Category Archives: NHS

Lessons from an IT disaster

Posted on 23/07/2012 | Leave a comment

By Tony Collins

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

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

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

–          A lack of independent challenge

–          Not enough testing of the system and new business processes

–          Inadequate contingency arrangements

–          Not enough time for data migration

–          Training systems not the same as those to be used

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

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

–          Staff did not always understand new or changed business processes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lack of effective quality controls

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

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

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

Lack of effective programme planning

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

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

Lack of effective programme governance

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

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

PwC’s Conclusions

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

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

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

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

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

PwC recommends that:

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

PwC also recommends that the Trust carry out a:

–  Governance review

– Capability/capacity review

– Cross programme plan review

– Operational assessment

– Review of process and controls

– Review of information requirement

– Technical resilience/infrastructure review

– Review of access controls

Comment:

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

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

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

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

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

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

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

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

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

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

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

4)  What’s the current position?

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

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

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

6) Is the Trust board to blame?

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

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

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

North Bristol apologises over Cerner go-live.

New hospital system caused chaos.

MP asks why two Cerner systems cost vastly different prices.

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Posted in Campaign4Change, culture, e-health, Gateway reviews, governance, Government IT, health, health records, IT projects, IT-related failures, NHS, npfit, openness and transparency, operational issues, project management, public sector, public services

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NHS Trust has “major concern” over spend on Cerner

Posted on 12/07/2012 | Leave a comment

By Tony Collins

North Bristol NHS Trust reports in its latest board papers that  “overall the level of spending on Cerner continues to be a major concern and the IM&T Director is working to develop a plan to identify what will be needed in the current year”.

The trust went live with Cerner Millennium in December 2011 and had various problems which the Trust said had been “overcome” by 1 May 2012.

But the Trust’s board papers last month hint that some difficulties are continuing.

“There are also clearly still data issues from Cerner which are affecting these numbers which the team are working on,” says a North Bristol finance paper in June.

The overspend on Cerner is about £900,000 for a two-month period. The paper says the “costs of Cerner remain a risk as some of the forecast spend may need to be re-classified as revenue.

“The detail on this is currently being reviewed by the Director of IM&T and isn’t included in the month 2 position… There has been relatively little spend in capital with the exception of Cerner which has incurred £0.9m of cost for 2 months.”

The anticipated spending on the Cerner implementation for the Trust will be more than £5m.

Comment:

It’s not unusual for hospitals to run into trouble with a Cerner Millennium implementation.  When confronted with serious IT-related difficulties private sector organisations sometimes confront what has gone wrong with urgency, pragmatism and trying not to pretend things are better than they are.

Public sector organisations, when facing IT-related difficulties, can fall into the trap of concentrating on what has gone right, and talk as little as possible about the problems. Indeed North Bristol’s latest board papers hardly mention the Millennium difficulties.  There is not a mention in the Audit Committee report. Not a mention in the board agenda.  Only a finance report says that spending on Cerner is a major concern. Elsewhere in the board papers there are short, oblique references to data difficulties.

“With reference to the figures in Table 3, it was confirmed that all patients had been contacted but accuracy of the data could still not be guaranteed and reporting continued to be 2 months behind…  There were also a lot of duplicate referrals on the system.  This was being rectified but may affect billing,” says one board paper.

It would be wrong to suggest that a culture of accentuating the positive and hunching the shoulders at the negative has anything to do with IM&T. It’s one of the differences between the private and public sectors.

North Bristol’s board needs to be more open. If it cannot admit its difficulties how will it tackle them? And what is the point of taxpayers paying for internal auditors that simply assure the board they are doing a great job?

NPfIT Cerner go-live at North Bristol has more problems than anticipated.

Halt Cerner implementations after patient safety problems at five hospitals says MP

Richard Granger “ashamed” of some systems

North Bristol overspends £1m on Cerner

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Posted in Campaign4Change, Government IT, improving communications, IT projects, IT-related failures, NHS, npfit, openness and transparency

All change at the DH, CfH and on NPfIT – or not?

Posted on 11/07/2012 | Leave a comment

By Tony Collins

Katie Davis is to leave as interim Managing Director of NHS Informatics, says eHealth Insider which has seen an internal memo.

.The memo indicates that Davis “intends to focus on being a full-time mother to her two children”.

She joined the Department of Health on 1 July 2011, on loan from the Cabinet Office where she was Executive Director, Operational Excellence, in the Efficiency and Reform Group.

Before that she was Executive Director of Strategy at the Identity and Passport Service in the Home Office.

