Category Archives: innovation

Civil Service too risk averse at a micro level

 Faced with big challenges, the Civil Service thought small thoughts.  [Tony Blair, memoirs]

A report by the House of Commons Public Administration Committee has warned that the Coalition Government needs a more transparent and flexible Civil Service when it comes to commissioning public services from charities, social enterprises, mutuals and private companies.

The Committee’s report says the Civil Service needs to transfer power out of Whitehall and into communities and as a result fundamentally change the way it works.

It says the challenge of this new role will be compounded by the need to meet sizeable reductions in administrative budgets set out in the 2010 Spending Review.

Its conclusions are that while the Government seeks to embrace change, it has failed to recognise the scale of reform required or to set out the change programme required to achieve this reform. It says there is a reluctance to produce what they see as the latest in a long line of reform initiatives in Whitehall. This antipathy to a plan for reform fails to take note of the critical factors for success in Civil Service reform initiatives and wider corporate change programmes: coordination from the centre and strong political leadership. As a result, it warns, key policies like the ‘Big Society’ agenda and decentralisation will fail.

The Committee says: “We have recommended that the Government should produce a comprehensive change programme articulating clearly what it believes the Civil Service is for, how it must change and with a timetable of clear milestones. Such a change programme would enable real change in Whitehall and avoid the fate of previous unsuccessful reform initiatives.

“Such a change programme must also include proposals for the Civil Service to retain and to develop the new skill sets required to meet the demands of the Big Society policy agenda, and to address long-running concerns about the decline in specialist expertise in Whitehall, the failure to innovate and to take risks, and the failure to work across departmental silos. Such a plan is required to combat inertia and deliver government policies where Ministers and departments may otherwise be unwilling or unable to drive change.

“To reflect the changing role of the Civil Service, we have also recommended that the Government should consider the development of a new Haldane model of accountability which can sustain localism and decentralisation; or they must explain how the existing model remains relevant. The new realities of devolving power out of Whitehall to local government and elsewhere should be codified in the Civil Service governance structures.

“Ministers seem to believe that change will just happen. It is essential that the Cabinet Office take leadership of the reforms and coordinate the efforts in individual departments and across Whitehall as a whole. The scale of the challenges faced by the Civil Service calls for the establishment of a world class centre of Government, headed by someone with the authority to insist on delivery across Whitehall.”

In particular, the report says the main change of task, which will affect many but not all departments, will be an increase in commissioning and contracting. More onerous and time-consuming, however, will be monitoring the contracting process and dealing with problems and complaints arising.

The report says Whitehall has traditionally performed three core roles: policy advice, the management of public services, and the supervision of public bodies. If the Civil Service is to connect with Ministers’ ambitions for public service reform a fourth capability will need to be added to this trio: the ability to engage with groups from the voluntary and private sectors through the contracting and commissioning process. Every government department must focus on developing this fourth capability, and the Cabinet Office must ensure that this is embedded in the Civil Service change programme across government.

The report explains why SMEs have made so few inroads into government work. 

It goes so far as to depict ministers as not understanding Civil Service inertia, which means they cannot come up with a plan to do anything about it. Cabinet Office Minister, Francis Maude, described a paradoxical situation where Government took huge risks at a macro level, but at a micro level tended to be very risk averse and hostile to innovation.

He added, “You do not often hear of someone’s career suffering because they preside over an inefficient status quo, but try something new that does not work and that can blot your copybook bigtime.”

 An example of one SME’s innovative ideas

Why Activity Streams and Social Analytics promise to be the future of enterprise collaboration

By David Bicknell

One of the most eagerly anticipated reports each year is Gartner’s Hype Cycle, which assesses more than 1,900 technologies on their maturity, business benefit and future direction.

It provides a cross-industry perspective on the trends that IT managers should consider adopting within their ‘must-watch this technology’ portfolios.

Throughout 2011, two of the most-watched technologies have been ‘Social Analytics’ and ‘Activity Streams’ which are in Gartner’s “Peak of Inflated Expectations” where typically a frenzy of publicity generates over-enthusiasm and unrealistic expectations of the technology, and which often means that although there may be some successful applications of a technology, there are likely to be more failures than fanfares.

These two, however, may be different. Activity Streams has been described as the future of enterprise collaboration, uniting people, data, and applications in real-time in a central, accessible, virtual interface. Take the idea of a company social network where every employee, system, and business process exchanges up-to-the-minute information about their activities and outcomes. Now, instead of pockets of knowledge, the company will have one central nervous system that unifies every piece of corporate information.

Activity Streams can fundamentally change how companies do business, unlocking and releasing the vast amount of information generated by everyday operations and making it instantly available, humanising every business process inside a company, while adding a social layer to data and opening up real-time collaboration.

