Category Archives: e-health

Firecontrol disaster and NPfIT – two of a kind?

Posted on 23/07/2013 | 5 comments

By Tony Collins

Today’s report of the Public Account Committee on the Firecontrol project could, in many ways, be a report on the consequences of the failure of the National Programme for IT in the NHS in a few years time.

The Firecontrol project was built along similar lines to the NPfIT but on a smaller scale.

With Firecontrol, Whitehall officials wanted to persuade England’s semi-autonomous 46 local fire authorities to take a centrally-bought  IT system while simplifying and unifying their local working practices to adapt to the new technology.

NPfIT followed the same principle on a bigger scale: Whitehall officials wanted to persuade thousands of semi-autonomous NHS organisations to adopt centrally-bought technologies. But persuasion didn’t work, in either the fire services or the NHS.

More similarities

The Department for Communities and Local Government told
the PAC that the Firecontrol control was “over-specified” – that it was unnecessary to have back-up to an incident from a fire authority from the other side of the country.

Many in the NHS said that NPfIT was over-specified. The gold-plated trimmings, and elaborate attempts at standardisation,  made the patient record systems unnecessarily complicated and costly – and too difficult to deliver in practice.

As with the NPfIT, the Firecontrol system was delayed and local staff  had little or no confidence it would ever work, just as the NHS had little or no faith that NPfIT systems would ever work.

Both projects failed. Firecontrol wasted at least £482m. The Department of Communities and Local Government cancelled it in 2010. The Department of Health announced in 2011 that the NPfIT was being dismantled but the contracts with CSC and BT could not be cancelled and the programme is dragging on.

Now the NHS is buying its own local systems that may or may not be interoperable. [Particularly for the long-term sick, especially those who have to go to different specialist centres, it’s important that full and up-to-date medical records go wherever the patients are treated and don’t at the moment, which increases the risks of mistakes.]

Today’s Firecontrol report expresses concern about a new – local – approach to fire services IT. Will the local fire authorities now end up with a multitude of risky local systems, some of which don’t work properly, and are all incompatible, in other words don’t talk to each other?

This may be exactly the concern of a post-2015 government about NHS IT. With the NPfIT slowly dying NHS trusts are buying their own systems. The coalition wants them to interoperate, but will they?  

Could a post-2015 government introduce a new (and probably disastrous) national NHS IT project – son of NPfIT – and justify it by drawing attention to how very different it is to the original NPfIT eg that this time the programme has the buy-in of clinicians?

The warning signs are there, in the PAC’s report on Firecontrol. The report says there are delays on some local IT projects being implemented in fire authorities, and the systems may not be interoperable. The PAC has 

” serious concerns that there are insufficient skills across all fire authorities to ensure that 22 separate local projects can be procured and delivered efficiently in so far as they involve new IT systems”.

National to local – but one extreme to the other?

The PAC report continues

“There are risks to value for money from multiple local projects. Each of the 22 local projects is now procuring the services and systems they need separately.

“Local teams need to have the right skills to get good deals from suppliers and to monitor contracts effectively. We were sceptical that all the teams had the appropriate procurement and IT skills to secure good value for money.

“National support and coordination can help ensure systems are compatible and fire and rescue authorities learn from each other, but the Department has largely devolved these roles to the individual fire and rescue authorities.

“There is a risk that the Department has swung from an overly prescriptive national approach to one that provides insufficient national oversight and coordination and fails to meet national needs or achieve economies of scale. 

Comment

PAC reports are meant to be critical but perhaps the report on Firecontrol could have been a little more positive about the new local approach that has the overwhelming support of the individual fire and rescue authorities.  

Indeed the PAC quotes fire service officials as saying that the local approach is “producing more capability than was expected from the original FiReControl project”. And at a fraction of the cost of Firecontrol.

But the PAC’s Firecontrol Update Report expresses concern that

– projected savings from the local approach are now less than originally predicted

– seven of the 22 projects are running late and two of these projects have slipped by 12 months

– “We have repeatedly seen failures in project management and are concerned that the skills needed for IT procurement may not be present within the individual fire and rescue authorities, some of which have small management teams,” says the PAC.

On the other hand …

The shortfall in projected savings is small – £124m against £126m and all the local programmes are expected to be delivered by March 2015, only three months later than originally planned.