The memo indicates that the director responsible for the day-to-day delivery of NHS programmes and services, Tim Donohoe, will take-over Davis’ role until NHS Connecting for Health shuts down at the end of March 2013.

CfH’s national projects look set to move to the NHS Commissioning Board in Leeds, while its delivery functions will move to the Health and Social Care Information Centre.

Davis had told eHeath Insider that her priorities included concluding a piece of unfinished business on the NPfIT – the future of the [CSC] local service provider deal for the North, Midlands and East.

Comment:

Davis has been a strong independent voice at the Department of Health. Partly under her influence buying decisions have passed to NHS trusts without penalties being paid by the NHS to NPfIT local service provider CSC.

It is a little worrying, though, that high-level responsibility for the rump of the NPfIT – CSC’s contracts, Choose and Book, the Spine, Summary Care Record and other centrally-managed projects and programmes – may fall to David Nicholson, Chief Executive of the NHS.

Labour appointed Nicholson in 2006 with a brief that included making a success of the NPfIT. He has been the NPfIT’s strongest advocate.

Indeed a confidential briefing paper from the Department of Health to the then PM Tony Blair in 2007 on the progress of the NPfIT said:

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

It is difficult to see the NPfIT being completely dismantled under David Nicholson. It’s probable that CfH will be shut down in name but recreated in other parts of the NHS, while the NPfIT programmes and projects run down very slowly.  It’s even conceivable that CSC’s and BT’s local service provider contracts will be extended before they are due to expire in 2015/16.

A comment on eHealth Insider says:

“My understanding is that NPfIT is leaving us with a legacy of ancient PAS systems barely fit for purpose which cost a fortune to operate and which will transfer to a massive service charge once national contracts end. That’s if you don’t count the most expensive PACS system in the universe. And I wonder what Lorenzo cost?”

It’s hard to argue with that. Meanwhile the costly NPfIT go-lives are due to continue, at Imperial College Healthcare NHS Trust, for example.

End game for Davis and CfH announced.

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Posted in Campaign4Change, change management, health records, IT-related failures, managing outsourced services, NHS, npfit, public sector, public services, reducing cost strategically

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Cancer waits mix-up – how concerned is the Trust?

Posted on 05/07/2012 | 2 comments

By Tony Collins

When a passenger jet crashes, if the airline’s next board meeting barely mentions it, and instead discusses a catering award and a staff survey, those booked on flights with the airline may have cause for concern.

So should patients at Imperial College Healthcare Trust be concerned that the trust has not mentioned in its latest published board papers a blunder that led to the Trust’s losing track, for nearly a year, of hundreds of patients with possible cancer?

The Department of Health requires that patients who go to their GP with symptoms that may indicate cancer are seen by a specialist within a maximum of two weeks.

Records incomplete

But Imperial has lost track of an unknown number of patients who went to their GPs with signs of possible cancer. It has been checking 900 hospital records which it found were incomplete.

For some of the patients the blunder won’t matter:  they will have been called by staff at GP practices, some of whom have systems that track patients under the two-week rule.

But some patients might have slipped through the net and not been alerted by Imperial to their urgent appointments. Imperial has no clear idea how many.

It has asked GP organisations for help in contacting patients, their carers or representatives, to‘ascertain whether the patient has received treatment or still requires treatment’”.

What detail has emerged on the problem has come not from Imperial but from NHS North West London which is a single management team that represents eight PCTs.  NWL  covers St Mary’s Hospital, Paddington, Hammersmith Hospital and Charing Cross Hospital, which are all managed by Imperial.

“Substantial concern”

NWL has what it calls “substantial concern” about the problems at Imperial. In addition to the problem reporting its two-week cancer waits, the Trust is trying to clear a backlog of patients who have waited more than 18 weeks from referral to consultant-led treatment.

“Systematic failings”

NWL executives report that Deloitte has carried out an external audit and “concerns remain about record keeping at Imperial”.  The executives say that “systematic failings” have been identified which will take time to resolve. This issue will be given close attention in the coming year, says NWL.

Patient safety an issue?

NWL also says that a “Clinical Review” is being carried out and a panel is being set up to look at the clinical issues that have arisen at Imperial. “The Director of Nursing confirmed that the clinical review would look at all patients affected by the problems at Imperial …”

In contrast to the concerns about Imperial’s performance among London PCTs, Imperial seems a little surprised that we are even investigating the problems.

“The problems are administrative and nothing to do with IT,” said a spokesperson.

The Trust is right. The problems are nothing to do with IT.  And yet the problems may be everything to do with IT. Appointments for patients with possible cancer have not been entered onto IT systems – and where they have, data has been incorrect, entered into duplicate records, or not followed up to check appointments were kept, or the patient seen for treatment and investigations.