As the Cisco Communities blog pointed out earlier this year, the overall concept of Activity Streams is compelling because streams allow applications to publish events that are captured by aggregators that serialise the items into a sequence of posts. Often items include options for people to “like”, comment, or react to the item in some manner through a rating. Aggregating events into a common stream also enables people to easily subscribe (“follow”) a collective set of events from one or more publishers.

Cisco Communities suggests potential benefits are not just accrued by people-centric activity streams. Indeed, applications of all types can also generate activities into a stream to keep people aware of system events (e.g., a new sales win, an urgent alert of some sort). As the enterprise considers how Activity Streams can be leveraged, interest in role-based and process-related streams is also likely to emerge. The idea is that both productivity and collaboration needs can be improved by making events more visible and allowing people to take action more effectively (sometimes collectively) based on that level of event transparency (especially when compared to how people rely on their e-mail inbox for much of this type of group notification and work coordination).

There are some riders, however. As more people and applications create events published into a common stream, the resulting volume and velocity by which events “stream by” can cause people to miss something relevant, which means they end up spending time scrolling up and down searching for things they might have missed. Depending on the way activities are aggregated, there may be limits as to how much information is actually kept around to enable historical review. The risk is that Activity Streams can become just as messy and burdensome as an email inbox. Better filtering may help – but this is still a developing area.

Where does Social Analytics come in, you might ask?  Social Analytics is closely related to Activity Streams because from the vast amount of real-time and dynamic information available, actionable insights need to be extracted so that the organisation can efficiently and effectively focus itself.

The Mvine platform has already developed this capability so that customers can create reports of what their users are doing with the site in real-time. Information created, detailing data such as age, gender, frequency to the site, downloads, location, job function, can then be used to produce reports and help target marketing campaigns and generate sales leads; providing a bespoke service to customers and an intelligent approach to understanding your user base.

It is important to be aware that when it comes to Social Analytics, one size never fits all. That is why there is a need for ‘Adaptive’ Social Analytics because the analytics will always depend on the context in which they’re being used, on which explicit application you’re using, and on the people and content you’re interested in.

For example, if you’re using an Mvine portal to communicate with a consumer-based client base, then you’ll want to know more about them as individuals, in particular their demographics. Are they ABC1, for example? However, if you’re using it to manage the content and communications in your supply chain, then the analytics required will need to cover roles and relevance i.e. Is the right department receiving and acting on your communications? Who there is receiving it? Is it the right information for their role? If your alerts are targeting Finance Directors, but your event attendees seem to be from HR, why is that? Are your alerts going to the right people, with the right demographics in terms of gender, age, responsibility and location? For example, why are you targeting an event at geographically-spread project managers in the South who never have time to meet, when better targets would be those in closer-knit locations in the North? And are your user group chapter and product discussion groups full of a silent majority of followers, or voluble – and valuable – opinion formers?  

If the company is a business-to-business organisation where regulation is critical, then the analytics information delivered will necessarily be concerned with proof that processes have been appropriately followed and that required review and sign-off complies with the organisation’s designated policies and procedures. Your analytics information will therefore comprise time-stamping information that details who did what, where and when.

Why is this important? Well, it’s all about people, context and content.  Just because we are talking about the Internet does not change the requirement for the basics to be right when it comes to the delivery of effective and usable information. We need the right information to be delivered to the right people, with the right context, in the right place, at the right time, and in the right way. Anything less, then we’re dealing with ineffective information, which is likely to herald an equally ineffective, or worse, a wrong business decision.

Could mutuals provide an innovative model for public sector IT delivery?

By David Bicknell

What are the implications for IT delivery of creating public service mutuals and what part might they play in the public sector?

One public sector IT director I spoke with recently suggested that there are areas where mutuals will work exceptionally well. And some  are already beginning to do so. Some may get private sector sponsorship, while others will get charitable status.

These, however, are smaller scale mutuals or social enterprises, and a distinction must be made between those and large scale organisations where, for example, you could set up a mutual company for the whole of IT in a county or region.

There is a belief that the oft-quoted ‘John Lewis co-operative model’ could be an effective one.  One possibility is a shared services model along those lines  as an alternative to outsourcing or a private sector partnership.

That offers the prospect of developing a public service partnership of different organisations, effectively a sort of mutual or co-operative, where everyone who joins the co-operative has a slice of the cake irrespective of their size. The co-operative shares common infrastructure and services, but operates on a semi-commercial basis, possibly working with a private sector partner. Although the model doesn’t yet exist in IT, it is said to work well in agriculture.

Arguably the model overcomes a number of the issues raised by outsourcing and big public-private sector partnerships where there has been financial pain when things go wrong.  The mutual model offers the prospect of a better way, though there is a large difference between this scale of model and smaller mutuals in terms of risk outlook and management.

The IT director said he believe there is an opportunity for mutuals to insist, ‘We’re better than the private sector. We are very responsible about the risks, and we have a public service ethos.  For us ,  it’s not just about making money. We have the discipline of commercial business rigour and the safety net that protects vulnerable adults, for example, in the case of care homes.’

