Category Archives: Department of Health

Inside Universal Credit IT – analysis of document the DWP didn’t want published

dwpBy Tony Collins

Written evidence the Department for Work and Pensions submitted to an FOI tribunal – but did not want published (ever) – reveals that there was an internal “lack of candour and honesty throughout the [Universal Credit IT] Programme and publicly”.

It’s the first authoritative confirmation by the DWP that it has not always been open and honest when dealing with the media on the state of the Universal Credit IT programme.

FOI tribunal grants request to publish DWP's written submission

FOI tribunal grants request to publish DWP’s written submission

According to the DWP submission, senior officials on the Programme became so concerned about leaks that a former member of the security services was brought in to lead an investigation. DWP staff and managers were the subjects of “detailed interviews”. Employee emails were “reviewed”, as were employee access rights to shared electronic areas.

Staff became “paranoid” about accidentally leaving information on a printer. Some of the high-security measures appear still to be in place.

Unpublished until now, the DWP’s written legal submission referred, in part, to the effects on employees of leak investigations.

The submission was among the DWP’s written evidence to an FOI Tribunal in February 2016.

The Government Legal Service argued that the DWP’s written evidence was for the purposes of the tribunal only. It should not be published or passed to an MP.

The Legal Service went further: it questioned the right of an FOI Tribunal to decide on whether the submission could be published. Even so a judge has ruled that the DWP’s written evidence to the tribunal can be published.

Excerpts from the submission are here.

Analysis and Comment

The DWP’s submission gives a unique glimpse into day-to-day life and corporate sensitivities at or near the top of the Universal credit IT programme.

It reveals the lengths to which senior officials were willing to go to stop any authoritative “bad news” on the Universal Credit IT programme leaking out. Media speculation DWP’s senior officials do not seem to mind. What appears to concern them is the disclosure of any credible internal information on how things are progressing on Universal Credit IT.

Confidential

Despite multiple requests from IT suppliers, former government CIOs and MPs, for Whitehall to publish its progress reports on big IT-based change programmes (some examples below), all central departments keep them confidential.

That sensitivity has little to do with protecting personal data.

It’s likely that reviews of projects are kept confidential largely because they could otherwise expose incompetence, mistakes, poor decisions, risks that are likely to materialise, large sums that have been wasted or, worst of all, a project that should have been cancelled long ago and possibly re-started, but which has been kept going in its original form because nobody wanted to own up to failure.

Ian watmore front cover How to fix government IROn this last point, former government CIO and permanent secretary Ian Watmore spoke to MPs in 2009 about how to fix government IT. He said,

“An innovative organisation tries a lot of things and sometimes things do not work. I think one of the valid criticisms in the past has been when things have not worked, government has carried on trying to make them work well beyond the point at which they should have been stopped.”

Individual accountability for failure?

Oblivious to MPs’ requests to publish IT progress reports, the DWP routinely refuses FOI requests to publish IT progress reports, even when they are several years old, even though by then officials and ministers involved will probably have moved on. Individual accountability for failure therefore continues to be non-existent.

Knowing this, MPs on two House of Commons select committees, Public Accounts and Work and Pensions, have called for the publication of reports such as “Gateway” reviews.

This campaign for more openness on government IT projects has lasted nearly three decades. And still Whitehall never publishes any contemporaneous progress reports on big IT programmes.

It took an FOI campaigner and IT projects professional John Slater [@AmateurFOI] three years of legal proceedings to persuade the DWP to release some old reports on the Universal Credit IT programme (a risk register, milestone schedule and issues log). And he had the support of the Information Commissioner’s legal team.

universal creditWhen the DWP reluctantly released the 2012 reports in 2016 – and only after an informal request by the then DWP secretary of state Stephen Crabb – pundits were surprised at how prosaic the documents were.

Yet we now know, thanks to the DWP’s submission, the lengths to which officials will go to stop such documents leaking out.

Understandable?

Some at the DWP are likely to see the submission as explaining some of understandable measures any government department would take to protect sensitive information on its largest project, Universal Credit. The DWP is the government largest department. It runs some of the world’s biggest IT systems. It possesses personal information on nearly everyone in Britain. It has to make the protection of its information a top priority.

Others will see the submission as proof that the DWP will do all it can to honour a decades-old Whitehall habit of keeping bad news to itself.

Need for openness

It’s generally accepted that success in running big IT-enabled change programmes requires openness – with staff and managers, and with external organisations and agencies.

IT-based change schemes are about solving problems. An introspective “good news only” culture may help to explain why the DWP has a poor record of managing big and successful IT-based projects and programmes. The last time officials attempted a major modernisation of benefit systems in the 1990s – called Operational Strategy – the costs rose from £713m to £2.6bn and the intended objective of joining up the IT as part of a “whole person” concept, did not happen.

Programme papers“watermarked”

The DWP’s power, mandate and funding come courtesy of the public. So do officials, in return, have the right to keep hidden mistakes and flawed IT strategies that may lead to a poor use – or wastage – of hundreds of millions of pounds, or billions?

The DWP’s submission reveals that recommendations from its assurance reports (low-level reports on the state of the IT programme including risks and problems) were not circulated and a register was kept of who had received them.

Concern over leaks

The submission said that surveys on staff morale ceased after concerns about leaks. IT programme papers were no longer sent electronically and were delivered by hand. Those that were sent were “double-enveloped” and any that needed to be retained were “signed back in”. For added security, Universal Credit programme papers were watermarked.

When a former member of the security services was brought in to conduct a leaks investigation, staff and mangers were invited by the DWP’s most senior civil servant to “speak to the independent investigator if they had any information”. This suggests that staff were expected to inform on any suspect colleagues.

People “stopped sharing comments which could be interpreted as criticism of the [Universal Credit IT] Programme,” said the submission. “People became suspicious of their colleagues – even those they worked closely with.

“There was a lack of trust and people were very careful about being honest with their colleagues…

“People felt they could no longer share things with colleagues that might have an honest assessment of difficulties or any negative criticism – many staff believed the official line was, ‘everything is fine’.

“People, even now, struggle to trust colleagues with sensitive information and are still fearful that anything that is sent out via email will be misused.

“For all governance meetings, all documents are sent out as password protected, with official security markings included, whether or not they contain sensitive information.”

“Defensive”

dwpLines to take with the media were added to a “Rolling Brief”, an internal update document, that was circulated to senior leaders of the Universal Credit IT programme, the DWP press office and special advisors.

These “lines to take” were a “defensive approach to media requests”. They emphasised the “positive in terms of progress with the Programme without acknowledging the issues identified in the leaked stories”.

This positive approach to briefing and media management “led to a lack of candour and honesty through the Programme and publically …”

How the DWP’s legal submission came about is explained in this separate post.

Were there leaks of particularly sensitive information?

It appears not. The so-called leaks revealed imperfections in the running of the Universal Credit programme; but there was no personal information involved. Officials were concerned about the perceived leak of a Starting Gate Review to the Telegraph (although the DWP had officially lodged the review with the House of Commons library).

The DWP also mentioned in its statement a leak to the Guardian of the results of an internal “Pulse” survey of staff morale – although it’s unclear why the survey wasn’t published officially given its apparent absence of sensitive commercial, personal, corporate or governmental information.

NPfIT

The greater the openness in external communications, the less likely a natural scepticism of new ways of working will manifest in a distrust of the IT programme as a whole.

The NHS’s National Programme for IT (NPfIT) – then the UK’s biggest IT programme costing about £10bn – was dismantled in 2011 after eight fraught years. One reason it was a disaster was the deep distrust of the NPfIT among clinicians, hospital technologists, IT managers, GPs and nurses. They had listened with growing scepticism to Whitehall’s oft-repeated “good news” announcements.

Ex-Government CIO wanted more openness on IT projects

When MPs have asked the DWP why it does not publish reports on the progress of IT-enabled projects, it has cited “commercial confidentiality”.

