Category Archives: culture

Does a Mid Staffs culture still pervade the NHS?

Posted on 06/03/2013 | 1 comment

By Tony Collins

The Francis report on Mid Staffordshire NHS Foundation Trust highlighted appalling record-keeping among other problems.

One of the case studies in the report was that of an insulin-dependent diabetic, Gillian Astbury,  who entered Cannock Hospital for a urinary tract infection, had a fall in the hospital, was discharged, and later admitted to Stafford Hospital on 1 April 2007 because of bones she damaged in the fall. She died ten days later, probably after not being given insulin.

Francis highlights the lack of records on her need for insulin. There was a “failure to keep nursing records adequately or at all … there was a failure to comply with professional guidelines on note taking …”

Astbury’s partner Ron Street told hospital staff that she was diabetic, a point which went into her medical notes – initially.  But, said Francis,  nursing records for Astbury were almost non-existent.

“There is no evidence of what care took place … during interview nursing staff admitted that they did not check or read the notes regularly (if at all) and there was no linkage with notes from other wards …” 

Francis’s recommendations included a call for trust staff and managers to be open and accountable when things that go wrong.

This isn’t happening.

Campaign4Change picked an NHS trust to test whether the pre-Francis culture still prevails: whether there is the same old secrecy and defensiveness over standards of record-keeping, and whether positive news suffocates real and potential problems in trust board reports.

North Bristol NHS Trust

North Bristol NHS Trust has a chronic problem with record-keeping. It installed the Cerner Millennium electronic patient record system in December 2011, prompting a “crisis”.

Later the trust’s PR officer said in response to an FOI request that there had been 16 clinical incidents in two months relating to the new electronic patient record system. “These were all clinical incidents where the new system was cited as a causal factor, such as wrong patient wrong notes, lack of notes, incorrect clinic list,” she said.

She added:  “However our robust safeguarding processes, as well as additional checks and balances in all departments, ensured that clinical safety was not compromised and no patients were put at risk. Our priority is always patient safety and there is no indication that this has been affected.”

Last year North Bristol asked PWC to review the Cerner implementation. In its report PWC claimed that the “Trust is now beginning to move out of the crisis and return to normal operations”. That was in July 2012.

The Trust has still not returned to normal operations. Last month the Department of Health singled out North Bristol as one of only two trusts in England that failed to submit to the DH “incomplete RTT” pathway data. Incomplete pathway data refers to patients still waiting for consultant-led treatment. RTT means referral to treatment.

In August and September 2012 North Bristol was the only trust in England that failed to submit to the DH “incomplete RTT” pathway data.

Trust’s “numerous difficulties”

With little explanation, a North Bristol trust board paper in January this year referred to numerous difficulties relating to IT systems. This was in the context of an increasing number of overdue responses to complaints from patients. Said the board paper:

“Difficulties with appointment bookings and notification letters are still numerous. These are all reported to IM&T.” Again with little explanation another North Bristol board report, in November 2012, referred to “ongoing pressure in Cerner recovery …”.

So what are the Cerner problems, why have they continued for more than a year and has the North Bristol Trust’s board of directors been properly informed about them?

To test North Bristol’s openness on its Cerner problems I asked the Trust’s press officer and its media relations manager whether they could send me any trust report on the problems with the Cerner implementation.

Two days later they said that “some patience would be appreciated” but declined to say when they would respond to my question, so I asked it under FOI. The Trust gave no acknowledgement.

Perhaps North Bristol is too busy to deal with external questions and challenges on its record keeping. But that was one of the big problems highlighted by Francis in his report on Mid Staffs: that the Trust did not respond to external questions and challenges.

Worryingly, North Bristol’s reporting culture seems to prefer the positive over the negative.  This was one of its replies to an FOI request in 2012:

“With respect to inpatients, during November (before the implementation of Cerner) 40 patients were cancelled on the same day as admission for non-clinical reasons. During December (after the implementation of Cerner) 33 patients were cancelled on the same day as admission for non-clinical reasons – 7 fewer than in November.”

This reply – and others  – gave the impression, without giving contextual evidence,  that things were better since the Cerner implementation than before.

Francis in his report on Mid Staffs said,

“… for all the fine words printed and spoken about candour, and willingness to remedy wrongs, there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism.”

This would, it seems, apply to North Bristol – and every one of the other NHS trusts that have had electronic patient record implementations go wrong.

Indeed it is unfair to pick on North Bristol. The positive tone of its board reports is standard practice for trust board reporting across the NHS in England.

Francis said the NHS needs to change. In his letter to Jeremy Hunt on his report, Francis referred to an “institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern”.

But can NHS boards change in the absence of compulsion?

Audits of trust board reports?

One thing Francis did not suggest was that trust boards should have their board reports audited independently for honesty and openness.  An audit would detect an overly buoyant tone that downplayed concerns.  “There were 5 serious falls in December an increase of 3 from November. There were 185 falls in December compared to 139 falls in November, which had the lowest number of falls in one month this year.”

This was from a North Bristol board report that gave no explanation of the five serious falls. But the report made the point that November (2012) had the lowest number of falls in one month this year. If you were among the five who’d had a serious fall in hospital – and in Gillian Astbury’s case a fall in Stafford Hospital led to her death – you would probably want the trust’s board to focus on an analysis of the five serious falls, rather than be told how good a month November was for falls.

Board reports are a window on the culture of a public sector organisation. In the NHS nobody in authority seems not to have noticed that an American corporate positivism pervades many NHS board reports.  It’s within this culture that needless deaths such as those at Mid Staffs went unnoticed.

Until NHS trust board reports become more business-like and deal with concerns and potentially serious problems as would a private sector board – instead of giving the impression that they are trying to celebrate so-called achievements – the Francis report may make little difference.

North Bristol’s apparent unwillingness to disclose any detail of its Cerner problems – perhaps to its own board – is to be expected; but that natural reluctance to disclose may be symptomatic of one of the NHS’s biggest problems. The unnecessary deaths at Mid Staffs will be for nothing if the NHS does not change in the light of the Francis report. Complacency, arrogance, a preoccupation with good news and a culture of downplaying or even trying to ignore bad news are the enemy. Unless a board approach of honesty and openness is independently audited and enforced, Francis’s recommendations may bring little lasting change.

