Tag Archives: CSC

Patient records go-live “success” – or a new NPfIT failure?

By Tony Collins

John Goulston says the go-live of a new patient records system at his trust is a “success”.

He should know. He’s Chief Executive of Croydon Health Services NHS Trust. He’s also chair of the trust’s Informatics Programme Board which has taken charge of bringing Cerner Millennium to Croydon’s community health services and the local University Hospital, formerly the Mayday.

He was formerly Programme Director of the London Programme for IT at NHS London – a branch of the NPfIT.

In a report two weeks ago Goulston said the trust deployed the “largest number of clinical applications in a single implementation in the NHS”. Croydon went live with Cerner Millennium on 30 September and 1 October 2013.

Said Goulston in his report:

“Administrative functions do not engage clinicians; providing them with a suite of clinical functionality has been justified as each weekday approx. 1,000 staff are logged on and using the system. CHS [Croydon Health Services] has in Phase 1 deployed, in addition to patient administration, the largest number of clinical applications in a single implementation in the NHS England.”

BT helped install Millennium at Croydon under the National Programme for IT.  The trust’s spokesman says the Department of Health provided central funding, and the trust paid for implementation “overheads”.  The Health and Social Care Information Centre was the trust’s partner for the go-live.

The Centre is the successor for Connecting for Health. It has taken on CfH’s officials who continue to help run the NPfIT contracts with BT and  CSC.

Goulston said that Cerner and BT have paid tribute to the trust which installed Millennium in A&E, outpatients, secretarial support and cancer services, and elsewhere.

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

Best Cerner implementation yet?

Optimistic remarks about their launch of Cerner Millennium were also made in 2012 by executives at the Royal Berkshire NHS Foundation Trust.  Their optimism proved ill-judged.

Of the Millennium go-live at Royal Berkshire, trust executives said that it “had been considered to be the best implementation of Cerner Millennium yet and that despite staff misgivings, the project was progressing well”.   This positive message should be disseminated, they said.

Months later they told the Reading Chronicle of patient safety issues and a financial crisis arising from the Millennium implementation.

A Royal Berkshire governors Rebecca Corre was quoted as saying: “There is a patient safety issue when staff write down observations and then there is an hour before they can get it onto the computer. If it is an experienced nurse, they may pick up a problem, but others may not.”

Ed Donald, Chief Executive of Royal Berkshire was quoted as saying:

“Unfortunately, implementing the EPR [electronic patient record] system has at times been a difficult process and we acknowledge that we did not fully appreciate the challenges and resources required in a number of areas.”

Are executives and managers at Croydon Health Services NHS Trust  now similarly afflicted with an unjustified optimism about the success of their Cerner go-live?  

Past consequences of NPfIT go-lives hidden?

The Department of Health has claimed benefits for the NPfIT of £3.7bn to March 2012 but there have been trust-wide failures: thousands of patients have had their appointments, care or treatment delayed by difficulties arising from past implementations of patient record systems under the NPfIT.  For thousands of patients waiting time standards have been exceeded or “breached” because of disruption arising from troubled go-lives.

In nearly every case trusts made it difficult for the facts to come out publicly. Vague or unexplained fragments of information about the consequences of the NPfIT implementation appeared  in different board papers over several months. The facts only emerged after a journalistic investigation that required scrutiny of many board papers and follow-up questions to the trust’s press office.

So Campaign4Change investigated Croydon Health’s implementation of Cerner Millennium to see if the Francis report’s call for a “duty of candour” over mistakes and problems in the NHS have made any difference to the traditional fragmentation of facts after NPfIT go-lives of patient record systems.

The Francis report called for “openness, transparency and candour“.  Trusts were told not to hide sub-standard practices under the carpet. The health secretary Jeremy Hunt said it can be “disastrous” when bad news does not emerge quickly and the public are kept in the dark about poor care.

To my questions about the Cerner Millennium implementation Croydon trust’s spokesman always responded promptly and tried to be helpful. But it appears that trust executives have given him limited information about consequences of the go-live, and have preferred to indulge the “good news” NHS culture that Jeremy Hunt warned about.

On being asked what problems the trust has faced since the go-live the spokesman gave various answers that made no mention of the problems.

“All of our staff received training on the system, and we are continuing to offer our teams support as it is embedded.”

What of the problems arising from the implementation, and has the board been fully informed?

“Millennium has featured regularly on the Corporate Risk Register presented to each Part 1 Board meeting.   In addition, implementation has received detailed confidential consideration at Part 2 of Board meetings, (which is why you won’t find it in our public board papers).”

Given Francis’s call for duty of candour,  should the trust be more open about its problems?

“The initial roll out for CRS Millennium was introduced over three days at the Trust, with a phased approach.  We did this to ensure the system was working in each department, before introducing it in another area.

“We are monitoring waiting time performance and records management so we can identify any issues if they emerge. The system is still being introduced in some services and when this is completed we will be able to assess the overall programme,” said the spokesman.

Does Croydon’s unwillingness to give in its statements to me any details of problems indicate that the culture of a lack of transparency in the NHS will be hard to change, no matter how many times Jeremy Hunt talks about the need for candour when things go wrong?

The spokesman:

“I’d like to be clear about the Trust’s approach:

  • The Trust board has been cited on the roll out of CRS Millennium and any potential risks throughout the process.  As I previously noted, the board received an update in September.  The board meeting, which will take place on Monday of next week, will receive a further update from the Chief Executive.  The papers from this meeting will be published on our website and the meeting takes place in public;
  • A meeting chaired by the Chief Operating Officer has reviewed any operational matters arising on a daily basis.  This is an internal meeting for clinicians and managers which has informed the implementation process;
  • Patients and visitors to the hospital have been kept fully appraised of the introduction of the system and were made aware that they may experience some delays to the check-in process while staff became familiar with the new computer system;

“These actions would suggest that the Trust has been transparent in its approach.  You are welcome to review the board papers when they are published.”

