Category Archives: LPfIT

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

dwpBy Tony Collins

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

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

FOI tribunal grants request to publish DWP's written submission

FOI tribunal grants request to publish DWP’s written submission

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

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

Unpublished until now, the DWP’s written legal submission referred, in part, to the effects on employees of leak investigations.

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

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 It should not be published or passed to an MP.

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

Excerpts from the submission are here.

Analysis and Comment

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

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

Confidential

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

That sensitivity has little to do with protecting personal data.

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

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

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

Individual accountability for failure?

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

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

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

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

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

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

Understandable?

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

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

Need for openness

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

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

Programme papers“watermarked”

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

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

Concern over leaks

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

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

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

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

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

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

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

“Defensive”

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

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

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

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

Were there leaks of particularly sensitive information?

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

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

NPfIT

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

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

Ex-Government CIO wanted more openness on IT projects

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

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

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

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

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

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

MPs and even IT suppliers want openness on IT projects

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

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

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

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

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

DWP headline late and over budget

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

The report said,

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

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

The costs of concealment

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

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

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

“Abysmal”

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

1984

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

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

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

Does it matter if the DWP is paranoid about leaks?

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

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

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

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

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

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

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

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

Red team

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

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

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

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

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

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

Wrong assumptions

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

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

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

Said Lord Bach,

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

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

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

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

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

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

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

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

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

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

Bad news

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

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

Ministers helpless to force openness on unwilling officials?

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

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

Brexit

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

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

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

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

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

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

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

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

 Excerpts from the DWP submission

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

By Tony Collins

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

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

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

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

Another health official tells the minister,

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

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

The Wachter team will, according to the government,

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

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

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

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

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

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

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

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

Existing systems?

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

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

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

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

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

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

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

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

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

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

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

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

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

A locum GP said on the Pulse website recently,

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

New appointments

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

Which is just what has happened.

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

Said the announcement,

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

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

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

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

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

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

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

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

A former trust chief executive told me,

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

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

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

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

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

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

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

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

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

Jargon

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

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

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

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

Wachter review terms of reference.

Review of IT in the NHS

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

Hunt announces Wachter review

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

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

By Tony Collins

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abandoned NHS IT plan has cost £10bn so far

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

By Tony Collins

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

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

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

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

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

Some GPs found they could not log on.

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

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

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

Other GPs said they avoided using technology to refer patients.

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

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

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

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

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

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

Comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

e-Referral Service “unavailable until further notice”

Hundreds of patients lost in NPfIT systems

Hospital has long-term NPfIT problems

An NPfIT success at Croydon? – Really?

Physicians’ views on electronic patient records

Patient record systems raise some concerns, says report

Electronic health records and safety concerns

Medication errors 6 months after “admin” system goes live

By Tony Collins

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

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

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

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

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

“CRS Millennium Lessons Learned

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

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

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

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

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

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

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

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

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

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

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

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

NPfIT

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

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

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

Comment

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

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

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

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

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

By Tony Collins

Croydon hospitals have built up a waiting list of 50,000 patients since a Cerner electronic patient record system go-live last October, according the trust’s latest board papers.

And, since the go-live, more than 2,200 patients have waited at least 6 weeks for diagnostic tests, of which 160 have been identified as “urgent suspected cancer and urgent patients”.  This backlog may take until the end of August to clear, say the board papers of the Croydon Health Services NHS Trust which includes Croydon’s Mayday Hospital, now the University Hospital.

The trust has declared a “serious incident” as a result of the diagnostics backlog. An SI can be reported when there is possibility of unexpected or avoidable death or severe harm to one or more patients.

“No harm”

The trust concedes that its waiting times pose a “potential clinical risk” but the board papers say several times that there is no evidence any patient has come to harm.  This assurance has been questioned by some trust board members. The trust continues to investigate.

Croydon is the latest in a long line of trusts to have had serious disruption after a Cerner go-live under the NPfIT, with BT as the installation partner.

