board …” Concealment of failures again?

- In the past the DH has been prepared to treat patients as guinea pigs in Cerner Big Bang implementations. The philosophy appears to be that the implementations will inevitably be disruptive but it’s for the good of patients in the longer term. That this approach may be unfair on patients in the short term, however, seems not to trouble the NHS hierarchy.

It’s clear clinicians and IT staff are doing their best and working hard for the benefit of patients but the implementation was beyond their control. Meanwhile complaints are increasing, Croydon Health Services was one of the lowest rated trusts for overall patient experience and a sizeable minority of local residents don’t choose the local hospitals for care or treatment. That said some patients rate their care very highly on NHS Choices (although some don’t). The University hospital is rated 2.5 stars out of 5.

One of the most surprising statements in the board papers is this: “… despite the weaknesses in the programme, the overall success of the deployment had been recognised at a national level”. A success? Can the trust in essence say what it likes? Nobody knows for sure what the facts are, given that the trust decides on what to publish and not to publish.

The trust’s response to the above points and questions:

“Due to a temporary failure of our administrative systems, the Trust found in February 2014 that a number of patients who needed to be seen by the imaging service were in breach of the six week waiting standard.

“We have taken immediate action to correct this and are undertaking a thorough review to confirm that no patients were harmed as a result.  The Trust is now working hard to treat patients currently on our waiting lists.  This is referenced in our publicly available Board papers.

“CRS Millennium has delivered a number of improvements that support improving patient experience at the Trust, including more efficient management of medicines, more detailed patient information being conveyed between shifts and departments and better management of beds within the organisation.”

Lessons?

Below are some of the lessons from Croydon’s Cerner go-live. Although the trust hasn’t published its “Lessons Learnt” report, some of lessons are mentioned in its latest board papers:

  • Insufficient engagement from operational and clinical colleagues
  • Time pressures were felt when a full dress rehearsal stretched the capabilities of the information team.
  • Insufficient time and resources were allocated to completion of the outline business and full business cases, as well as to due diligence on the options and costs.  [Business cases for Cerner are still unpublished.]
  • Trust directors agreed that a business case for a project of the size and complexity of the CRS Millennium should have taken longer than 6 weeks to prepare.
  • A failure of senior managers to take stock of the project at its key stages.
  • Too strong a focus on technical aspects
  • Clinicians not always fully appreciating the impact of the changes the system would deliver
  • The hiring of an external change manager to lead the deployment who proved to be “less than wholly successful because of the resulting deficiency in previous experience or knowledge of the culture of the organisation”.
  • The individual left the organisation part way through deployment which led to further challenges.
  • The right people with the right skills mix were not in place at the outset to achieve the transformational change necessary to successfully deploy a new system such as CRS

Comment 

NHS trusts have good reason to modernise their IT using the widely-installed  Cerner electronic patient record system, especially  if it’s a go-live under the remnants of the NPfIT, in which case hospitals receive DH funding and gain from having BT as their installation partner.

But why does a disruption that borders on chaos so often follow NPfIT Cerner implementations? Perhaps it’s partly because the benefits of Cerner, and the extra work required by nurses and doctors and clerical staff to harvest the benefits, is underestimated.

It is in any case difficult to convey to busy NHS staff that the new technology will, in the short-term, require an increase in their workload. Staff and clinicians will need to capture more data than they did on the old system, and with precision. The new technology will change how they work, so doctors may resent it initially, especially as there may be shortcomings in the way it has been implemented which will take time to identify and solve.

The problem with NPfIT go-lives is that they take place in an accountability void. Nobody is held responsible when things go badly wrong, and it’s easy for trusts to play down what has gone wrong. They have no fear of authoritative contradiction because they keep their implementation assessments confidential.

What a difference it would make if trusts had an unequivocal duty of candour over electronic health record – EHR – deployments. They would not be able to go live until they were ready.

The disruption that has followed NPfIT Cerner go-lives has been serious. Appointments and tests for suspected cancer have been lost in the administrative confusion that follows go-live. There have been backlogs of appointments for tens of thousands of patients. Operating theatres have gone under-used because of mis-scheduled appointments.

Now and again a patient may die unnecessarily but the problems have been regarded by the NHS centrally as collateral damage, the price society pays for the technological modernisation of the NHS.

Richard Granger, when head of the NPfIT, said he was ashamed of some Cerner installations. He described some of them as “appalling” but since he made his comments in 2007, some of the Cerner installations have been more disruptive than those he was referring to.