Serious problems now emerge

Croydon did indeed publish its board papers on 25 November 2013 – which is to its credit because not all NHS trusts publish timely board papers.

But it’s mostly in the small print of various board papers that details emerge of Millennium-related problems. The shortcomings are mentioned as individual items rather than in a single, detailed Cerner Millennium deployment report.  This leaves one to question whether trust directors have an overview of the seriousness of the difficulties arising from its implementation of a new patient records system.

These are some excerpts from deep inside Croydon’s latest board papers:

Breaches in waiting time standards

– “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 providing CHS with the required scale of N3 access (>600 concurrent users and >1,600 users on any day – which is the largest network usage of any trust in England).”

– • “Hospital Based Pathways: The deployment of CRS Millennium was a particular challenge in the month across the multiple service areas within the Directorate of A&E, Surgery and Maternity.

• “Cancer & Core Functions: With the implementation of CRS Millennium, the open pathways part of RTT [referral to treatment – patient waiting times) may fail the standard – validation will be completed after the narrative for this report… “

Excessive waits in A&E

– “The main drivers adversely affecting the performance in the month [October 2013) for A&E were the deployment of CRS Millennium and the commencement of winter pressures due to the seasonality change.  A&E  4-Hour Total Time in Department Target: 95.00%. Actual: 91.57%.”

Over budget

“The Trust position as at October is an adverse variance of £4.1m. This is a significant deterioration on the Month 6 position. The movement is mainly due to a significant reduction in income mainly as a result of operating issues caused by the Cerner deployment (£0.9m)…  Actual £14.8 (£14.8)m; Budget £10.7m; Variance £4.1m.”

“Cerner Millennium: Plan YTD [year-to-date] £245,000; Actual YTD  £621,000;

Significant loss in income

“… A new patient administration system was deployed in the Trust on the 30th September and 1st October (Cerner Millennium). The deployment has resulted in significant loss in income in September and October £ 1.1m. Trust performance on Activity Planning Assumptions and Key Performance Indicators is substantially worse than plan …”

Extra costs

“Medical £412k and admin £148k agency levels continue to be high due to cover for vacancies, annual leave, sickness and release of staff for Cerner training. The Trust has also incurred additional costs associated with the Cerner deployment (£600k) including overtime payments to administration staff and training costs.”

Bid to recover Cerner costs?

“… The Trust is currently forecasting a deficit position of £17.8m, which is £3.3m off the plan submitted to the NHS Trust Development Authority. This is a £3m movement from the month 6 forecast and is as a result of operational issues caused by the Cerner deployment. The current projected impact is an additional costs £1.7m and a loss in activity £1.1m . An application is to be made to recover the additional cost/losses relating to the Cerner deployment [of £2.9m] …”

HSCIC support for delays

“Cerner Millennium – Revised implementation date to Sept 2013 (achieved) ,with resultant additional costs including additional PC requirements of £146k, specialist support services £300k, procurement costs £91k, data cleansing costs £200k.

“Health& Social Care Information Centre (HSCIC) has confirmed support for the delayed implementation will be provided, accounting treatment of support to be confirmed with Department of Health.”

More money to stabilise operational position?

“As a result of operational issues caused by the Cerner deployment , Income is significantly reduced in October. The forecast assumes that the Trust will resume normal operating levels from November and that an element of the income lost will be will be recovered in the latter part of the year. A business case is being submitted to the Trust Board for additional investment in Cerner to stabilise the operational position.

“If there are further operational issues due to the Cerner deployment then this will significantly impact on the year end forecast…”

Over-optimism?

Principal risk -reporting output from Cerner is not accurate or timely. Officer in charge: CEO. Before go-live risk scores: June 2013 – 16; July – 16; Aug  – 10; Sept – 10. After go-live risk score (for Oct): 20 [high risk of likelihood and consequences]

Principal risk – operational readiness following the implementation of Cerner. Officer in charge: COO.  Before go-live risk score 15. Post go-live: 20. Risk rating before go-live – Green. After go-live – Red.

Red risks

Corporate Risk Assurance Framework

Nine risks are reported as Red [two of which relate directly to Millennium]:

“… Reporting output from Cerner is not accurate or timely. Data migration was successful. However reliance on external provider as internal knowledge has not yet been fully gained. A data quality dashboard with exception reporting is in place.

“… Operational readiness following the implementation of Cerner CRS Millennium impact conveyed to Trust Development Authority e.g. ED [Emergency Department] reporting and cost overruns

Risk scores

– Failure of CRS millennium to deliver anticipated benefits – 12. Officer in charge: CEO

– Reporting output from Cerner is not accurate or timely – 20. Officer in charge: CEO

– Operational readiness following the implementation of Cerner – 20. Officer in charge: COO

Croydon’s trust’s response to problems

Said John Goulston, Croydon’s CEO, in his latest [November 2013] report to the board of directors:

“The issues being encountered now with CRS Millennium are not due to any lack of integration testing with legacy applications or testing of workflow. They can be attributed to changing from a 25 year old Patient Administration System (Patient Centre) which did not require working in real time, was simple and intuitive to use, easily configurable and flexible to our needs.

“CRS Millennium’s patient administration functions are almost the complete opposite and the language used is new for our staff i.e. conversations, encounters etc. For our staff it has been a big ask for them to step into and up to such a complex application.”

He added: “The benefits of the new system are that each patient will have a single accurate electronic record that can be viewed and kept up-to-date by hospital and community clinical staff. This will eventually mean less time searching for patient notes, missing documentation and duplicating patient information…

“As with any massive change, there are still some challenges to tackle in making the system work effectively for every single user, in a diverse and complex organisation.

“However the success we have achieved to date is the result of the efforts of every single system user and all staff members. I would like to thank all our staff for their hard work in getting the Trust to this important stage.”