Some local authorities are already considering using mutuals to provide some ICT services. For example, the London Borough of Hammersmith & Fulham has become a Mutuals Pathfinder and proposed a pilot scheme with partners Kensington and Chelsea and Westminster to set up an employee-led mutual to deliver IT services to schools and the council, with the council planning to commission some services from the mutual for a four year period.  The scheme is due to get underway early next year.

Agile – a series of London Tea Parties

By Tony Collins

Anyone interested in agile techniques  – users and suppliers, public and private sectors – is invited to share ideas at a London Tea Party on 22 September at the Cafe Zest, 2nd Floor of the House of Fraser on Victoria Street, from 4pm – 6pm.

It is arranged by Abby Peel who has recently joined Mark O’Neill in the Innovation and Delivery team within the Government Digital Service. Peel is Head of Community.

Peel says that “AgileTea”  is an informal get-together for those who work with agile methods, are interested in it, or who know nothing about it but want to know more.

An example of agile in government is the Government e-petitions website which was launched recently to much public interest after being developed by the Innovation team in six weeks.

AgileTea will be the first of a regular series of informal, BarCamp style events that will bring together like-minded people to hear, contribute and engage in discussion of agile methods.

Each meeting will have guest speakers. Anyone can ask to give a short presentation of up to 10 minutes.  At the first AgileTea speakers will be Richard Pawson  from Naked Objects who’ll talk on “Experience of very large scale agile development at the Irish Department of Social Protection” and Mark Foden of Foden Grealy who’ll speak on “Where agile fits”.

Why this SME’s innovative ideas may help Nick Clegg understand the real causes of the riots

Could a new approach detect the early warning signs of radicalism in a way that ordinary research, surveys and intelligence gathering couldn’t? Or spot when programmes to reduce re-offending aren’t working?

In this guest blog, Andrew Moore, chief operating officer at DAV Management, whose customers include large public and private sector organisations, explains why government research into complex situations, such as the causes of the recent riots or making offender management more effective, requires a different approach that goes beyond supporting preconceived hypotheses to give new insights and fresh perspectives, and crucially, offers a means of detecting the early signals of situations that are developing in communities which can either be encouraged for the wider good or damped down before they can pose a threat.

Improving the Citizen Experience

An innovative approach to surveys and research

There is a currently a great deal of interest within government circles to determine how best to engage with its various stakeholders in different, more effective (and understandably less expensive) ways.

There’s the Big Society, the attempt to establish ‘happiness’ as a measure of the nation’s wellbeing (rather than just good old GDP), the need to engage citizens in a more direct and effective manner, with services designed around them rather than the structure of government.  In addition there are specific events that trigger the Government’s need to interact with sections of the population, such as the recent announcement by Nick Clegg that he wants to engage with communities affected by the summer riots in England, in order to understand who did what and why.  Then there are the government’s internal stakeholders – its employees, with whom it is seeking an altogether more symbiotic relationship – devolving power to the people on the front line who frequently know how to run services in a more effective and efficient manner.

Mutualisation’ and ‘Third Sector’ are terms that I suspect everyone is likely to become more familiar with over the next few years, even if now they may require some defining.  The long running debate about the future of the NHS is a very good case in point. And there’s the stated desire to get SMEs delivering innovation as part of effective government procurement.  As an interesting adjunct to this, let’s not forget that employees are also citizens, creating a fascinating cross-over of interlinked perspectives.

Of course there are other groups who may be thought of as stakeholders and these will have a very specific perspective on the delivery of public services.  I’m thinking here of offenders – those serving their debt to society and for whom the government is seeking ways to improve rehabilitation, reduce re-offending and become much more effective at identifying those most susceptible to radicalisation, extremism or self-harm. This of course has been brought into sharper focus by discussions over the severity of post-riot sentencing.

All in all, this represents a hefty agenda of public services reform and one which will test the government’s strategic planning and policy implementation ability to the max.  With such degrees of change being considered, it is encouraging to hear that government is embarking upon a listening exercise to garner the views of citizens, employees and service users, as some recipients of public services are now known.  Understanding what people want in order to deliver services they will use is a laudable objective, but what a task this must represent.  How on earth do you make this achievable?  Consider for a moment the potential population sample.  What constituency would you choose?  How do you get people to participate with sensible and meaningful responses?

Even if you can get all this feedback, how do you make sense of it?  How would you store, manage and interpret the sheer volume of data, relating to so many different aspects of life and stakeholder groups?  How could you be sure it doesn’t end up as an exercise designed to prove (or disprove) preconceived positions?  How would you spot the things that you don’t recognise – the identification of a strong belief system (that could make or break any changes in the way public services are delivered); the early signs of a rise in community ‘temperature’ that could lead to the kind of civil disorder witnessed in cities across England during August this year; or the indicators that some offenders are significantly more willing (and likely) to rehabilitate under certain conditions?  I could go on but I don’t want to labour the point.

