By Tony Collins
When a passenger jet crashes, if the airline’s next board meeting barely mentions it, and instead discusses a catering award and a staff survey, those booked on flights with the airline may have cause for concern.
So should patients at Imperial College Healthcare Trust be concerned that the trust has not mentioned in its latest published board papers a blunder that led to the Trust’s losing track, for nearly a year, of hundreds of patients with possible cancer?
The Department of Health requires that patients who go to their GP with symptoms that may indicate cancer are seen by a specialist within a maximum of two weeks.
But Imperial has lost track of an unknown number of patients who went to their GPs with signs of possible cancer. It has been checking 900 hospital records which it found were incomplete.
For some of the patients the blunder won’t matter: they will have been called by staff at GP practices, some of whom have systems that track patients under the two-week rule.
But some patients might have slipped through the net and not been alerted by Imperial to their urgent appointments. Imperial has no clear idea how many.
It has asked GP organisations for help in contacting patients, their carers or representatives, to‘ascertain whether the patient has received treatment or still requires treatment’”.
What detail has emerged on the problem has come not from Imperial but from NHS North West London which is a single management team that represents eight PCTs. NWL covers St Mary’s Hospital, Paddington, Hammersmith Hospital and Charing Cross Hospital, which are all managed by Imperial.
NWL has what it calls “substantial concern” about the problems at Imperial. In addition to the problem reporting its two-week cancer waits, the Trust is trying to clear a backlog of patients who have waited more than 18 weeks from referral to consultant-led treatment.
NWL executives report that Deloitte has carried out an external audit and “concerns remain about record keeping at Imperial”. The executives say that “systematic failings” have been identified which will take time to resolve. This issue will be given close attention in the coming year, says NWL.
Patient safety an issue?
NWL also says that a “Clinical Review” is being carried out and a panel is being set up to look at the clinical issues that have arisen at Imperial. “The Director of Nursing confirmed that the clinical review would look at all patients affected by the problems at Imperial …”
In contrast to the concerns about Imperial’s performance among London PCTs, Imperial seems a little surprised that we are even investigating the problems.
“The problems are administrative and nothing to do with IT,” said a spokesperson.
The Trust is right. The problems are nothing to do with IT. And yet the problems may be everything to do with IT. Appointments for patients with possible cancer have not been entered onto IT systems – and where they have, data has been incorrect, entered into duplicate records, or not followed up to check appointments were kept, or the patient seen for treatment and investigations.
Eye off the ball?
For nearly a year the problem was not spotted, which has left some North West London executives wondering how it could have happened. It is known the Trust has devoted time and attention of senior management to a replacement of existing systems with Cerner, under the National Programme for IT. Has the Trust taken its eye off the ball while making plans for Cerner?
Some working in the NHS may ask whether it was more important for the Trust to have ensured that appointments for possible cancer were entered correctly onto existing systems, and routines written into software to provide alerts when cancer records were not closed off, or were incomplete.
Below are some of the comments of NWL PCTs about Imperial’s problems. Their concerns raise questions about whether the Trust’s processes and administration are stable enough for a transition from existing IT to new systems, which could cause further disruption.
These are some NWL statements in its board papers relating to Imperial:
“It was reported that at Imperial, the calculations of the backlog of referrals had been completed and work is underway to clear the backlog. However Deloitte has carried out an external audit and concerns remain about record keeping at Imperial. Systematic failings have been identified which will take time to resolve. This issue will be given close attention in the coming year.
“A Clinical Review is being carried out and a panel is being set up to look at the clinical issues that have arisen. The Director of Nursing confirmed that the clinical review would look at all patients affected by the problems at Imperial …”
Does NWL always trust what Imperial says?
Jeff Zitron [Chair, NHS NW London, Inner & Outer NWL Sub Clusters] said that the Board needs evidenced assurance that the issues that have arisen at Imperial and North West London Hospitals are being adequately addressed.
“Trish Longdon [Vice-chairman, NHS North West London Cluster Board] noted that although the Imperial targets were shown as ‘Green’ this does not reflect the true position. This was agreed and it was noted that they were in fact being treated as if they were Amber.”
“The Chairman asked for an update on the situation at Imperial College Healthcare Trust which had been the subject of substantial concern at the last INWL Inner North West London NHS] Board meeting. The INWL Board had agreed that an urgent meeting should be held with the Chairman and Chief Executive of Imperial, involving the CCG Chairs, the Tri-Borough Cabinet Members for Health, himself and Anne Rainsberry [Chief Executive North West London Cluster]. This was taking place later that day.”
“ Following investigation of Serious Incidents in May 2011, ICHT [Imperial College Healthcare NHS Trust] is unable to provide sufficient assurance of robust data quality in regard to reported performance for 18 weeks RTT [Referral To Treatment], cancer waiting times and the elective waiting list.