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Posted in Campaign4Change, change, change management, culture, e-health, health records, NHS, openness and transparency, oversight, Politics, private sector lessons for the public sector

Shouldn’t David Nicholson stay?

Posted on 06/03/2013 | 3 comments

By Tony Collins

Sir David Nicholson seems to have a glass half-full view of life as the Chief Executive of the NHS. Perhaps unfairly there are calls for him to resign over the deaths at Mid Staffordshire NHS Foundation Trust.  He says he did not know what was happening there.

But he was wrong to suggest the problems at Mid-Staffs were not systemic. Fourteen hospitals are being investigated for unusually high death rates.

Nicholson was also wrong in 2007 when he gave a reassuring briefing to the then prime minister Tony Blair on the state of the National Programme for IT. The paper on which his briefing was based was supposed to have been a secret but it was mistakenly put on the web then removed. I kept a copy.

It showed a bar chart that implied that the main elements of the NPfIT were complete.  It said that,

“ … much of the programme is complete with software delivered to time and to budget”.

That wasn’t correct then, or today – which is six years later. The main element of the NPfIT, a national electronic health record, does not exist. Arguably the NPfIT is one of the worst IT-related disasters of all time – and Sir David Nicholson remains its official Senior Responsible Owner. He has defended the NPfIT even after coalition ministers criticised it.

He also personally rejected a call by 23 academics in 2006 for an independent review of the NPfIT. When I was in his company a few years ago he said (politely) that he would not put the idea of an independent review to his ministers.

So why shouldn’t he go? The resignation of one man over pervasive cultural problems within the NHS could be an irrelevance, a harmful distraction. It could imply that the NHS is cured of the pervasive cultural problems highlighted by Francis in his report on Mid Staffs.

Perhaps Nicholson should stay because he is a reminder that the health service’s senior management doesn’t really change however many times new governments impose reorganisations. Particularly at trust board level directors keep the same principles of defensiveness and denial when things go wrong. Nicholson, perhaps, should remain as a symbol of what is wrong with the NHS.

If he resigned, his successor would most likely be appointed by a panel that would be attracted to the virtues Nicholson displayed at his interviews for the job of NHS Chief Executive. In other words Nicholson may be replaced by someone very similar – someone who would, at heart, defend the NHS, and particularly the Department of Health, against whinging outsiders including politicians, the media and patients.

Does a Mid Staffs culture still pervade the NHS?

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Posted in Campaign4Change, culture, e-health, excessive secrecy, health, health records, IT-related failures, NHS, npfit, openness and transparency

Big IT suppliers and their Whitehall “hostages”

Posted on 30/01/2013 | 6 comments

By Tony Collins

Mark Thompson is a senior lecturer in information systems at Cambridge Judge Business School, ICT futures advisor to the Cabinet Office and strategy director at consultancy Methods.

Last month he said in a Guardian comment that central government departments are “increasingly being held hostage by a handful of huge, often overseas, suppliers of customised all-or-nothing IT systems”.

Some senior officials are happy to be held captive.

“Unfortunately, hostage and hostage taker have become closely aligned in Stockholm-syndrome fashion.

“Many people in the public sector now design, procure, manage and evaluate these IT systems and ignore the exploitative nature of the relationship,” said Thompson.

The Stockholm syndrome is a psychological phenomenon in which hostages bond with their captors, sometimes to the point of defending them.

This month the Foreign and Commonwealth Office issued  a pre-tender notice for Oracle ERP systems. Worth between £250m and £750m, the framework will be open to all central government departments, arms length bodies and agencies and will replace the current “Prism” contract with Capgemini.  

It’s an old-style centralised framework that, says Chris Chant, former Executive Director at the Cabinet Office who was its head of G-Cloud, will have Oracle popping champagne corks. 

“This is a 1993 answer to a 2013 problem,” he told Computer Weekly.

In the same vein, Georgina O’Toole at Techmarketview says that central departments are staying with big Oracle ERP systems.   

She said the framework “appears to support departments continuing to run Oracle or, indeed, choosing to move to Oracle”. This is “surprising as when the Shared Services strategy was published in December, the Cabinet Office continued to highlight the cost of running Oracle ERP…”

She said the framework sends a  message that the Cabinet Office has had to accept that some departments and agencies are not going to move away from Oracle or SAP.

“The best the Cabinet Office can do is ensure they are getting the best deal. There’s no doubt there will be plenty of SIs looking to protect their existing relationships by getting a place on the FCO framework.”

G-Cloud and open standards?

Is the FCO framework another sign that the Cabinet Office, in trying to cut the high costs of central government IT, cannot break the bond – the willing hostage-captive relationship –  between big suppliers and central departments?

The framework appears to bypass G-Cloud in which departments are not tied to a particular company. It also appears to cock a snook at the idea of replacing  proprietary with open systems.

Mark Thompson said in his Guardian comment: 

– Administrative IT systems, which cost 1% of GDP, have become a byword for complexity, opacity, expense and poor delivery.

– Departments can break free from the straitjackets of their existing systems and begin to procure technology in smaller, standardised building blocks, creating demand for standard components across government. This will provide opportunities for less expensive SMEs and stimulate the local economy.

– Open, interoperable platforms for government IT will help avoid the mass duplication of proprietary processes and systems across departments that currently waste billions.

–  A negative reaction to the government’s open standards policy from some monopolistic suppliers is not surprising.

Comment

It seems that Oracle and the FCO have convinced each other that the new framework represents change.  But, as Chris Chant says, it is more of the same.

If there is an exit door from captivity the big suppliers are ushering senior officials in departments towards it saying politely “you first” and the officials are equally deferential saying “no – you first”. In the end they agree to stay where they are.

Will Thompson’s comments make any difference?

Some top officials in central departments – highly respected individuals – will dismiss Thompson’s criticisms of government IT because they believe the civil service and its experienced suppliers are doing a good job: they are keeping systems of labyrinthine complexity running unnoticeably smoothly for the millions of people who rely on government IT.

Those officials don’t want to mess too much with existing systems and big IT contracts in case government systems start to become unreliable which, they argue, could badly affect millions of people.

These same officials will advocate reform of systems of lesser importance such as those involving government websites; and they will champion agile and IT-related reforms that don’t affect them or their big IT contracts.