The trust has kept the implications for patients confidential. This may contravene the NHS’s “duty of candour” – to report publicly on things that go wrong. The duty has come about in the wake of the suffering of hundreds of people in the care of Mid Staffordshire NHS Trust.

Croydon Health Services NHS Trust has decided not to publish its “Cerner Deep Dive” or Cerner “Lessons Learnt” reports, and discussions on the reports have been in Part 2 confidential sections of board meetings.

The trust defended its “Part 2” approach in its statement (below).

Meanwhile the Health and Social Care Information Centre, which runs the NPfIT local service provider contracts, including BT’s agreement to supply Cerner to hospitals in London,  has commissioned Cerner to capture the benefits nationally of Cerner installations.

Q&A

My questions and points to the trust, and its responses are below.

From me to the trust:

Croydon had good reasons to go live with Cerner, and DH funding was a further incentive but the trust does not appear to have been in a position to go live – at any stage – with a Big Bang Cerner implementation. The 7 aborted official go-live dates might have been a sign of why.  It would have been a brave decision to cancel the implementation, especially as:

–  the trust had spent 2 years preparing for it

– DH, BT and Cerner had put a lot of work into it

– there was DH pressure to go live especially after all the missed go-live dates.

The latest board papers say 6 or more times in different places that there has been no harm to patients as a result of the delays and waits.  Some members have raised questions on this and there is the matter of whether the trust is commissioning its own assessments (marking its own work).

On this:

– 50,000 on waiting list

– Cerner deep dive not published

– Lessons Learnt not published (concealment of failures, against the spirit of duty of candour called for by Robert Francis QC and Jeremy Hunt?)

– Diagnostics – an SI reported. The trust has considered the contributing issues which related to Cerner implementation but has not published details of the discussion. Again a concealment of failures?

– An accumulation of over 2,200 patients that were waiting over 6 weeks for diagnostics. Out of that number 160 patients were identified as urgent suspected cancer (USC) and urgent patients.  Can the trust – and patients – be sure there has been no harm?

– “… external assurance through an external clinician will provide the assurance that no patients have suffered harm as a result of the length of the waiting times”. Bringing in an external clinician to provide an assurance no patients have been harmed seems to pre-judge the outcome.  The trust appears to be marking its own work, especially as the backlog of patients awaiting diagnostics may not be cleared until the end of August.

– Managing public and GP perceptions? “Members agreed that GP interactions should be held off until the investigations had produced definite findings. However the Communications Department are on standby to publish information to GPs if required, and the Trust is ready to react to other enquiries. The Trust will in any event publish the incident report after the investigation has been completed.”

– “… the implementation of Cerner in October 2013 had an impact on activity levels and the delivery of RTT standards”. Again no report on this published.

– “An independent assessor would re-check all patients to assure that no harm has resulted. The Committee noted the progress report and requested that this is referred to a Part 2 meeting of the Trust Board …” Concealment of failures again?

– In the past the DH has been prepared to treat patients as guinea pigs in Cerner Big Bang implementations. The philosophy appears to be that the implementations will inevitably be disruptive but it’s for the good of patients in the longer term. That this approach may be unfair on patients in the short term, however, seems not to trouble the NHS hierarchy.

It’s clear clinicians and IT staff are doing their best and working hard for the benefit of patients but the implementation was beyond their control. Meanwhile complaints are increasing, Croydon Health Services was one of the lowest rated trusts for overall patient experience and a sizeable minority of local residents don’t choose the local hospitals for care or treatment. That said some patients rate their care very highly on NHS Choices (although some don’t). The University hospital is rated 2.5 stars out of 5.

One of the most surprising statements in the board papers is this: “… despite the weaknesses in the programme, the overall success of the deployment had been recognised at a national level”. A success? Can the trust in essence say what it likes? Nobody knows for sure what the facts are, given that the trust decides on what to publish and not to publish.