The Trust board have approved a reporting break until end of June 2012 which has been agreed by the Cluster in conjunction with NHS London. To ensure due diligence, an independent audit of waiting list management across all specialities has been undertaken and a set of recommendations made.
“ICHT continue to provide shadow reports to NHS NWL during this period with weekly reporting. Some evidence of improved performance management is observed. However this is not yet consistently embedded Trust- wide and clearance of the current backlog of patients is not at sufficient pace to meet the agreed trajectory…
“A clinical review will be undertaken to ensure that patients have not experienced harm due to an elongated wait.”
“Anne Rainsberry [Chief Executive North West London Cluster] referred to a range of discussions taking place on Imperial’s performance issues, focussing on the backlog of the Referral to Treatment waiting lists which had resulted in a reporting break being granted.
“Work was concluding at the end of April  to reduce the original backlog of patient cases and enable reporting systems to get back on track in June. A clinical review had also started to determine if any risks to patients had arisen due to the delays. The review findings would be brought back to the Board…
“Anne Rainsberry referred to a meeting she had attended with the Department of Health to review Imperial‟s approach to resolving these issues.”
Big organisational challenge
“Simon Weldon [Director of Commissioning and Performance, North West London Cluster Board] … asked the NWL Board to be aware of the enormity of the organisational challenge facing Imperial and that remedial actions would take time to take effect.”
Campaign4Change put it to Imperial College Healthcare NHS Trust that there is nothing in its latest published board papers to show the trust is concerned about the problems relating to cancer waits and lost appointments. We said that PCT papers referred to “substantial concern” but there was nothing similar in Imperial’s latest published papers. We let Imperial know we would be asking the question: how concerned is Imperial about the confusion over cancer waits?
This was the reply of Imperial’s spokeswoman (in full)
“The safety of patients is our absolute priority. Our Trust is taking the issues involved in the current situation very seriously and at all times the well-being of the patients we serve is foremost in our minds.
“We acknowledge that some patients may have been caused additional pain and anxiety associated with a prolonged wait for diagnosis and treatment and worked to address the problem as robustly and quickly as possible.”
Separately, in May 2012, Imperial told us that it was in the process of validating 900 patient records that indicate that a patient might have been waiting longer than two weeks.
At that stage it had closed more than 400 of the 900 records “as the majority indicated that patients have either received or are receiving treatment, or that the patient did not attend their appointment and their GP had advised there was no need for further follow up”.
The spokeswoman said “To date our investigations have found no suggestion that any delay in treatment has caused a patient to come to serious harm.”
She said “This is not an IT issue, but an administrative issue related to the physical input and extraction of data from patient records. It is entirely unrelated to IT systems.”
It is extraordinary that Imperial is seeking to replace existing systems when it is organisationally in a questionable state. Simon Weldon, Director of Commissioning and Performance, North West London Cluster Board, referred to the “enormity of the organisational challenge facing Imperial”.
Under the NPfIT, a number of implementations of Cerner at several NHS sites have gone badly wrong – and they did not have Imperial’s problems before going live. It would be common sense for Imperial to get its data accurate and its management processes and checks reliably in place before attempting a major switch of IT systems.
Two other things are particularly worrying: Imperial appears not to concede in public it has any major problems, and it appears to separate IT from administration.
Having the best IT in the NHS is of limited value if important parts of the Trust are in a state of administrative disorder. If data is unreliable, incomplete and inaccurate, and solid processes are not in place to ensure that the correct data is entered into systems when it needs to be entered, and routines are not in place to provide alerts and follow-ups, costly hardware and software may not compensate. Is this an IT issue or not? Does that matter?
We would not like to see a Cerner NPfIT debacle similar to the ones at Barts in London, Royal Free Hampstead, and at hospitals in Oxford, Milton Keynes, Weston-super-Mare, Morecambe Bay, Worthing and Bristol.
But is Imperial particularly concerned? Is it in denial over the seriousness of its problems? Why is it reporting its position at Green when North West London NHS regards its position as Amber? Why do its latest published board papers not mention its problems tracking patients under the two-week rule? Is the Trust so preoccupied with replacing its existing systems with Cerner that it is not doing the basics well?
One specialist in the NHS said: “If the Trust wasn’t spending so much time and effort doing the Cerner deployment then maybe they would have concentrated its scarce resources on performing the job of managing patients.”
Accountability for failure in the NHS is poor to non-existent. So will Imperial be able to do what it wants regardless?
Troubled Cerner NPfIT go-lives, so far:
St George’s Healthcare NHS Trust
*We acknowledge Pulse which broke the story on Imperial’s cancer wait problems.