In a sense they are right. But they ignore the fact that government IT costs much too much. They may also exaggerate the extent to which government IT works well. Indeed they are too quick to dismiss criticisms of government IT including those made by the National Audit Office.

In numerous reports the NAO has drawn attention to weaknesses such as the lack of reliable management information and unacceptable levels of fraud and internal error in the big departments. The NAO has qualified the accounts of the two biggest non-military IT spending departments, the DWP and HMRC.

Ostensible reformers are barriers to genuine change.  They need to be replaced with fresh-thinking civil servants who recognise the impossibility of living with mega IT contracts.

Mark Thompson’s Guardian article.

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Posted in Agile, Campaign4Change, Capgemini, change management, Cloud, Cloud Computing, cost avoidance, cost reduction, culture, DWP, G-Cloud, Government IT, HMRC, innovation, managing change, managing outsourced services, open source, open standards, operational issues, Oracle ERP, Politics, private sector lessons for the public sector, procurement, project management, reducing cost strategically, supplier relationships

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Summary Care Record “unreliable”

Posted on 05/10/2012 | 1 comment

By Tony Collins

The  central Summary Care Record database (which is run by BT under its NPfIT Spine contract) is proving unreliable, Pulse reports today.

The SCR is supposed to give clinicians , particularly those working in A&E and for out-of-hours services, a view of the patient’s most recent medicines, allergies and bad reactions to drugs.

But one criticism of the scheme has always been the lack of any guarantee that the data in the SCR could be accurate or complete.

Researchers at University College, London, led by Trisha Greenhalgh, found in a confidential draft report that doctors were unable to trust the SCR database as a single source of truth. They found in some cases that  some information on the database was wrong, and what should have been included in the patient’s record was omitted for unknown reasons.

Now Pulse reports that some GP-derived information is going on the patient’s SCR, and some isn’t. One problem is that GPs must use smartcards to update the SCR database and some don’t use them.

The General Practitioners Committee of the British Medical Association has raised the matter with the Department of Health.

Dr Paul Roblin, chief executive of Oxfordshire, Buckinghamshire and Berkshire local medical committee told Pulse that  smartcards were not often used in Buckinghamshire, because they slowed down the practice IT system for normal use, with one practice reporting that it had interfered with allergy data.

Dr Roblin said that this made the record ‘unreliable’ and said that although most GPs would prefer to take their own history rather than relying on the SCR, and would double check all details with the patient, other health professionals may not realise the record is incomplete, and may not check the data.

He said “Drugs lists might not be complete and recent allergies may not be uploaded. The Summary Care Record is unreliable. Don’t rely on it. It’s an expensive initiative without a lot of benefit.”

Dr Chaand Nagpaul, GPC lead negotiator on IT, said the current arrangements  undermine the benefit and usefulness of summary care records.

“The GPC have suggested workaround systems for practices who do not use smartcards, such as a ‘mop-up’ session where all new data is uploaded on to the national spine once a day. However, the DH decided against this option.”

There may be professionals who believe the SCR database  represents an up to date record said Nagpaul.

A DH spokesperson said that most practices which have created Summary Care Records use smartcards.

[Whether justified or not the SCR  scheme is believed to have cost about £250m so far.]

In 2010 Professor Ross Anderson at Cambridge University argued that the SCR could do more harm than good.

Richard Veryard also wrote on the unreliability of the SCR in 2010.

The Devil’s in the Detail – UCL report on the Summary Care Record.

Summary Care Record – where does the truth lie?

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Posted in BT, BT Health, Campaign4Change, change management, culture, data sharing, e-health, Government IT, health, health records, NHS, npfit, Summary Care Record

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DWP starts media campaign on Universal Credit IT tomorrow

Posted on 19/09/2012 | Leave a comment

By Tony Collins

The Work and Pensions Secretary Iain Duncan Smith has told MPs his department is launching a “major exercise” tomorrow to inform the media about Universal Credit, including progress with the IT project.

The public relations push will include a demonstration to journalists of the Univeral Credit front-end, and an explanation of the ability of “agile” to rectify problems as you go along. Duncan Smith said there is a lot of ignorance in the media, and suppositions, that need tackling head on.

His full statement on the PR campaign is at the foot of this article.

Comment

Iain Duncan Smith’s remarks to MPs sound remarkably like the statements that were made in the early part of the National Programme for IT in the NHS, when DH ministers and senior officials were anxious to correct ignorance and suppositions in the media – and to show journalists the front end of new electronic patient record systems.

Several times journalists were invited to Richmond house in Whitehall, the HQ of the DH, to hear how well the NPfIT was going. So anxious were the minister and leading officials to give a good impression of the programme that, on one occasion, trade journalists who had an insight into the NPfIT’s progress and could ask some awkward questions in front of the general media were barred from attending.

I would like Universal Credit to succeed. In concept it simplifies the excessively complex and costly benefit system. The worrying thing about the scheme, apart from the DWP’s overly sensitive reactions to scepticism in the media, is the way UC seems to be following the path which led to NPfIT’s downfall.

The Secretary of State attacks the media while trying to show UC in a glowing light and at the same time keeps secret all the DWP’s interview reviews and reports on actual progress. Duncan Smith says that the DWP wants to be open on UC but his department is turning down FOI requests.

There is no doubt that Duncan Smith has a conviction that the programme is on course, on budget, and will deliver successfully. But there still a morass of uncertainty for the DWP to contend with, and lessons to be learnt from pilots, some of which could be important enough to require a fundamental re-think. That’s to say nothing of HMRC’s Real-Time Information project which is part of UC.

Duncan Smith says the UC project is not due to be complete until 2017 which gives the DWP ample time to get it right. But ministers and officials in the last administration gave the NPfIT 10 years to complete; and today, nine years later, the scheme is being officially dismantled.

Did NPfIT ministers really know or understand the extent of the project’s true complexities and uncertainties?  Did they fully grasp the limited ability of suppliers to deliver, or the willingness of the NHS to change?  But they were impressed with the patient record front-end system and they organised several Parliamentary events to demonstrate it to MPs.

The NPfIT public relations exercises – which included DH-sponsored DVDs and a board game to market the NPfIT – were all in the end pointless.

Should Duncan Smith be running Universal Credit?

This is another concern. Duncan Smith is much respected and admired in Parliament but he appears too close to UC to be an objective leader. At a hearing of the Work and Pensions this week Duncan Smith took mild criticism of UC as if it were a verbal attack on his child.