But in 2009, Ian Watmore (the former Government CIO) said in answer to a question by Public Account Committee MP Richard Bacon that he’d endorse the publication of Gateway reviews, which are independent assessments of the achievements, inadequacies, risks, progress and challenges on risky IT-based programmes.

“I am with you in that I would prefer Gateway reviews to be published because of the experience we had with capability reviews (published reports on a department’s performance). We had the same debate (as with Gateway reviews) and we published them. It caused furore for a few weeks but then it became a normal part of the furniture,” said Watmore.

Capability reviews are no longer published. The only “regular” reports of Whitehall progress with big IT programmes are the Infrastructure and Projects Authority’s annual reports. But these do not include Gateway reviews or other reports on IT projects and programmes. The DWP and other departments publish only their own interpretations of project reviews.

In the DWP’s latest published summary of progress on the Universal Credit IT programme, dated July 2016, the focus is on good news only.

But this creates a mystery. The Infrastructure and Projects Authority gave the Universal Credit programme an “amber” rating in its annual report which was published this month. But neither the DWP nor the Authority has explained why the programme wasn’t rated amber/green or green.

MPs and even IT suppliers want openness on IT projects

Work and Pensions Committee front coverIn 2004 HP, the DWP’s main IT supplier, told a Work and Pensions Committee inquiry entitled “Making IT work for DWP customers” in 2004 that “within sensible commercial parameters, transparency should be maintained to the greatest possible extent on highly complex programmes such as those undertaken by the DWP”.

The Work and Pensions Committee spent seven months investigating IT in the DWP and published a 240-page volume of oral and written in July 2004. On the matter of publishing “Gateway” reviews on the progress or otherwise of big IT projects, the Committee concluded,

“We found it refreshing that major IT suppliers should be content for the [Gateway] reviews to be published. We welcome this approach. It struck us as very odd that of all stakeholders, DWP should be the one which clings most enthusiastically to commercial confidentiality to justify non-disclosure of crucial information, even to Parliament.”

The Committee called for Gateway reviews to be published. That was 12 years ago – and it hasn’t happened.

Four years later the Committee found that the 19 most significant DWP IT projects were over-budget or late.

DWP headline late and over budget

In 2006 the National Audit Office reported on Whitehall’s general lack of openness in a report entitled “Delivering successful IT-enabled business change”.

The report said,

“The Public Accounts Committee has emphasised frequently the need for greater transparency and accountability in departments’ performance in managing their programmes and projects and, in particular, that the result of OGC Gateway Reviews should be published.”

But today, DWP officials seem as preoccupied as ever with concealing bad news on their big IT programmes including Universal Credit.

The costs of concealment

The DWP has had important DWP project successes, notably pension credits, which was listed by the National Audit Office as one of 24 positive case studies.

But the DWP has also wasted tens of millions of pounds on failed IT projects.

Projects with names such as “Camelot” [Computerisation and Mechanisation of Local Office Tasks] and Assist [Analytical Services Statistical Information System) were cancelled with losses of millions of pounds. More recently the DWP has run into problems on several big projects.

“Abysmal”

On 3 November 2014 the then chairman of the Public Accounts Committee Margaret Hodge spoke on Radio 4’s Analysis of the DWP’s ‘abysmal’ management of IT contracts.”

1984

As long ago as 1984, the House of Commons Public Accounts Committee called for the civil service to be more open about its progress on major computer projects.

Today there are questions about whether the Universal Credit IT will succeed. Hundreds of millions has already been spent. Yet, as mentioned earlier, current information on the progress of the DWP’s IT programmes remains a state secret.

It’s possible that progress on the Universal Credit IT programme has been boosted by the irregular (but thorough) scrutiny by the National Audit Office. That said, as soon as NAO reports on Universal Credit are published, ministers and senior officials who have seen copies in advance routinely dismiss any criticisms as retrospective and out-of-date.

Does it matter if the DWP is paranoid about leaks?

A paper published in 2009 looks at how damaging it can be for good government when bureaucracies lack internal challenge and seek to impose on officials a “good news” agenda, where criticism is effectively prohibited.

The paper quoted the then Soviet statesman Mikhail Gorbachev as saying, in a small meeting with leading Soviet intellectuals,

“The restructuring is progressing with great difficulty. We have no opposition party. How then can we control ourselves? Only through criticism and self-criticism. Most important: through glasnost.”

Non-democratic regimes fear a free flow of information because it could threaten political survival. In Russia there was consideration of partial media freedom to give incentives to bureaucrats who would otherwise have no challenge, and no reason to serve the state well, or avoid mistakes.

The Chernobyl nuclear disaster, which occurred on April 26, 1986, was not acknowledged by Soviet officials for two days, and only then after news had spread across the Western media.

The paper argued that a lack of criticism could keep a less democratic government in power. But it can lead to a complacency and incompetence in implementing policy that even a censored media cannot succeed in hiding.

As one observer noted after Chernobyl (Methvin in National Review, Dec. 4, 1987),

“There surely must be days—maybe the morning after Chernobyl—when Gorbachev wishes he could buy a Kremlin equivalent of the Washington Post and find out what is going on in his socialist wonderland.”

Red team

Iain DuncanSmithA lack of reliable information on the state of the Universal Credit IT programme prompted the then secretary of state Iain Duncan Smith to set up his own “red team” review.

That move was not known about at the time. Indeed in December 2012 – at a point when the DWP was issuing public statements on the success of the Universal Credit Programme – the scheme was actually in trouble. The DWP’s legal submission said,

“In summary we concluded (just before Christmas 2012) that the IT system that had been developed for the launch of UC [Universal Credit] had significant problems.”

One wonders whether DWP civil servants kept Duncan Smith in the dark because they themselves had not been fully informed about what was going on, or because they thought the minister was best protected from knowing what was going on, deniability being one key Whitehall objective.

But in the absence of reliable internal information a political leader can lose touch completely, said the paper on press freedom.

“On December 21, 1989, after days of local and seemingly limited unrest in the province of Timi¸ Ceausescu called for a grandiose meeting at the central square of Bucharest, apparently to rally the crowds in support of his leadership. In a stunning development, the meeting degenerated into anarchy, and Ceausescu and his wife had to flee the presidential palace, only to be executed by a firing squad two days later.”

Wrong assumptions

Many times, after the IT media has published articles on big government IT-based project failures, TV and radio journalists have asked to what extent the secretary of state was responsible and why he hadn’t acted to stop millions of pounds being wasted.

But why do broadcast journalists assume ministers control their departments? It is usually more likely that ministers know little about the real risks of failure until it is too late to act decisively.

Lord Bach, a minister at DEFRA, told a House of Commons inquiry in 2007 into the failure of the IT-based Single Payment Scheme that he was aware of the risks but still officials told him that systems would work as planned and farmers would receive payments on time. They didn’t. Chaos ensued.

Said Lord Bach,

“I do think that, at the end of the day, some of the advice that I received from the RPA [Rural Payments Agency] was over-optimistic.”

Lord WhittyAnother DEFRA minister at the time Lord Whitty, who was also party in charge of the Single Payment Scheme, told the same inquiry,

“Perhaps I ought also to say that this was the point at which I felt the advice I was getting was most misleading, and I have used the term ‘misleading’ publicly but I would perhaps prefer to rephrase that in the NAO terms …”

Even the impressive Stephen Crabb – who has now quit as DWP secretary of state – didn’t stand much of chance of challenging his officials. The department’s contracts, IT and other affairs, are so complex and complicated – there are bookcases full of rules and regulations on welfare benefits – that any new ministers soon find themselves overwhelmed with information and complexity.

They will soon realise they are wholly dependent on their officials; and it is the officials who decide what to tell the minister about internal mistakes and bad decisions. Civil servants would argue that ministers cannot be told everything or they would be swamped.