The trust spokesman gave me this statement on the problems:

“The Trust board has been given regular reports on the roll out of CRS Millennium and any potential risks throughout the process, not least through its regular reviews of the Corporate Risk and Board Assurance Frameworks.  As I previously noted, the board received a specific update in September.

“As you already know, November’s board meeting received a further update from the Chief Executive.  The papers from this meeting were published and the meeting takes place in public;  Those attending are invited to put forward questions.

“A meeting chaired by the Chief Operating Officer continues to review operational matters.  This is an internal meeting for clinicians and managers which has informed the implementation process;

“Patients and visitors to the hospital have been kept fully appraised of the introduction of the system and were made aware that they may experience some delays to the check-in process while staff became familiar with the new computer system;

“As you highlight from the board report, Cerner & BT noted that ‘the Trust has undertaken one of the most efficient roll-outs of the system they have worked on’   The papers also note some operational challenges as the system was rolled out.  These have been addressed as part of the daily meetings I reference above – these are mainly concerned with users familiarising themselves with the system and have been addressed through the support and training staff received.

“In terms of the costs, the introduction of CRS Millennium has been supported by central funding from the Department of Health with the Trust paying the implementation overheads.   These costs are a matter of public record and the Trust publishes annual Accounts as part of its Annual Report.”

Comment

When you go into hospital it’s reassuring to know the directors will be well informed and open about problems that could affect you.

The approach of Croydon Health Services NHS Trust to openness about its problems is not reassuring. It is no better or worse than other trusts that have implemented Cerner’s Millennium. In fact the timely publication of its board papers means it is more open than some.

But it should not require a time-consuming journalistic investigation to establish the consequences for patients of an NPfIT go-live. It has required just such an investigation after the go-live of Millennium at Croydon.

Board directors will not have the time to dig for, and piece together, information about internal problems that could delay patient appointments, treatment and care. They need the unpalatable facts in one place. Croydon Health Services has failed to make it easy for patients or board directors to see what has gone wrong.

NPfIT deployments at other trusts have led, cumulatively, to thousands of patients having appointments that were disrupted, or who had to wait longer to be seen than necessary, or whose records were not available, or who were seen with another patient’s records.

In shying away from telling the whole truth trusts take their cue from the top: the Department of Health has always made it hard to establish facts about anything to do with the NPfIT.  Said the Public Accounts Committee in its report The National Programme for IT in the NHS: an update on the delivery of detailed care records systems in July 2011:

 “It is unacceptable that the Department [of Health] has neglected its duty to provide timely and reliable information to make possible Parliament’s scrutiny of this project.

“Basic information provided by the Department to the National Audit Office was late, inconsistent and contradictory.”

Unanswered questions

Croydon has questions to answer, such as how many breaches of waiting time standards it has had, and may still be having, due to problems arising from the go-live. Other unanswered questions:

– What does a “a large number of breaches” in the Emergency Department mean? Have each the patients affected been told?

– Why are the risks related to the implementation much higher after go-live than before, given that the trust has had years to prepare for the go-live, and the many lessons it could have learned from other trusts?

– Exactly what problems are still affecting patients?

In a post-Francis NHS, Jeremy Hunt has demanded openness about mistakes and problems. There is an agreed need for change – but how can Hunt change an NHS culture – indeed a public sector culture – in which senior executives, in troubled IT implementations, will always emphasise the good news over the bad, perhaps hoping the bad will always remain hidden?

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Trust spends £16.6m on consultants for Cerner EPR

By Tony Collins

Reading-based Royal Berkshire NHS Foundation Trust says in an FOI response that its spending on “computer consultants since the inception of the EPR system is £16.6m”.

The Trust’s total spend on the Cerner Millennium system was said to have been £30m by October 2012.

NHS IT suppliers have told me that the typical cost of a Trust-wide EPR [electronic patient record] system, including support for five years, is about £6m-£8m, which suggests that the Royal Berkshire has spent £22m more than necessary on new patient record IT.

Jonathan Isaby, Taxpayers’ Alliance political director, said: “This is an astonishing amount of taxpayers’ money to have squandered on a system which is evidently failing to deliver results.

“Every pound lost to this project is a pound less available for frontline medical care. Those who were responsible for the failure must be held to account for their actions as this kind of waste cannot go unchecked.”

 The £16.6m consultancy figure was uncovered this week through a Freedom of Information request made by The Reading Chronicle. It had asked for the spend on consultants working on the Cerner Millennium EPR [which went live later than expected in June 2012].

The Trust replied: “Further to your request for information the costs spent on computer consultants since the inception of the EPR system is £16.6m.”

The Chronicle says that the system is “meant to retrieve patient details in seconds, linking them to the availability of surgeons, beds or therapies, but has forced staff to spend up to 15 minutes navigating through multiple screens to book one routine appointment, leading to backlogs on wards and outpatient clinics”.

Royal Berkshire’s chief executive Edward Donald had said the Cerner Millennium go live was successful.  A trust board paper said:

 “The Chief Executive emphasised that, despite these challenges, the ‘go-live’ at the Trust had been more successful than in other Cerner Millennium sites.”

A similar, stronger message had appeared was in a separate board paper which was released under FOI.  Royal Berkshire’s EPR [electronic patient record] Executive Governance Committee minutes said:

“… the Committee noted that the Trust’s launch had been considered to be the best implementation of Cerner Millennium yet and that despite staff misgivings, the project was progressing well. This positive message should also be disseminated…”

Comment

Royal Berkshire went outside the NPfIT. But its costs are even higher than the breathtakingly high costs to the taxpayer of NPfIT Cerner and Lorenzo implementations.

As senior officials at the Department of Health have been so careless with public funds over NHS IT – and have spent millions on the same sets of consultants – they are in no position to admonish Royal Berkshire.

So who can criticise Royal Berkshire and should its chief executive be held accountable?

