Category Archives: Summary Care Record

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?

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When “life and death” NHS IT goes down

By Tony Collins

Almost unnoticed outside the NHS an email was circulated by health officials last weekend about a national “severity 1” incident involving the Electronic Prescription Service, running on BT’s data Spine .

“The EPS [electronic prescriptions service] database is currently experiencing severe degradation of performance. … BT engineers [are] currently investigating with the database application support team,” said the email.

A severity 1 or 2 incident, which involves a temporary loss of, or disruption to, the Spine or other national NHS system,  is not unusual, according to a succession of emails forwarded to Campaign4Change.

The Department of Health defines a severity 1 incident as a  failure that has the potential to:

— have a significant adverse impact on the provision of the service to a large number of users; or

— have a significant adverse impact on the delivery of patient care to a large number of patients; or

— cause significant financial loss and/or disruption to NHS Connecting for Health [now the Health and Social Care Information Centre], or the NHS; or

— result in any material loss or corruption of health data, or in the provision of incorrect data to an end user.

The Health and Social Care Information Centre, which manages BT’s Spine and other former NPfIT contracts, reports that the spine availability is 99.9% or 100%. But the HSCIC’s emails tell a story of service outage or disruption that is almost routine.

If the spine and other national services  are really available 99.9% of the time, is that good enough for the NHS, especially when ministers and officials are increasingly expecting clinicians and nurses to depend on electronic patient records and electronic prescriptions?  In short, are national NHS IT systems up to the job?

NHS staff access the spine tens of millions of times every month, often to trace patients before accessing their electronic records.  The spine is pivotal to the use of patient records held on Rio and Cerner Millennium systems in London. It is critical to the operation of Choose and Book, the Summary Care Record, Electronic Prescription Service pharmacy systems, GP2GP, iPM/Lorenzo, and the Personal Demographics Service.

According to a Department of Health letter sent to the Public Accounts Committee, payments to BT for the Spine totalled £1.08bn by March 2013.

BT says on its website that its 10-year NHS Spine contract involves developing systems and software to support more than 899,000 registered NHS users. The HSCIC says the Spine is used and supported 24 hours a day, 365 days a day.

“There is a huge amount of industrial-strength robustness, availability, disaster recovery, that you cannot get someplace else,” said a BT executive when he appeared before MPs in May 2011.

Life and death  

Sir David Nicholson spoke of the importance of the spine and other national NHS systems at a hearing of the Public Accounts Committee in 2011. He said they were

“providing services that literally mean life and death to patients today … So the Spine, and all those things, provides really, really important services for our patients…”

When Croydon Health Services NHS Trust went live with a Cerner Millennium patient records system at the end of September a “significant network downtime” – of BT’s N3 network – had an effect on patients.

A trust board paper, dated 25 November 2013 says:

“CRS Millennium (Cerner) Deployment -Network downtime – Week 1.  In particular, the significant network downtime in week 1 (BT N3 problem) led to no electronic access to Pathology and Radiology which resulted in longer waits for patients in the Emergency Department (ED) leading to a large number of breaches. This was a BT N3 problem which has been rectified with BT …”

Below are some of the emails passed to Campaign4Change in the past four months. Written by the Health and Social Care Information, the emails alert NHS users to outages or disruption to GP or national NHS IT systems.

Some HSCIC messages of disruption to service

October 2013

Severity 2
HSCIC
National
CQRS has not received a number of participation status messages.
Also affecting: GPES
USER IMPACT:
CQRS Users are not able to manually submit specific information, this will impact the users’ business process for entry of achievement data.
ACTION BEING TAKEN:
Following a configuration change by the GPES Business Unit a specific code has now been added to the GPET-Q Database. We are currently awaiting confirmation that the addition of the relevant code has been successful. Discussions are taking place regarding the re-submission of status messages. HSCIC conference calls are on-going.

[A severity 2 service failure is a failure [that] has the potential to:

– have a significant adverse impact on the provision of the service to a small or moderate number of service users; or

– have a moderate adverse impact on the delivery of patient care to a significant number of service users; or

– have a significant adverse impact on the delivery of patient care to a small or moderate number of patients; or

– have a moderate adverse impact on the delivery of patient care to a high number of patients; or

– cause a financial loss and/or disruption … which is more than trivial but less severe than the significant financial loss described in the definition of a Severity 1 service failure.]

**

Severity 2
HSCIC
BT Spine
National
Intermittent performance issues on TSPINE.
T-Spine
RESOLUTION:
BT Spine have confirmed that the incident has been resolved and users are able to perform routine business processes without delays.