But the paper on press freedom said that in order to induce high effort within a bureacucracy, the leader needs “verifiable information on the bureaucrats’ performance”.

The paper made a fascinating argument that the more complacent the bureaucracy, the more aggressively it would control information. Some oil-rich countries, said the paper, have less media freedom than those with scarcer resources.

“Consistent with our theory, [some] non-democratic countries … have vast resources and poor growth performance, while the Asian tigers (South Korea, Taiwan, Hong Kong, and Singapore), while predominantly non-democratic in the 1970s and 1980s, have high growth rates and scarce natural resource.”

In an apparent opening up of information, the government in China passed a law along the lines of the U.S. Freedom of Information Act (“China Sets Out to Cut Secrecy, but Laws Leave Big Loopholes,” New York Times, Apr. 25, 2007). But was this law self-serving? It, and the launch of local elections, provided the central government with relatively reliable information on the performance of provincial bosses.

These stories from less democratic countries may be relevant in Britain because politicians here, including secretaries of state, seem to be the last to know when a big IT-based programme is becoming a disaster.

Bad news

Whtehall’s preoccupation with “good news only” goes well beyond the DWP.

T auditors Arthur D Little, in a forensic analysis of the delays, cost over-runs and problems on the development of a huge air traffic control IT project for National Air Traffic Services, whose parent was then the Civil Aviation Authority, which was part of the Department for Transport, referred to an “unwillingness to face up to and discuss bad news”.

Ministers helpless to force openness on unwilling officials?

Francis Maude came to the Cabinet Office with a reforming zeal and a sophisticated agenda for forcing through more openness, but the effects of his efforts began to evaporate as soon as he left office. Even when he was at the height of his power and influence, he was unable to persuade civil servants to publish Gateway reviews, although he’d said when in opposition that he intended to publish them.

His negotiations ended with central departments agreeing to publish only the “traffic light” status of big projects – but only after a minimum delay of at least six months. In practice the delay is usually a year or more.

Brexit

Brexit campaigners argue that the EC is undemocratic, that decisions are taken in Brussels in secret by unelected bureaucrats. But the EC is at least subject to the scrutiny, sometimes the competing scrutiny, of 29 countries.

Arguably Whitehall’s departments are also run by unelected bureaucrats who are not subject to any effective scrutiny other than inspections from time to time of the National Audit Office.

Yes Minister parodied Sir Humphrey’s firm grip on what the public should and should not be told. Usually his recommendation was that the information should be misleadingly reassuring. This was close enough to reality to be funny. And yet close enough to reality to be serious as well. It revealed a fundamental flaw in democracy.

Nowhere is that flaw more clearly highlighted than in the DWP’s legal submission. Is it any surprise that the DWP did not want the submission published?

If officials had the choice, would they publish any information that they did not control on any of their IT projects and programmes?

That’s where the indispensable work of the National Audit Office comes into the picture – but it alone, even with the help of the Public Accounts Committee, cannot plug the gaping hole in democracy that the DWP’s submission exposes.

These are some thoughts I am left with after reading the legal submission in the light of the DWP’s record on the management of IT-based projects …

  • Press freedom and the free flow of information cannot be controlled in a liberal democracy. But does Whitehall have its own subtle – and not so subtle – ways and means?
  • In light of the DWP’s track record, the public and the media are entitled to distrust whatever ministers and officials say publicly about their own performance on IT-related programmes, including Universal Credit.
  • More worryingly, would the DWP’s hierarchy care a jot if the media and public didn’t believe what the department said publicly about progress on big projects such as Universal Credit?
  • Is the DWP’s unofficial motto: Better to tell a beautiful lie than an ugly truth?
  • AL Kennedy mentioned the “botched” Universal Credit programme  when she gave a “point of view” on Radio 4 last week. Not referring specifically to Universal Credit she said facts can be massaged but nature can’t be fooled. A girder that won’t hold someone’s weight is likely to fail however many PR-dominated assurance reports have gone before. “Facts are uncompromising and occasionally grim. I wish they weren’t. Avoiding them puts us all at increased risk,” she said.

 Excerpts from the DWP submission

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NHS “Wachter” digital review is delayed – but does it matter?

By Tony Collins

The Wachter review of NHS technology was due to be published in June but has been delayed. Would it matter if it were delayed indefinitely?

A “Yes Minister” programme about a new hospital in North London said it all, perhaps. An enthusiastic NHS official shows the minister round a hospital staffed with 500 administrators. It has the latest technology on the wards.

“It’s one of the best run hospitals in the country,” the NHS official tells the minister, adding that it’s up for the Florence Nightingale award for the standards of hygiene.

“But it has no patients,” says the minister.

Another health official tells the minister,

“First of all, you have to sort out the smooth running of the hospital. Having patients around would be no help at all.” They would just be in the way, adds Sir Humphrey.

In the Wachter’s review’s terms of reference (“Making IT work: harnessing the power of health IT to improve care in England“)  there is a final bullet point that refers, obliquely, to a need to consider patients. Could the Wachter terms of reference have been written by a satirist who wanted to show how it was possible to have a review of NHS IT for the benefit of suppliers, clinical administrators and officialdom but not patients?

The Wachter team will, according to the government,

• Review and articulate the factors impacting the successful adoption of health information systems in secondary and tertiary care in England, drawing relevant comparisons with the US experience;

• Provide a set of recommendations drawing on the key challenges, priorities and opportunities for the health and social care system in England. These recommendations will cover both the high levels features of implementations and the best ways in which to engage clinicians in the adoption and use of such systems.

In making recommendations, the board will consider the following points:

• The experiences of clinicians and Trust leadership teams in the planning, implementation and adoption of digital systems and standards;

• The current capacity and capability of Trusts in understanding and commissioning of health IT systems and workflow/process changes.

• The current experiences of a number of Trusts using different systems and at different points in the adoption lifecycle;

• The impact and potential of digital systems on clinical workflows and on the relationship between patients and their clinicians and carers.

Yes, there’s the mention of “patients” in the final bullet point.

Existing systems?

nhsSome major IT companies have, for decades, lobbied – often successfully – for much more public investment in NHS technology. Arguably that is not the priority, which is to get existing systems to talk to each other – which would be for the direct benefit of patients whose records do not follow them wherever they are looked at or treated within the NHS.

Unless care and treatment is at a single hospital, the chances of medical records following a patient around different sites, even within the same locality, are slim.

Should a joining up of existing systems be the main single objective for NHS IT? One hospital consultant told me several years ago – and his comment is as relevant today –

“My daughter was under treatment from several consultants and I could never get a joined-up picture. I had to maintain a paper record myself just to get a joined-up picture of what was going on with her treatment.”

Typically one patient will have multiple sets of paper records. Within one hospital, different specialities will keep their own notes. Fall over and break your leg and you have a set of orthopaedic notes; have a baby and you will have a totally different set of notes. Those two sets are rarely joined up.

One clinician told me, “I have never heard a coroner say that a patient died because too much information was shared.”

And a technology specialist who has multiple health problems told me,

“I have different doctors in different places not knowing what each other is doing to me.”

As part of wider research into medical records, I asked a hospital consultant in a large city with three major hospitals whether records were shared at least locally.

“You must be joking. We have three acute hospitals. Three community intermediate teams are in the community. Their records are not joined. There is one private hospital provider. If you get admitted to [one] hospital and then get admitted to [another] the next week your electronic records cannot be seen by the first hospital.  Then if you get admitted to the third hospital the week after, again not under any circumstances will your record be able to be viewed.”

Blood tests have to be repeated, as are x-rays; but despite these sorts of stories of a disjointed NHS, senior health officials, in the countless NHS IT reviews there have been over 30 years, will, it seems, still put the simplest ideas last.

It would not cost much – some estimate less than £100m – to provide secure access to existing medical records from wherever they need to be accessed.