When it’s official policy to spend tens of millions on EPRs that may or may not make things better for hospitals and patients – and could make things much worse – how can accountability play any part in the purchase of the systems and consultants?

The enormously costly Cerner and Lorenzo EPR implementations go on – in an NHS IT world that is largely without credible supervision, control, accountability or regulation.

Cash squandered on IT help

Trust loses £18m on IT system

The best implementation of Cerner Millennium yet?

Did officials exaggerate death of the NPfIT?

By T0ny Collins

In 2011 the Department of Health made a major announcement that implied the NHS IT programme, the NPfIT, was dead when it wasn’t.

The DH’s press release announced an “acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority”.

It said the Authority had concluded that the NPfIT was “not fit to provide the modern IT services that the NHS needs…” The National media took the press release to mean that the NPfIT was dead.

What the announcement didn’t mention was that at least £1.1bn had still to be spent, largely with CSC, provided that the company successfully completed all the work set out in its revised contracts, and that the projected end-of-life of some centrally-chosen NHS IT systems was 2024.

Some will say: who cares if the DH issues a press release that is misleading. Others may say that in a democracy one should be able to trust institutions of state. If the DH issues an official notice that has the effect of manipulating public perceptions – gives a false impression – can citizens trust the Department’s other official notices?

The press release in question did not say the NPfIT was closing but gave that impression. The announcement distanced the government and the Department of Health from an IT scheme, perhaps the world’s largest non-military IT programme, that was failing. This was the press release:

The government today announced an acceleration of the dismantling of the National Programme for IT.

“The government today announced an acceleration of the dismantling of the National Programme for IT, following the conclusions of a new review by the Cabinet Office’s Major Projects Authority (MPA). The programme was created in 2002 under the last government and the MPA has concluded that it is not fit to provide the modern IT services that the NHS needs…”

The press release was given added weight by those quoted in it. They included the Department of Health, Francis Maude, Minister for the Cabinet Office and Sir David Nicholson, Chief Executive of the NHS.

But the truth about the press release emerged this week at a hearing of the Public Accounts Committee.

Margaret Hodge, chair of the Public Accounts Committee, began a hearing on the NPfIT on Wednesday by asking Sir David Nicholson, the NHS chief, a canny question.

Hodge:  “There was a big announcement back in 2011 that you were closing the NPfIT programme.”

“Yes,” replied Sir David.

“That’s not true,” said Hodge. “It was a PR exercise to say you closed it.”

Nicholson: “It certainly was not a PR exercise.”

Hodge: “What changed?”

Nicholson: “The governance arrangements changed.  So there are separate senior responsible officers for each of the individual programmes [within the NPfIT].”

Hodge: “With the greatest respect, changing governance arrangements is not closing the programme.. .I think the impression you were trying to give was that you were closing the programme. All you were doing was shifting the deckchairs on the Titanic. You were shifting the way you were running it but you were keeping all that expenditure running… The impression given to the public was that you were going to get out of some of these contracts.”

On the basis of the press release the Daily Mail published a front page lead story with this headline:

£12bn NHS computer system is scrapped… and it’s all YOUR money that Labour poured down the drain

On the day of the press release the Daily Telegraph reported that the £11.4bn NHS IT programme was “to be abandoned”.  Similar reports appeared in the trade press.

But this week’s Public Accounts Committee heard that the NPfIT is very much alive:

– the estimated worth of CSC’s contracts under the NPfIT has risen from £3.1bn to £3.8bn at today’s prices.

–  officials expected to pay CSC a further £1.1bn on top of the £1.1bn it has already received, and this payment may include up to £600m for Lorenzo deployments at only 22 trusts. Hodge said: “You are going to spend another half a billion with this rotten company providing a hopeless system” – to which the DH argues that CSC has delivered thousands of (non-Lorenzo) working systems to the NHS which trusts and community health services rely on.

– About £500m of the £1.1bn still set aside for CSC will go on GP systems supplied by CSC’s subcontractor TPP Systmone.

– Further spending on the NPfIT may come as a result of Fujitsu’s legal action against the DH after it left the NPfIT in 2008, which leaves the taxpayer with a potential pay-out of £700m or more. The outcome of a formal arbitration is expected in about six months. The closing arguments are due at the end of this month.

– £31.5m has so far been spent on the DH’s legal costs in the Fujitsu case, mostly with the .law firm DLA Piper.

– DH has agreed a compensation payment to CSC of £100m. In return CSC has released the Department of Health from a contractual commitment for 160 NHS trusts to take the Lorenzo system. The DH has made a further payment to CSC of £10m in recognition of changes to its software which had been requested by the NHS but not formally agreed with CSC.

Comment

It appears there has been no deliberate deception and no deliberate manipulation of public perceptions of the NPfIT. But the fact remains that the DH made a major announcement in 2011 which gave the impression the NPfIT was dead when this was not true.

When a BBC Radio 4 journalist called me this week and we spoke briefly about the NPfIT he said: “I thought it was dead”.

Perhaps the mindset of officials was that the NPfIT was dead because everyone except the suppliers wanted it to be. But because local service provider contracts had to stay in place – the suppliers being much better equipped than the DH to handle any disputes over early termination – large payments to CSC and BT had to continue.

It’s a little like the political row over weapons of mass destruction in Iraq. It’s unlikely Blair lied over the existence of WMD. He probably convinced himself they existed. In a similar act of self-delusion officials appear to have convinced themselves the NPfIT was dead although it wasn’t.

But if we cannot believe a major DH announcement one starts to ask whether any of the department’s major announcements can be believed.

Uncoloured information on the NPfIT has always been hard to come by. So credit is due to the Public Accounts Committee and particularly its MP Richard Bacon for finding out so much about the NPfIT.  All credit to Margaret Hodge for picking up on Bacon’s concerns. Were it not for the committee, with indispensable support from the National Audit Office, the DH would have been a sieve allowing only bits of information it wanted to release to pass through.