November 2013

Severity 1
BT Spine
HSCIC
National
Users are unable to log into PDS.
USER IMPACT:
All sites are currently unable to access PDS, this is causing a delay to normal services.
ACTION BEING TAKEN:
BT Spine are working to restore service.

**

Severity 2
BT Spine
HSCIC
National EPS users.
Slow performance on reliable and unreliable messages for EPS.
USER IMPACT:
This is causing delays to routine business processes as some users may be experiencing slow performance with the EPS service.
BT investigating.

**

Severity 2
BT Spine
HSCIC
National
Slow performance on EPS Messaging.
USER IMPACT:
This is causing delays to routine business processes as some users may be experiencing slow performance with the EPS service.
ACTION BEING TAKEN:
BT moved the database to an alternate node following application server restarts. This temporarily restored normal message response times however performance has started to degrade again. BT Investigation continues.

**
Severity 1
Atos
HSCIC
National
Multiple users were unable to log in to the Choose & Book application.
ATOS made some network configuration changes overnight 19th/20th November which restored service. After a period of monitoring throughout the day yesterday the service has remained stable and at expected levels. Further activities and investigation will be carried out by several resolver teams which will be scheduled through change management.

**
Severity 2
BT Spine
HSCIC
National
Slow performance on EPS Messaging.
No further issues of slow response times with EPS messaging have occurred today. BT Spine to continue root cause investigation.

**

Severity 2
Cegedim RX
HSCIC
National
Cegedim RX – Users are experiencing slow performance in EPS 1 and EPS 2.
USER IMPACT:
Users are experiencing slow performance and delays to routine business processes when using EPS 1 and EPS 2.
ACTION BEING TAKEN:
Following a restart of application services, traffic has improved for all new EPS messages. However there is a backlog of EPS messages which may cause delays to routine business processes. Cegedim RX to continue to investigate.

**

December 2012

Severity 1
BT Spine
HSCIC
National
Performance issues have been detected with the transaction messaging system (TMS).
Also affecting: Choose and Book, GP2GP
USER IMPACT:
This may cause delays to routine business processes. This may have an effect on all Spine related systems. This includes PDS, Choose and Book, PSIS, SCR, ACF Services.
ACTION BEING TAKEN:
This has been resolved but BT are currently monitoring performance. Further investigation is required by BT into the root cause.

**

Severity 2
GDIT – CQRS
HSCIC
National
DTS has not processed a CQRS payment file.
CQRS
Also affecting: GPES
USER IMPACT:
This is causing delays to routine business processes.
ACTION BEING TAKEN:
GDIT are currently developing a fix which will be rolled out tomorrow evening, pending successful testing.

January 2014

Severity 1
BT Spine
HSCIC
National
TMS reliable messaging unavailable.
USER IMPACT:
TMS reliable messaging unavailable and users having to implement manual workarounds.
ACTION BEING TAKEN:
Issues experienced due to a planned change overrunning, BT Spine continue to implement the transition activity in order to restore service.

**

Severity 2
BT Spine
HSCIC
National
Users have experienced intermittent issues with the creation and cancellation of smartcards in CMS [Card Management Service for managing smartcards].
CMS
USER IMPACT:
This is intermittently causing delays to routine business processes as some users have been unable to create, cancel, cut or print cards in CMS.
ACTION BEING TAKEN
Users may experience issues with the creation and cancellation of cards in CMS. BT have identified a fix for the issue which is currently undergoing testing prior to deployment into the live environment.

**

Severity 2
BT Spine
HSCIC
National
The maternity browser was unavailable within NN4B.
RESOLUTION:
BT identified a problematic server which was recycled to restore system functionality.

**

Spine scheduled outage for essential maintenance activity.

During critical work to migrate to a new storage solution on Spine an issue was experienced on the Transaction Messaging Service (TMS) in September of this year. The issue resulted in BT failing over the TMS database from its usual site on Live B to Live A to restore service. The failover was completed well within the Service Level Agreement and no detrimental long term impacts to the service were incurred.

On the 15th January 2014 between approximately 22:00-23:30, HSCIC, in conjunction with BT, are planning to relocate the TMS database back to Live B, this is for several critical reasons:

  1. The issues experienced, which prompted the failover, are fully resolved and will not be experienced again as the storage migration work is now complete.
  2. The Spine service is designed to operate with all databases running on Live B so this work supports the optimum configuration for the service.
  3. Most critically the transition for all data on Spine to Spine2 has been designed to operate from a standby site with no live databases on it. Therefore to support the Spine2 transition this work is absolutely essential.

In order to facilitate a safe relocation of the database a 1.5 hour outage is required to TMS. The impact of this to Spine is significant and results in effectively an outage for Spine and its interfaces to connecting systems for that period. The time and date is aimed at the lowest times of utilisation for Spine, to minimise impact to end users, as well as not impacting critical batch processing and Choose & Book slot polls.