It’s clear that in an exercise that will fundamentally change how most people interact with both central and local government, it makes sense to give those people a voice.  But this has to be in a controlled and manageable way, so that it is quick and easy to understand what that voice is telling you; gaining truly unique insights and fresh perspectives from which actionable decisions can be made and monitored that make a real difference to people’s lives, be they citizens, employees or service users – or, in some circumstances, perhaps a combination of all three!

Making people part of the process in this way is also an effective way of getting buy-in.  People are more likely to feel engaged, even if it’s by proxy (i.e. evidence of meaningful consultation establishes a degree of credibility) and by its very nature, changes the basis of the relationship between government and those stakeholders with whom it is seeking to engage.

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So what’s the point in all this, why are these things being suggested as anything new?  After all, the idea of planning, shaping and delivering services against a well-defined need is surely common sense and is recognised as such by most people.  Well, as they say, the problem with common sense is that it’s not that common.  The truth is that the kind of knowledge and insight that is likely to be required by government in order to shape and deliver its vision for public services, is difficult (if not impossible) to gain from traditional methods and technology. A different approach is required.

What if you were able to poll large samples of the population on a variety of different topics and have the findings presented to you quickly and simply, in a way that wasn’t mediated by ‘experts’ and allowed you to interact directly with the data – at both a quantitative and qualitative level?  What if you were able to see things that you hadn’t expected; things that blew away commonly held perceptions about citizens or employees – giving you a clear and substantiated view of how people are feeling, what they really think of particular programmes and initiatives and how they are responding to specific policies and interventions?  Imagine being able to detect early opportunities to take action on a particular initiative that enabled you to maximise the benefits downstream or damp down a threat before it was even recognised as such.

It all sounds too good to be true, but advances in cognitive based solutions, using micro-narratives (snippets, stories, reports and other qualitative data) captured from samples of your target ‘audience’ and self-indexed by them to provide meaning from which incisive action can be taken, are turning these scenarios into reality.

The problem for strategists and policy and decision makers is that the environment in which they are operating is hugely complex; there are many small causes that interact and interweave to produce an end result, but no one cause is dominant.  The whole environment is continually adapting and changing and you can’t measure it at a point in time – it’s constantly evolving.  This is what’s known as a ‘complex adaptive system’.  It’s the kind of environment where outcomes are difficult to predict.  It’s highly sensitive to small changes, meaning emerges through interaction and, with the benefit of hindsight, you might be able to see where, when and why things have happened and how you could have dealt with a particular situation, but at the time it was erratic and novel.  Sadly, hindsight does not lead to foresight and processes to prevent a similar situation occurring next time will fail, because the next time things will happen differently.  The August riots in England were a perfect example of this scenario, where multiple small, erratic events interacted and evolved to produce a disproportionate, unpredictable and, in this case, catastrophic outcome, which the government is still trying to understand the cause of.

Complex situations frequently occur when you are dealing with people because they are inherently unpredictable and often driven by emotion.  The bad news for government is that, one way or another, people are at the heart of all of the major change initiatives and civil events that are currently under the policy spotlight.  You begin to get a sense for the scale of the challenge.  Not an overnight thing this.  [By the way, if you’re having difficulty getting to grips with the concept of a complex adaptive system think of mayonnaise.  If you’ve ever tried to make this from scratch you’ll know how uncertain it feels as the ingredients combine and the mayo gradually emerges.  One slip and it will curdle, the end result is never the same and it can’t be reverse engineered].

Fortunately, when trying to get to grips with a complex situation, a cognitive approach again comes to our rescue.  It enables us to probe the situation, sense what’s happening where and why and then respond accordingly.  It’s liberating for policy makers as it opens the door for innovation, enabling organisations to try things and see what works best in particular situations.  Fast feedback loops promote a low-risk, ‘safe-to-fail’ environment where those ideas that aren’t working are quickly identified and turned off, enabling us to get behind those that are delivering tangible results.  In this way, new services and new ways of working can evolve, meaning that the end result has a much higher chance of widespread adoption and, hence, long-term success.

The really good news for government is that game changing solutions of this type are really in the sweet spot when it comes to getting ‘more for less’, as today’s economy demands.  The levels of investment required are a fraction of the amounts that have typically been associated with major government change initiatives.  They are also much simpler to implement and run.  Once set up, data capture, analysis and reporting can be built into an organisation’s day to day operational processes, supporting (and stimulating) how it interacts with the citizens or service users it serves, or the employees it depends upon for the delivery of those services.  For example, making it part of how Offender Managers (previously known as Probation Officers) interact with offenders to try and reduce re-offending would be an excellent way to capture how the latter group is responding, say, to changing institutional attitudes and behaviours, revealing to what extent infantilisation (i.e. treating offenders in a condescending manner, as if still children) is being reduced.