The fall-out from the NPfIT will continue for years. We still don’t know, for example, what all the trusts with BT and CSC systems will do when the NPfIT contracts expire in the next three years. The hope is for transparency – and not of the sort characterised by the DH’s announcement in 2011 of the NPfIT’s dismantling.

This post also appears on ComputerworldUK

Cornwall Council rushes to sign BT outsourcing deal before elections

By Tony Collins

Cornwall council logoCornwall Council was a model of local democracy in the way it challenged and then rejected a large-scale outsourcing plan. Now it has gone to the other extreme.

Amid extraordinary secrecy the Council’s cabinet is rushing through plans to sign a smaller outsourcing contract with BT – a deal that will include IT – before the May council elections.

Councillors who have been given details are not allowed to discuss them. No figures are being given on the costs to the council, or the possible savings. The Council’s cabinet is not releasing information on the risks.

Councillors are being treated like children, says ThisisCornwall. Documents with details of the BT outsourcing plans have to be handed back by councillors, and cabinet papers are being printed individually with members’ names as a watermark, on every page, to guard against copying and to help identify any whistleblowers.

The council’s Single Issue Panel has a timetable for the IT outsourcing plan.

– Recommendation to Cabinet to approve release of ITT – 27 February 2013

– Evaluation of bid – March 2013

– If contract awarded, commencement of implementation work – April 2013

– Staff transfer date – July 2013

The SIP report emphasises that the timetable for signing a deal is tight. “Evidence received is that there is little room for slippage in the timetable, but that potential award of contract is achievable by the end of March 2013… It is expected that a contract could be ready to be issued as part of the ITT [invitation to tender] pack by early in the week commencing 4 March 2013.”

The SIP report concedes that the plan is “fast moving”.

In the past, the SIP group of councillors has been open and challenging in its reports on the council’s plans with BT (and CSC before the company withdrew from negotiations). Now the SIP’s latest report is vague and unchallenging. The risks are referred to in the report as a tick-box exercise. Entire paragraphs in the SIP report appear to have little meaning.

“Risk log and programme timelines are reviewed and updated on a regular basis… 

“The Council and health partners have been working on and have reached agreement on their positions in relation to commercial aspects in the contract and their expectations have been part of the dialogue with BT.”

“Previous concerns of the Panel relating to the area of new jobs have been addressed with BT in contract discussions and contract clauses have been revised to reflect this…”

It is also unclear from the SIP report why the council is outsourcing at all, only perhaps a hint that the deal will be value for money.

“The contract will be fully evaluated by the Head of Finance and her team to ensure value for money once the final bid is received. No savings have been assumed for 2013/14 budgetary purposes, although there are assumptions of savings for the indicative figures for future years,” says the SIP report.

Comment

It is a pity that Cornwall Council’s cabinet is rushing to sign a deal for which it won’t be accountable if things go wrong. In a few weeks a new council will be voted in and, if the outsourcing deal with BT ends up in a dispute or litigation, the new council will simply blame the old, as happened when Somerset County Council’s joint venture deal with IBM, Southwest One, went into dispute.

In essence, with the local elections only two months away, Cornwall Council’s cabinet has a freedom to make whatever decision it likes with impunity; and it appears to be taking that freedom to an extreme, almost to the point of sounding, in the latest SIP report, as if the council is an arms-length marketing agent of BT.

Cornwall Council’s cabinet has a mandate from the full council to move to a contract with BT. The full council has voted to “support” a deal. But that vote was a mandate to negotiate, not to sign anything BT wants to sign.

Openness has gone out of the window and BT, it seems, is no longer being rigorously  challenged – by Cornwall’s cabinet, the full council, the public or the media.

How exactly can BT guarantee jobs and make savings? We don’t know. The Cabinet isn’t saying, and its members are doing all they can to stop councillors saying.

Are BT’s promises reliant on the fact that IT is subject to constant and sometimes costly change – often unforeseen change – and that is bound to continue, at least in the form of supporting changing legislation and reorganisations?

Unforeseen changes could add unforeseen costs which the council may have to pay because IT is at the heart of business continuity.  In any dispute with the council  – and BT knows its way around the world of contested contracts – the company would have the upper hand because of its experience with litigation and the fact that the council would need undisrupted IT at a time of change and could not afford, without risk, to take the service back in-house.

We have seen how normality broke down at Mid Staffs NHS Foundation Trust amid a lack of openness and excessive defensiveness;  and we have seen, in Somerset County Council’s joint venture with IBM, Southwest One, what can happen when a contract signing is rushed.

Cornwall Council’s cabinet is doing both. It is rushing to sign a contract; and it is rushing to sign it amid excessive secrecy.

Surely Cornwall Council can do better than slip into the shadows to sign a deal with BT before the council elections in May?  If it is such a good deal, the new council will want to sign it. A new council should have the chance to do so.

For Cornwall Council to outsource now what is arguably its single most important internal resource – IT – is bad for local democracy: it is snub to anyone who holds true the idea that local councillors are accountable to local people.

Thank you to campaigner Dave Orr who drew my attention to information that made this post possible.

* Cornwall Council, by the way, has one of the best local authority websites I have seen.  If the website is a reflection of the imagination and efficiency of its IT department, Cornwall Council should be selling its IT skills to BT for a small fortune – not giving staff away.

Will coalition sign a new NPfIT deal with CSC?

By Tony Collins

CSC has told investors that its discussions with the UK government on an interim agreement for deploying Lorenzo to the NHS are “continuing positively”.

CSC says that an agreement could commit a certain number of NHS trusts to take Lorenzo. Some of those trusts would be named in the interim agreement and the remainder within six months. CSC refers to them as “committed named trusts”.