Eye off the ball?

For nearly a year the problem was not spotted, which has left some North West London executives wondering how it could have happened. It is known the Trust has devoted time and attention of senior management to a replacement of existing systems with Cerner, under the National Programme for IT.  Has the Trust taken its eye off the ball while making plans for Cerner?

Some working in the NHS may ask whether it was more important for the Trust to have ensured that appointments for possible cancer were entered correctly onto existing systems, and routines written into software to provide alerts when cancer records were not closed off, or were incomplete.

**

Below are some of the comments of NWL PCTs about Imperial’s problems. Their concerns raise questions about whether the Trust’s processes and administration are stable enough for a transition from existing IT to new systems, which could cause further disruption.

These are some NWL statements in its board papers relating to Imperial:

“It was reported that at Imperial, the calculations of the backlog of referrals had been completed and work is underway to clear the backlog. However Deloitte has carried out an external audit and concerns remain about record keeping at Imperial. Systematic failings have been identified which will take time to resolve. This issue will be given close attention in the coming year.

“A Clinical Review is being carried out and a panel is being set up to look at the clinical issues that have arisen. The Director of Nursing confirmed that the clinical review would look at all patients affected by the problems at Imperial …”

Does NWL always trust what Imperial says?

Jeff Zitron [Chair, NHS NW London, Inner & Outer NWL Sub Clusters] said that the Board needs evidenced assurance that the issues that have arisen at Imperial and North West London Hospitals are being adequately addressed.

**

“Trish Longdon [Vice-chairman, NHS North West London Cluster Board] noted that although the Imperial targets were shown as ‘Green’  this does not reflect the true position. This was agreed and it was noted that they were in fact being treated as if they were Amber.”

“Urgent meeting”

“The Chairman asked for an update on the situation at Imperial College Healthcare Trust which had been the subject of substantial concern at the last INWL Inner North West London NHS] Board meeting. The INWL Board had agreed that an urgent meeting should be held with the Chairman and Chief Executive of Imperial, involving the CCG Chairs, the Tri-Borough Cabinet Members for Health, himself and Anne Rainsberry [Chief Executive North West London Cluster]. This was taking place later that day.”

Clinical harm?

“ Following investigation of Serious Incidents in May 2011, ICHT [Imperial College Healthcare NHS Trust] is unable to provide sufficient assurance of robust data quality in regard to reported performance for 18 weeks RTT [Referral To Treatment], cancer waiting times and the elective waiting list.

The Trust board have approved a reporting break until end of June 2012 which has been agreed by the Cluster in conjunction with NHS London. To ensure due diligence, an independent audit of waiting list management across all specialities has been undertaken and a set of recommendations made.

“ICHT continue to provide shadow reports to NHS NWL during this period with weekly reporting. Some evidence of improved performance management is observed. However this is not yet consistently embedded Trust- wide and clearance of the current backlog of patients is not at sufficient pace to meet the agreed trajectory…

“A clinical review will be undertaken to ensure that patients have not experienced harm due to an elongated wait.”

**

“Anne Rainsberry [Chief Executive North West London Cluster] referred to a range of discussions taking place on Imperial’s performance issues, focussing on the backlog of the Referral to Treatment waiting lists which had resulted in a reporting break being granted.

“Work was concluding at the end of April [2012] to reduce the original backlog of patient cases and enable reporting systems to get back on track in June. A clinical review had also started to determine if any risks to patients had arisen due to the delays. The review findings would be brought back to the Board…

“Anne Rainsberry referred to a meeting she had attended with the Department of Health to review Imperial‟s approach to resolving these issues.”

Big organisational challenge

“Simon Weldon [Director of Commissioning and Performance, North West London Cluster Board] … asked the NWL Board to be aware of the enormity of the organisational challenge facing Imperial and that remedial actions would take time to take effect.”

Imperial responds

Campaign4Change put it to Imperial College Healthcare NHS Trust that there is nothing in its latest published board papers to show the trust is concerned about the problems relating to cancer waits and lost appointments. We said that PCT papers referred to  “substantial concern” but there was nothing similar in Imperial’s latest published papers. We let Imperial know we would be asking the question: how concerned is Imperial about the confusion over cancer waits?

This was the reply of Imperial’s spokeswoman (in full)

“The safety of patients is our absolute priority. Our Trust is taking the issues involved in the current situation very seriously and at all times the well-being of the patients we serve is foremost in our minds.