The trust’s response to the above points and questions:

“Due to a temporary failure of our administrative systems, the Trust found in February 2014 that a number of patients who needed to be seen by the imaging service were in breach of the six week waiting standard.

“We have taken immediate action to correct this and are undertaking a thorough review to confirm that no patients were harmed as a result.  The Trust is now working hard to treat patients currently on our waiting lists.  This is referenced in our publicly available Board papers.

“CRS Millennium has delivered a number of improvements that support improving patient experience at the Trust, including more efficient management of medicines, more detailed patient information being conveyed between shifts and departments and better management of beds within the organisation.”

Lessons?

Below are some of the lessons from Croydon’s Cerner go-live. Although the trust hasn’t published its “Lessons Learnt” report, some of lessons are mentioned in its latest board papers:

  • Insufficient engagement from operational and clinical colleagues
  • Time pressures were felt when a full dress rehearsal stretched the capabilities of the information team.
  • Insufficient time and resources were allocated to completion of the outline business and full business cases, as well as to due diligence on the options and costs.  [Business cases for Cerner are still unpublished.]
  • Trust directors agreed that a business case for a project of the size and complexity of the CRS Millennium should have taken longer than 6 weeks to prepare.
  • A failure of senior managers to take stock of the project at its key stages.
  • Too strong a focus on technical aspects
  • Clinicians not always fully appreciating the impact of the changes the system would deliver
  • The hiring of an external change manager to lead the deployment who proved to be “less than wholly successful because of the resulting deficiency in previous experience or knowledge of the culture of the organisation”.
  • The individual left the organisation part way through deployment which led to further challenges.
  • The right people with the right skills mix were not in place at the outset to achieve the transformational change necessary to successfully deploy a new system such as CRS

Comment 

NHS trusts have good reason to modernise their IT using the widely-installed  Cerner electronic patient record system, especially  if it’s a go-live under the remnants of the NPfIT, in which case hospitals receive DH funding and gain from having BT as their installation partner.

But why does a disruption that borders on chaos so often follow NPfIT Cerner implementations? Perhaps it’s partly because the benefits of Cerner, and the extra work required by nurses and doctors and clerical staff to harvest the benefits, is underestimated.

It is in any case difficult to convey to busy NHS staff that the new technology will, in the short-term, require an increase in their workload. Staff and clinicians will need to capture more data than they did on the old system, and with precision. The new technology will change how they work, so doctors may resent it initially, especially as there may be shortcomings in the way it has been implemented which will take time to identify and solve.

The problem with NPfIT go-lives is that they take place in an accountability void. Nobody is held responsible when things go badly wrong, and it’s easy for trusts to play down what has gone wrong. They have no fear of authoritative contradiction because they keep their implementation assessments confidential.

What a difference it would make if trusts had an unequivocal duty of candour over electronic health record – EHR – deployments. They would not be able to go live until they were ready.

The disruption that has followed NPfIT Cerner go-lives has been serious. Appointments and tests for suspected cancer have been lost in the administrative confusion that follows go-live. There have been backlogs of appointments for tens of thousands of patients. Operating theatres have gone under-used because of mis-scheduled appointments.

Now and again a patient may die unnecessarily but the problems have been regarded by the NHS centrally as collateral damage, the price society pays for the technological modernisation of the NHS.

Richard Granger, when head of the NPfIT, said he was ashamed of some Cerner installations. He described some of them as “appalling” but since he made his comments in 2007, some of the Cerner installations have been more disruptive than those he was referring to.

Provided each time there is no incontrovertible evidence of harm to patients as a result of a go-live, officials give the go ahead for more NPfIT Cerner installations.

Guinea pigs?

Disruption after go-live is too often treated as an administrative problem. Croydon’s statement refers to a “temporary problem with our administrative systems”. But new patient record systems can harm patients, as the inquest on 3-year-old Samuel Starr heard.