[Such a legal commitment for named NHS trusts to take Lorenzo may run counter to the post-NPfIT coalition philosophy of giving trusts the freedom to buy what they want, when they want, and from whom they want. The named trusts might have indicated on a  DH questionnaire a wish to take Lorenzo but an agreement between the government and CSC would commit the trusts irrevocably, or the DH could have to pay CSC compensation for non-deployment.]

CSC says the deployed product would be categorized as “base product” or “additional product” for pricing purposes. The DH would commit money to the base product. Other funds would be available centrally available for “additional products,  supplemental trust activity and local configuration”.

The DH would give CSC a structured set of payments following certain product deliveries, as well as additional payments to cover various deployments for the named trusts and payments for work already performed.

If the government does not sign a new deal, and allows CSC’s existing contracts to run down until they expire formally in 2015, this could keep further NPfIT-related costs to the taxpayer to a minimum.  But it risks legal action from CSC, which says the NHS contract is enforceable and that the NHS has no existing right to terminate the contract, unless for convenience (which is unlikely).

If the government had terminated CSC’s contracts for its convenience (as opposed to alleged breach of contract) it would have had to pay CSC a termination fee capped at £329m as of 29 June 2012. CSC would also have been entitled to compensation for the profit it would have earned for the 12 months after the contract was terminated.

If the contract is not terminated, a new deal not signed, and no legal action is taken by either side, the amounts the UK government would have to pay CSC are likely to be minimised.  It is in CSC’s interests to maintain and enhance Lorenzo for those NHS sites that have deployed it.

So will the government sign a new deal with CSC at least to reduce the risks of CSC legal action? Or could the government hold out not signing any agreement until expiry of the contracts in 2015 on the basis that CSC has not delivered all it promised?

If a new deal is signed – and CSC indicates that an agreement is likely – the government may face accusations that it has broken its undertaking to dismantle the NPfIT.

David Camerson intervened personally to have the Cabinet Office’s Major Projects Authority look closely at NPfIT commitments.  His “efficiency” minister Francis Maude is likely to resist the signing of any new agreement

But will CSC accept the government’s refusal to sign a new deal, when such a deal could enable CSC to recover at least some of the $1.485bn (£0.95bn) it recorded as an NPfIT contract charge in the third quarter of 2012?

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

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.

TPP stops gift offers to GPs

By Tony Collins

IT supplier TPP has stopped offering gifts to GPs while it has talks with NHS Connecting for Health and CSC.

TPP has offered tea at The Ritz, theatre tickets, Marks and Spencer vouchers and chocolates to GPs in return for their hosting demonstrations of its SystmOne  product.

Parts of the NHS have clearly-defined rules on the acceptance of gifts or hospitality, though the rules do not apply to GPs. NHS Sheffield tells its staff:

“All offers of hospitality should be approached with caution. Modest hospitality, for example, a drink and sandwich during a visit or a working lunch is normal and reasonable and does not require approval of a manager. Offers of hospitality relating to theatre evenings, sporting fixtures, or holiday accommodation, or other hospitality must be declined…”

The guidance adds:

“Casual gifts by contractors or others, e.g. at Christmas time, must not be in any way connected with the performance of duties …”

On 30 January 2012 Campaign4Change reported that TPP has offered gifts to tea at The Ritz or two tickets to a West End show to GP leaders in return for helping to organise an event that would give the company a chance to demonstrate its systems.

TPP SystmOne has said in its marketing literature that its systems hold a third of the country’s patient records and have about 100,000 users.

In reply to our questions about TPP’s offers to GPs, the Department of Health said in January that TPP had ceased offering the incentives after a DH intervention.

“We were made aware and asked the supplier about this activity,” said a Department of Health spokesperson. “The supplier has subsequently confirmed that they have ceased offering incentives to GPs.”

Ten days later Pulse reported that TPP was still offering incentives to GPs. Pulse quoted TPP as saying that it had “momentarily stopped offering the incentives over Christmas but will be resuming during February”.

TPP told Pulse: ‘The incentives were offered only to GPs and practice managers and were completely optional … ‘Our ‘Tea at the Ritz’ offer actually costs considerably less than the cost of catering for such a practice meeting. We at TPP appreciate that GPs and their staff are extremely busy and so any thank-you gifts we offer staff are simply that, a thank-you for an hour or two of their time.’

Campaign4Change then questioned whether the DH is powerless to stop TPP offering gifts.

We said that a level playing field for suppliers would mean that all suppliers offered tea at the Ritz or Marks and Spencer vouchers in return for a chance to demo their systems to GPs. Alternatively suppliers could agree that none offers gifts.

Now Pulse has reported that TPP has stopped offering gifts to GP, at least while it has talks with CSC and  NHS  Connecting for Health. TPP is quoted in Pulse as saying:

Obviously TPP would not have begun offering incentives as a thank-you for a GP’s time, if we were not highly confident that we are not doing anything wrong legally or ethically. That remains our position.

However following recent communication with CSC and Connecting for Health we have postponed the sending of marketing material that offers incentives for SystmOne demonstrations, until all parties have agreed a way forward.

There may have been miscommunications in the past about what incentives were offered, when and to whom, but TPP has always been upfront about any promotional incentives that are offered. All parties are now keen to ensure we can agree on ways to advertise and promote our products whilst maintaining our high ethical standards.’

‘In the meantime we will continue to consult with GPs, their staff and any NHS guidelines, in order to gain feedback about the best ways to demonstrate SystmOne to them.

Comment:

Whether or not the talks between TPP, CSC and the Department of Health might have been prompted, in part, by recent publicity over TPP’s offering of gifts, we’re pleased the talks are taking place.

If all IT suppliers to the NHS offered gifts to GPs then some doctors could end up seeing IT demos based in part on the attractiveness of the gifts on offer.

Links:

IT company’s “tea at the Ritz” offer to GPs.

Can officials stop TPP offering gifts to GPs?