 

Date & Time

Change Start Change Finish Services Affected Outage Duration
15/01/2013 22:00 15/01/2013 23:30 Transaction Messaging Service (TMS) 1.5 hours
Service  Impact Description
Choose and Book The Choose and Book service will be available but functionality will be limited until the TMS database has switched over.Users of the web application will experience limited retrievals during the outage window.The system will not be able to create shared-secret for patients who have not been referred via Choose and Book before.Service Providers will be unable to:

  • Perform clinic re-structures and re-arrange appointments for patients for directly bookable services
  • Send DNA messages to Choose and Book.

For directly bookable services the following functionality will be unavailable:

  • Booking appointments
  • Rearranging appointments
  • Creating new patient accounts

Choose & Book systems will need to queue the messages and resend to Spine once the TMS service is enabled.

Due to the timing of the outage slot polls will not be affected.

Summary Care Record application (SCRa) The SCRa application will be available but functionality will be limited until the TMS database has switched over. Simple traces can be completed on PDS data but users will be unable to perform any PSIS updates (e.g. GP summary updates)
DSA The DSA application will be available but functionality will be limited until the TMS database has switched over.Simple traces can be completed on PDS data but users will be unable to perform any PSIS updates (e.g. GP summary updates).
Electronic Prescription Service (EPS)Pharmacy Systems Reliable messaging will be unavailable for the duration of the switchover work as the TMS service will be suspended dual site. All messages received from EPS systems will be rejected and not go into retry.EPS systems will need to queue the messages and resend to Spine once the TMS service is enabled.
EPS Batch The PPA response for any “claim” messages will not be sent to PPA/PPD. However, EPS will send those response(s) again when the retry jobs are re-activated after the switchover exercise is over. Response for any “claim” messages will not be received until after the switchover. Retry jobs will resend the responses once the TMS service is enabled.
Existing Service Providers (ESPs) There will be varying impacts depending on the product, release version and Spine compliant modules of the solution.ESP systems will need to queue the messages and resend to Spine once the TMS service is enabled.
GP2GP GP2GP will be unavailable until the TMS database has switched over.GP2GP systems will need to queue the messages and resend to Spine once the TMS service is enabled.
GP Extraction Service (GPES) GPES functionality will be unavailable until the TMS database has switched over.Messages will be queued on Spine and processed once the TMS service is restored.
GP Systems Functionality for Choose & Book, EPS and GP2GP, SCR will be limited until the TMS database has switched over.For Choose & Book directly bookable services the following functionality will be unavailable:

  • Booking appointments
  • Rearranging appointments
  • Creating new patient accounts

Systems will need to queue the messages and resend to Spine once the TMS service is enabled.

iPM/Lorenzo The real-time connection to Spine will be unavailable during the TMS outage. However both systems can be disconnected from Spine and operate without synchronised PDS data.iPM/Lorenzo will need to queue the messages and resend to Spine once the TMS service is enabled.
Millennium An outage of PDS reliable messaging will impact Millennium users.Users will be unable to:

  • trace patients
  • register new patients on PDS
  • book or reschedule appointments

Millennium will need to queue the messages and resend to Spine once the TMS service is enabled.

NN4B Trusts will need to be aware that during the outage NHS numbers cannot be generated, new-births cannot be registered and blood-spot labels cannot be generated and should plan accordingly.All birth notifications will be queued and processed once the TMS service is enabled.
Personal Demographics Service (PDS) Simple traces can be completed on PDS data.PDS reliable messaging will be unavailable until the TMS database has switched over.
RiO Users will be unable to:

  • trace patients
  • register new patients
  • book or reschedule appointments

The RiO system will need to queue the messages and resend to Spine once the TMS service is enabled.

TMS Event Service (TES) The majority of TES functionality will be unavailable during the outage.Trusts will need to be aware EPS, Death notifications, and Patient Care Provision Notifications (change of pharmacy) will be queued and sent to the receiving systems once the TMS service is restored.Any impacted notifications will be queued and sent to the receiving systems once TMS is restored.
TMS Batch (DBS, CHRIS, ONS) DBS will be unavailable until the TMS database has switched over (DBS processing will be suspended for the duration of the exercise).As the TMS switchover will be scheduled to start at 22:00, CHRIS batch should complete before the outage starts (CHRIS batch runs at 20:00 nightly).ONS processing will start at 18:00 nightly. If it doesn’t complete before 22:00, the messages will be queued and processed once the TMS service is restored.