And, as the PAC says, the Department for Communities and Local Government has told MPs that a central peer review team is in place to help share good practice – mainly made up of members of fire and rescue authorities themselves.

In addition, part of the £82m of grant funding to local fire services has been used by some authorities to buy in procurement expertise.

Whether it is absolutely necessary – and worth the expense – for IT in fire services to link up is open to question, perhaps only necessary in a national emergency.

In the NHS it is absolutely necessary for the medical records of the chronically sick to link up – but that does not justify a son-of-NPfIT programme. Linking can be done cheaply by using existing records and having, say, regional servers pull together records from individual hospitals and other sites.

Perhaps the key lesson from the Firecontrol and the NPfIT projects is that large private companies can force their staff to use unified IT systems whereas Whitehall cannot force semi-autonomous public sector organisations to use whatever IT is bought centrally.

It’s right that the fire services are buying local IT and it’s right that the NHS is now too. If the will is there to do it cheaply, linking up the IT in the NHS can be done without huge central administrative edifices.

Lessons from FireControl (and NPfIT?) 

The National Audit Office identifies these main lessons from the failure of Firecontrol:

– Imposing a single national approach on locally accountable fire and rescue authorities that were reluctant to change how they operated

–  Launching the programme too quickly without applying basic project approval checks and balances

– Over optimism on the deliverability of the IT solution.

– Issues with project management including consultants who made up half of the management team and were not effectively managed

MP Margaret Hodge, chair of the Public Accounts Committee, today sums up the state of Firecontrol

“The original FiReControl project was one of the worst cases of project failure we have seen and wasted at least £482 million of taxpayers’ money.

“Three years after the project was cancelled, the DCLG still hasn’t decided what it is going to do with many of the specially designed, high-specification facilities and buildings which had been built. Four of the nine regional control centres are still empty and look likely to remain so.

“The Department has now provided fire and rescue authorities with an additional £82 million to implement a new approach based on 22 separate and locally-led projects.

“The new programme has already slipped by three months and projected savings are now less than originally predicted. Seven of the 22 projects are reportedly running late and two have been delayed by 12 months. We are therefore sceptical that projected savings, benefits and timescales will be achieved.

“Relying on multiple local projects risks value for money. We are not confident that local teams have the right IT and procurement skills to get good deals from suppliers and to monitor contracts effectively.

“There is a risk that the DCLG has swung from an overly prescriptive national approach to one that does not provide enough national oversight and coordination and fails to meet national needs or achieve economies of scale.

 “We want the Department to explain to us how individual fire and rescue authorities with varied degrees of local engagement and collaboration can provide the needed level of interoperability and resilience.

“Devolving decision-making and delivery to local bodies does not remove the duty on the Department to account for value for money. It needs to ensure that national objectives, such as the collaboration needed between fire authorities to deal with national disasters and challenges, are achieved.”

Why weren’t NPfIT projects cancelled?

 NPfIT contracts included commitments that the Department of Health and the NHS allegedly did not keep, which weakened their legal position; and some DH officials did not really want to cancel the NPfIT contracts (indeed senior officials at NHS England seem to be trying to keep NPfIT projects alive through the Health and Social Care Information Centre which is responsible for the local service provider contracts with BT and CSC).

PAC report on Firecontrol

What Firecontrol and the NPfIT have in common (2011)

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Posted in BT, BT Health, Campaign4Change, change management, consultants, CSC, data sharing, e-health, efficiency savings, Firecontrol, Government IT, health records, IT-related failures, managing outsourced services, NHS, outsourcing, project management, public sector, public services, shared services, Summary Care Record, supplier relationships

How to cost-justify the NPfIT disaster – forecast benefits a decade away

Posted on 07/06/2013 | 2 comments

By Tony Collins

To Jeremy Hunt, the Health Secretary, the NPfIT was a failure. In an interview with the FT, reported on 2 June 2013, Hunt said of the NPfIT

“It was a huge disaster . . . It was a project that was so huge in its conception but it got more and more specified and over-specified and in the end became impossible to deliver … But we musn’t let that blind us to the opportunities of technology and I think one of my jobs as health secretary is to say, look, we must learn from that and move on but we must not be scared of technology as a result.”

Now Hunt has a different approach.  “I’m not signing any big contracts from behind [my] desk; I am encouraging hospitals and clinical commissioning groups and GP practices to make their own investments in technology at the grassroots level.”