Is TPP defying assurance on gifts to GPs? – Pulse

Software firm pulls tea at the Ritz incentives for GPs – Pulse

Cerner system “too entrenched to be scrapped”

By Tony Collins

A report by Deloitte on problematic Cerner installations at some hospitals in Australia calls for the government to appoint a chief medical information officer to oversee computer projects across the State.

The Deloitte report is a reminder that new IT in hospitals can have good – and adverse – safety implications for patients.

Obtained by the Sydney Morning Herald under Australia’s Freedom of Information Act, the Deloitte report is said to accept complaints last year that the system put patients’ health at risk by providing insufficient alerts to clinicians when messages did not reach their destination.  Deloitte found no evidence of harm to patients.

Though the Deloitte report is specific to the Cerner “FirstNet”  system as installed at some emergency departments in New South Wales, the idea of a chief medical information officer is arguably a good one for the UK where the Department of Health’s CIO (currently Katie Davis, interim Managing Director, NHS Informatics) is not responsible for the medical implications of IT go-lives in NHS hospitals.

New systems bypass the sort of regulation that helps protects the public against harm from medical devices. After hospital IT disasters there is no requirement for a genuinely independent investigation, as happens after airline crashes.

The Sydney Morning Herald [SMH] reports Deloitte as saying that the FirstNet system, which was installed to help run emergency departments across New South Wales, is chronically underfunded.

Deloitte was asked to report on the system after some hospital staff last year lost confidence in the software and returned to manual record-keeping.

Despite continuing problems and excessive time spent on data entry, the FirstNet system is too entrenched to be scrapped and the government should instead invest in bringing it up to scratch, said Deloitte.

”With some exception, FirstNet reporting is inadequate for effective governance of [emergency department] operations,” said Deloitte as reported by the SMH.

Nurses and doctors had complained that the system increased the amount of time they spent at a screen and reduced contact with patients. But the Deloitte report said more time spent on data entry ”was essential to realise the eventual benefits of an eventual [electronic medical record]”, such as greater accuracy of test results and medicine orders.

Upgrades were improving safety at some hospitals but needed to be across the state.

The government should appoint a chief medical information officer to oversee computing projects across the state, and pay for continuing development and training for FirstNet, said Deloitte.

The Health Minister, Jillian Skinner, said clinicians did not want to scrap FirstNet because they didn’t “want to start anew”.

The list of hospitals that have had serious problems after IT installations is growing, in part because the increasing use of technology in healthcare. Though hospital staff tend to learn in time to manage new systems, the unanswered question is whether patient care and treatment – and potentially their health and safety – should be damaged in an unregulated way until the problems are solved or mitigated.

Below is the UK list where it is known that the installation of new IT has caused serious disruption.  Any effect on individual patients has gone unreported:

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

**

Links:

Does Hospital IT need airline-style certification?

Hospital computer system found lacking – Sydney Morning Herald

Jon Patrick’s essay on the effectiveness and impact of Cerner’s FirstNet system in some hospitals in New South Wales.

CSC may cut 500 jobs after NHS write-off – end of NPfIT?

By Tony Collins

CSC has confirmed in a statement to Techweekeurope that it may cut 500 jobs on its NHS account.

“We can confirm that, regrettably, we have recently started a formal 90-day consultation process in the UK which could reduce the number of people working on our NHS account by up to a maximum of 500 people,” CSC told TechWeek Europe.

“This action is necessary mainly because we have now substantially completed many key development activities with NHS, and are now moving away from a focus on development work.”

CSC told The Register that it regretted having to take put jobs at risk, but it was necessary because its NHS workload was getting smaller.

CSC has confirmed it is to write-off almost $1.5bn (£957m) as a result of its involvement in the National Programme for IT (NPfIT).

Comment:

CSC is by no means quitting the NHS. Its NPfIT contract is still in force although it remains unrevised, out of date and subject to legal discussions. CSC has large numbers of UK trusts and GP practices as customers, which will need support and upgrades. If it cuts 500 jobs this may indicate the effective end of the monolith that was the NPfIT which will continue in a much diminished, though still expensive, form, largely because of contracts between the Department of Health and BT.

It appears that the dismantling of the NPfIT has begun in earnest, thanks largely to Cabinet Office officials, its Major Projects Group, the Cabinet Office minister Francis Maude, David Cameron and the Department of Health’s Managing Director of NHS Informatics Katie Davis.

The campaign to stop a new deal being signed with CSC was led by the Conservative MP Richard Bacon, a member of the House of Commons’ Public Accounts Committee who was concerned that a new deal would not be good value for money.

It’s to be hoped that CSC will manage to find other work for the 500. The company says it hopes to achieve the job changes through voluntary redundancies and redeploying people within other parts of its business, without the need for compulsory redundancies.

Techweek europe article that includes CSC’s statement.

MP contacts No 10 and Cabinet Office over future of the NPfIT.

Can officials stop TPP offering gifts to GPs?

By Tony Collins

On 13 July 2011 CSC gave this written assurance to NHS Connecting for Health at its headquarters in Leeds.

“CSC can confirm that its subcontractor TPP will no longer be sending out letters to practices offering  gifts in return for organising demonstrations of SystmOne.”

TPP has continued to offer gifts, and the Department of Health is now concerned enough to divulge the letters it has sent to CSC.

It can do little more, for GPs are not bound by NHS rules on the acceptance of gifts.

NHS Connecting for Health became involved after TPP sent out a letter in April 2011 offering tea at The Ritz or two tickets to a West End show of the GP choice.

“All we ask for in return is a short slot at your [local practice manager] meeting so we can demonstrate the benefits of SystmOne,” TPP said. “We’re [sic] a proven system and a real alternative to EMIS and Vision. With a third of the country’s patient records and more than 90,000 users, SystmOne is the leader in hosted clinical systems.