It’s time officials stopped regarding patients as guinea pigs in IT go-lives. It compounds the lack of accountability when trusts such as Croydon keep the reports from the go-live secret.

Trusts need better technological support but not at the cost of treating any harm to patients as collateral damage.

A tragic outcome for Cerner implementation at Bath?

Openness and honesty is a rarity after health IT problems

Mishandled electronic health record transition

A botched Cerner EHR implementation?

Trinity Medical Center reaches Cerner settlement

CEO and CIO resign after troubled EHR go-live

By Tony Collins

At the foot of the Blue Ridge Mountains, Georgia, in America’s deep south, about 70 miles from Atlanta, is Athens .

It was named at the turn of the 19th century to associate its university with Aristotle and Plato’s academy in Greece. It is home to the Athens Regional Medical Centre, one of the USA’s top hospitals.

There on 4 May 2014 the Centre went live with what it described as the most meaningful and largest scale information technology system in its 95-year history – a Cerner EHR implementation.

Now the Centre’s CEO James Thaw and CIO Gretchen Tegethoff have resigned. The Centre’s implementation of the electronic health record system seems to have been no more or less successful than at UK hospitals.

The main difference is that more than a dozen doctors complained in a letter to Thaw and Tegethoff.  A doctor leaked their letter to the local paper.

“Medication errors”

The letter said the timescales to install the Cerner EHR system were too “aggressive” and there was a “lack of readiness” among the intended users. They called the system cumbersome.

The letter referred to “medication errors … orders being lost or overlooked … (emergency department) and patients leaving after long waits”. An inpatient wasn’t seen by a physician for five days.

“The Cerner implementation has driven some physicians to drop their active staff privileges at ARMC [Athens Regional Medical Centre],” said the letter. “This has placed an additional burden on the hospitalists, who are already overwhelmed. Other physicians are directing their patients to St. Mary’s (an entirely separate local hospital) for outpatient studies, (emergency room) care, admissions and surgical procedures. … Efforts to rebuild the relationships with patients and physicians (needs) to begin immediately.”

The boldness of the letter has won praise in parts of the wider American health IT community.

It was signed by the centre’s most senior medical representatives: Carolann Eisenhart, president of the medical staff; Joseph T. Johnson, vice president of the medical staff; David M. Sailers, surgery department chair; and, Robert D. Sinyard, medicine department chair.

A doctor who provided the letter to the Athens Banner-Herald refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues.

Swift action

One report said that at a meeting of medical staff 200 doctors were “solid in their vote of no confidence in the present hospital administration.”

Last week Thaw wrote in an email to staff: “From the moment our physician leadership expressed concern about the Cerner I.T. conversion process on May 15, we took swift action and significant progress has been made toward resolving the issues raised … Providing outstanding patient care is first and foremost in our minds at Athens Regional, and we have dedicated staff throughout the hospital to make sure the system is functioning as smoothly as possible through this transition.”

UK implications?

The problems at the Athens centre raise questions about whether problematic Cerner installations in the NHS should have consequences for CEOs.  Health IT specialists say that, done well, EHR implementations can improve the chances of a successful recovery. Done badly an EHR implementation can harm patients and contribute to death.

The most recent installations of Cerner in the NHS, at Imperial College Healthcare NHS Trust and Croydon Health Services NHS Trust, follow the pattern of other Cerner EHR go-lives in the NHS where there have been hints of problems but the trusts are refusing to publish a picture of how patients are being affected.

What has gone wrong at Athens Regional?

IT staff, replying to the Banner-Herald’s article, have given informed views on what has gone wrong. It appears that the Athens Regional laid off about a third of the IT staff in February 2014, about three months before go-live.

Past project disasters have shown that organisations often need more, not fewer, IT staff, advisers and helpers, at the time of a major go-live.