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A recent case in Canada illustrates how the solution can be implemented to improve the delivery of healthcare services.  In this instance, the authorities in British Columbia initiated a programme to help them understand the perspectives of all parties implicated in the unfortunate death of an elderly patient.  This had resulted from a breakdown in communication and subsequent decision making following the patient’s admittance to hospital suffering from congestive heart failure. Not unusually in these circumstances the single, sentinel event of the patient’s death was seen from very different perspectives by the various groups involved.  By adopting a cognitive based approach the authority was able to bring together front line and management staff to make sense of these conflicting perspectives and, as a result of the unique ‘safe-to-fail’ experimentation techniques supported by the approach, it was able to trial and subsequently implement changes in both policy and service delivery that will not only help to prevent similar incidents occurring in the future but also raised the quality of healthcare provided to patients more generally.

Just think how powerful such an approach would be for Nick Clegg in his quest to understand the complex human behaviours and emotions that came together to fuel the aforementioned riots in England.  And to have this at your disposal not only as a platform from which to take decisive action now but also to generate alerts when the ‘community temperature’ again begins to rise, must surely present a huge opportunity that any civil authority worth its salt would want to take advantage of. Instead it would appear that research initiatives are being launched by those with an interest in understanding and curing society’s ills that, albeit well-meaning and based on credible empirical evidence, may still ultimately turn out to be incomplete.  My concern would be that if a traditional research approach is adopted to try and make sense of what is essentially a complex situation (as I have defined above) then such initiatives risk revealing only those things that are readily recognisable and, having been mediated by ‘experts’, support preconceived hypotheses.  They are likely to  miss the opportunity to discern unexpected findings arising directly from the contribution of the people affected by (and involved in) the riots and fail to detect the early signals of situations that are developing in those communities, which can either be encouraged for the wider good or damped down before they can cause further unrest.  Addressing these issues by adopting a cognitive based approach will provide a much more effective feed into future policy decisions and social interventions.

If you’re new to the concept of cognitive based solutions it can be a bit of a challenge to get to grips with how they work and just what they give you, but once you’ve experienced the power of the knowledge and understanding that they deliver, you start to see applications everywhere you look.  The big advantage is that it’s easy to get started with low-cost, low-risk pilots that can start to make a difference to any organisation in a very short space of time.

To learn more, visit http://davmanagement.com/default.asp?id=833&ver=1

Contact Andrew Moore at andrew.moore@davmanagement.com

Or call +44 (0)1189 974 0100

An NHS success story – what’s to learn from it?

By Tony Collins

IM&T at Trafford General Hospital makes visits to hospital safer for patients and gives managers the information they need to monitor the work of clinicians. Even doctors like the advanced technological environment and come up with ideas for improvements. So what lessons can be learnt? Here are four:

–           Be in control of your IT suppliers. Too often in the public sector it’s the other way around

–           Don’t buy from suppliers that seem excessively secretive and talk much about their proprietary information – which may include your data. Know their systems well enough to produce the reports you want, when you want them and in the format you want, rather than wait for your information to be given to you when the suppliers want to give it, and in their format.

–           Don’t impose change. Have the push come from the business users [in Trafford’s case clinicians] who understand what technology can do for them.

–           Keep IT in the background – not centre stage.

Advanced health technology on a £1.5m yearly budget

By Tony Collins

[This is the final part of a 3-part series on how Trafford Healthcare NHS Trust’s IM&T team achieves much on a small budget]

Trafford General Hospital bought its main systems outside of the £11.4bn the National Programme for IT [NPfIT]. The hospital, though, is one of the most technologically-advanced in the UK.

Part one of our series on Trafford Healthcare NHS Trust covered the clinical support for IM&T, integrated systems, and the openness that’s required of the trust’s suppliers.

Part two covered the trust’s  control of its data, how NPfIT could ever have worked, how patients benefit from the IM&T,  why doctors keep their smartcards on them at all times, links between hospital and GP systems, the real-time view of free beds, why duplicated patient records are rare, board support for  integrated electronic patient record systems, and some of the remaining challenges.

Some of  Trafford’s further challenges include:

–           Securing the agreement of all GPs in the area to share a synopsis of their records. About half have agreed so far.

–           Scanning in all paper notes to the EPR. At present about 50% of patient notes have been scanned and are available to clinical staff as “PDF” files, normally with chapter headings. They include diagrams, charts and handwritten text.

–           Dealing with any uncertainties that arise when the Trust is acquired – in all probability by Central Manchester Foundation Trust .

–           Maximising the IM&T opportunities that the acquisition will bring both Trusts in terms of modernising systems and extending the concept of the shared electronic patient record across a wide area of Manchester.

Costs

Trafford has 14 people working on IM&T and IT infrastructure related matters who handle support, infrastructure and integration. The total yearly cost, including salaries, is about £1.5m in capital and revenue which covers the spend with all of Trafford’s  IM&T suppliers.