“Following recent success in the London area, TPP are looking to sponsor local practice manager meetings. We’ll provide lunch and refreshments for all your attendees. As a thank-you the organiser of the event will will also receive afternoon tea at The Ritz or two tickets to a West End show of their choice …Don’t wait around for an alternative that might not arrive – SystmOne is available, right here, right now…”

SystmOne is supplied to the NHS by CSC under the National Programme for IT, at a cost to taxpayers that remains confidential under NPfIT contracts. GPs can also buy the system directly under GP Systems of Choice. Some PCTs are said to be putting pressure on GP practices to replace existing systems with SystmOne.

Three months after TPP’s “tea at The Ritz” letter, on 6 July 2011, NHS Connecting for Health’s Programme Director, GP IT, wrote to CSC.

Dear Sirs

GPSoC [GP Systems of Choice] Marketing Activity by Subcontractor (TPP)

It has come to the attention of the Authority [Connecting for Health/Department of Health] that TPP have been sending letters to practices which include offers of gifts in return for organising meetings of practice managers  during which SystmOne would be demonstrated. The gifts on offer include tea at The Ritz, two tickets to a West End show and £50 of Marks and Spencer vouchers.

The activities being carried out by TPP state that they are in relation to the provision of SystmOne through GP Systems of Choice. As the Supplier of SystmOne under the Framework Agreement, the Authority requests that CSC review these activities and provides a response to the Authority, by no later than 13 July, to advise whether TPP, as their subcontractor, will be continuing with such activity.”

CSC’s Primary Care Product Executive replied on 13 July:

“CSC was not aware of such activities being undertaken by TPP and immediately entered into dialogue with TPP.

CSC can confirm that its subcontractor TPP will not be sending out letters to practices offering gifts in return for organising demonstrations of SystmOne.”

In December 2011 Campaign4Change learned that TPP was offering £25 Marks and Spencer vouchers to GPs in return for a “short slot at your meeting so we can talk to you and demonstrate the benefits of SystmOne”. By that time TPP put the number of its users at more than 100,000.

We asked the Department of Health in December 2011 whether it approved of TPP’s incentives. It replied:

“We were made aware and asked the supplier about this activity. The supplier has subsequently confirmed that they have ceased offering incentives to GPs.”

Then we learned of a TPP offer of Hotel Chocolat chocolates.

“Happy Christmas and a Happy New Year from TPP.

“To find out why 1800 GP practices have already moved to SystmOne, just call me on the number below to book your short GP demo. Book before 24th December to get a box of Hotel Chocolat chocolates on the day of your demonstration…”

This month, February 2012, TPP sent out this message:

TPP sponsorship for your practice meeting

“TPP are looking to sponsor your practice manager meeting! We’ll provide lunch and refreshments for all of your attendees. As a thank-you, the organiser of the meeting will also receive £25 Marks and Spencer vouchers! All we ask for in return is a short slot at your meeting so we can talk to your attendees and demonstrate the benefits of SystmOne to those practices not yet using it. Anyone that books a SystmOne demonstration on the day of the meeting will also recieve £25 Marks and Spencer vouchers!

“You already know all the great reasons to move to SystmOne, why not share them with other practices in your area? The more practices that move to SystmOne, the more benefits you’ll see.

“To arrange sponsorship for your next meeting and take advantage of this great offer, just contact us on the number below or reply to this email.”

We asked DH why it had suggested that the gift offers had ceased when they hadn’t. Its reply:

“The Department contacted CSC (as the GPSoC supplier) about this activity by their subcontractor TPP. CSC confirmed that TPP would cease offering gifts to GPs in return for organising demonstrations of SystmOne. We have contacted CSC about TPP’s position which is not in line with the assurances previously provided.”

We also asked the DH why it was concerned about the gifts. It did not reply directly but sent us copies of the letter it had sent to CSC, and CSC’s reply.

Is the DH powerless to stop TPP offering gifts?

TPP told Pulse this week:  “We momentarily stopped offering the incentives over Christmas but will be resuming during February … The incentives were offered only to GPs and practice managers and were completely optional.

“Our ‘Tea at the Ritz’ offer actually costs considerably less than the cost of catering for such a practice meeting. We at TPP appreciate that GPs and their staff are extremely busy and so any thank-you gifts we offer staff are simply that, a thank-you for an hour or two of their time.”

CSC has made no comment.

Pulse reports that the GP Systems of Choice framework agreement prohibits software providers from offering gifts to any servant of the authority or a PCT. The ban does not include GPs because they do not sign the framework. Suppliers can offer gifts to GPs without breaching the framework agreement says Pulse.

It quotes Dr Charlie Stuart-Buttle, a former chair of the EMIS user group and a GP in Tonbridge, Kent, as saying the incentives were an unacceptable way of going about things. It also quotes Dr Trefor Roscoe, a GP in Sheffield and former medical IT consultant, as saying the incentives were not a problem as long as the GPs felt the system in question was worth demonstrating in the first place.

Comment

Some will say that GPs are bombarded with offers of freebies from drug companies. So why does it matter if an IT company offers gifts?

Another argument is that drugs are different. GPs can stop offering drugs that become too expensive. They cannot simply stop using a GP system. It’s a big decision for any GP practice to choose a new system even with subsidies from the Department of Health under GP Systems of Choice GPs, while the GPSoC framework lasts. Any new GP system is likely to be a long-term commitment because of the disruption of changing.

GPs should surely choose their IT supplier on the basis of the facts and after shortlisting suppliers.

We dislike the expression “level playing field” but if applied here it would mean that GPs chose new systems only after demos at which all shortlisted suppliers offered tea at the Ritz or Marks and Spencer vouchers to certain GPs.

Alternatively the suppliers could agree that none offers gifts.

IT company’s tea at The Ritz offer to GPs.

Pulse article on TPP incentives

Are PCTs putting GPs under pressure to switch to SystmOne?