No need for a massive investment in new technology. No need for a central patient database, or a central health record. Information can stay at its present location.  Just bring local information together on local servers and provide secure access.

A locum GP said on the Pulse website recently,

“If you are a member of the Armed Forces, your MO can get access to your (EMIS-based) medical record from anywhere in the world. There is no technical reason why the NHS cannot do this. If need be, the patient could be given a password to permit a GP to see another Surgery’s record.”

New appointments

To avoid having patients clog up super-efficient hospitals, Sir Humphrey would have the Wachter review respond to concerns about a lack of joined up care in the NHS by announcing a set of committees and suggesting the Department of Health and NHS England appoint a new set of senior technologists.

Which is just what has happened.

Last week NHS England announced  “key appointments to help transform how the NHS uses technology and information”. [One of the NHS appointments is that of a Director of Digital Experience, which is not a fictional title, incidentally. Ironically it seems to be the most patient-facing of the new jobs.]

Said the announcement,

“The creation of these roles reflects recommendations in the forthcoming review on the future of NHS information systems by Dr Bob Wachter.

“Rather than appoint a single chief information and technology officer, consistent with the Wachter review the NHS is appointing a senior medical leader as NHS Chief Clinical Information Officer supported by an experienced health IT professional as NHS Chief Information Officer.

“The first NHS Chief Clinical Information Officer will be Professor Keith McNeil, a former transplant specialist who has also held many senior roles in healthcare management around the world, including Chief Executive Officer at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust and Chief Executive Officer at the Royal Brisbane and Women’s Hospital in Australia.

“The new NHS Chief Information Officer will be Will Smart, currently Chief Information Officer at the Royal Free London NHS Foundation Trust. Mr Smart has had an extensive career in IT across the NHS and in the private sector.

“The NHS CCIO and NHS CIO post-holders will act on behalf of the whole NHS to provide strategic leadership, also chairing the National Information Board, and acting as commissioning ‘client’ for the relevant programmes being delivered by NHS Digital (previously known as the Health and Social Care Information Centre).

“The roles will be based at NHS England and will report to Matthew Swindells, National Director: Operations and Information, but the post-holders will also be accountable to NHS Improvement, with responsibility for its technology work with NHS providers.

“In addition, Juliet Bauer has been appointed as Director of Digital Experience at NHS England. She will oversee the transformation of the NHS Choices website and the development and adoption of digital technology for patient ‘supported self-management’, including for people living with long term conditions such as diabetes or asthma. Ms Bauer has led delivery of similar technology programmes in many sectors, including leading the move to take Times Newspapers online…”

Surely a first step, instead of arranging new appointments and committees, and finding ways of spending money on new technology, would be to put in place data sharing agreements between hospitals?

A former trust chief executive told me,

“In primary care, GPs will say the record is theirs. Hospital teams will say it is our information and patient representative groups will say it is about patients and it is their nformation. In maternity services there are patient-held records because it is deemed good practice that mums-to-be should be fully knowledgeable and fully participating in what is happening to them.

“Then you get into complications of Data Protection Act. Some people get very sensitive about sharing information across boundaries: social workers and local authority workers. If you are into long-term continuous care you need primary care, hospital care and social care. Without those being connected you may do half a job or even less than that potentially. There are risks you run if you don’t know the full information.”

He added that the Summary Care Record – a central database of every patient’s allergies, medication and any adverse reactions to drugs, was a “waste of time”.

“You need someone selecting information to go into it [the Summary Care Record]so it is liable to omissions and errors. You need an electronic patient record that has everything available but is searchable. You get quickly to what you want to know. That is important for that particular clinical decision.”

Is it the job of civil servants to make the simple sound complicated?

Years ago, a health minister invited me for an informal meeting at the House of Commons to show me, in confidence, a one-page civil service briefing paper on why it was not possible to use the internet for making patient information accessible anywhere.

The minister was incredulous and wanted my view. The civil service paper said that nobody owned the internet so it couldn’t be used for the transfer of patient records.  If something went wrong, nobody could be blamed.

That banks around the world use the internet to provide secure access to individual bank accounts was not mentioned in the paper, nor the existence of the CHAPS network which, by July 2011, had processed one quadrillion (£1,000,000,000,000,000) pounds.

Did the briefing paper show that the civil service was frightened by the apparent simplicity of sharing patient information on a secure internet connection? If nothing else, the paper showed how health service officials will tend, instinctively, to shun the cheapest solutions. Which may help to explain how the (failed) £10n National Programe for IT came into being in 2002.

Jargon

Radiation_warning_symbolNobody will be surprised if the Wachter review team’s report is laden with  jargon about “delays between technology being introduced and a corresponding rise in output”. It may talk of how new technology could reduce the length of stay by 0.1528 of a bed day per patient, saving a typical hospital £1.8m annually or 7,648 bed days.

It may refer to visions, envisioning fundamental change, establishing best practice as the norm, and a need for adaptive change.

Would it not be better if the review team spoke plainly of the need for a patient with a fractured leg not having to carry a CD of his x-ray images to different NHS sites in a carrier bag?

Some may await the Wachter report with a weary apprehension that its delay – even indefinitely – will make not a jot of difference. Perhaps Professor Wachter will surprise them. We live in hope.

Wachter review terms of reference.

Review of IT in the NHS

https://ukcampaign4change.com/2016/02/09/another-npfit-it-scandal-in-the-making/

Hunt announces Wachter review

What can we learn from the US “hospitalist” model?

Another NPfIT IT scandal in the making?

By Tony Collins

Jeremy Hunt may have forgotten what he told the FT 2013, as reported in the paper on 2 June 2o13.

Referring to the failed National Programme for IT [NPfIT] in the NHS he said at that time,

“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.”

He added, “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.”

Now the Department of Health (and perhaps some large IT suppliers) have encouraged Hunt to find £4bn for spending on technology that is (again) of questionable immediate need.

Says Computing, “A significant part of the paperless NHS plans will involve enabling patients to book services and order prescriptions online, as well as giving them the choice of speaking to their doctor online or via a video link.”

The £4bn, if that’s what it will cost, is much less than the cost of the NPfIT. But are millions to be wasted again?

[NPfIT was originally due to cost £2.3bn over three years from 2003 but is expected to cost £9.8bn over 21 years, to 2024.]

Yesterday (8 February 2016) the Department of Health announced a “review of information technology in the NHS”. Announcing it Hunt said.

“Improving the standard of care patients receive even further means embracing technology and moving towards a fully digital and paperless NHS.

NHS staff do incredible work every day and we must give them and patients the most up-to-date technology – this review will tell us where we need to go further.”

The NPfIT was supposed to give the NHS up-to-date technology – but is that what’s needed?

A more immediate need is for any new millions of central funding (for the cost would be in the tens of millions, not billions) to be spent on the seemingly mundane objective of getting existing systems to talk to each other, so that patients can be treated in different parts of the NHS and have their electronic records go with them.

This doesn’t need a new national programme for IT. Some technologists working in the NHS say it would cost no more than £150m, a small sum by NHS IT standards, to allow patient data to reside where it is but be accessed by secure links anywhere, much as secure links work on the web.

But the review’s terms of reference make only a passing reference to the need for interoperability.

Instead the review will have terms of reference that are arguably vague – just as the objectives for the NPfIT were.

The Department of Health has asked the review board, when making recommendations, to consider the following points:

  • The experiences of clinicians and Trust leadership teams in the planning, implementation and adoption of digital systems and standards;
  • The current capacity and capability of Trusts in understanding and commissioning of health IT systems and workflow/process changes.
  • The current experiences of a number of Trusts using different systems and at different points in the adoption lifecycle;
  • The impact and potential of digital systems on clinical workflows and on the relationship between patients and their clinicians and carers.

The head of the review board Professor Wachter will report his recommendations to the secretary of state for health and the National Information Board in June 2016.