A further problem is that there appears to have been little understanding or support among doctors for the changes they would need to make in their business practices to accommodate the new system.  Had the organisation done enough to persuade doctors and nurses of the benefits to them of changing their ways of working?

If clinicians do not support the need for change, they may focus unduly on what is wrong with the new system. An organisation that is inherently secretive and resentful of constructive criticism will further alienate doctors and nurses.

Doctors who fully support an EHR implementation may find ways around problems, without complaining.

One comment on the Banner-Herald website says:

“While I have moved on from Athens Regional, I still have many friends and colleagues that are trying to work through this mess. Here is some information that has been reported to me…

“Medications, labs and diagnostic exams are not getting done in a timely manner or even missed all together. Some of this could be training issues and some system.

“Already over worked clinical staff are having to work many extra hours to get all the information in the system. This obviously takes away from patient care.

“Senior leadership tried to implement the system in half the amount of time that is usually required to do such things, with half the staff needed to do it. Why?

“Despite an environment of fear and intimidation the clinical staff involved with the project warned senior administration that the system was not ready to implement and posed a safety risk.

“I have ex-colleagues that know staff and directors that are involved with the project. They have made a valiant effort to make things right. Apparently an 80 to even a 100 hour work week has been the norm of late.

“Some questions that I have: where does the community hospital board stand with all this? Were they asking the questions that need to be asked? Why would the software company agree to do such a tight timeline? Shouldn’t they have to answer some questions as well?”

“Hopefully, this newspaper will continue to investigate what has happened here and not cave to an institution that spends a lot of money on frequent giant full page ads.

“Please remember there are still good people (staff, managers and administrators) that work at ARMC and I am sure they care about the community they serve and will make sure they provide great patient care.”

“The last three weeks have been very challenging for our physicians, nurses, and staff,” said Athens Regional Foundation Vice President Tammy Gilland. “Parts of the system are working well while others are not. The medical staff leadership has been active in relaying their concerns to the administration and the administration has taken these concerns very seriously. Maintaining the highest quality of patient care has always been the guiding principle of Athens Regional Health System.”

Keeping quiet

NHS trusts go quiet about the effect on patients of EHR implementations despite calls by Robert Francis QC and health secretary Jeremy Hunt for openness when things go wrong.

Imperial College Healthcare NHS Trust, which comprises St Mary’s Paddington, Hammersmith Hospital, Charing Cross Hospital, Queen Charlotte’s and Chelsea Hospital, and Western Eye hospital in Marylebone Road, went live with Cerner– but its managers and CEO are refusing to say what effect the system is having on patients.

An FOI request by eHealth Insider elicited the fact that Imperial College Healthcare had 55 different consultants working on the Cerner Millennium project and 45 Trust staff. The internal budget for electronic patient record deployment was £14m.

Croydon Health Services NHS Trust, which comprises Croydon University Hospital (formerly Mayday) and the Purley War Memorial Hospital, went live with Cerner last year, also under BT’s direction.

The trust has been a little more forthcoming than Imperial about the administrative disruption, unforeseen extra  costs and effects on patients, but Croydon’s officials, like Imperial College Healthcare’s spokespeople,  refuse to give any specific answers to Campaign4Change’s questions on the Cerner implementation.

Comment

It was probably unfair of doctors at Athens Regional to judge the Cerner system so soon after go-live but their fierce reaction is a reminder that doctors exist to help patients, not spend time getting to grips with common-good IT systems.

Would an NHS CEO resign after a rebellion by UK doctors over a problematic EHR implementation? It’s highly unlikely – especially if trusts can stop news leaking out of the effects on patients. In the NHS that’s easy to do.

Athens Regional CEO resigns

A tragic outcome for Cerner Millennium implementation?

Athens Regional is addressing computer problems encountered by doctors

Athens Regional is addressing computer problems after patients put at risk

CEO forced out?