“We acknowledge that some patients may have been caused additional pain and anxiety associated with a prolonged wait for diagnosis and treatment and worked to address the problem as robustly and quickly as possible.”

Separately, in May 2012, Imperial told us that it was in the process of validating 900 patient records that indicate that a patient might have been waiting longer than two weeks.

At that stage it had closed more than 400 of the 900 records “as the majority indicated that patients have either received or are receiving treatment, or that the patient did not attend their appointment and their GP had advised there was no need for further follow up”.

The spokeswoman said “To date our investigations have found no suggestion that any delay in treatment has caused a patient to come to serious harm.”

She said “This is not an IT issue, but an administrative issue related to the physical input and extraction of data from patient records. It is entirely unrelated to IT systems.”

Comment

It is extraordinary that Imperial is seeking to replace existing systems when it is organisationally in a questionable state. Simon Weldon, Director of Commissioning and Performance, North West London Cluster Board, referred to the “enormity of the organisational challenge facing Imperial”.

Under the NPfIT, a number of implementations of Cerner at several NHS sites have gone badly wrong – and they did not have Imperial’s problems before going live. It would be common sense for Imperial to get its data accurate and its management processes and checks reliably in place before attempting a major switch of IT systems.

Two other things are particularly worrying: Imperial appears not to concede in public it has any major problems, and it appears to separate IT from administration.

Having the best IT in the NHS is of limited value if important parts of the Trust are in a state of administrative disorder.  If data is unreliable, incomplete and inaccurate, and solid processes are not in place to ensure that the correct data is entered into systems when it needs to be entered, and routines are not in place to provide alerts and follow-ups, costly hardware and software may not compensate. Is this an IT issue or not? Does that matter?

We would not like to see a Cerner NPfIT debacle similar to the ones at Barts in London, Royal Free Hampstead, and at hospitals in Oxford, Milton Keynes, Weston-super-Mare, Morecambe Bay, Worthing and Bristol.

But is Imperial particularly concerned? Is it in denial over the seriousness of its problems? Why is it reporting its position at Green when North West London NHS regards its position as Amber? Why do its latest published board papers not mention its problems tracking patients under the two-week rule? Is the Trust so preoccupied with replacing its existing systems with Cerner that it is not doing the basics well?

One specialist in the NHS said: “If the Trust wasn’t spending so much time and effort doing the Cerner deployment then maybe they would have concentrated its scarce resources on performing the  job of managing patients.”

Accountability for failure in the NHS is poor to non-existent. So will Imperial be able to do what it wants regardless?

Troubled Cerner NPfIT go-lives, so far:

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

*We acknowledge Pulse which broke the story on Imperial’s cancer wait problems.

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

Other links:

Halt NPfIT Cerner deployments says MP Richard Bacon

Bacon calls for halt on Millennium.

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Posted in Campaign4Change, Cerner, Deloitte, e-health, health, health records, NHS, npfit, openness and transparency, operational issues, oversight, private sector lessons for the public sector, public sector

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Cerner questions hospital bid process

Posted on 04/07/2012 | 2 comments

by Tony Collins

NHS software supplier Cerner has written to Cambridge University Hospitals Foundation Trust questioning a process to procure an electronic patient record system.

The Trust chose Epic and HP as preferred supplier for a common platform for the Cambridge trust and Papworth Hospital Foundation Trust.

Now Cerner, which bid for the contract, is asking for the process to be be re-run, says the Health Service Journal. The Trust told the Health Service Journal its procurement was open and fair.

The Health Service Journal said it had seen Cerner’s letter. It quoted the letter as saying that the Trust’s favouring of Epic was in clear breach of the ‘equal treatment’ principle.

The letter said that Cerner found it difficult not to conclude that the Trust had made a pre-determined decision to award the tender to Epic some time before it designed the procurement process. This gave other vendors no realistic possibility of winning, said the letter.

The trust said it was continuing to proceed with the procurement process for “eHospital”.

Cerner supplies the NHS with the Millennium software, either directly or through BT under the NPfIT.

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Posted in Campaign4Change, health, health records, NHS, npfit

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Medical dictionary should help prevent medication mistakes

Posted on 03/07/2012 | Leave a comment

By Tony Collins

The Department of Health says that a medicines dictionary, which is approved today, will make medical errors less likely by ensuring all staff who work in the NHS and healthcare use the same terminology when referring to medicines.

The Information Standards Board for Health and Social Care has approved the NHS dictionary of medicines and devices – called “dm+d” –  as a standard which, says the Department of Health,  “must be used by all staff”.