It is doubtful anyone working for Duncan Smith would dare give him bad news on UC , though he attends lots of departmental meetings. Doubtless he listens to all those who agree with him, those who are walking press releases on the progress of the UC programme. He’d be a good marketing/PR man on UC. But surely not its leader. Not the one making the most important decisions. For that you would need somebody who’s free from the politics, who is independently minded, and who welcomes informed criticism.

Is there any point in a demo of front-end systems?

Seeing a front-end system means little or nothing. The question is will it work in practice when it is scaled up, when exceptions come to light, and when large numbers of people try to contact the helpdesks because they cannot get to grips with the technology and the interfaces,  or have particular difficulties with their claim.

What will a media campaign achieve?

If the NPfIT experiences are anything to go by, journalists who criticise the UC project will be made to feel stupid or uninformed.

In a totalitarian regime the media could be forced to publish what the government wants people to believe. Will the DWP’s PR campaign be designed to achieve the same end without the slightest attempt at coercion?

Duncan Smith’s comments to MPs

Below is some of what Iain Duncan Smith told Work and Pensions Committee MPs this week. He had been asked by a Committee MP to have a dialogue with the media to ensure that people believe that Universal Credit is a good thing.

Duncan Smith:

“On Thursday we are carrying out a major exercise in informing the median about what we are doing, looking at the system front-end, about budgets and all the elements the committee has been inquiring into.

“We will take them through that, show them that. We are going to open up much more. It is such an important system that I want people to learn what it is all about.  There is a lot of ignorance in the media and suppositions made; things that are important to tackle head on. Everyone says you mustn’t have a big bang; you are not going to be ready in time. The time we deliver this is 2017 when it is complete.  That is over four years…”

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Posted in Agile, Campaign4Change, change, change management, culture, DWP, e-health, excessive secrecy, FOI, Government IT, IT projects, managing change, managing outsourced services, NHS, npfit, Politics, procurement, project management, public sector, public services, Real-Time Information, Universal Credit

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IBM in dispute with its joint venture partners on £585m contract

Posted on 31/08/2012 | 1 comment

By Tony Collins

IBM says it is currently in dispute with the joint venture partners on a number of contractual matters relating to South West One, a joint venture between IBM and three public authorities. IBM owns the joint venture company.

South West One’s annual report says that a mediation was held on 4 and 5 July 2012 between IBM and Somerset County Council, which is the main public authority partner, on a confidential basis.

“No settlement has been reached and accordingly the board [of South West One] will be reviewing which of the remaining options in the contractual procedure should now be pursued,” says SW1’s annual report.

South West One’s report doesn’t give any detail on the “contractual matters” in dispute.

Possible matters under discussion might have included a withholding of money (the councils are expected to pay IBM about £585m over 10 years, from 2007),  contention over KPIs (IBM did not meet all of its key performance indicators and indeed met fewer of Somerset’s KPIs in 2011 than in 2010), changes to the contract which is being re-negotiated, a lack of remedial action over accounting problems in Somerset’s finance department following a major SAP implementation , a shortfall in expected savings, and the council’s extra costs of working around SAP-related problems .

It is known that a contract renegotiation has been underway for some time.

The contract was subjected to review after the Conservatives took control of Somerset County Council from the Liberal Democrats in May 2009.

The review in June 2010 found that some aspects of the contract had been successful but “figures provided do, however, tend to indicate that the anticipated procurement savings are currently falling short of projections”.

On service delivery the review said there had been “major and minor system problems and difficulties in implementation have been experienced which have often involved Somerset County Council staff in additional time and effort in working around these issues”.

It said that a “significant area of difficulty has been in relation to financial and processing components of SAP which have also had a serious effect on others outside Somerset County Council.

“As a result, there appears to have been substantial but unquantified additional direct and indirect costs incurred by the County Council and others in resolving the various difficulties encountered.

“Southwest One has also provided intensive additional resources at its own expense, notably in addressing the issues that arose in relation to the SAP phase one roll out where lessons have clearly been learned and applied to the more successful phase two implementation. More work is, however, still required as a priority in some key areas where concerns remain around the efficiency and effectiveness of service delivery and financial systems.”

South West One is dependent on the financial support of IBM to continue trading, says  company’s annual report. It adds that the “difficult political and economic environments in which the company has been operating have not shown any signs of easing”. Somerset has taken back from South West One finance, an HR advisory service, design and print.

“The difficult environment for business, both public and private, will continue to place strains upon opportunities for South West One,” said the annual report.

“There will be specific challenges in the forthcoming year due to the implementation of Universal Credit, the requirements of the Winsor report and changes in regard to the move from Police Authorities to Police Crime Commissioners.”

South West One made a loss in 2011 of £6.8m (a loss of £22.7m in 2010) and has accumulated net liabilities of £43.2m. The company can continue trading, in part because it has the support of IBM UK’s parent:  International Business Machines Corporation based at Armonk New York.

IBM owns 75% of the shares in South West One. Somerset owns 11.75%, Avon and Somerset Police Authority 8.25%, and Taunton Deane Borough Council 5%.

This article owes much to Dave Orr who has campaigned tenaciously for the facts of the South West One deal to be made known.  

Comment

The unsettled dispute suggests that the “partnership” aspect of the contract between IBM and the three public authorities – Somerset County Council, Taunton Deane Borough Council and Avon and Somerset Police Authority –  is at an end. A partnership normally implies a harmonious relationship between the parties.

Is it any surprise that things have come to this?

The South West One contract was signed in 2007, in the early hours, at a weekend, amid great haste and secrecy.  The deal was driven by a senior official at Somerset who wanted to take the council “beyond excellence”. But the joint venture had little support from many of the council staff who were seconded to South West One. Most councillors took little interest in the setting up of South West One.

IBM has found to its cost that signing a major contract with just an inner circle of enthusiasts is not enough to make such a deal work. Though some have changed many of Somerset’s councillors remain. It could be said that they deserve the deal they have got, given that so few of them took any interest in the negotiations in 2007.

Besides, it is unlikely that any joint venture which doesn’t have the support of most staff will work, which makes mutuals a potentially better shared-services option.

IBM struggles with SAP two years on – a shared services warning?