 

BT earns £1.3bn extra from “dismantled” NHS IT scheme

By Tony Collins

The Department of Health paid BT £1.3bn more from the “dismantled” NHS IT contracts than the company first expected.

In 2004 BT expected £2.1bn from its contracts under the NHS IT scheme, the National Programme for IT. In fact BT’s payments totalled  £3.4bn to March 2013, according to information contained in a DH letter to the Public Accounts Committee.  The DH’s letter has gone unpublicised until now.

The size of the payments to BT, in the light of financial pressures elsewhere in the NHS, indicate that Connecting for Health, and its successor the Health and Social Care Information Centre,  regard BT’s data spine, the N3 broadband network,  and Cerner and Rio patient administration systems as indispensable.

The Public Accounts Committee has described the NHS IT scheme, the NPfIT,  as a “failed” programme.

Though important parts of BT’s work on the scheme have been successful, a national care records service in which an individual’s electronic patient record can be accessed across  the NHS, hasn’t materialised.

A cut-down version, the Summary Care Record, exists but the NHS and MPs regarded the creation of a detailed national electronic patient record as the main reason for the National Programme for IT.

Despite the extra money  is delivering far fewer Cerner Millennium systems to London’s acute trusts than originally intended, and none of the GP systems.

Payments to BT

After BT won three NPfIT contracts in 2003, the company said in its annual report of 2004 that the deals would be worth a total of £2.1 billion. The NHS deals were among “some of the largest BT has ever won”, said BT’s  2004 annual report. 

Now the DH’s letter to the Public Accounts Committee shows the amounts paid under NPfIT contracts to March 2013: 

  • N3 broadband network  – £937.7 m [BT]. Original contract value £533m.
  • Spine (including Secondary Uses Service)   £1.083.8m [BT]. Original contract value £620m.
  • Core contracts for local clinical systems in London (London Programme for IT, formerly part of the NPfIT ) –  £865.9m [BT]. Original contract value £996m. BT is delivering to far fewer trusts than it originally envisaged.
  •  Core contracts for the south of England – £586.3m. [BT]. No payments were due to BT for the south of England in the original contracts. BT replaced Fujitsu as the local service provider in the south. The DH spent a total of 737.3m on NPfIT contracts in the south of England to March 2013 but of this £151m had been paid to Fujitsu. The Fujitsu NPfIT local service provider contract is the subject of a protracted legal dispute between the company and the DH.

MP Richard Bacon, a member of the Public Accounts Committee, has criticised the size of some of the payments to BT.

Further payments are due to BT under the NPfIT contracts and it may also receive new payments for work under the Care.data project.

Comment

BT’s stunning financial success from the NHS IT scheme shows the value, from a supplier’s perspective, of getting a foot in the door. For some time it has been a monopoly supplier to the NHS. Its grip on the NHS, the HSCIC and the Department of Health, could be diminished if the HSCIC split up its work and awarded a set of new contracts. That is unlikely to happen. Indeed the signs are that some Whitehall officials would like to tie in the NHS to BT for the foreseeable future.

NHS database: is it a top IT priority?

By Tony Collins

It’s called the NHS database but the new “giant” medical records system is to be run by the Health and Social Care Information Centre, largely for the benefit of researchers.

Though it may help patients in the longer term, say by helping to identify what treatments work and don’t, it is arguably not the NHS’s most immediate IT priority.

I said on BBC R4’s Today programme this morning that a top NHS IT priority is providing secure links to health records so that patients with acute and chronic illnesses can be treated in one part of the NHS one week and another part of the health service the following week – perhaps in a different county – and have their updated records accessible wherever they go.

At present patients with multiple problems can end up being treated in different NHS or non-NHS centres without each organisation knowing what the other is doing.  This is dangerous for patients and gives the impression the NHS is technologically backwards.

Links can be made to existing medical records – there are millions of electronic records already in the NHS – without creating a big central database. The records can reside where they are at the moment, inside and outside the NHS, and be linked to securely by clinicians and nurses, subject to the patient’s specific consent.