Members of the National Advisory Group on health IT in England (the review board) are:

  • Robert Wachter, MD, (Chair) Professor and Interim Chairman, Department of Medicine,University of California, San Francisco
  • Julia Adler-Milstein, PhD, Associate Professor, Schools of Information and of Public Health, University of Michigan
  • David Brailer, MD, PhD, CEO, Health Evolution Partners (current); First U.S. National Coordinator for Health IT (2004-6)
  • Sir David Dalton, CEO, Salford Royal NHS Foundation Trust, UK
  • Dave deBronkart, Patient Advocate, known as “e-Patient Dave”
  • Mary Dixon-Woods, MSc, DPhil, Professor of Medical Sociology, University of Leicester, UK
  • Rollin (Terry) Fairbanks, MD, MS, Director, National Center for Human Factors in Healthcare; Emergency Physician, MedStar Health (U.S.)
  • John Halamka, MD, MS, Chief Information Officer, Beth Israel Deaconess Medical Center; Professor, Harvard Medical School
  • Crispin Hebron, Learning Disability Consultant Nurse, NHS Gloucestershire
  • Tim Kelsey, Advisor to UK Government on Health IT
  • Richard Lilford, PhD, MB, Director, Centre for Applied Health Research and Delivery, University of Warwick, UK
  • Christian Nohr, MSc, PhD, Professor, Aalborg University (Denmark)
  • Aziz Sheikh, MD, MSc, Professor of Primary Care Research and Development, University of Edinburgh
  • Christine Sinsky, MD, Vice-President of Professional Satisfaction, AMA; Primary care internist, Dubuque, Iowa
  • Ann Slee, MSc, MRPharmS, ePrescribing Lead for Integrated Digital Care Record and Digital Medicines Strategy, NHS England
  • Lynda Thomas, CEO, MacMillan Cancer Support, UK
  • Wai Keong Wong, MD, PhD, Consultant Haematologist, University College London Hospitals; Inaugural chair, CCIO Leaders Network Advisory Panel
  • Harpreet Sood, MBBS, MPH, Senior Fellow to the Chair and CEO, NHS England and GP Trainee

Comment

Perhaps egged on by one or two major suppliers in behind-the-scenes lobbying, Hunt has apparently found billions to spend on improving NHS IT.

Nobody doubts that NHS IT needs improving.  But nearly all GPs have impressive systems, as do many hospitals.  But the systems don’t talk to each other.

The missing word  from the review board’s terms of reference is interoperability. True, it’s difficult to achieve. And it’s not politically aggrandizing to find money for making existing systems interoperable.

But at present you can have a blood test at the GP, then a separate blood test at the local hospital and the full results won’t go on your electronic record because the GP and hospital are on different systems with no interoperability between them.

If you’re treated at a specialist hospital for one ailment, and at a different hospital 10 to 20 (or say 100) miles away for something else, it may take weeks for your electronic record to reflect your latest treatment.

Separate NHS sites don’t always know what each other is doing to a patient, unless information is faxed or posted between them.

The fax is still one of the NHS’s main modes of cross-county communication. The DoH wants to be rid of the fax machine but it’s indispensable to the smooth running of the NHS, largely because new and existing systems don’t talk to each other.

The trouble with interoperability – apart from the ugliness of the word – is that it is an unattractive concept to some of the major suppliers, and to DoH executives, because it’s cheap, not leading edge and may involve agreements on data sharing.

Getting agreements on anything is not the DoH’s forte. [Unless it’s an agreement to spend more money on new technology, for the sake of having up-to-date technology.]

Last year I broke my ankle in Sussex and went to stay in the West Midlands at a house with a large ground floor and no need to use stairs. There was no communication between my local GP and the NHS in the West Midlands other than  by phone, post or fax, and even then only a summary of healthcare information went on my electronic record.

I had to carry my x-rays on a CD. Then doctors at my local orthopaedic department in Sussex found it difficult to see the PACS images because the hospital’s PCs didn’t have CD players.

A government employee told me this week of a hospital that gave medication to a patient in the hope she would not have an adverse reaction. The hospital did not have access to the patient’s GP records, and the patient was unsure of the name of the medication she’d previously had an allergic reaction to.

Much of the feedback I have had from those who have enjoyed NHS services is that their care and treatment has been impeded by their electronic records not moving with them across different NHS sites.

Mark Leaning, visiting professor, at University College, London, in a paper for health software supplier EMIS, says the NHS is “not doing very well when it comes to delivering a truly connected health system in 2016. That’s bad for patient outcomes.”

That GPs and their local hospital often cannot communicate electronically  is a disgrace given the billions various governments have spent on NHS IT.  It is on interoperability that any new DoH IT money needs to be spent.

Instead,  it seems huge sums will be wasted on the pie-in-the-sky objective of a paperless NHS by 2020. The review board document released today refers to the “ambition of a paper- free health and care system by 2020”.

What’s the point of a paperless NHS if a kaleidoscope of new or existing systems don’t properly communicate?

Congratulations, incidentally, to GP software suppliers TPP and EMIS. They last year announced direct interoperability between their core clinical systems.

Their SystmOne and EMIS Web systems hold the primary care medical records for most of the UK population.

And this month EMIS announced that it has become the first UK clinical systems provider to implement new open standards for interoperability in the NHS.

It says this will enable clinicians using its systems to securely share data with any third party supplier whose systems comply with a published set of open application programme interfaces.

The Department of Health and ministers need to stop announcing things that will never happen such as a paperless NHS and instead focus their attention – and any new IT money – on initiatives that are not subconsciously aimed at either political or commercial gain.

It would be ideal if they, before announcing any new IT initiative, weighed up diligently whether it is any more important, and any more of a priority, than getting existing systems to talk to each other.

Review of information technology in the NHS

EMIS implements open standards

 

Another fine NHS IT mess

By Tony Collins

Today the National Audit Office reports on the General Practice Extraction Service, an IT system that allows patient data to be extracted from all GP practices in England.

The report says that Department of Health officials – who were then working for the NHS Information Centre – signed off and paid for a contract even though the system was unfit for use. The original business case for the system grossly underestimated costs.

And the system was developed using the highest-risk approach for new IT – a combination of agile principles and traditional fixed-price contract.

Some of the officials involved appear to be those who worked for NHS Connecting for Health – the organisation responsible for what has become the UK’s biggest IT-related failure, the £10bn National Programme for IT (NPfIT).

As with the NPfIT it is unlikely anyone responsible for the latest failure will be held accountable or suffer any damage to their career.

The NAO says officials made mistakes in the original procurement. “Contract management contributed to losses of public funds, through asset write-offs and settlements with suppliers.” More public money is needed to improve or replace the system.

Labour MP Meg Hillier MP, the new chairman of the Public Accounts Committee, sums up today’s NAO’s report:

“Failed government IT projects have long been an expensive cliché and, sadly for the taxpayer and service user, this is no exception.

“The expected cost of the General Practice Extraction Service ballooned from £14m to £40m, with at least £5.5m wasted on write-offs and delay costs.

“GPES has managed to provide data for just one customer – NHS England – and the data was received 4 years later than originally planned.

“While taxpayers are left picking up the tab for this failure, customers who could benefit, such as research and clinical audit organisations, are waiting around for the system to deliver what they need to improve our health service.”

Some GPs who do not want patient data to be extracted from their systems – they believe it could compromise their bond of confidentiality with patients – may be pleased the extraction system has failed to work properly.

But their concern about patient confidentiality being compromised will not make the failure of the extraction service any more palatable.

The NAO says it only learned of the failure of the extraction system through its financial audit of the Health and Social Care Information Centre. It learned that the system was not working as expected and that HSCIC had agreed to pay additional charges through a settlement with one of the main suppliers, Atos IT Services UK Ltd.

An NHS Connecting for Health legacy?