IBM-led model partnership based on SAP makes loss

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Posted in Campaign4Change, change, change management, cost reduction, culture, IBM, IT-related failures, legal disputes, local government, managing outsourced services, mutuals, openness and transparency, operational issues, outsourcing, Politics, procurement, public-private partnerships, SAP, shared services, Universal Credit

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Lessons from an IT disaster

Posted on 23/07/2012 | Leave a comment

By Tony Collins

Only rarely is an independent report on an IT-related disaster published.  So North Bristol NHS Trust deserves credit for publishing a report  by Pricewaterhousecoopers into the problematic go-live of Cerner Millennium in December 2011.  PwC calls the Cerner system a “business-critical patient record system”.

The implementation, says PwC,  resulted in significant continuing  operational difficulty. PwC was asked to review the implementation, identify what went wrong and make recommendations.

What is clear from PWC’s report is that North Bristol NHS Trust repeated the known mistakes of other trusts that had gone live with Cerner Millennium:

–          A lack of independent challenge

–          Not enough testing of the system and new business processes

–          Inadequate contingency arrangements

–          Not enough time for data migration

–          Training systems not the same as those to be used

–          Preparations treated as an IT project, not a change programme.

–          Differences between legacy and Cerner systems not fully understood before go live

–          Staff did not always understand new or changed business processes

In 2007 the National Audit Office reported in detail on the lessons from the go-live of Cerner Millennium at Nuffield Orthopaedic Centre, Oxford in December 2005.

One of those lessons was that the Trust did not learn lessons from earlier NPfIT Cerner Millennium go-lives. This happened again at North Bristol, suggests the PwC report:

“There were not dissimilar Cerner implementations within the Greenfield [other ex-Fujitsu and now BT-managed Cerner Millennium implementations under the NPfIT] systems running a few months before NBT’s [North Bristol Trust] implementation. Similar difficulties were experienced there, but they were more successfully addressed.”

Below are extracts from PwC’s report “Independent review of Cerner Millennium implementation North Bristol NHS Trust”.

“The success of an implementation of this scale, complexity and timing depends on substantial, robust and enduring programme management focusing on:

–          The IT implementation. Incorporating configuration of Cerner Millennium, infrastructure, security, interfaces and testing;

–          The migration of data from the two legacy PAS systems into Cerner Millennium;

–          Change management to engage and train stakeholders, embed change in the organisation and ensure that processes and procedures are aligned to the new system;

–          Continuous communication with users about changes to business processes as a result of the implementation; and

–          Quality control criteria and the association governance to ensure that go-live went ahead in a safe and sustainable manner.

–          The Trust needed stringent programme management with programme and project managers of the highest quality, to ensure that effective governance and project planning procedures were followed.

–          The go-live decision and assurances needed to pass strict criteria with sufficient evidence to provide assurance to the board that all necessary activities were completed prior to go-live.

The implementation in both the wards and the Emergency Department (ED) went well. Staff in ED were well engaged in the project and as a result were fully aware of the changes to their business processes at go live. There were some minor system issues initially but these were resolved quickly and ED was fully operational with Cerner Millennium soon after go live. One of the underlying factors in the success of the deployment to ED was that there was no data migration required as the historical data remains in the old system.

The launch in the wards went as expected; the functionality was tested well and the data was loaded manually, although there now appear to be issues with staff engaging and using the system as intended.

The majority of problems encountered at go live related to the theatre and outpatient clinic builds.

Outpatients had the most disruption immediately after go live. The Trust’s back office team had not finished building the outpatient clinics in Cerner Millennium, so the new and old systems did not mirror each other and data could not successfully migrate. Changes continued to be made to clinics in the old PAS systems, and these were not all reflected in Cerner Millennium.

Ad hoc clinics were used in the old PAS system to allow overbooking to maximise activity. These were not separated from real clinics at go live and migrated to Cerner Millennium as real clinics. The ad hoc clinics in PAS had deliberately abnormal timings so they could be excluded from time-based reports, for example 12:30am and 5:30am. The system generated letters for these ad hoc out- of-hours clinics, and many were sent to patients.

In the old system, clinics for a number of consultants could be pooled to facilitate patients seeing the next available consultant.  All clinics in Cerner Millennium are specific to a consultant and this caused significant confusion to administration staff using the new system.

PAS [the legacy patient administration system] treats “weeks” differently to Cerner Millennium. On migration, weeks were misaligned and the dates for clinics and theatres was incorrect. This created huge confusion as patient notes did not agree with Cerner Millennium , despite exhaustive work before go live to ensure that all patient notes were ready for the clinics that should have been on the system.  This also affected information in letters, with patients advised to attend their appointment on the wrong date.

There was a further issue in theatres relating to theatre procedure codes. The Trust did not map the old procedure codes to the new to ensure that all the required procedures would be available in Cerner Millennium for the data to migrate successfully. The Trust identified this issue soon after go live and has run a parallel manual process to ensure patients received the correct procedures.

The training provided to staff by the Trust did not equip them to be able to use Cerner Millennium at go live. The training environment did not mirror the system the Trust implemented as certain elements of the system were not complete when the training domain was created. Theatre staff and outpatient appointments could not train on a system with theatre schedules and outpatient clinics built in.

The Trust is now beginning to move out of the crisis and return to normal operations.

Lack of effective quality controls

There was insufficient rigour over the controls criteria and sign off of the gateway reviews.

There was inadequate operational control over the go live process, such as clinic freeze and updates pre-, during, and post go-live. Evidence from the interviews suggests that:

  • There was little challenge to confirm that the gateway criteria had in fact been met.
  • There was no evidence presented to the Cerner Programme Board or the Trust Board to demonstrate that the gateway criteria had been met.
  • There was not enough focus on or monitoring of risks and issues and their impact on go live.
  • The cleansing of old and out-of-date data from the legacy PAS systems was inadequate; as a result, erroneous data became live data in the Cerner system.
  • Data Migration issues were not all resolved and their impact on go live was not considered.
  • The outpatient and theatre builds were neither complete nor accurate, and there were no controls which could have detected this before go live.
  • There were inadequate controls over clinic freeze and clinic changes prior to go live.