The DH says that “all doctors, nurses and pharmacists should move towards using the common medicines dictionary so that information exchanged electronically is accurate and safe”.

Using a single drug terminology will “enable information about patients’ medicines to transfer more effectively between different healthcare settings, reducing the risk of medication mistakes caused by human error”.

The NHS dictionary of medicines and devices is already used in the UK for the exchange of clinical information, including the Electronic Prescription Service and for patients’ Summary Care Records.

Dr Charles Gutteridge, National Clinical Director for Informatics at the Department of Health and Medical Director, Barts and the London NHS Trust said

“The adoption of dm+d is an important milestone. It will mean clearer and consistent communication throughout the NHS ensuring health professionals in all care settings …. I encourage all clinicians to accelerate their use of this common medical dictionary for the benefit of the patients we care for.”

Heidi Wright, from the Royal Pharmaceutical Society (RPS) said “The Royal Pharmaceutical Society supports the need for a single terminology to facilitate interoperability and to enable such initiatives as the Electronic prescription Service (EPS). We believe that the opportunities created for using dm+d are substantial in terms of interoperability, opportunities for comparison and reducing variation, enhancing patient safety i.e. reducing risks associated with system interfaces and providing links to clinical systems such as the British National Formulary .”

The dictionary contains unique identifiers and associated textual descriptions for medicines and medical devices.  It was developed and delivered through a partnership between the Department of Health Informatics Directorate  and the NHS Business Services Authority.

The DH Information Strategy says that  reducing the number of inconsistent or incompatible terminologies will allow better integration between systems and across health and social care, and better information to support care and improvement of care.

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Posted in change, change management, data sharing, Government IT, health, health records, NHS

We operated on the wrong organ – but hey, it’s OK.

Posted on 27/06/2012 | Leave a comment

By Tony Collins

When a surgeon operates on the wrong organ the NHS calls it “wrong site surgery” (a euphemism which makes it sound like an official part of a medical student’s curriculum).

A surgical intervention on the wrong organ could never be a source of reassuring news unless it’s in the board papers of an NHS trust.  NHS board papers are, more often than not, the source of good news announcements, statistics and graphs. Bad news is between the lines.

This was North Bristol NHS Trust’s account of what it said was a “surgical intervention [that] was performed on the wrong organ in a patient”. The operation was complex due to distortion of the patient’s anatomy. “This incident has resulted in some long term harm for the patient although the patient has since fully recovered.” The trust reports more reassuring news:

–  the patient has been fully informed

–   and given an apology

–    a full investigation has been carried out and lessons learnt

–   the consultant surgeon was experienced, and was assisted by another specialist

–   the World Health Organisation Surgical Safety Checklist was used correctly and as such, could not have prevented this error.

–  the case was discussed at directorate clinical governance meetings and disseminated widely to raise awareness of distorted anatomy with clinical staff.

–  the Clinical Risk Committee, Commissioners and the National Patient Safety Agency are assured that human error is an acceptable reason for this incident and that all procedures were carried out correctly.

Comment:

It sounds reassuring that all procedures had been carried out correctly, and that the World Health Organisation Surgical Safety Checklist was used correctly. But if a sleeping driver injures someone, should his colleagues be assured that he’d just put the car through an MoT and was driving under the speed limit?

Trust board papers need to connect with everyday reality. I’d venture to suggest they are not the place for announcements on managerial successes.

The same trust reported the separate case of an  “Unintended retention of a foreign object post surgical intervention”. The retained object was a small microvascular clamp and this was removed during a subsequent operation,

“which resulted in a satisfactory outcome for the patient”.  Good news then.

We wonder how the trust will report the findings from its investigation of recent IT troubles.

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Posted in Campaign4Change, improving communications, NHS, public services

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How London IT director saves millions by buying patient record system.

Posted on 07/06/2012 | 4 comments

By Tony Collins

An NHS organisation in London has bought an electronic patient record system for less than a third of the cost of similar technology that is being supplied by BT to other trusts in the capital and the south of England.

The £7.1m purchase by Whittington Health – a trust that incorporates Whittington Hospital near Archway tube station – raises further questions about why the Department of Health is paying BT between £31m and £36m for each installation of the Cerner Millennium electronic patient record [EPR] system under the NPfIT.

Whittington Health is buying the Medway EPR system from System C which is owned by McKesson. The plan is for the EPR to operate across GP, hospital and social care boundaries.

It will include a patient portal. The idea is that patients will use the portal to log on to their Whittington Health accounts, see and save test results and letters, and manage outpatient appointments on-line.