Work on the GP Extraction Service project began in 2007, first by the NHS Information Centre, and then by the HSCIC.

The NHS Information Centre closed in 2013 and responsibility transferred to the HSCIC which combines the Department of Health’s informatics functions – previously known as NHS Connecting for Health or CFH – and the former NHS Information Centre.

What went wrong 

The original business case said the extraction service would start in 2009-10, but it took until April 2014 for HSCIC to provide the first data extract to a customer.

Meanwhile other potential users of the system have found alternative sources of patient data in the absence of the HSCIC system.

The NAO says that officials changed the procurement strategy and technical design for the GPES extraction systems during the project. “This contributed to GPES being unable to provide the planned number and range of data extracts.”

The NHS Information Centre contracted with Atos to develop a tool to manage data extraction. In March 2013, the Centre accepted delivery of this system from Atos.

But officials at the HSCIC who took over the system on 1 April 2013 found that it had fundamental design flaws and did not work. “The system test did not reflect the complexity of a ‘real life’ data extract and was not comprehensive enough to identify these problems”.

To work in a ‘real life’ situation, the GPES query system needed to communicate accurately with the four separate extraction systems and other systems relying on its data.  The test officials and Atos agreed was less complex. It did not examine extractions from multiple extraction systems at once.

Nor did the test assess the complete process of extracting and then passing GPES data to third-party systems.

Fixed price and agile – a bad combination

Officials began procuring the GPES query tool in April 2009, using a fixed-price contractual model with ‘agile’ parts. The supplier and officials would agree some of the detailed needs in workshops, after they signed the contract.

But the NAO says there was already evidence in central government at this time that the contractual approach – combining agile with a fixed price – was high risk.

The NAO’s report “Shared Services in the Research Councils”reviewed how research councils had created a shared service centre, where a similarly structured IT contract failed.

In the report, Fujitsu and the shared service centre told the NAO that: “the fixed-rate contract awarded by the project proved to be unsuitable when the customers’ requirements were still unclear.”

The court case of De Beers vs. Atos Origin highlighted a similar failure.

To make matters worse officials relied too heavily on contractors for development and procurement expertise.  And 10 project managers were responsible for GPES between 2008 and 2013.

Once health officials and Atos had signed the query tool contract, they found it difficult to agree the detailed requirements. This delayed development, with Atos needing to start development work while some requirements had yet to be agreed. Officials and Atos agreed to remove some minor components. Others were built but never used by HSCIC.

A Department of Health Gateway 4 review in December 2012 found that difficulties with deciding requirements were possibly exacerbated by development being offshore.

They raised concerns about the project management approach:

“The GPET-Q [query tool] delivery is being project managed using a traditional ‘waterfall’ methodology. Given the degree of bespoke development required and the difficulties with translation of requirements during the elaboration parts of R1, the Review Team considers that, with hindsight, it might have been beneficial to have adopted an Agile Project Management approach instead.”

General Practice Extraction Service – an investigation. NAO report. 

Latest healthcare IT disaster is a reminder of how vital government digital transformation is.

 

What do Ben Bradshaw, Caroline Flint and Andy Burnham have in common?

By Tony Collins

Ben Bradshaw, Caroline Flint and Andy Burnham have in common in their political past something they probably wouldn’t care to draw attention to as they battle for roles in the Labour leadership.

Few people will remember that Bradshaw, Flint and Burnham were advocates – indeed staunch defenders – of what’s arguably the biggest IT-related failure of all time – the £10bn National Programme for IT [NPfIT.

Perhaps it’s unfair to mention their support for such a massive failure at the time of the leadership election.

A counter argument is that politicians should be held to account at some point for public statements they have made in Parliament in defence of a major project – in this case the largest non-military IT-related programme in the world – that many inside and outside the NHS recognised was fundamentally flawed from its outset in 2003.

Bradshaw, Flint and Burnham did concede in their NPfIT-related statements to the House of Commons that the national programme for IT had its flaws, but still they gave it their strong support and continued to attack the programme’s critics.

The following are examples of statements made by Bradshaw, Flint and Burnham in the House of Commons in support of the NPfIT, which was later abandoned.

Bradshaw, then health minister in charge of the NPfIT,  told the House of Commons in February 2008:

“We accept that there have been delays, not only in the roll-out of summary care records, but in the whole NHS IT programme.

“It is important to put on record that those delays were not because of problems with supply, delivery or systems, but pretty much entirely because we took extra time to consult on and try to address record safety and patient confidentiality, and we were absolutely right to do so…

“The health service is moving from being an organisation with fragmented or incomplete information systems to a position where national systems are integrated, record keeping is digital, patients have unprecedented access to their personal health records and health professionals will have the right information at the right time about the right patient.

“As the Health Committee has recognised in its report, the roll-out of new IT systems will save time and money for the NHS and staff, save lives and improve patient care.”

[Even today, 12 years after the launch of the National Programme for IT, the NHS does not have integrated digital records.]

Caroline Flint, then health minister in charge of the NPfIT,  told the House of Commons on 6 June 2007:

“… it is lamentable that a programme that is focused on the delivery of safer and more efficient health care in the NHS in England has been politicised and attacked for short-term partisan gain when, in fact, it is to the benefit of everyone using the NHS in England that the programme is provided with the necessary resources and support to achieve the aims that Conservative Members have acknowledged that they agree with…

“Owing to delays in some areas of the programme, far from it being overspent, there is an underspend, which is perhaps unique for a large IT programme.

“The contracts that were ably put in place in 2003 mean that committed payments are not made to suppliers until delivery has been accepted 45 days after “go live” by end-users.

“We have made advance payments to a number of suppliers to provide efficient financing mechanisms for their work in progress. However, it should be noted that the financing risk has remained with the suppliers and that guarantees for any advance payments have been made by the suppliers to the Government…

“The national programme for IT in the NHS has successfully transferred the financing and completion risk to its suppliers…”

Andy Burnham, then Health Secretary, told the House of Commons on 7 December 2009:

“He [Andrew Lansley] seems to reject the benefits of a national system across the NHS, but we do not. We believe that there are significant benefits from a national health service having a programme of IT that can link up clinicians across the system. We further believe that it is safer for patients if their records can be accessed across the system…” [which hasn’t happened].

Abandoned NHS IT plan has cost £10bn so far

Why was NHS e-Referral service launched with 9 pages of known problems?

By Tony Collins

Were GPs guinea pigs for live testing of the new national NHS e-Referral Service?

Between 2004 and 2010 the Department of Health marked as confidential its lists of problems with national NPfIT systems, in particular Choose and Book.

So the Health and Social Care Information Centre deserves praise for publishing a list of problems when it launched the national “e-Referrals” system on Monday. But that list was 9 pages long.

The launch brought unsurprised groans from GPs who are used to new national systems going live with dozens of known problems.

The e-Referral Service, built on agile “techniques” and based on open source technology, went live early on Monday to replace “Choose and Book” for referring GP patients to hospitals and to other parts of the NHS.

Some GPs found they could not log on.

“As expected – cannot refer anything electronically this morning. Surprise surprise,” said one GP in a comment to “Pulse” on its article headlined “Patient referrals being delayed as GPs unable to access e-Referrals system on launch day.”

A GP practice manager said: “Cannot access in south London. HSCIC debacle…GPs pick up the pieces. Changing something that wasn’t broken.”

Another GP said: “I was proud never to have used Choose and Book once. Looks like this is even better!”

Other GPs said they avoided using technology to refer patients.

“Why delay referral? Just send a letter. (Some of us never stopped).”

Another commented: “I still send paper referrals – no messing, you know it has gone, no time wasted.”

Dr Faisal Bhutta, a GP partner in Manchester, said his practice regularly used Choose and Book but on Monday morning he couldn’t log in. “You can’t make a referral,” he said.