Hunt’s indictment of the NPfIT has never been accepted by some senior officials at the DH, particularly the outgoing chief executive of the NHS Sir David Nicholson. Indeed the DH is now making strenuous attempts to cost justify the NPfIT, in part by forecasting benefits for aspects of the programme to 2024.

The DH has not published its statement which attempts to cost justify the NPfIT. But the National Audit Office yesterday published its analysis of the unpublished DH statement. The NAO’s analysis “Review of the final benefits statement for programmes previously managed under the National Programme for IT in the NHS” is written for the Public Accounts Committee which meets next week to question officials on the NPfIT. 

A 22 year programme?

When Tony Blair gave the NPfIT a provisional go-ahead at a meeting in Downing Street in 2002, the programme was due to last less than three years. It was due to finish by the time of the general election of 2005. Now the NPfIT  turns out to be a programme lasting up to 22 years.

Yesterday’s NAO report says the end-of-life of the North, Midlands and East of England part of the NPfIT is 2024. Says the NAO

“There is, however, very considerable uncertainty around whether the forecast benefits will be realised, not least because the end-of-life dates for the various systems extend many years into the future, to 2024 in the case of the North, Midlands and East Programme for IT.”

The DH puts the benefits of the NPfIT at £3.7bn to March 2012 – against costs of £7.3bn to March 2012.

Never mind: the DH has estimated the forecast benefits to the end-of-life of the systems at £10.7bn. This is against forecast costs of £9.8bn to the end-of-life of the systems.

The forecast end-of-life dates are between 2016 and 2024. The estimated costs of the NPfIT do not include any settlement with Fujitsu over its £700m claim against NHS Connecting for Health. The forecast costs (and potential benefits) also exclude the patient administration system Lorenzo because of uncertainties over the CSC contract.

The NAO’s auditors raise their eyebrows at forecasting of benefits so far into the future. Says the NAO report

“It is clear there is very considerable uncertainty around the benefits figures reported in the benefits statement. This arises largely because most of the benefits relate to future periods and have not yet been realised. Overall £7bn (65 per cent) of the total estimated benefits are forecast to arise after March 2012, and the proportion varies considerably across the individual programmes depending on their maturity.

“For three programmes, nearly all (98 per cent) of the total estimated benefits were still to be realised at March 2012, and for a fourth programme 86 per cent of benefits remained to be realised.

There are considerable potential risks to the realisation of future benefits, for example systems may not be deployed as planned, meaning that benefits may be realised later than expected or may not be realised at all…”

NPfIT is not dead

The report also reveals that the DH considers the NPfIT to be far from dead. Says the NAO

“From April 2013, the Department [of Health] appointed a full-time senior responsible owner accountable for the delivery of the [the NPfIT] local service provider contracts for care records systems in London, the South and the North, Midlands and East, and for planning and managing the major change programme that will result from these contracts ending.

“The senior responsible owner is supported by a local service provider programme director in the Health and Social Care Information Centre.

“In addition, from April 2013, chief executives of NHS trusts and NHS foundation trusts became responsible for the realisation and reporting of benefits on the ground. They will also be responsible for developing local business cases for the procurement of replacement systems ready for when the local service provider contracts end.”

The NAO has allowed the DH to include as a benefit of the NPfIT parts of the programme that were not included in the original programme such as PACS x-ray systems.

Officials have also assumed as a benefit quicker diagnosis from the Summary Care Record and text reminders using NHSmail which the DH says reduces the number of people who did not attend their appointment by between 30 and 50 per cent.

Comment

One of the most remarkable things about the NPfIT is the way benefits have always been – and still are – referred to in the future tense. Since the NPfIT was announced in 2002, numerous ministerial statements, DH press releases and conference announcements have all referred to what will happen with the NPfIT.

Back in June 2002, the document that launched the NPfIT, Delivering 21st Century IT for the NHS, said:

“We will quickly develop the infrastructure …”

“In 2002/03 we will seek to accelerate the pace of development …

“Phase 1 – April 2003 to December 2005 …Full National Health Record Service implemented, and accessible nationally for out of hours reference.”

In terms of the language used little has changed. Yesterday’s NAO report is evidence that the DH is still saying that the bulk of the benefits will come in future.