Provided each time there is no incontrovertible evidence of harm to patients as a result of a go-live, officials give the go ahead for more NPfIT Cerner installations.

Guinea pigs?

Disruption after go-live is too often treated as an administrative problem. Croydon’s statement refers to a “temporary problem with our administrative systems”. But new patient record systems can harm patients, as the inquest on 3-year-old Samuel Starr heard.

It’s time officials stopped regarding patients as guinea pigs in IT go-lives. It compounds the lack of accountability when trusts such as Croydon keep the reports from the go-live secret.

Trusts need better technological support but not at the cost of treating any harm to patients as collateral damage.

A tragic outcome for Cerner implementation at Bath?

Openness and honesty is a rarity after health IT problems

Mishandled electronic health record transition

A botched Cerner EHR implementation?

Trinity Medical Center reaches Cerner settlement

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.

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?

Who polices police IT reports?

By Tony Collins

The police, and civil and public servants in central government, the NHS and local authorities criticise journalists for biased reporting – taking selected facts out of context.

They’re sometimes right.  Journalists working for national newspapers can draft an article that is diligently balanced only to find, by the time it’s published, it leaves out facts which would have complicated, blunted, or contradicted the main points.

It’s one thing for this to happen in the world of journalism. You don’t expect public bodies to report on their own affairs with a partiality that rivals out-of-context reporting by some newspapers.

But it appears to be happening so regularly that one-sided self-reporting on organisational performance may be becoming the norm in the public sector.

In the NHS subjective, positive reporting in board papers – where managers tell directors what they think they want to hear – could help to explain why Cerner patient record implementations have, for years, gone badly wrong for the same reasons.

In recent months reports without balance have been published on the performance of Avon and Somerset Police’s IT outsourcing contract with IBM. 

Somerset County Council, Taunton Deane Borough Council and Avon and Somerset Police  are minority shareholders in a private company, Southwest One,  which is owned by IBM.

Confusingly, Taunton Deane Borough Council issued positive reports about its successful partnership with Southwest One – and then it decided to take some services back in-house.

Now it has emerged – only as a result of FOI requests by Somerset resident and campaigner Dave Orr – that two independent organisations, the National Audit Office, and HM Inspectorate of Constabulary, have commented positively on Avon and Somerset Constabulary’s partnership with Southwest One, based entirely on the unaudited opinions of the police force itself.

SAP

From his FOI requests Orr learned that the Avon and Somerset’s outsourcing deal with Southwest One has not gone entirely as expected. The National Audit Office’s FOI team has released notes of a joint visit by the NAO and HM Inspectorate of Constabulary to Avon and Somerset police in December 2012.  The visit was to find out about how well Southwest One was delivering services to the police force.  

The NAO’s notes are positive in parts. They say that performance has improved considerably since the implementation of the contract.

“Implementation of SAP improving the accounts close-down process, initial issues being resolved and a good quality of service being provided regularly.”

But there is another side to the story that is not reflected in the published accounts of Avon and Somerset’s relationship with Southwest One. The NAO’s [unpublished] field notes say:

“Fewer than expected benefits have been realised from IT due to the considerably different security requirements of the Police compared to the Councils.

“It also took a long time for SAP to be implemented. There has yet to be a duty management system implemented by SWOne which is part of the contract… SAP would have benefited from some pre-launch testing or piloting.”

A letter to Orr from the Home Office appears to confirm that Avon and Somerset Police’s participation in Southwest One is an unequivocal success.

“The private sector can help to deliver police support services better and at lower cost. Every pound saved means more money for the front line, putting officers on the streets…

“In its report “Policing in Austerity: rising to the challenge [2013] Her Majesty’s Inspectorate of Constabulary identified the Southwest One partnership as being a key element in achieving savings for Avon and Somerset Constabulary while ensuring better procurement, streamlining business support processes, and ensuring better use of police officer time.

“The report also noted that the Southwest One collaboration was the first of its kind for policing in England and Wales and that to date, no other force has delivered this level of partnership with local authorities.”

A little of the other side of the story comes in the last sentence of the Home Office letter to Orr which says: “We understand that Avon and Somerset Constabulary continues to work closely with IBM to resolve any technical difficulties and improve the services provided by Southwest One.”

Indeed a table on page 155 of HMIC ‘s 2013 report Policing in austerity: rising to the challenge indicates that Avon and Somerset Constabulary has one of the worst records of any police force when it comes to savings delivered between 2010/11 and 2012/13. [Table: Key indicators of the challenge - quartile analysis.]