In a board paper, Whittington Health’s IT Director Glenn Winteringham puts the case for spending £7.1m on a single integrated EPR.  Winteringham puts the average cost of  System C’s Medway at £8m. This cost, he says, represents “significant value for money” against the average deployment costs for the NHS Connecting for Health solution (Cerner Millennium) for London of £31m. In the south of England the average cost of Cerner Millennium is £36m, says Winteringham in his paper.

He also points out that the new EPR will avoid costs for using “Rio” community systems. The NPfIT contract with BT for Rio runs out mid 2015. “From this date onwards the Trust will incur an annual maintenance and support cost. Implementing the EPR will enable cost avoidance to the [organisation] of £4m per year to use RIO (indicative quotes from BT are £2m instance of RIO and the [organisation] has 2 – Islington and Haringey).

BT’s quote to Whittington for Rio is several times higher than the cost of Rio when supplied directly by its supplier CSE Healthcare Systems. A CSE competitor Maracis has said that, during a debrief, it was told that its prices were similar to those offered by CSE Healthcare for a Rio deployment – then less than £600,000 for installation and five years of support.

In comparison BT’s quote to Whittington for Rio, as supplied under the NPfIT, puts the cost of the system at more than fifteen times the cost of buying Rio directly.

In short Whittington and Winteringham will save taxpayers many millions by buying Medway rather than acquiring Cerner and Rio from BT.

Why such a price difference?

The difference between the £31m and £36m paid to BT for Cerner Millennium and the £8m on average paid to System C could be partly explained by the fact that Whittington (and University Hospitals Bristol) bought directly from the supplier, not through an NPfIT local service provider contract between the Department of Health and BT. Under the NPfIT contract BT is, in essence, an intermediary.

But why should an EPR system cost several times more under the NHS IT scheme than bought outside it?

Comment:

Did officials who agreed to payments to BT for Cerner and Rio mistakenly add some digits?

Whittington’s purchase of System C’s Medway again raises the question – which has gone unanswered despite the best efforts of dogged MP Richard Bacon – of why the Department of Health has intervened in the NHS to pay prices for Rio and Cerner that caricature profligacy.

Perhaps the DH should give BT £8m for each installation of Cerner Millennium and donate the remaining £21m to a charity of BT’s choice. The voluntary sector would gain hundreds of millions of pounds and the DH could at last be praised for spending its IT money wisely.

Whittington buys Medway and scraps Rio – E-Health Insider

NHS IT supplier “corrects” Health CIO’s statements

MP seeks inquiry into BT’s £546m NHS deal

NPfIT go-live at Bristol – trust issues apology

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Posted in Campaign4Change, cost avoidance, Government IT, health, health records, IT and the Business, IT projects, managing outsourced services, NHS, npfit, reducing cost strategically, supplier relationships

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Whitehall to relent on secrecy over mega projects – after 10-year campaign?

Posted on 29/05/2012 | 1 comment

By Tony Collins

The Cabinet Office may be about to change its decade-old policy of not publishing reports on  the progress or otherwise of its large, costly and risky IT-based projects.

A change of policy from secrecy to openness would give MPs and the public warning of when a major project is in trouble and needs rescuing or cancelling.

Parliament last to know

For more than a decade campaigners have sought to persuade successive governments to publish “Gateway” reviews, which are short independent audits on the state of big projects.  The secrecy has meant that Parliament is usually the last to know when new national schemes go wrong. IT-related failures have hit many public services including those related to tax, benefits, immigration, passports, the fire service, prisons, schools examinations, student loans, the police and health services.

Now Sir Bob Kerslake, head of the civil service, has hinted to campaigning Conservative MP Richard Bacon that the Cabinet Office may change its policy and publish the “red, amber, green” status of large projects as they are routinely assessed.

Kerslake was replying to Bacon at a hearing of the Public Accounts Committee meeting on transparency. Bacon pointed out at the hearing that the Public Accounts Committee had, years ago, called for Gateway reviews to be published.

Not learning from mistakes

“Something I have always been puzzled by is why government does not learn from its mistakes particularly but not only in the area of IT where things go wrong again and again, again and again,” said Bacon. “I have come to the conclusion government does not learn from its mistakes because it does not have a learning curve. If you don’t have a learning curve you are not going to learn.”

He cited the example of how Ian Watmore, Permanent Secretary at the Cabinet Office, had, at Bacon’s request, arranged for an “Opening Gate” report on Universal Credit to be published in the House of Commons library.