Next week (12 June) NHS chief Sir David Nicholson is due to appear before the Public Accounts Committee to answer questions on the NPfIT. One thing is not in doubt: he will not concede that the programme has been a failure.

Neither will he concede that a fraction of the £7.3bn spent on the programme up to March 2012 would have been needed to join up existing health records for the untold benefit of patients, especially those with complex and long-term conditions.

Isn’t it time MPs called the DH to account for living in cloud cuckoo land? Perhaps those at the DH who are still predicting the benefits of the NPfIT into the distant future should be named.

They might just as well have predicted, with no less credibility, that in 2022 the bulk of the NPfIT’s benefits would be delivered by the Flower Fairies.

It is a nonsense that the DH is permitted to waste time on this latest cost justification of the NPfIT. Indeed it is a continued waste of money for chief executives of NHS trusts and NHS foundation trusts to have been made responsible, as of April 2013, for reporting the benefits of the NPfIT.

Jeremy Hunt sums up the NPfIT when he says it has been a huge disaster. It is the UK’s biggest-ever IT disaster. Why does officialdom not accept this?

Instead of wasting more money on delving into the haystack for benefits of the NPfIT, it would be more sensible to allocate money and people to spreading the word within Whitehall and to the wider public sector on the losses of the NPfIT and the lessons that must be learnt to discourage any future administrations from embarking on a multi-billion pound folly.

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Posted in Atos, BT, BT Health, Campaign4Change, change, change management, CSC, e-health, excessive secrecy, Fujitsu, health records, IT projects, IT-related failures, legal disputes, Major Projects Authority, managing change, managing outsourced services, NHS, npfit, public sector, public services, Summary Care Record

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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

Informatics in a post-Francis era

Posted on 01/03/2013 | 1 comment

 Jean Roberts has been involved in health informatics since the early 70s; in the NHS, for solution and service providers, academia and now as the Director (Standards), UK Council for Health Informatics Professions (www.ukchip.org).  In a  guest blog she writes on the importance of informatics and informaticians in the light of the Francis report.

There are significant areas where health informaticians can help with appropriate information in the right context to support ongoing decision making and monitoring post-Francis.

I was delighted that an informatics-competent professional was recognised in the Francis report as a necessary asset at Board level. I hope it happens. To make the most of such a Board asset, the professional’s capability, capacity and professional principles will need to be understood.

The current focus on the faster introduction of electronic health records [EHRs] is only one area; there is a risk that the politicians and the NHS per se fall into the trap that if the systems exist all will be well -they in fact need to be designed, developed, delivered and operated by professionals who understand the health domain in all its idiosyncratic ways. Patient safety is paramount but the front-line staff need to have good decision support and that will need extraction and interpretation in the light of specific contexts.

For example looking at an ‘average’ mortality normal range is inappropriate if certain hospitals are ‘on take’ for the more complex challenging cases as well as a ‘normal mix’ of cases – sadly a larger proportion of the very sick will die than normal, but specialist locations with excellent staff and appropriate resources will save more than would have otherwise died, but it takes a skilled analyst to build and present that case, even if they have the ear of the Board.  Hence I continue to repeat that business intelligence analysts and health informaticians need to be professional, domain-sensitive and domain-literate…. and their patch will get more complex as it starts to include social care interventions and medical tourism.

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Posted in capacity building, e-health, health records, NHS

A paperless NHS by 2018? Could it ever happen?

Posted on 16/01/2013 | 1 comment

By Tony Collins

The NHS should go paperless by 2018 to save billions, improve services and help meet the challenges of an ageing population, Health Secretary Jeremy Hunt will say today.

In a speech to the Policy Exchange this evening, the Health Secretary will say that patients should have compatible digital records so their health information can follow them around the health and social care system.

This would mean, says the DH, that in most cases, whether patients needs a GP, hospital or a care home, the professionals involved in their care could see patient histories “at the touch of a button”.

Hunt’s speech comes as two reports are also published which – says the DH – demonstrate the potential benefits of making better use of technology.

The DH says a report by PriceWaterhouseCoopers on the potential benefits of better use of IT “found that measures such as more use of text messages for negative test results, electronic prescribing and electronic patient records could improve care, allow health professionals to spend more time with patients and save billions”.