Indeed patients should be able to look at their record online and correct any mistakes.

Research database

My comment on BBC R4 Today that a research database is a good idea has brought a mixed response – understandably, because are risks. We need some facts from the Health and Social Care Information Centre on who is going to run the database, and how information will be made genuinely anonymous.

The HSCIC concedes in its information material that some patient information on the database will be potentially identifiable, but it implies this is acceptable if the organisations using the data can be trusted.

Why must information be potentially identifiable? And to what extent can the HSCIC be trusted to run the database? It is, after all, managing contracts under the National Programme for IT, a scheme which Jeremy Hunt called a “huge disaster”.

How much extra will be paid to BT which runs the SUS database under the “dismantled” NPfIT? It is likely that BT’s Spine and SUS-related work will link into the new “NHS database”. Have any new contracts gone to open competitive tender?

Dare anyone criticise this IT project – with the CEO as leader?

By Tony Collins

Croydon Health Services NHS Trust has had mixed success with its go-live of the Cerner Millennium system.

It is said to be a technical success but last week board members of the Croydon Clinical Commissioning Group expressed concerns about ongoing problems with the system.

Fouzia Harrington, director of quality and governance told the Croydon Advertiser: “The implementation [of Cerner] itself went well in technical terms, but there have been some implications about how it has been used by staff.

“It’s had far more impact in terms of the time it takes to book people in, for example. There have also been implications in terms of lost information about patients.

“There has been a lack of information about hospital activity, which has an impact on finances and, potentially,the quality of services patients are receiving…”

David Hughes, a lay member of the board, was not satisfied with that reassurance.

“You say that no harm has occurred,” he said,  “but while we’ve had no direct incident so far, patient care has definitely suffered.

“You talk about increased waiting times and there’s a risk that harm may occur because of the difficulty in getting in touch with clinicians who actually know what is going on with the patient.

“I’m very concerned from a quality point of view that our main provider has a serious problem with its information systems.”

Hughes called for action. Although the trust may not be aware of an incident yet it may “come out through further investigation that there has been”.

Some waiting times have increased,  the CCG cannot be certain of exact levels of activity at the hospital, and missing information has made it difficult to commission some services.

The concerns were raised at a board meeting on Tuesday.

Dr Tony Brzezicki, chairman of the CCG, said new system would eventually lead to improvements.  “Hospital patients had five sets of notes before. That in itself posed a risk that Cerner will mitigate,” he said.

“However, there have been administrative delays which mean longer waiting times for patients.There are also issues for the service to primary care which is a significant risk. Some of the problems have been resolved though I am concerned at the time scale because they are certainly impacting on my practice.”

Success

John Goulston is the Croydon Health Services NHS Trust CEO. One of his previous jobs was as Programme Director of the London Programme for IT at NHS London. The LPfIT was formerly part of the National Programme for IT. 

As well as CEO, he chairs the trust’s Informatics Programme Board which has taken charge of bringing Cerner Millennium to Croydon’s community health services and the local University Hospital, formerly the Mayday.

Goulston reported to his board that the Cerner go-live – on 30 September and 1 October last year – was a success.

“Our partners Cerner, BT and Ideal have commented that the Trust has undertaken one of the most efficient roll-outs of the system they have worked on, with more users adopting the system more quickly and efficiently than other trusts … the success we have achieved to date is the result of the efforts of every single system user and all staff members,” said Goulston.

Goulston has said the trust deployed the “largest number of clinical applications in a single implementation in the NHS”. 

The Department of Health provided central funding, and the trust paid for implementation “overheads”.  The Health and Social Care Information Centre was the trust’s partner for the go-live.

The Croydon Advertiser asked Croydon Health Servicesa series of questions about Cerner, including its cost to the NHS, but was sent a short statement.

A spokesman told the Advertiser the system would improve patient administration and means that nurses have access to “quality, detailed information” when delivering care.