Southwest One began a 10-year contract providing services to Avon and Somerset Police in 2008. The services included enquiry offices, district HR, estates, financial services, site administration, facilities, corporate human resources, information services, purchasing and supply, and reprographics. The contract involves 554 seconded staff.

Comment

Police forces, councils, the NHS and central government departments need  a few Richard Feymans to report on their organisation’s performance. Feynman was a gifted scientist, MIT graduate and noble prize winner who was chosen as a commissioner to report on the cause , or causes, of the Challenger Space Shuttle “O” rings accident on 28 January 1986.

He reported with such independence of mind and diligence that his hard-hitting findings were not considered acceptable to be included in the main report of the Presidential Commission of inquiry into the accident.  Feynman had to be content with having his findings published as an appendix to the Commission’s report – and an edited appendix at that.  

He suggested in his book “What do you care what other people think?” that his appendix was the only genuinely balanced part of the official inquiry report. 

“For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled,” said Feynman.

One of his questions was whether “organisation weaknesses that contributed to the [Shuttle] accident [was] confined to the solid rocket booster sector, or were they a more general characteristic of NASA.”

One of Feynman’s conclusions:

“It would appear that, for whatever purpose – be it for internal or external consumption – the management of NASA exaggerates the reliability of its product to the point of fantasy.”

If such exaggeration happens at NASA it can happen in UK police force IT reports, and in board papers on the performance of councils and NHS trusts.

When journalists get it wrong it’s usually to their eternal regret. In the public sector positive unbalanced reporting is so “normal” that hardly anyone involved realises it’s a deviant practice. The US author Diane Vaughan coined a phrase for such corporate behaviour.  She called it the normalisation of deviance.  

It’s surely time for public bodies to move away from the norm and start reporting on their performance, and the performance of their outsourcing other private sector contracts, with balance, objectivity and independence of mind.   

If managers knew that reports on the progress of their contracts would be audited for impartiality and competence over organisational self-interest, perhaps they would have a greater incentive to avoid badly thought through outsourcing deals and IT implementations.

Is this why some council and NHS scandals stay hidden for years?

NAO report “Private sector partnering in the police service”

Dave Orr’s HMIC FOI requests and answers

NAO’s FOI responses on Avon and Somerset Police

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?

Did officials exaggerate death of the NPfIT?

By T0ny Collins

In 2011 the Department of Health made a major announcement that implied the NHS IT programme, the NPfIT, was dead when it wasn’t.

The DH’s press release announced an “acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority”.

It said the Authority had concluded that the NPfIT was “not fit to provide the modern IT services that the NHS needs…” The National media took the press release to mean that the NPfIT was dead.

What the announcement didn’t mention was that at least £1.1bn had still to be spent, largely with CSC, provided that the company successfully completed all the work set out in its revised contracts, and that the projected end-of-life of some centrally-chosen NHS IT systems was 2024.

Some will say: who cares if the DH issues a press release that is misleading. Others may say that in a democracy one should be able to trust institutions of state. If the DH issues an official notice that has the effect of manipulating public perceptions – gives a false impression – can citizens trust the Department’s other official notices?

The press release in question did not say the NPfIT was closing but gave that impression. The announcement distanced the government and the Department of Health from an IT scheme, perhaps the world’s largest non-military IT programme, that was failing. This was the press release:

The government today announced an acceleration of the dismantling of the National Programme for IT.

“The government today announced an acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority (MPA). The programme was created in 2002 under the last government and the MPA has concluded that it is not fit to provide the modern IT services that the NHS needs…”

The press release was given added weight by those quoted in it. They included the Department of Health, Francis Maude, Minister for the Cabinet Office and Sir David Nicholson, Chief Executive of the NHS.

But the truth about the press release emerged this week at a hearing of the Public Accounts Committee.

Margaret Hodge, chair of the Public Accounts Committee, began a hearing on the NPfIT on Wednesday by asking Sir David Nicholson, the NHS chief, a canny question.

Hodge:  “There was a big announcement back in 2011 that you were closing the NPfIT programme.”

“Yes,” replied Sir David.

“That’s not true,” said Hodge. “It was a PR exercise to say you closed it.”

Nicholson: “It certainly was not a PR exercise.”

Hodge: “What changed?”

Nicholson: “The governance arrangements changed.  So there are separate senior responsible officers for each of the individual programmes [within the NPfIT].”

Hodge: “With the greatest respect, changing governance arrangements is not closing the programme.. .I think the impression you were trying to give was that you were closing the programme. All you were doing was shifting the deckchairs on the Titanic. You were shifting the way you were running it but you were keeping all that expenditure running… The impression given to the public was that you were going to get out of some of these contracts.”