But the DH press release – and coverage of it by the BBC – does not mention the reservations in Pwc’s report.

Pwc says it could take 10 years or more for the NHS to derive the full benefits from some of the priority actions and further actions mentioned in its report.

Pwc also says that “significant further work is required to further substantiate some of the evaluations of potential benefit, and especially the evaluations of potential financial benefit. This work should be completed before the broad implementation of the recommended actions commences…”

A National Mobile Health Worker report, also published today, was a pilot study on introducing laptops at 11 NHS sites.

On the way towards the 2018 goal, Hunt will say that he wants to see:

– By March 2015 – everyone who wishes will be able to get online access to their own health records held by their GP.

– Adoption of paperless referrals – instead of sending a letter to the hospital when referring a patient to hospital, the GP can send an email instead.

– Clear plans in place to enable secure linking of these electronic health and care records wherever they are held, so there is as complete a record as possible of the care someone receives.

– Clear plans in place for those records to be able to follow individuals, with their consent, to any part of the NHS or social care system.

– By April 2018 – digital information to be fully available across NHS and social care services, barring any individual opt outs.

The NHS Commissioning Board is leading implementation and it has set a clear expectation that hospitals should plan to make information digitally and securely available by 2014/15.

This means that different professionals involved in one person’s care can start to safely share information on their treatment. This is set out in the NHS Commissioning Board’s recent publication ‘Everyone Counts: planning for patients in 2013/14′.

Hunt says:

“The NHS cannot be the last man standing as the rest of the economy embraces the technology revolution.

“It is crazy that ambulance drivers cannot access a full medical history of someone they are picking up in an emergency – and that GPs and hospitals still struggle to share digital records.

“Previous attempts to crack this became a top down project akin to building an aircraft carrier. We need to learn those lessons – and in particular avoid the pitfalls of a hugely complex, centrally specified approach.

“Only with world class information systems will the NHS deliver world class care.”

The Government recently announced it would be making £100 million available to NHS nurses and midwives to spend on new technology.

Challenges

The Pwc report is not an analysis of the costs of introducing shared electronic records across the NHS. But it does mention some of the challenges. It says:

“There are delivery risks to be addressed before the potential benefits can be realised.”

This is Pwc’s list of challenges of introducing better IT in the NHS, especially a shared electronic patient record:

– “The realisation of the potential benefits will depend on the concerted action and commitment of bodies from across the health and social care system.”

– “… the maximum possible benefits presented by this review will not be realised unless key supporting elements are put in place and unless appropriate and timely investments are made.”

–  “The availability of funds to cover one-off investment costs in technologies, information gathering or reworked organisational processes.”

– “The willingness of system bodies to adopt the technologies or commit to information gathering and use.”

–  “The clear and concise documentation of the benefits achieved and challenges faced by pilot programmes or early adopters of technologies or information protocols, to support other organisations in implementing actions in a cost-effective and efficient way.”

– “Strong and positive leadership to promote use of information and technology, and prioritise the commitment of resources and time to it and commitment of bodies from across the health and social care system.

– “The incentivisation of the adoption of the proposed actions, particularly when coordinated system-wide action is required.”

– “Measures to make contracting for the provision of systems and services as easy, quick and cost-effective as possible; and

– “The development of new or revised robust governance processes to not only support programme delivery but scrutinise the delivery of benefits.”

Comment:

On the face of it Hunt’s good intentions and the DH’s press release on his speech are little more than political rhetoric.

Indeed it appears that Hunt commissioned the Pwc report to give an independent voice to a political announcement. Pwc concedes in its report that it was commissioned to highlight the “potential benefits that could be achievable through the more efficient and effective use of information and technology in the NHS and social care before any action is taken”.

It is inconceivable that the NHS will be paperless or have shared electronic patient records by 2018. Each ward in every major hospital has a range of paper forms. These will take an unknown number of years to standardise for the purposes of electronic records; and shared electronic records will not take place across the NHS without enormous changes in culture and practice, and initial investments.

Nearly every secretary of state for health, shortly after coming to the post, is given a draft speech by his officials about the NHS’s having shared electronic patient records by a distant date.  A new government will be in power by 2018 and Hunt’s promise in January 2013 will have long been forgotten.

Yet Hunt’s announcement is still welcome because it will continue to add energy to the very slow move to shared electronic records.