Lack of effective programme planning

Programme plans were not rigorously updated as the programme progressed and planning around training, testing and data migration and build was not robust. The Trust failed to recognise this programme as a change programme and did not effectively manage the engagement and feedback from their stakeholders. Evidence from the interviews suggests that:

  • The Trust did not factor contingency into its programme plan to account for changes to the go live date.
  • The Cerner Programme Management Office was not effective because of inadequate resource and programme tools.
  • The Trust had a lack of sufficiently skilled resources for a project on this scale.
  • The Trust’s operational staff were not fully engaged in the Cerner project.
  • The Cerner project was treated as an IT project and not a business change programme.
  • The training was inadequate and did not provide users with the skills they needed to be able to use the system at go live.
  • The testing focused on the functionality of the system and not end-user testing of the outpatient and theatre builds.
  • There was no end-user testing of the final outpatient clinic and theatre builds prior to go live.
  • There was lack of understanding of roles within the wider programme team.
  • External parties offered NBT help and advice. They felt that the advice was not taken and the help was refused.

Lack of effective programme governance

Programme governance processes were not reviewed and updated regularly to ensure that they were adequate and there was inappropriate accountability for key decision making. During the implementation, the Trust established new overarching change management arrangements for the Building our Future programme. Evidence from the interviews suggests that:

  • The Cerner Project team failed to comply with the Trust’s Building our Future governance processes
  • The information presented to the Cerner Programme Board and the Trust board by the Cerner Project team was inadequate for them to make informed decisions;
  • The Cerner Programme Board was not effective; and
  • Significant issues relating to the theatre and outpatient clinic build were not escalated to the Cerner Programme Board or the Trust board.

PwC’s Conclusions

For a programme of this scale and complexity, the management arrangements were not sufficiently extensive or robust. There were many issues with the software and data migration, the training of users and operational go live planning. The Trust Board and the Cerner Programme Board did not plan to have, and did not receive, independent assurance that the state of the programme supported a decision to go-live.

Complex IT implementations are never without risks and issues that need to be managed, even at the point of go live. The scale of the issues in this implementation was not properly understood by those with responsibility, and as a result they were not in a position to make sound decisions.

Many of the problems are associated with poor data and process migration. Staff found that a significant proportion of migrated data was incorrect in the new system, and this had rapid and substantial operational impact which has taken a considerable time to rectify with manual processes. Staff needed to be more directly involved in migration and process testing.

The implementation was manifestly a complex change programme. But IT took the lead, and there was no intelligent customer with sufficient distance from IT to ensure products and progress were properly challenged.

There were not dissimilar Cerner implementations within the Greenfield running a few months before NBT implementation. Similar difficulties were experienced there, but they were more successfully addressed.”

PwC recommends that:

–  the Trust “stop and take stock”. It says  “The Trust needs to take stock of its position and develop a coherent and detailed plan for the remainder of the recovery stage. The Trust then needs to ensure that effective cross programme planning and governance arrangements are enforced for all current projects, especially those under the Building Our Future programme.”

PwC also recommends that the Trust carry out a:

–  Governance review

– Capability/capacity review

– Cross programme plan review

– Operational assessment

– Review of process and controls

– Review of information requirement

– Technical resilience/infrastructure review

– Review of access controls

Comment:

To me the PwC report throws up at least six points:

1) Are NPfIT go-lives more political than pragmatic?

In the 1990s Barclays Bank went live with new systems for all its branches. During the night (I was invited to watch the go-live at head office) the most striking element was a check list that asked questions on progress so far. The answers determined whether the go-live would happen. The check-list was completed repeatedly – seemingly endlessly – during the night.

Many  different types of mishaps could have stopped the go-live.  None did.  Go-lives of Cerner Millennium are different. They seem unstoppable, whatever the circumstances, whatever the problems.  There was nothing political about the Barclays go-live. But NPfIT go-lives are intensely political.

Would North Bristol’s board have accepted with equanimity a last-minute cancellation, especially after go-lives had been postponed at least twice before?

2)  Are NHS boards too focused on “good news” to oversee an NPfIT go live?

North Bristol NHS Trust deserves praise for publishing the PwC report.  But it’s not the whole story.  The report says little about any potentially serious impact on patients. Also it mentions (almost in passing) that the Trust board discussed in November 2011 the readiness of Cerner Millennium to go live. That discussion was probably positive because Millennium went live a month later. But there is no mention of that discussion in the Trust’s board papers for November 2011.

Why did the Trust discuss its readiness to go live in secret? And why did it keep secret its November 2011 report on its readiness to go live?

If North Bristol, like so many NHS trusts, is congenitally beset with a good news culture at board level, can the full truth ever be properly discussed?

3) Isn’t it time Cerner lessons were learnt?

After seven years of Cerner implementations in the NHS, several of them notorious failures, isn’t it time Trusts learnt the lessons?

4)  What’s the current position?

PwC’s report is succinct and professional. It’s also diplomatically-worded. There is little in the report that points to how the Trust is coping with the operational difficulties. Indeed it suggests the Trust is returning to normal. “The Trust is now beginning to move out of the crisis and return to normal operations,” says the PwC report. But that is, in essence, what the Trust has been saying publicly since January 2012.  PwC says nothing about whether the safety of patients has been jeopardized by the go-live.

5) Where were the Trust’s Audit Committee – and internal auditors?

Every NHS Trust has an audit committee and internal auditors to warn about things that are going wrong, or may go wrong. It appears that they were out to lunch when it came to North Bristol’s Cerner Millennium project and its consequences.  The Audit Committee seems hardly to have mentioned the project. Should North Bristol’s board hold the Audit Committee and internal auditors to account?

6) Is the Trust board to blame?

Perhaps rightly PwC does not seek to apportion blame. But did the Trust board ask the right questions often enough?  The tacit criticism in the PwC report is of the IT department and layers of management below board level. But is that criticism misdirected? If the board’s culture of encouraging good news – of “bring me solutions not problems” –  has not changed, perhaps little or nothing will have been learned from North Bristol’s IT-related disaster.

PWC report Independent review of Cerner Millennium implementation North Bristol NHS Trust.

Lessons from Nuffield Orthopaedic’s Cerner Millennium implementation in 2005.

North Bristol apologises over Cerner go-live.

New hospital system caused chaos.

MP asks why two Cerner systems cost vastly different prices.