The Health and Social Care Information Centre has apologised for the disruption. A statement on its website says:

“There are a number of known issues, which are currently being resolved. It is not anticipated that any of these issues will pose a clinical safety risk, cause any detriment to patient care or prevent users from carrying out essential tasks. We have published the list of known issues on our website along with details of how to provide feedback .”

But why did the Centre launch the e-Referral Service with 9 pages of known problems? Was it using GPs as guinea pigs to test the new system?

Comment

The Health and Social Care Information Centre is far more open, less defensive and a better communicator than the Department of Health ever was when its officials were implementing the NPfIT.

But is the HSCIC’s openness a good thing if it’s accompanied by a brazen and arrogant acceptance that IT can be introduced into the NHS without a care whether it works properly or not?

In parts of the NHS, IT works extraordinarily well. Those who design, test, implement and support such systems care deeply about patients. In many hospitals the IT reduces risks and helps to improve the chances of successful outcomes.

But in other parts of the NHS are some technology enthusiasts – at the most senior board level – who seem to believe that all major IT implementations will be flawed and will be improved by user feedback.

The result is that IT that’s inadequately designed, tested and implemented is foisted on doctors and nurses who are expected to get used to “teething” troubles.

This is dangerous thinking and it’s becoming more and more prevalent.

Many poorly-considered implementations of the Cerner Millennium electronic patient record system have gone live in hospitals across England with known problems.

In some cases, poor implementations – rather than any faults with the system itself – have affected the care of patients and might have contributed to unnecessary deaths when records needed urgently were not available, or hospitals lost track of urgent appointments.

A CQC report in March 2015 said IT was a possible factor in the death of a patient because NHS staff were unable to access electronically-held information.

In another incident a coroner criticised a patient administration system for being a factor in the death of three year-old Samuel Starr whose appointment for a vital scan got lost in the system.

Within NHS officialdom is a growing cultural acceptance that somehow a poor IT implementation is different to a faulty x-ray machine that delivers too high a dose of radiation.

NHS officials will always brush off IT problems as teething and irrelevant to the care and safety of patients. Just apologise and say no patient has come to any harm.

So little do IT-related problems matter in the NHS that unaccountable officials at the HSCIC have this week felt sufficiently detached from personal accountability to launch a national system knowing there are dozens of problems with the use of it.

Their attitude seems to be: “We can’t know everything wrong with the system until it’s live. So let’s launch the system and fix the problems as GPs give us their feedback.”

This is a little like the NHS having a template letter of regret to send to relatives and families of patients who die unexpectedly in the care of the NHS. Officials simply fill in the appropriate name and address. The NHS can then fix the problems as and when patients die.

It’s surely time that bad practice in NHS IT was eradicated.  Board members need to question more. When necessary directors must challenge the blind positivism of the chief executive.

Some managers can learn much about the culture of care at the hospitals that implement IT successfully.

Patients, nurses and doctors do not exist to tell hospital managers and IT suppliers when electronic records are wrong, incomplete, not available or are somebody else’s record with a similar name.

And GPs do not exist to be guinea pigs for testing and providing feedback on new national systems such as the e-Referral Service.

e-Referral Service “unavailable until further notice”

Hundreds of patients lost in NPfIT systems

Hospital has long-term NPfIT problems

An NPfIT success at Croydon? – Really?

Physicians’ views on electronic patient records

Patient record systems raise some concerns, says report

Electronic health records and safety concerns

After billions spent on NHS IT, a carrier bag to transfer x-ray images

By Tony Collins

After fracturing my angle (slipping on a slope while mowing the lawn) I’ve been surprised how well parts of the NHS work – but not when it comes to the electronic transfer of records and PACS x-ray images from one trust area to another.

The minor injuries unit at one trust wasn’t able to send its PACS images to another trust’s orthopaedic department because it used a different PACS.  [The NHS has spent more than £700m on PACS ]

“Can’t we email the images?” said a senior nurse at the minor injuries unit. In reply the clinician looking at my x-rays gave a look that suggested emailing x-rays was impossible,  perhaps for security and cost reasons. [PACS images are sometimes tens of MBs.]

In the end the minor injuries unit (which within its own sections shared data electronically) had to download my x-rays onto CD for me to take the other trust’s orthopaedic department.  The CD went into a carrier bag.

The next day, at a hospital with an orthopaedic department, after 4-5 hours of waiting in a very busy A&E, I gave a doctor the CD. “I don’t think we can read that,” he said. “We don’t have any computers which take CDs.”

After a long search around a large general hospital the tired doctor eventually found a PC with a CD player. Fortunately the minor injuries unit had downloaded onto the disc a self-executing program to load the x-rays. Success. He gave his view of the fracture.

Even then he didn’t have my notes from the minor injuries unit.

Comment

My care was superb. What was surprising was seeing how things work – or don’t – after the NHS has spent more than £20bn on IT over the past 20 years.

The media is bombarded with press releases about IT innovations in the NHS. From these it’s easy to believe the NHS has the most up-to-date IT in the world. Some trusts do have impressive IT – within that trust.

It’s when records and x-rays need to be transferred outside the trust’s area that the NHS comes unstuck.

As a nurse at my GP’s practice said, “Parts of the NHS are third-world.”

Since 2004 billions has been spent on systems to create shareable electronic patient records.  But it’s not happening.

Within those billions spent on IT in the NHS, couldn’t a little bit of money be set aside for transferring x-rays and patient notes by secure email? That’s the real innovation the NHS needs, at least for the sake of patients.

In the meantime the safest way for x-rays and notes to be transferred from one trust to another is within the patient’s carrier bag.

Raytheon/Home Office IT dispute rolls on

By Tony Collins

Another big, old government IT contract goes wrong. It’s part of civil service tradition that officials blame the supplier for missing milestones and not delivering what the end-users needed or wanted; and the supplier blames the customer for causing or contributing to the alleged defaults.

The Raytheon Systems/Home Office eBorders legal dispute is going along these lines – as did the Department of Health’s dispute with CSC over parts of the failed National Programme for IT [NPfIT].

It’s tradition for the civil service not to take big IT suppliers to court: a hearing could mean that civil servants have to talk about government business in an open courtroom.

Senior Whitehall officials do not want the public knowing how departments are really managed, or not managed.

In 2002 a 44-day court case between National Air Traffic Services and EDS [now HP] ended suddenly – minutes before a senior civil servant was due to give evidence.

Arbitration is different. It’s in secret so a long dispute can be tolerated.

And so a Home Office mega-contract awarded to US company Raytheon in 2007 has ended up in arbitration and is set for a sequence of hearings and appeals that could last years.

It took 10 years for an IT dispute between HP and BSkyB to be settled, and it could take this long for Raytheon and the Home Office to settle their dispute.

Chronology 

In 2003 Tony Blair launches the eBorders programme. He wants a database of foreign travellers entering and leaving Britain to help fight the war on terror.

A year later the Home Office launches Project Semaphore with IBM to pilot an electronic borders system.

In 2007 Jacqui Smith, Labour’s home secretary, signs an eBorders contract with Raytheon Systems as lead supplier and Serco, Detica, QinetiQ and Accenture as subcontractors. It’s worth £750m. Within two years Home Office officials are expressing concern that milestones are being missed.

In 2010 a new coalition government that’s determined not to put up with big, underperforming IT deals, terminates the Raytheon contract after a recommendation by the Major Projects Authority and a coalition review group.

In 2011 it emerges that Raytheon is threatening to sue the Home Office for £500m for repudiating the contract. Raytheon blames project delays on UK Border Agency mismanagement. It’s far from clear that officials knew what they wanted from the systems.  Arbitration proceedings begin.

In 2013 it emerges that IBM, Fujitsu and Serco are carrying out some of the original eBorders work.

Home Office loses arbitration

Last year an arbitration tribunal ruled that the Home Office must pay £224m to Raytheon. It found that the decision to terminate Raytheon’s contract was unlawful on a number of grounds. The Home Office had not fully considered the extent to which the Home Office and the UK Border Agency had caused or contributed to the alleged defaults.