It is astonishing in a technological age that patients with chronic diseases such as diabetes, or have complex health problems, can be treated at different specialist centres in various parts of the UK without their records being shared. A patient can be seen within a week in two different hospitals without each hospital sharing the patient’s most recent notes and diagrams.   This problem has to be grabbed by the throat – but not with a centralised system or database as proposed in the NPfIT.

Hunt recognises this. He talks of the need for records to be linked – from where the data currently resides. But Hunt needs to say how it will happen, and provide some limited investment for it to happen – tens and not hundreds of millions of pounds.

The political will is there – but without the means to achieve a shared electronic record it may never happen.

Pwc report

Jeremy Hunt challenges the NHS to go paperless by 2018 – DH press release

Going paperless would save the NHS billions – BBC online

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Posted in Campaign4Change, e-health, ERP, Government IT, health, health records, NHS, npfit, operational issues

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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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CSC signs NHS agreement with UK government – finally

Posted on 04/09/2012 | 1 comment

By Tony Collins

Four-year deal to deliver Lorenzo and other healthcare products

CSC announced today that it entered into an agreement with the NHS on August 31, 2012 to amend the existing contract under which CSC has developed and is deploying an integrated electronic patient records system using CSC’s Lorenzo Regional Care software products.

CSC says the agreement has received the approval of all required UK Government officials and is effective immediately. It offers “substantial flexibility to NHS trusts in their choice of electronic care records solutions while affording CSC the opportunity to expand and accelerate its marketing of the Lorenzo solution to NHS trusts across England”.

The term of the agreement extends through July 2016. It includes full mutual releases of all claims between the parties through the date of the agreement.

Under the deal the NHS will not be subject to minimum volume commitments which were part of the original NPfIT local service provider contracts. These controversial clauses had committed the Department of Health to a minimum spend with CSC, and could have led to the DH paying for deployments of Lorenzo that did not actually happen.

In return for this concession CSC has agreed to non-exclusive deployment rights in its designated regions. Trusts will receive ongoing managed services from CSC for a period of five years from the date of Lorenzo deployment by a trust, provided deployment is complete or substantially complete by July 2016.

“This agreement is a significant milestone in our relationship with the National Health Service and represents a renewed commitment by the NHS and CSC to a long-term partnership as well as CSC’s healthcare solutions,” said Mike Lawrie, CSC’s president and chief executive officer.

“Under this agreement CSC will continue to have the opportunity to support the NHS Information and Communications Technology infrastructure through deployment of our groundbreaking Lorenzo base product solutions, now rigorously tested and approved for wide-scale deployment across NHS.

“We are already seeing strong demand from NHS trusts that are confident our solutions will bring the safety and efficiency gains required by a modern NHS.”

Under the agreement the parties have redefined the scope of the Lorenzo products and have established deployment and ongoing service pricing.

CSC will deliver additional Lorenzo implementations “based on demand from individual NHS trusts”. The supplier says that a flexible arrangement has been established for these trusts to combine additional clinical modules with the core care management functionality of the Lorenzo solution to meet their specific requirements.

CSC and the NHS have also agreed to a streamlined approach for trusts which wish to take the Lorenzo products within the NHS-designated North, Midlands and East regions of England to obtain central funding from the DH for implementation of the Lorenzo products.

CSC may offer the Lorenzo solutions throughout the rest of England where trusts select CSC’s solutions through a separate competitive process.

It will offer a range of other solutions and services to the NHS, including general practitioner, ambulance and community systems, digital imaging and other related services.

CSC has told the US regulator the SEC that the new agreement “forms the basis on which the parties will subsequently finalize a full restatement of the contract”.

CSC gets £68m settlement up to 31 August 2012

The DH will pay CSC £68m, which represents what CSC says is “payment for value delivered to date, a net settlement amount for mutual claims of the parties and removal of exclusivity to provide a flexible market driven approach”.

But what the costs will be of continuing the NPfIT contracts, albeit modified, are not stated.

Comment

On the face of it the deal seems a reasonable one, though no figures are given. The big concession from CSC is the release of the NPfIT minimum volume commitments. It means the DH is not tied to minimum payments to CSC, whatever is deployed.

One question remaining though is whether trusts that have indicated they will take Lorenzo will be contractually committed to taking it. There’s a big difference between an intention to deploy and signing a contract to deploy it. Has the government made a promise to CSC to deploy Lorenzo at those trusts that have indicated a willingness to deploy it?

