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.
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.
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).
– 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.”
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
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.
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.