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How CIOs and IT suppliers view GovIT change

Posted on 25/06/2012 | 3 comments

By Tony Collins

CIOs and IT suppliers give their views on Government ICT in an authoritative report published today by the Institute for Government

Inside the wrapper of generally positive words, a report published today on government ICT by the Institute for Government suggests that major change is unlikely to happen, despite the best efforts of  CIOs and the Cabinet Office minister Francis Maude.

The report “System upgrade? The first year of the Government’s ICT strategy”  says progress has been made. But its messages suggest that reforms are unlikely to  amount to more than tweaks.

These are some of the key messages in the report:

If the minister and CIOs cannot direct change who can?

–          “… while the Minister for the Cabinet Office and government CIO are viewed as being responsible for delivering the ICT strategy (for example by the Public Accounts Committee) they currently lack the full authority to direct change.”

Not so agile

–           “While just over half of government departments may be running an agile project, there were concerns that these were often very minor projects running on the fringe of the departments.”

–          “We heard concerns from the supplier community and those inside government that in some areas projects may be being labelled as ‘agile’ without having really changed the way in which they were run.”

–          “CIOs should question whether they are genuinely improving the ways that they are working in areas such as agile, or whether they are just attaching a label to projects to get a tick in the box,” says the Institute for Government.

Savings not real?

–          “There was also an element of challenge to the savings figures provided by government. For example, some from government and the supplier community questioned whether the numbers represented genuine savings or just cuts in the services provided or deferred expenditure. “

–          “Others … cautioned that project scope creep or change requests could reduce actual savings in time. It was pointed out that the NAO [National Audit Office] will scrutinise whether savings have been achieved in future, which was seen as a clear incentive for accuracy – but there were, nonetheless, concerns that pressure to provide large savings figures meant that inadequate attention might be paid to verifying the savings …”

CIOs want faster ICT progress

–          “Among the CIOs we interviewed, there was a clear recognition that government ICT needed to improve.  ‘You expect an Amazon experience from a government department…’ ”

Lack of money good for change

–          “As one ICT lead noted, a lack of money was ‘always helpful’ in driving change as it promoted cross-government solution-sharing and led to more rigour in approving new spend.”

–          “Both ICT leaders and suppliers felt that the ICT moratorium had been a helpful stimulus for increased focus on value for money.”

–          “Though some of the larger suppliers felt bruised by the ‘smash and grab’ of initial interactions with the Coalition government, there was a recognition that the moratorium had been about ‘stopping things which were inappropriate’”.

GDS challenges norms

–          “New ways of working in the new Government Digital Service and the opening up of government through the Transparency agenda were also seen as providing a challenge to existing norms.”

–          The new Government Digital Service (GDS) is providing an example of a new way of doing things, and was pointed to by those inside and outside of government as embodying mould-breaking attitudes, using innovative techniques and … delivering results on very short timescales. Several interviews mentioned being invigorated by the positive approach of the GDS and their focus on delivering services to meet end-user needs.

ICT so poor staff circumvent it

–          “Public servants are increasingly frustrated that the ICT they use in their private lives appears to be far more advanced than the tools available to them at work. Indeed, there are already examples of employees circumventing the ICT that government provides them as they attempt to perform their job more effectively: creating what is known as a system of ‘shadow ICT’ that creates significant challenges for maintaining government security, collaborative working and government knowledge management.”

Joined-up Govt impossible?

–          “The possibility that departmental incentives continue to trump corporate contributions is further suggested by our survey results. Individuals do not yet feel that corporate contributions are valued or rewarded … elements of the [ICT] strategy call for departments to give up an element of autonomy and choice for the ‘greater good’. Several CIOs expressed concerns that by adopting elements of the strategy that were being developed or delivered by another department, they would end up having to accept a service that had been designed  around the needs of a different department.”

–          “Similarly, there were concerns that the host department would be at the top priority in the event of any problems or opportunities to develop services further. This speaks to a strongly department-centric culture. Suppliers noted, for example, that certain parts of government were still happy to ‘pay a premium for their autonomy’.”

–          “… the vast majority of those we spoke to suggested that departmental interests would almost always ultimately trump cross-government interests in the current government culture and context.”

–          “CIOs felt that they would be rewarded for delivery of departmental priorities – not pan-government work …”

CIO Council frustrations

“CIOs noted that there could be a discrepancy between what got agreed at the old CIO Council meetings and what people actually went away and did. Larger department CIOs also expressed frustration that – despite holding the largest budgets and carrying the largest delivery risks – their voices could easily be outweighed by the multitude of other people round the table.”

“The delivery board model [which has superseded CIO Council] has been recognised by both big and small departments as pragmatically dealing with both sides of this issue. Larger departments now form part of an inner-leadership circle, but with this recognition of their clout comes additional responsibility to own and drive through parts of the strategy… the challenge will now be to ensure that the ICT strategy doesn’t become a ‘large department-only’ affair and that other ICT leads can be effectively engaged.”

Canny suppliers?

–          The majority of ICT leads …stated that they believed the ICT strategy would benefit their department and government as a whole. This confidence was less apparent in the attitudes of suppliers who were, on the whole, more sceptical of government’s ability to drive change, though again generally supportive of the direction of travel.

A toothless ICT Strategy is of little value?

–          “…There was also a lack of clarity on how different elements of the [ICT] strategy would be enforced. As one ICT leader commented … ‘Is this a mandatable strategy or a reference document?’ ”

–          … “there are risks that the strategy could be delivered in a way that still doesn’t transform ICT performance.”

Francis Maude an asset

–          “Government ICT has also been a priority of the Minister for the Cabinet Office, Francis Maude – giving the [change] agenda unprecedented ministerial impetus. He has been a visible face of ICT to many inside and outside of government, from demanding departmental data on ICT to being heavily involved in negotiations with ICT suppliers. Though few of his ministerial colleagues appear as passionate about improving government ICT, the CIOs we interviewed overwhelmingly expressed confidence that they would receive the support they needed to implement the changes in ICT.”

Smaller-budget CIOs out of the loop?

–          “With the CIO Council in hiatus for most of the last year, the CIOs of smaller departments felt out of the loop …”

Most ICT spending is outside SW1

–          “Suppliers and other ICT leaders pointed out, rightly, that the vast majority of ICT expenditure happens outside SW1 – with agencies, local government and organisations like primary care trusts and police forces still determining much of the citizen and workforce experience of ICT.”