On the basis of the press release the Daily Mail published a front page lead story with this headline:

£12bn NHS computer system is scrapped… and it’s all YOUR money that Labour poured down the drain

On the day of the press release the Daily Telegraph reported that the £11.4bn NHS IT programme was “to be abandoned”.  Similar reports appeared in the trade press.

But this week’s Public Accounts Committee heard that the NPfIT is very much alive:

- the estimated worth of CSC’s contracts under the NPfIT has risen from £3.1bn to £3.8bn at today’s prices.

-  officials expected to pay CSC a further £1.1bn on top of the £1.1bn it has already received, and this payment may include up to £600m for Lorenzo deployments at only 22 trusts. Hodge said: “You are going to spend another half a billion with this rotten company providing a hopeless system” – to which the DH argues that CSC has delivered thousands of (non-Lorenzo) working systems to the NHS which trusts and community health services rely on.

- About £500m of the £1.1bn still set aside for CSC will go on GP systems supplied by CSC’s subcontractor TPP Systmone.

- Further spending on the NPfIT may come as a result of Fujitsu’s legal action against the DH after it left the NPfIT in 2008, which leaves the taxpayer with a potential pay-out of £700m or more. The outcome of a formal arbitration is expected in about six months. The closing arguments are due at the end of this month.

- £31.5m has so far been spent on the DH’s legal costs in the Fujitsu case, mostly with the .law firm DLA Piper.

- DH has agreed a compensation payment to CSC of £100m. In return CSC has released the Department of Health from a contractual commitment for 160 NHS trusts to take the Lorenzo system. The DH has made a further payment to CSC of £10m in recognition of changes to its software which had been requested by the NHS but not formally agreed with CSC.

Comment

It appears there has been no deliberate deception and no deliberate manipulation of public perceptions of the NPfIT. But the fact remains that the DH made a major announcement in 2011 which gave the impression the NPfIT was dead when this was not true.

When a BBC Radio 4 journalist called me this week and we spoke briefly about the NPfIT he said: “I thought it was dead”.

Perhaps the mindset of officials was that the NPfIT was dead because everyone except the suppliers wanted it to be. But because local service provider contracts had to stay in place – the suppliers being much better equipped than the DH to handle any disputes over early termination – large payments to CSC and BT had to continue.

It’s a little like the political row over weapons of mass destruction in Iraq. It’s unlikely Blair lied over the existence of WMD. He probably convinced himself they existed. In a similar act of self-delusion officials appear to have convinced themselves the NPfIT was dead although it wasn’t.

But if we cannot believe a major DH announcement one starts to ask whether any of the department’s major announcements can be believed.

Uncoloured information on the NPfIT has always been hard to come by. So credit is due to the Public Accounts Committee and particularly its MP Richard Bacon for finding out so much about the NPfIT.  All credit to Margaret Hodge for picking up on Bacon’s concerns. Were it not for the committee, with indispensable support from the National Audit Office, the DH would have been a sieve allowing only bits of information it wanted to release to pass through.

The fall-out from the NPfIT will continue for years. We still don’t know, for example, what all the trusts with BT and CSC systems will do when the NPfIT contracts expire in the next three years. The hope is for transparency – and not of the sort characterised by the DH’s announcement in 2011 of the NPfIT’s dismantling.

This post also appears on ComputerworldUK

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.

Is Major Projects annual report truly ground-breaking?

By Tony Collins

Francis Maude, the Cabinet Office minister, describes as “nothing short of groundbreaking” a report of the Major Projects Authority which gives the RAG (Rred/Amber/Green) status of more than 100 major projects.

That the report came out late on Friday afternoon as most journalists were preparing to go home, some of them for the whole bank holiday weekend, suggests that the document was a negotiated compromise: it would be published but in such a way as to get minimal publicity.

Indeed the report is a series of compromises. It has the RAG status of projects but not the original text that puts the status into context.

Another compromise: senior civil servants in departments have persuaded Maude to publish the RAG decisions when they are at least six months old.

This enables departmental officials to argue their case in the “narrative” section of the MPA annual report that a red or amber/red decision is out-of-date and that there has been significant improvement since. This is exactly the DWP’s justification for the amber/red status on Universal Credit.

The DWP says in the MPA report: “This rating [amber/red] dates back to September 2012, more than seven months ago. Since then, significant progress has been made in the delivery of Universal Credit. The Pathfinder was successfully launched and we are on course both to expand the Pathfinder in July 2013 and start the progressive national roll-out of Universal Credit in October.”