This compares with costs of between £23m and £31m for each NPfIT installation at acute trusts in London and the South – and these sums do not include the costs of running a hospital’s IM&T and associated infrastructure. Neither do the NPfIT costs include the salaries for an acute hospital’s IT and IM&T staff.

Steve Parsons, Head of IM&T, says of his hospital’s technology: “This is bargain stuff”.

If Trafford can do so much for so little, can centrally-bought NPfIT systems costing many times more – for less – still be justified? The Department of Health argues that NPfIT systems offer more than non-NPfIT. But how much more could Trafford offer its clinical staff, in terms of proven technologies and integration?

Asked where he’d put Trafford in a league table of UK hospitals with systems that clinicians need and want to use, Peter Large, Director of Planning, pauses and says with a slight smile: “Let’s be modest – in the top 10%.”

He’s probably not joking.

**

•           Since writing this article Parsons and his team have been short-listed by the eHealth Insider Awards for the trust’s electronic whiteboard project, in the category of “innovation in healthcare interoperability”.

Part one: How does this IM&T team achieve so much for so little money?

Part two: How does this IM&T team achieve so much for so little money? (2)

Civil service “full of brilliant people terribly managed”

By Tony Collins

Andrew Adonis was transport secretary in Tony Blair’s government. Last year he became director of the Institute for Government which Adonis describes as a thinktank that speaks truth to power.  Among other things it produced the excellent System error: fixing the flaws in government IT which advocates an agile approach to innovation at the front line.  

Now in an interview with Politics.co.uk  Adonis points out the institutional weaknesses of the civil service.  “My criticisms are about the machine,” he says. “My own view is that the civil service is full of brilliant people who are terribly managed.”

One of the biggest problems is what he calls the  “laughably” named permanent civil service. People change jobs because of a merry-go-round culture which makes no sense, he says.  It’s not a problem that’s going away: since the general election ten of the 16 departments of state have had changes in their permanent secretary.

“The machine really is very badly run,” he says.

Comment

What Adonis says is important because institutional resistance to change and innovation is largely because what exists is said to be work well. It doesn’t work well because government administration costs tens of billions much more than it should and the National Audit Office has found that fraud and error in two of the biggest departments, HMRC and DWP, are at unacceptable levels. 

It’s time that the point made by Adonis, and many others of some authority, is given more credence.  Systems within government need changing and, particularly, simplifying  – not in a rush and not without proper thought and testing.

The old argument that government administration aint broke so leave it alone doesn’t stand up to independent scrutiny. It is broke and it needs intelligent, inventive and cheap-to-implement change.

How does this tech team achieve so much on so little money? (2)

By Tony Collins

One reason doctors and nurses hold the tech team at Trafford General Hospital in high regard is the quiet professionalism of Steve Parsons who’s a civil engineer and Head of IM&T at Trafford Healthcare NHS Trust in Manchester.

Civil engineering is a  world where openness  is allied to safety. Parsons  designed buildings and pumping stations in the water industry where managers don’t tolerate unnecessary secrecy from their suppliers. From there he became involved in managing IT-led change and came to Trafford General Hospital in 2000.

“It’s having an analytical questioning mind, not just accepting what people say. I will ask all the questions that can make me seem a pain. You want to know why it [a supplier’s software] is going to work,” he says.

“If they don’t give me the confidence that their product is going to work under certain conditions I will not want it. I will not take a black box without knowing what is going to happen with it. I am not having that dependency. I want to strip it down to its basics. It has to be practical. Where else is it working? What is the underlying database?”

Patient data and suppliers 

He says that hospital data belongs to the hospital, not the supplier. “There are people working in the health service who will say: ‘we are the system supplier. It is our data.’ But ours is patient data. This is client’s data, not the supplier’s.”

To an outsider – one who doesn’t work in the NHS – the most surprising thing about seeing the IM&T engine rooms at Trafford General is the complexity and the different ways each ward works. These complexities have to be managed to give doctors and nurses a seamless view of what is happening with each patient.

Could the NPfIT ever have worked?

It’s remarkable, given these complexities, that anyone thought a national system – the National Programme for IT in the NHS –  could ever have worked. It’s hard enough to integrate IM&T within a single hospital let alone on a regional or national scale.

Parsons and Peter Large, Director of Planning at Trafford Healthcare NHS Trust,  consider it lucky that Trafford went live with the Graphnet patient record technology as early as 2003, several months before the tenders for the NPfIT systems were awarded.

It meant that, while some in the NHS were waiting in eager anticipation for NPfIT systems that never arrived, Trafford’s technical staff were learning in precise terms what clinicians wanted and converting this knowledge into working systems. At no point did the promised national systems offer more than Trafford’s.