He added: “During the initial switch over of systems in September while staff were getting used to the system, some patients did need to wait slightly longer to check in for their clinic appointments.

“The trust has maintained and surpassed our 18 week referral to treatment targets from the initial roll out.”

Croydon’s response

Campaign4Change put some questions to the Croydon trust. These are the questions and its responses: .

Is the trust being completely open – taking seriously the duty of candour –  about problems arising from the Cerner Millennium go-live?

“The Trust takes its duty of candour on all issues very seriously; we believe that transparency is essential in running a modern NHS organisation. We are held to account by our board at public meetings, where the public are able to attend and question our senior management team, by our local health overview and scrutiny committee and our commissioners.

“Recent press coverage on CRS Millennium appeared in the local press when the system was discussed in a public meeting of our commissioners.”

As the CEO is leading the Cerner Millennium project, does this make it difficult for trust staff and trust directors to say anything even mildly critical about the implementation?

“Staff opinions on the implementation of CRS Millennium, both positive and negative, are welcomed by the Trust. Staff have given their frank opinions of the system directly to the Chief Executive both in our monthly all staff meetings and at the open staff engagement surgeries held by our Chief Executive and Chairman. All staff opinions are taken seriously and are acted upon appropriately.”

Given the CEO’s enthusiasm for the implementation is there a special onus on the press office to defend the implementation and play down problems? [I note that the Croydon Advertiser implied its questions had not been answered, and that the Trust gave a short statement instead.]

“The communications team respond to and facilitate a large number of external requests, including from the media, in a transparent, timely and appropriate manner. This same approach is followed on questions about CRS Millennium.

“CRS Millennium will bring about many improvements to patient care and Trust efficiency and we are enthusiastic about communicating these; it is unfortunate that recent press coverage did not consider these positive benefits in any depth.”

A comment on the Croydon Advertiser’s website says:

“When I checked in to out-patients I supplied all my personal details; however the post code I gave was declared invalid by the new system. That filled me with confidence. I also gave my contact as a mobile; however they tried to ring me using an old landline number.”

Comment

It’s generally accepted that having a high-level sponsor for an IT project is essential but when the lead is the CEO, does that make it difficult for people to challenge and constructively criticise?

A “good news” culture tends to prevail – as happened on Universal Credit, on the BBC’s Digital Media Initiative, and within the Department of Health on the NPfIT. Nobody dared to speak the whole truth to power. The truth tends to surface only when a new administration takes over or, in the case of Universal Credit, the minister obtained his own independent reports on project progress.

Campaign4Change put it to the Croydon trust that board directors see reports on the Cerner implementation only every two months and much can happen in the intervening period. This it did not deny.

Even if the trust’s directors met daily would they dare to challenge the CEO? And will the full facts  ever emerge? Things could be much better than CCG directors believe  – or much worse.

After nearly every major NPfIT implementation of the Cerner Millennium system in London and beyond (such as North Bristol) the facts were scarce, and reassurances that no patients had come to harm were plentiful. 

Here we go again?

**

Should lessons have been learned from these Cerner go-lives?

Barts and The London

Royal Free Hampstead

Weston Area Health Trust

Milton Keynes Hospital NHS Trust

Worthing and Southlands

Barnet and Chase Farm Hospitals NHS Trust

Nuffield Orthopaedic

North Bristol.

St George’s Healthcare NHS Trust

University Hospitals of Morecambe Bay NHS Foundation Trust

Birmingham Women’s Foundation Trust

NHS Bury

GPs asked to contact hundreds of patients who may have missed treatment after hospital’s cancer referrals blunder  – Pulse

London LMCs alert over Imperial cancer waits mix-up – Pulse.

GPs kept in the dark over hospital cancer blunder – Pulse

 IT system has increased waiting times and led to lost patient data.

Patient records go-live success – or NPfIT failure