That the Pathfinder was launched successfully might have nothing to do with Universal Credit’s amber/red status which could be because of uncertainties over how the IT will perform at scale, given the complexities and interdependencies.  The MPA report says nothing about the uncertainties and risks of Universal Credit.

More compromises in the MPA annual report: the Cabinet Office appears to have allowed departments to hide their cost increases on projects such as HMRC’s Real-time Information [RTI] in the vague phrase “Total budgeted whole life costs (including non-government costs).”

The Cabinet Office has also allowed departments to write their own story to accompany the RAG status. So when HMRC writes its story on RTI it says that “costs have increased” but not by how much or why. We know from evidence that HMRC gave to the Public Accounts Committee that RTI costs have risen by “tens of millions of pounds”. There is nothing to indicate this in the MPA annual report.

Another compromise in the MPA annual report: there are no figures to compare the original forecast costs of a project with the projected costs now. There are only the 2012/13 figures compared with whole-life projected costs (including non-government projected spend).

And the MPA report is not comprehensive. It came out on the same day the BBC announced that it was scrapping its Digital Media Initiative which cost the public £98m. The MPA report does not mention the BBC.

The report is more helpful on the G-Cloud initiative, showing how cheap it is – about £500,000. But there is little information on the NHS National Programme for IT [NPfIT] or the Summary Care Record scheme. 

Yet the MPA annual report is ground-breaking. Since Peter Gershon, the then head of the Office of Government Commerce, introduced Gateway reviews of risky IT projects about 12 years ago with RAG decisions, they have remained unpublished, with few exceptions. The Cabinet Office is now publishing the RAG status of major departmental projects for the first time. Maude says

“A tradition of Whitehall secrecy is being overturned. And while previous Governments buried problems under the carpet, we are striving to be more open. By their very nature these works are high risk and innovative.

“They often break new ground and dwarf anything the private sector does in both scale and complexity. They will not always run to plan. Public scrutiny, however uncomfortable, will bring about improvement. Ending the lamentable record of failure to deliver these projects is our priority.”

Comment

The MPA annual report is a breath of fresh air.

Nearly every sentence, nearly every figure, represents compromise. The report reveals that the Universal Credit project was last year given an amber/red status – but it doesn’t say why. Yet the report has the DWP’s defence of the amber/red decision. So the MPA report has the departmental defences of the RAG decisions, without the prosecution evidence. That’s a civil service parody of openness and accountability: Sir Humphrey is allowed to defend himself in public without the case against him being heard.

But it’s still useful to know that Universal Credit is at amber/red.  It implies well into the project’s life that the uncertainties and risks are great. A major project at amber/red at this stage, a few months before go-live, is unlikely to turn green in the short term, if ever.

Congratulations

The Cabinet Office deserves congratulations for winning the fight for publication of the RAG status of each major project. Lord Browne, the government’s lead non-executive director and a member of the Cabinet Office’s Efficiency and Reform group, has said  that billions of pounds of taxpayers’ money is being frittered away because of “worryingly poor” management of government projects.

“Nobody ever stops or intervenes in a poor project soon enough. The temptation is always to ignore or underreport warning signs,” he says.

The management of some large projects – usually not the smaller ones – is so questionable that departments ignore advice to have one senior responsible owner per major project, says the MPA.

The MPA annual report will not stop the disasters. Its information is so limited that it will not even enable the public – armchair auditors – to hold departments to account. Senior civil servants have seen to that.

But the report’s publication is an important development: and it provides evidence of the struggle within Whitehall against openness. Francis Maude and Sir Bob Kerslake, head of the civil service, have had to fight to persuade departmental officials to allow the RAG status of projects to be published. The Guardian’s political editor Patrick Wintour says of the MPA annual report

“Publication led to fierce infighting in Whitehall as government departments disputed the listings and fought to prevent publication.”

Large-scale change

If Maude and Kerslake struggled to get this limited distance, and there is still so much left to reform, will large-scale change ever happen?

Maude and his officials have as comprehensive mandate for change from David Cameron as they could hope for. Yet still the Cabinet Office still seems to have little influence on departments. When it comes to the big decisions, Sir Humphrey and his senior officials hold onto real power. That’s largely because the departments are responsible to Parliament for their financial decisions – not the Cabinet Office.

Maude and his team have won an important battle in publishing the MPA annual report. But the war to bring about major change is still in its very early stages; and there’s a general election in 2015 that could halt Maude’s reform plans altogether.

The Major Projects Authority Annual Report.