How patients benefit from Trafford’s IM&T   

In a room close to each ward is a 46” screen known as the “whiteboard” which shows lists of every patient, whether in a bed or visiting outpatients. Allied to the patient’s name are relevant details including colour-coded alerts to warn if a VTE [thrombosis] check hasn’t yet been done, an observation is overdue or an x-ray has not been assessed. In A&E the icon turns red if a patient has waited for three hours, and purple if more than four hours.

Also on the whiteboards, breaches of Department of Health guidelines on waiting times are shown clearly for each patient. The screen also shows which doctor is responsible for any breaches of waiting times.

If nothing else, these system alerts and icons – which include ticking clocks – show how technology can make treatment and care safer for patients.

Why doctors keep their smartcards at all times 

Clinical staff must use smartcards to access the system, and they are unlikely to forget them because they also allow access to the car park.

In trials of NPfIT systems, some doctors were reluctant to use smartcards because of the time taken to log on each time they returned to the computer. At Trafford log-on takes a few seconds, and Imprivata’s single sign-on means that holders of smartcards do not have to remember different passwords. Take out the smartcard and the screen goes blank.

Says Parsons: “We are dependent on EPR now. A year ago one or two consultants refused to look at the EPR. Their secretaries had to print off the last letter from outpatients because they would rather not look at it on a screen. That’s changed.”

Patients give their details only once 

In parts of the NHS patients give their name and address every time they visit a different part of the hospital. At Trafford General Hospital a new patient has a file created at, say, A&E. It is then available to all parts of the hospital, ready for staff to order electronically a blood test or x-ray, or book an appointment.

Links to GPs 

Through Sunquest’s Anglia order communications system and using the HL7 messaging standard, GPs can from their desks order hospital blood tests and x-rays, and get the results in their inboxes. The orders and test results are recorded in the hospital’s Graphnet EPR.

If the local GP has authorised it – and so far about half in Trafford’s catchment area have – A&E doctors will soon be able to see a synopsis of the GP-held patient record which would show any treatments outside the Manchester area as well as medications and significant medical events. The synopsis comes into a hospital server that is controlled by GPs, using their local Emis or Vision systems. In return, GPs have access to their own patients within the hospital-based EPR where they can see all the records related to a patient’s episodes of treatment .

Real-time view of free beds

On the whiteboard, staff can see when beds are due to become vacant, doctors having given the system an estimated time and date of departure for each inpatient. If a doctor fails to give an estimate the system shows an alert.

Says Laura Slatcher who is an assistant to Parsons, “Doctors are restricted with what they can do with the patient’s record  – cannot make referrals, cannot update whiteboards – unless the estimated discharge date is kept up to date. Doctors will complain that they cannot get on because clerks or nurses haven’t kept this administrative information up to date.”

The estimated discharge date is also useful to ensure that the system has alerted district nurses if the patient, after leaving hospital, needs physiotherapy, dietary monitoring or help from social services.

Bed management is a module now removed from the “Lorenzo” system as part of the Department of Health’s plans to cut the costs of NPfIT contracts.

Duplicated patient records are rare

Parsons and his team have done much to tackle the bane of hospital administration: duplicate patient records. Says Parsons: “We have a central patient index which is updated nightly from all GP practices. If you say your name we check date of birth and previous addresses, maybe from the GP – you may still get two people with the same name living in the same house.

“Once we have updated John Jone to John Jones, the central system will update all other related systems to the new spelling. One single ID for everyone avoids having duplicates which could end up with patients having the wrong records. That’s critical to get right.”

Medical Director Dr. Simon Musgrave says: “Duplicates are a fairly rare event now.”

Staff in A&E can create duplicates very easily from patient provided information but “we have systems in place to track those in the following 24 hours and merge them back to the correct record”, says Parsons.

The hospital’s old iSoft patient administration system had 150,000 duplicate files in a database of 460,000 patients. That was typical for an acute hospital says Parsons.

Trafford dispensed with its patient administration system –  it doesn’t have one, having replaced it with the Graphnet’s EPR and Ultragenda from iSoft [now owned by CSC].

EPR goes beyond Trafford

Many doctors are sceptical of the need to make electronic patient records available across England, which was one of the main – and ultimately unsuccessful – aims of the NPfIT. The sceptics say it is very rare for patients to need treatment outside their locality.

Trafford has 250,000 patients in its catchment area but its EPR has 1.4 million records which includes most people in Manchester.

Board support

Trafford adopted the Department of Health’s pre-NPfIT strategy in the late 1990s which called for hospitals to install, incrementally, six levels of EPR – electronic patient records. Level one was a patient administration system and departmental systems. The highest, level six, was a full multi-media EPR online.

Says Parsons: “I have been fortunate of having the support of the Trust Board throughout the 10-year period of staying on a strategy that said: ‘we will continue to build that six-level EPR and all that went with it until an equivalent and better came from the National Programme for IM&T  through Connecting for Health’.”