**

Severity 2
BT Spine
HSCIC
National
Users are unable to grant worklist items within UIM.
USER IMPACT:
This is causing delays to routine business processes as users are unable to complete their worklist items within the UIM application.
ACTION BEING TAKEN:
BT investigating.

**

Severity 1
BT Spine
HSCIC
National
The EPS database is currently experiencing severe degradation of performance.
USER IMPACT:
Delays to routine business processes.
ACTION BEING TAKEN:
BT engineers currently investigating with the database application support team.

Comment

David Nicholson is right. The NHS has become dependent on systems such as the Spine. But can doctors ever trust any aspect of the safety of patients to systems that are not available 24×7 as they need to be in a national health service?

It appears that BT and other suppliers have not been in breach of service level agreements, and the HSCIC has a good relationship with the companies.  But does the HSCIC have too great an interest in not finding fault with its suppliers or the contracts, for finding fault  could draw attention to any defects in a service for which the HSCIC is responsible?

Have national NHS IT suppliers a strong enough commercial or reputational interest  in avoiding  a disruption or loss of service, so long as they keep within their service level agreements? 

If nobody sees anything wrong with the reliability of existing national NHS IT services improvements are unlikely. Diane Vaughan’s book on the culture and organisation of NASA shows that experts in a big organisation can do everything right according to the rules  and procedures – and still have a disastrous outcome.

Firecontrol disaster and NPfIT – two of a kind?

By Tony Collins

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

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

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

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

More similarities

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

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

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

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

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

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

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

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

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

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

National to local – but one extreme to the other?

The PAC report continues

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

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

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

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

Comment

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

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

But the PAC’s Firecontrol Update Report expresses concern that

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

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

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

On the other hand …

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

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

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

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

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

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

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

Lessons from FireControl (and NPfIT?) 

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

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

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

– Over optimism on the deliverability of the IT solution.

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

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

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

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

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

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

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

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

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

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

Why weren’t NPfIT projects cancelled?

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

PAC report on Firecontrol

What Firecontrol and the NPfIT have in common (2011)

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

By Tony Collins

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

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

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

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

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

A 22 year programme?

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

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

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

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

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

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

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

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

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

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

NPfIT is not dead

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

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

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

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

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

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

Comment

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

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

“We will quickly develop the infrastructure …”

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

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

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

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

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

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

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

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

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

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

Summary Care Record “unreliable”

By Tony Collins

The  central Summary Care Record database (which is run by BT under its NPfIT Spine contract) is proving unreliable, Pulse reports today.

The SCR is supposed to give clinicians , particularly those working in A&E and for out-of-hours services, a view of the patient’s most recent medicines, allergies and bad reactions to drugs.

But one criticism of the scheme has always been the lack of any guarantee that the data in the SCR could be accurate or complete.

Researchers at University College, London, led by Trisha Greenhalgh, found in a confidential draft report that doctors were unable to trust the SCR database as a single source of truth. They found in some cases that  some information on the database was wrong, and what should have been included in the patient’s record was omitted for unknown reasons.

Now Pulse reports that some GP-derived information is going on the patient’s SCR, and some isn’t. One problem is that GPs must use smartcards to update the SCR database and some don’t use them.

The General Practitioners Committee of the British Medical Association has raised the matter with the Department of Health.

Dr Paul Roblin, chief executive of Oxfordshire, Buckinghamshire and Berkshire local medical committee told Pulse that  smartcards were not often used in Buckinghamshire, because they slowed down the practice IT system for normal use, with one practice reporting that it had interfered with allergy data.

Dr Roblin said that this made the record ‘unreliable’ and said that although most GPs would prefer to take their own history rather than relying on the SCR, and would double check all details with the patient, other health professionals may not realise the record is incomplete, and may not check the data.

He said “Drugs lists might not be complete and recent allergies may not be uploaded. The Summary Care Record is unreliable. Don’t rely on it. It’s an expensive initiative without a lot of benefit.”

Dr Chaand Nagpaul, GPC lead negotiator on IT, said the current arrangements  undermine the benefit and usefulness of summary care records.

“The GPC have suggested workaround systems for practices who do not use smartcards, such as a ‘mop-up’ session where all new data is uploaded on to the national spine once a day. However, the DH decided against this option.”

There may be professionals who believe the SCR database  represents an up to date record said Nagpaul.

A DH spokesperson said that most practices which have created Summary Care Records use smartcards.

[Whether justified or not the SCR  scheme is believed to have cost about £250m so far.]

In 2010 Professor Ross Anderson at Cambridge University argued that the SCR could do more harm than good.

Richard Veryard also wrote on the unreliability of the SCR in 2010.

The Devil’s in the Detail – UCL report on the Summary Care Record.

Summary Care Record – where does the truth lie?