SMEs still left out?

–          “Smaller suppliers … were generally encouraged that government was trying to use more contractual vehicles which would be open to them – but noted that it was ‘still extremely difficult to get close to government as an SME’.”

Who knows if use of ICT is improving?

–          “Government still lacks the information it needs to judge whether use of ICT across government is improving.”

System upgrade? The first year of the Government’s ICT Strategy.

Too early to claim success on GovIT – Institute for Government

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Posted in Campaign4Change, capacity building, change, change management, CIO, cost reduction, culture, efficiency savings, governance, Government IT, IT projects, IT-related failures, Major Projects Authority, managing change, managing outsourced services, procurement, reducing cost strategically

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Civil service reform plan – real change or a tweak?

Posted on 19/06/2012 | Leave a comment

By Tony Collins

The civil service reform plan is to be published this afternoon, at 3.30pm.  The Cabinet Office minister  Francis Maude and Sir Bob Kerslake, the head of the civil service, write about it in today’s Daily Telegraph.

They say that the plan will help deliver a civil service culture that is “pacier, more innovative, less hierarchical and focused on outcomes not process”. They write:

“We also need sharper accountability, in particular from permanent secretaries and those leading major projects, and we need more digital services, better data and management information and for policy and implementation to be linked seamlessly together…”

In the same edition of the Telegraph Andrew Haldenby,  director of the independent think tank Reform, criticises the reform plan which, although not yet published, has been foretold in newspapers including the Financial Times yesterday.

He said the reform plan will “leave the flawed structures of Whitehall in place and do no more than propose some minor variations on a theme”.

We await publication of the paper before we judge it. We hope it will, at least, require the publication of “Gateway” review reports on the progress or otherwise of major IT-enabled projects.

Without timely publication of the Major Projects Authority’s Gateway reports, MPs and the public will continue to learn of failed schemes such as the NPfIT and Firecontrol when it is too late to do much about any rescue; and without contemporaneous publication there will continue to be no accountability for the rigour or otherwise of the reviews, or their outcome.

Civil service reform – meltdown or business as usual? – Institute for Government

Cabinet Office promises unprecedented openness on big, risky projects.

Civil service shake-up – Guardian

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Francis Maude talks open govt – and Whitehall does the opposite

Posted on 12/06/2012 | Leave a comment

By Tony Collins

“If people do not know what you’re doing, they don’t know what you’re doing wrong.” – Sir Arnold Robinson, Cabinet Secretary in a discussion on open government in Yes Minister.

Francis Maude, the Cabinet Office minister, said all the right things at the Intellect World Class Public Services conference 2012.

He said that:

– smaller, innovative and efficient suppliers were finding themselves locked out of the supply of services to Government because of what was described by Parliament as a powerful “oligopoly” of large suppliers

– for the first time in Government “we are using agile, iterative processes, open source technology platforms and world-class in-house development teams alongside the best digital innovation the market can offer”

– “We must eliminate failure waste. At the moment, a large proportion of our service delivery costs are incurred through incomplete or failed digital transactions. And these transactions create cross-channel duplication, which burdens the user and costs Government a huge amount in repeated costs. For HMRC alone, they estimate that 35% of calls to its contact centres are avoidable, which would save £75m.”

– “Transparency is a defining passion for this Government …”

Comment:

How much influence does Maude really have? Can he persuade permanent secretaries to effect major change? The evidence so far is that departmental officials and Maude have different ideas on what reform means.

In “Yes Minister” civil servants were proud of a new hospital that was the best run and most hygienic in the country, with no medical staff, 500 administrators and no patients.

Maude may also recall that Antony Jay and Jonathan Lynn, the acclaimed writers of Yes Minister, spoke of the Whitehall law of inverse relevance – “the less you intend to do about something, the more you have to keep talking about it”.

Open government? 

Perhaps civil servants are letting Maude get on with talking the talk while they find every way to keep things much as they are. A good example: The Guardian reported yesterday that a key part of the Government’s transparency drive has stalled amid reports of ministry opposition.

The paper’s political editor Patrick Wintour reported that plans to publish regular ‘traffic-light’ progress reports on large, costly and risky IT projects “appear to have been shelved”.

When it comes to IT this could have been the coalition’s most important single reform. It would have given MPs and the public a way of knowing when mega projects such as Universal Credit are failing. Usually we don’t know about a failed IT-related project unless there is a leak to the media, or the National Audit Office finds out and decides, with its limited budget, to do a study.

Sir Bob Kerslake, who is head of the civil service,  had indicated to MP Richard Bacon that “Gateway” review reports on large and risky IT and construction projects may be published in the civil service reform plan which is expected to be released this month.

Gateway reports to go unpublished?

Now it seems that departmental civil servants  have persuaded the Sir Bob not to publish “Gateway” reports. So the secrecy over the progress or otherwise of government mega projects is set to continue.

Yes, civil servants will allow the Cabinet Office to have its way on the publication of data about, say, some government spending. But it’s becoming clear that the civil service will not allow any publication of its reports on the progress or otherwise of major projects. It has been that way since Gateway reviews were introduced in 2001.

Some senior officials – by no means all – say they want a confidential “safe space” to discuss the progress of projects. The reality is that they do not want outsiders – MPs, the media and NAO auditors – meddling in their failing schemes – schemes such as Firecontrol and e-filing at the Ministry of Justice.

Unlike Maude, senior civil servants have what Jay and Lynn call a “flexible approach to open government”. This means in practice that Whitehall will happily release data – but not project reports on which the civil servants themselves can be judged.

Activity is not achievement

Maude’s speeches will give the impression of activity. But activity is the civil service’s substitute for achievement. I quote Jay and Lynn again, in part because their depiction of Whitehall seems to have been taken as serious wisdom by those officials who think Sir Humphrey a character worth living up to.

It’s time Maude and his team got a grip on departments. Until they do, permanent secretaries and their senior officials will regard Maude as trying to get out of situations that don’t need getting out of.

Whitehall to relent on secrecy over mega projects?

The empty hospital – Yes Minister

Government’s transparency drive stalls.

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Posted in Campaign4Change, change management, cost avoidance, cost reduction, culture, excessive secrecy, Gateway reviews, Government IT, IT-related failures, Major Projects Authority, openness and transparency, oversight, Politics, SME

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