The DH says the new deal with CSC will save £1bn. CSC’s NPfIT contracts were worth £2.9bn. Much of that was unspent by August 2012. Does this new deal mean that CSC’s NPfIT contracts could still be worth about £1.9bn over 10 years, to 2015/16?

Open government requires that the DH release the terms of the deal, especially given the NPfIT’s disastrous history. But will that happen? Is the NPfIT being “dismantled” as the DH said it would be – or does this new deal with CSC keep it alive?

Is NPfIT being dismantled – brick by brick?

CSC gets £68m settlement

DH statement

The DH says that savings of over £1bn will be reinvested into the NHS following its “legally binding agreement with CSC”.

The DH press release says that the agreement will give local hospitals and NHS organisations the power to make their own decisions about which IT systems they use.

“The money saved will go back into the NHS and would be enough to pay for half a million extra knee and hip operations, and almost 15,000 extra doctors”.

The DH says it is committed to dismantling the National Programme for IT.

“The Department of Health, the local NHS and Cabinet Office have been in negotiations with CSC to ensure the existing Electronic Patient Record system, known as Lorenzo, is fit for purpose and focuses on the NHS’s current needs as well as providing value for money.

“Under the new agreement, CSC’s exclusive rights to be the only provider of clinical IT systems in the North, Midlands and East of England have been removed.

“The Government has been renegotiating its major contracts to not only ensure  wasteful spending is eradicated but that major suppliers are offering the best value for money.”

Health Minister, Simon Burns said  “We’ve removed the restrictive, top-down, centralised approach and given the local NHS the power to make their own decisions about which IT systems they use.

“The modern NHS still needs healthcare IT systems to exchange information securely and meet the needs of their patients. By re-shaping this contract, delays will be avoided in delivering much needed IT systems to the NHS, and will ensure the investment made to date is not wasted.

“This agreement marks a step in the right direction and a move to a new way of working which will allow the NHS to secure value for money and tailor its IT systems to meet the needs of its local patients.”

Minister for the Cabinet Office Francis Maude said

“Since May 2010 we have been building a strong operations centre at the heart of Whitehall to ensure that Government runs more like the best businesses.  As part of this we have been negotiating with our major suppliers, acting as a true ‘single client’, and generating savings of £806m and £437m respectively in the first two years of this Parliament alone.

“As I emphasised when I met with 20 of our top suppliers just last month, ours is not a Government that will tolerate poor performance – and today’s announcement will leave suppliers in no doubt that we will act to strip out waste from contracts where they offer poor value for the taxpayer.”

The Dh says that local NHS organisations “will no longer be committed to using Lorenzo, and will have the freedom to decide what IT systems are most suitable for their needs”.

CSC will retain responsibility for rolling out Lorenzo which is being used by 10 NHS organisations in the North, Midlands and East of England.

The DH says that if eligible local NHS organisations wish to use Lorenzo they will be able to access centralised support and funding but will first need to develop a robust business case and demonstrate value for money in order to gain approval to do so.

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Posted in CSC, e-health, health, health records, IT-related failures, NHS, openness and transparency, procurement, project management

Well done Eric Pickles – more open government to engulf councils

Posted on 29/08/2012 | 2 comments

By Tony Collins

Few people have noticed but changes to the law next month could force councils to be much more open about big spending decisions including those that involve contracting out IT and other services.

It is a pity though that similar changes will not apply to the NHS.

The Local Government Association says that councils are already more open than Whitehall which is true.

Even so some councils are innately secretive about IT-related spending decisions, and discussions about projects that go wrong. Somerset County Council was notoriously secretive about its Southwest One joint venture with IBM in 2007. The deal has not made the expected savings and has consistently made losses. IBM claims the deal is a success.

Haringey Council’s “Tech refresh” project which went way over budget is another example. Evasive answers to opposition questions and meetings in secret were the norm.

Liverpool City Council was extraordinarily defensive and secretive about progress or otherwise on its Liverpool Direct Ltd joint venture with BT. The deal included giving BT control of IT.

Better public scrutiny

Now Local Government Secretary Eric Pickles has announced that changes to the law will mean that all decisions including those affecting budgets and local services will have to be taken in an open and public forum.