But, said Bacon, when an IT journalist applied to the Department for Work and Pensions, under the FOI Act, for the release of all Gateway reports on Universal Credit, the DWP would not publish any of them  – and even refused an FOI request to release the report Watmore had arranged to be placed in the House of Commons library, which Bacon obtained.  “So there is still a culture of intuitive, instinctive secrecy,”  Bacon said. Kerslake replied:

“Yes, actually we are looking at this specific issue as part of the Civil Service Reform Plan….I cannot say exactly what will be in the plan because we have not finalised it yet, but it is due in June and my expectation is that I am very sympathetic to publication of the RAG [red, amber, green] ratings.”

Bacon pointed out that the Cabinet Office Structural Reform Plan Monthly Implementation Updates had said Gateway reviews would be published.  But the commitment was removed for no apparent reason. When the Cabinet Office was asked why,  it said the Structural Reform Plans were only ever “drafts”.

Bacon asked Kerslake if the Government now plans to publish the Gateway reports.  “The Cabinet Office Structural Reform Plan Monthly Implementation Updates originally said Gateway reviews would be published  and then it somehow got downgraded into a draft; and from what’s publicly available at the moment the position of the government is not to publish Gateway reviews.  You sound as if you’re saying that’s going to change. Is that right?” asked Bacon.

“Watch this space,” replied Kerslake. “I am sympathetic. I generally broadly welcome, in principle, the idea of publishing information but there are lots of risks …”

Peter Gershon introduced Gateway reviews when he was Chief Executive of the Office of Government Commerce, which is now part of the Cabinet Office’s Efficiency and Reform Group. The reviews are carried out at key decision times in a project and are sometimes repeated:

  • Gateway Review 0 – Strategic assessment
  • Gateway Review 1 – Business justification
  • Gateway Review 2 – Procurement strategy
  • Gateway Review 3 – Investment decision
  • Gateway Review 4 – Readiness for service
  • Gateway Review 5 – Benefits realisation

Are Gateway reviews a success?

Gateway reviews are now supplemented by regular assurance audits carried out for the Cabinet Office’s Major Projects Authority. None of the reports is published.

Gateway reviews have not stopped costly failures such as Firecontrol or the NPfIT.  One permanent secretary told an MP that the reviews in his department were considered unimportant by senior responsible owners, for whom the reports are written. This may be because SROs often have charge of many projects; and even their SRO responsibilities are often in addition to their main jobs.

But Gershon had high hopes of Gateway reviews when they were introduced in February 2001. This is evident from the number of times he referred to Gateway reviews at one hearing of the Public Accounts Committee in December 2001.

 “… as the Gateway review process cuts in, which I have referred to on a number of occasions when I have appeared at this Committee …”

“… Through things like the Gateway process we are helping to sharpen the focus on the whole life aspects of these and other forms of complex projects in public sector procurement…”

“ …First, we have the introduction of the Gateway review process…”

“ … The Gateway process is a demonstrable example of how we have introduced a technique to support that whole life approach…”

“… If you look at the guidelines around the Gateway review process that is one of the things that is tested by these independent reviews …”

“… we recognised that that was a problem some time ago, which is why in the Gateway review one of the things that is explicitly tested is things like the skills and capabilities of the team at the design and build stage and that the skills and capabilities of the team at the procurement stage …”

“… in this area with the Gateway review process, from when we first launched it last February, we have been helping the department take a whole life approach to these forms of complex projects …”

“… Part of the Gateway Review process is to get a much sharper insight on to where we see good things happening where we can encourage other clients to replicate them…”

“… Now, with the Gateway Review process, my experience has been because of where we have deliberately focused the attention on the early life of projects where there is the greater scope for management to take corrective action, the accounting officers are paying a lot of attention to the recommendations that are emerging because, much to my surprise, most of them do not seem to like coming here defending what has gone wrong in the past. They seem to welcome the recommendations that we are providing to them to help try to get projects on to much stronger foundations in the future…”

“… With the Gateway Review, my experience has been that the Accounting Officers respond to the recommendations very positively…”

“…Gateway Reviews explicitly test how the department is planning in the pre-contract phase to secure ongoing value for money in the post-contract phase…”

“… Take, firstly, the Gateway Review process. That is testing various points in the life cycle of the project, from the very earliest stage…”

“… I would certainly expect in Gateway Reviews that the review team would be testing what methods were in place to facilitate the ongoing management of the contract…”

“… I think it is encouraging that Sir Ian Byatt thought the Gateway Review process had sufficient value to recommend it in his own review…”

And so forth.

Comment:

We applaud Richard Bacon MP for his persistent call for Gateway reports to be published.