Reporting, accountability and safety 

Trafford publishes hundreds of reports to operational managers: how long patients have been in their bed or how have they waited, how many patients have had certain types of forms filled in such as VTE forms. Every morning emails to consultants tell them the number of patients they had admitted the day before and how many have not had, say, thrombosis assessments.

Standard reports from some suppliers to the NHS may be too limited for Trafford’s demands, says Parsons. “Some of the questions we are asking require difficult algorithms. On bed occupancy for example doctors get credits for the numbers of patients they are caring for. The standard unit for care is one day or night in hospital.  If somebody is in for six hours, if you work in units of one day, nobody gets credits for that. We want to break IM&T down to parts of days and look at trends.”

Challenges remaining

Ensuring patient safety during the transition from paper to computer needs careful management.

Says Musgrave, Trafford General’s Medical Director: “When you ask for an x-ray [on paper] you fill out a form, get the x-ray done, and the x-ray report is written on a piece of paper which comes back to you so your secretary gets a bit of paper that says “cancer” on it. That’s the end point, the safe point, and you do something about it.

“If you order it on a computer and you do not have a paper record, you have to have some other different system for making it safe.  How do you know the x-ray has been ordered, has been done, and been reported? And what is the report? There is no back-stop there unless you invent one via the computer.”

“Will we ever do entirely without paper?” asks Parsons. “Hmm.”

Part one – How does this tech team achieve so much on so little money?

Final part – How does this tech team achieve so much on so little money?

How does this tech team achieve so much on so little money?

By Tony Collins

Laura Slatcher dreams of forms – reducing the number of them.

She works with a small IM&T team at Trafford General Hospital that is trying to standardise and reduce the number of paper forms doctors and nurses use in the care and treatment of patients.

As is typical for a hospital of its size there are up to 70 – mostly different – paper forms on every ward. Slatcher is working with clinicians to define ways of switching from paper to electronic records – which they are doing with alacrity.

“We have to standardise here,” says Steve Parsons, Head of IM&T at Trafford Healthcare NHS Trust in Manchester. “The doctors and nurses welcome that. They want to work better and more efficiently because they are under pressure themselves to do that.”

Clinical support 

Trafford General bought its main systems outside of the £11.4bn the National Programme for IT [NPfIT]. The hospital, though, is one of the most technologically-advanced in the UK says Peter Large, Trafford Healthcare NHS Trust’s Director of Planning.

There has been no risky “Big Bang” implementation of a Whitehall-bought patient administration system. Rather, Parsons’s approach has been step by step progress over 10 years: implementing systems, learning from what went well and not so well, and integrating hardware and software from a range of suppliers. This strategy could help to explain why the clinical staff we spoke to at Trafford hold the small IM&T team in high regard.

In 2000 the hospital had rudimentary technology – isolated systems in some departments. Now the IM&T team is able to give clinicians what they have asked for; and at Trafford it’s the doctors and nurses who say what they want. Systems are not imposed on them. Here the technologists are in the background, not centre-stage as in the NPfIT.

Trafford and the NPfIT

Says Large: “We found ourselves in the position of being ahead of the game. When we were asked to commit to the National Programme we held back because we needed to know we would be committing to a better solution than was already available to us.”

Parsons adds: “Some trusts didn’t really have anything at all so were desperate to be in the first wave. From their perspective the national programme was a brilliant step forward. But the right products never arrived.”

Integrated systems

One reason for Trafford’s success is the integration of the hospital main and departmental systems. Before electronic patient records, patients could come into hospital without their paper notes being available. Now doctors across the hospital’s departments and clinics can access at the hospital’s XML-based electronic patient records at any time, day or night – and from home if they have remote access.

Doctors can view x-rays and assessments of them from the patient record; and from system alerts and patient tracking, operational managers can see how well individual doctors and nurses are coping with the numbers of patients on their daily lists.

No black-box technology

The hospital’s three main systems are an electronic patient record from Graphnet, software to schedule and manage appointments from Ultragenda, owned by iSoft (now acquired by CSC), and the “Ensemble” integration engine from InterSystems.

What sets these and the hospital’s other systems apart is that they are not black boxes, impenetrable to Trafford’s technologists. Parsons insists that Trafford’s suppliers make their software transparent so that it can be understood by the hospital’s IM&T staff and integrated with other systems, at database “field” level if necessary. That way Parsons can produce any report clinicians need and usually in real-time.

When a supplier keeps its software opaque for reasons of proprietary and commercial confidentiality, Parsons is restricted in the type of medical and administrative reports he can ask the company to supply – and may have to wait hours or a day to get them. He wants none of that.

It’s this level of control that Parsons believes he has a right to expect – and he seems a little surprised that CIOs don’t always require openness from their software suppliers.

How does this tech team achieve so much on so little money? (2)

How does this tech team achieve so much on so little money [final part]