Ministers have put new regulations before Parliament that would come into force next month to extend the rights of people to attend all meetings of a council’s executive, its committees and subcommittees.

Pickles says the changes will result in greater public scrutiny. “The existing media definition will be broadened to cover organisations that provide internet news thereby opening up councils to local online news outlets. Individual councillors will also have stronger rights to scrutinise the actions of their council.

“Any executive decision that would result in the council incurring new spending or savings significantly affecting its budget or where it would affect the communities of two or more council wards will have to be taken in a more transparent way as a result.”

Councils will no longer be able to cite political advice as justification for closing a meeting to the public and press. Any intentional obstruction or refusal to supply certain documents could result in a fine for the individual concerned.

The changes clarify the limited circumstances where meetings can be closed, for example, where it is likely that a public meeting would result in the disclosure of confidential information. Where a meeting is due to be closed to the public, the council must now justify why that meeting is to be closed and give 28 days notice of such decision.

Chris Taggart, of OpenlyLocal.com, which has long championed the need to open council business up to public scrutiny, said

“In a world where hi-definition video cameras are under £100 and hyperlocal bloggers are doing some of the best council reporting in the country, it is crazy that councils are prohibiting members of the public from videoing, tweeting and live-blogging their meetings.”

These are the changes to be made by the  The Local Authorities (Executive Arrangements) (Meetings and Access to Information) (England) Regulations 2012 (the 2012 Regulations) which will come into force on 10 September 2012.

– Local authorities will have to provide reasonable facilities for members of the public to report council proceedings (regulation 4). This will make it easier for new ‘social media’ reporting of council executive meetings, opening proceedings to blogging, tweeting and hyper-local news/forum reporting.

– In the past council executives could hold meetings in private without giving public notice. From 10 September 2010 councils must give 28 days notice where a meeting is to be held in private, during which time people may make representations on why the meeting should be held in public. When the council wants to over-ride the notice period, it must publish a notice as soon as reasonably practicable explaining why the meeting is urgent and cannot be deferred (regulation 5).

– A document explaining the key decision to be made, the matter in respect of which a decision would be made, the documents to be considered before the decision is made, and the procedures for requesting details of those documents, has to be published (regulations 9).

– The new regulations create a presumption that all meetings of the executive, its committees and subcommittees are to be held in public (regulation 3) unless a narrowly-defined legal exception applies.

– Where the council has a document that contains materials relating to a business to be discussed at a public meeting, members of the local authority have additional rights to inspect such a document at least five days before the meeting (regulation 16). Previously no timescale existed.

– Where the council decides not to release the whole or part of a document to a member of an overview and scrutiny committee as requested by a councillor, it must provide a written statement to explain the reasons for not releasing such document (regulation 17).

– Documents relating to a key decision including background papers must be on the relevant local authority’s website (regulations 5, 6, 7, 9, 10, 14, 15, and 21).

Comment

Well done to Eric Pickles and the coalition. These are important and welcome changes. If council decision-makers know their discussions will be open to scrutiny they may give proper consideration to risks as well as the potential benefits of big IT-related investments. With inadequate scrutiny the potential benefits often drive decisions, which was the case with the flawed setting up of Southwest One. The press office at Liverpool City Council was so used to controlling information that its spokesman was outraged at questions we asked about its outsourcing venture with BT.

But what about the NHS?

It’s a pity the NHS is not subject to the new legal changes. Few trusts are open about their big IT-related investments; and when things go wrong, as has happened with some Cerner implementations, NHS trusts tend to lock all the doors, talk in whispers and instruct their press offices to issue statements that claim “teething troubles” have been largely addressed. The trust and everyone reading the statement know it is disingenuous but the facts to prove it are kept under wraps.

Organisations such as Imperial College Healthcare NHS Trust are taking decisions about major IT upgrades that could affect the safety, health and lives of patients without proper scrutiny. Pickles may want to mention his legal innovations to Andrew Lansley.

Eric Pickles announcement on opening up council discussions and decisions 

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Posted in BT Health, Campaign4Change, Cerner, decision-making, e-health, excessive secrecy, health, health records, improving communications, IT-related failures, local government, managing outsourced services, NHS, npfit, openness and transparency, operational issues, outsourcing, Politics, public sector, public services, public-private partnerships, shared services

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