Gateway reviews have defeated expectations that they would stop failures; and the National Audit Office tells us that central departments don’t even request Gateway reviews on some big and risky projects although they are supposed to be mandatory.

But Gateway and other project assurance reports could prove invaluable if they are published. In the public domain the reports would enable Parliament and Francis Maude’s “armchair auditors” to hold officials and SROs to account for projects that are in danger of failing. That would be an incentive for officialdom to fail early and fail cheaply; and Gateway reviewers may take greater care to be neutral in their findings – not too lenient, or too harsh – on the basis that the reports would be open to public scrutiny. SROs would also have to take the review reports seriously – not just put them in a draw because nobody knows about them anyway.

We welcome Kerslake’s comments but hope that he and his colleagues plan to publish more than the RAG (Red/Amber/Green) status of projects. Otherwise they will be missing an opportunity.  Gateway reports and other assurance reviews are expensive. Reviewers can earn up to £1,000 a day. This money  could be well spent if the reviews are to be published; but it will add to public waste if the reports are kept secret and continue to be deemed pointless or unimportant by departments.

It is ironic, incidentally, that the Ministry of Justice, which introduced the FOI Act, gives advice to departments to keep the RAG status of Gateway reviews confidential. In its advice on Gateway reviews and the FOI, the MoJ tells departments that the “working assumption” is that the substance of the Gateway reports should be kept confidential until at least two years have elapsed.

It’s time for a culture change. Maybe the Civil Service Reform Plan next month will be worth reading.

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Posted in change management, cost reduction, culture, excessive secrecy, Freedom of Information, Gateway reviews, Government IT, IT-related failures, Major Projects Authority, managing change, NHS, npfit, openness and transparency, oversight, Politics, project management, public sector, public services, Universal Credit

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Healthspace was failing in 2010 – why is it being kept alive?

Posted on 25/05/2012 | 2 comments

By Tony Collins

“Too many failing projects are continued for too long” – Ian Watmore, House of Commons, 2009.

HealthSpace, a centrally-run system that has, for years, provided unneeded work for consultants based at Connecting for Health, software developers, civil servants, and IT suppliers,  at a cost of tens of millions of pounds, is to close “from” March 2013.

A report commissioned by the Department of Health and NHS Connecting for Health in 2010 found that the system had never worked satisfactorily. But the Department and CfH has kept the project going, paying consultants and IT suppliers, although it was clear from an early stage that the scheme was doomed.

Will the Department of Health continue paying consultants and IT suppliers for a system that is to be cancelled?

HealthSpace was designed to be a personal health organiser. It was based on a good idea – that some patients could benefit from access to their health records – but the technology was too complicated and never fit for the public to use. It is said that those involved in the project spoke in a technological, managerial and procurement language – and rarely mentioned patients.

The Guardian this week reports Charles Gutteridge, national clinical director for informatics at the Department of Health, as saying that Healthspace is “too difficult to make an account; it is too difficult to log on; it is just too difficult.”

The Department of Health later told The Guardian that Healthspace would be closed down “from” March 2013.

In 2010 a report by Trisha Greenhalgh and her team, The devil’s in the detail, which was commissioned by CfH, found that HealthSpace had involved professional advisers, software developers, security testing contractors, business managers who wrote the benefits realisation cases, lawyers who advised on privacy and regulatory matters and many others.

Yet the system was doomed from the start. Greenhalgh’s report in May 2010 revealed that:

“Project leads from participating NHS organisations repeatedly raised concerns with Connecting for Health in monthly management meetings about the low uptake of advanced HealthSpace accounts, since the benefits predicted, such as lower NHS costs and patient driven improvements to data quality, could not possibly be achieved unless the technology was used.”

Comment:

It’s not known how many millions has been wasted – and continues to be wasted – on Healthspace; and it is difficult to avoid the conclusion that the continuance of the scheme benefits nobody except those who are paid to work on it, which includes contractors and IT suppliers.

Why is the scheme to be cancelled “from” 2013, when it should have been cancelled when Trisha Greenhalgh and her team produced their report in May 2010?

Shouldn’t ministers have some control – especially given that we are supposed to be in an age of public sector austerity? Ian Watmore, Permanent Secretary at the Cabinet Office and former Government CIO, has said that failing projects are continued for too long. He said that in 2009. So isn’t it time ministers and particularly civil servants applied the principle of ‘fail early, fail cheaply‘?

Link:

In 2010 ComputerworldUK had an account of how Healthspace was being kept alive unnecessarily.

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Posted in Campaign4Change, e-health, excessive secrecy, Government IT, health, health records, IT projects, IT-related failures, NHS, npfit, supplier relationships