Home Office wins appeal

Now the Home Office has won an appeal against the arbitration tribunal’s ruling. A good account of the appeal judgment is on the Pinsent Masons website. Pinsent Masons was acting for the Home Office.  The appeal judge found that the arbitration award had been tainted by legal irregularities that could have caused a substantial injustice. The judge took the unprecedented step of setting aside the arbitration award and ordered that the dispute be resolved by a new tribunal.

Raytheon appeal

Raytheon has announced that it is appealing. It points out that the arbitration had 42 days of oral hearings with testimony from multiple witnesses, and had issued a 276 page award decision. Raytheon says it is determined to recover the sums it is due because of the “wrongful” termination of the contract.

Comment:

It’s five years since Raytheon’s contract was cancelled. It could easily be another five years before all the rulings and appeals are finally over.

It’s easy in hindsight to say, but would it have been better if the Home Office and coalition ministers had spent longer negotiating with Raytheon rather than doing the macho thing of cancelling the contract?

Pinsent Masons – latest ruling

Raytheon contests Home Office’s High Court verdict over e-Borders
 

Secrecy is one reason gov’t IT-based projects fail says MP

By Tony Collins

The BBC, in an article on its website about Fujitsu’s legal dispute with the Department of Health, quotes Richard Bacon MP who, as a member of the Public Accounts Committee, has asked countless civil servants about why their department’s IT-based change projects have not met expectations.

Bacon is co-author of a book on government failures, Conundrum, which has a chapter on the National Programme for IT [NPfIT] in the NHS.

In the BBC article Bacon is quoted as saying that the culture of secrecy surrounding IT-based projects is one of the main reasons they keep going so badly – and expensively – wrong.

He says it has been obvious to experts from an early stage that the NPfIT, which was launched by Tony Blair’s government, would be a “train wreck” because the contracts were signed “in an enormous hurry” and contained confidentiality clauses preventing contractors from speaking to the press.

He says the urge to cover things up means that “we never learn from our mistakes because there is learning curve, but when things go wrong with IT the response is to keep it quiet”.

Citing the example of air accident investigations, which are normally conducted in a spirit of openness so lessons can be learned, he says “It is the complete opposite in IT projects, where everyone keeps their heads down and goes hugger-mugger.”

Fujitsu versus Department of Health

Fujitsu sued the Department of Health for £700m after the company was ejected six years early [2008] from a 10-year £896m NPfIT contract signed in January 2004.  The case went to arbitration – and is still in arbitration, largely over the amount the government may be ordered to pay Fujitsu.  Bacon says the amount of the settlement will have to be disclosed.

“I don’t know how the government can honestly keep this number quiet. It simply cannot do it. It is not possible or sensible to keep it quiet when you are spending this much money,” says Bacon.

The BBC article quotes excerpts from a Campaign4Change blog

Government ‘loses £700m NHS IT dispute with Fujitsu’ – BBC News

 

Medication errors 6 months after “admin” system goes live

By Tony Collins

When Croydon Health Services NHS Trust went live with Cerner Millennium in October 2013 a spokesman told eHealth Insider:

“The new system will give everyone working at the trust better access to information and an accurate picture of what all of our services are doing. This will allow staff to make quicker, more informed decisions about the care patients need. It will improve the quality, safety and efficiency of care.”

The go-live has indeed brought some benefits. The trust says these include more efficient management of medicines, more detailed patient information being conveyed between shifts and departments, and better management of beds.

But earlier this week Campaign4Change reported on some of the problems associated with the go-live including 50,000 patients on the trust’s waiting list and a “serious incident” declared over diagnostic waits including extended waits for patients with suspected cancer.

Said the trust’s Audit Committee in March 2014 – 6 months after the go-live of the Cerner Millennium Care Records Service [CRS] :

“CRS Millennium Lessons Learned

“KB [COO and Deputy Chief Executive] outlined the context in which the implementation of CRS had taken place from the time the Business case had been approved in 2010 to the commencement of deployment in January 2011 and its subsequent implementation to date.

“She noted the 7 official “go live” dates which were reflected in the lessons learned report many of which fell during a period of organisational change.

“She noted that the deployment in CHS [Croydon Health Services NHS Trust] had been the most comprehensive deployment to take place nationally.

“It was noted that Programme Team had considered the lessons learned from other [NPfIT] Care Records Service deployments as part of the implementation programme at CHS and that there was no evidence of harm to patients despite the challenges around delivery of service.

” However significant operational challenges were experienced and a deep dive into the implementation of CRS was carried out and the findings submitted to the Finance & Performance Committee and the Trust Development Authority.

“In relation to ‘no harm to patients’ SC [Chairman] asked what empirical evidence there was to support the findings of the Deep Dive.

“KB explained from October 2013 to date there were 50,000 patients on the waiting list, but a patient validation exercise had taken place which had confirmed that no patients had come to any harm.

“The potential backlog would be cleared by the end of March but in the meantime those patients on waiting lists would be subject to a further clinical review to ensure that there was no harm.”

In fact the trust is still working through the backlogs; and long waiting times are not the only matters arising from the Cerner Millennium implementation. A medication safety report for the month of March 2004 highlights these lessons:

“The patient was prescribed Furosemide for acute pulmonary oedema on 12/03/2014. The drug was not administered and the reason not documented. On review of the incident, it was identified that there was a mis-communication between both nurses and the fact that they have started using a new computer system had caused confusion which led to the error. Once error identified the dose was given and ward sister has ensured that staff will go for further training if unsure on how to use the CRS Millennium system…

“Third incident was a failure to administer fluids (Normal Saline) in an acute kidney injury patient with an admission creatinine of greater than 700. Again there was confusion with the electronic prescribing system and the nurse thought that patient did not have a drug chart as the electronic prescribing system had gone live whereas in fact there was a paper drug chart for the fluid. The position of the venflon on the patient arm also contributed to the delay. Once error identified the fluids were given but were not running to time and patient improved. Ward sister has ensured that staff will go for further training if unsure on how to use the CRS Millennium system and staff were also briefed about poor documentation of the incident…

“Fourth incident occurred involved a patient prescribed ACS protocol for NSTEMI, Positive trop T. The aspirin 300mg, clopidogrel 300mg and fondaparinux 2.5mg were not administered and not signed for. Omission of medicines was discussed with doctor looking after the patient and the patient did not come to any harm. Omission occurred as agency staff did not know how to use CRS Millennium. On review of incident all staff were briefed on importance of patients being administered medicines on time and in particular a discussion took place between agency staff and for agency staff to have adequate CRS Millennium training. There are champion users nurses on wards who are able to train Agency staff.

NPfIT

Cerner Millennium is provided to the trust under a national contract hosted by the Department of Health and managed via a Local Service Provider (LSP) contract with BT. The contract covers trusts in London and the south of England.

The DH contract expires on 31st October 2015 after which point the DH will no longer fund any of the services currently hosted by them. This includes both the software and licencing costs for Cerner Millennium as well as the BT data storage facilities and other costs.

The DH requires all trusts with Cerner under the NPfIT to commit to an exit strategy before 31st October 2015.

Comment

Is Cerner Millennium merely an administrative system as officials at Croydon Health Services NHS Trust claim it is?  The implication is, with an administrative system, that it cannot be involved in any harm to patients. Officials at Connecting for Health when they ran the NPfIT used to describe Cerner Millennium as an administrative system.

It is the deployment of this “admin” system at Croydon that is implicated in medication errors, a waiting list of 50,000 people, and long waits for diagnostic tests for people with suspected cancer.

If Whitehall and NHS officials cannot see the system as other than administrative, this is a mistake that may help to explain why a poor service for patients, which sometimes has serious potential clinical implications,  is so commonplace, even months after go-live.

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