Patrick Kesteven, a consultant haematologist at Freeman
Hospital, Newcastle, is open and clear-minded when talking about
why his trust board decided to break away from the £12.7bn National
Programme for IT in the NHS.
"The National Programme was taking forever," he says. He is not
even sure that the National Programme for IT (NPfIT) - the UK
government's biggest IT investment - will ever work as originally
intended.
Far from being a renegade, Kesteven is ensconced in Newcastle's
medical establishment. He chairs a programme board which is
planning for a
system of e-records to start going live at three hospitals in
Newcastle in May next year.
Executives at the Newcastle Upon Tyne Hospitals NHS Foundation
Trust, which employs 11,000 clinical and administrative staff, have
given up waiting for e-record systems from the NPfIT. They want as
soon as possible to give doctors and nurses systems which, with a
single log-on, provide an overview of patients' treatments and
histories, who is supervising them, where they are in the hospital
and whether, for example, they have just had an adverse reaction to
a general anaesthetic.
The trust also wants better information to ensure it is paid for
all it does. When patients are given extra treatment unrelated to
their initial problem, the work can go unrecorded on existing
payment-related systems.
The NPfIT was specified to provide the solutions, but the
government promised it would be in place by 2006. When ministers
announced the NPfIT in 2002, they promised that patients would have
a national electronic health record by the end of 2005.
That has not happened, nor is it expected to happen for years.
The National Audit Office says it will be 2015 before a national
e-records scheme will be rolled out across England, and believes
even that date may be optimistic.
So the Newcastle board has decided to buy its systems from the
US University of Pittsburgh Medical Center, which has introduced an
integrated e-records system at its 20 hospitals.
The purchase cuts out CSC, the national programme's local
service provider to NHS organisations north of Oxford. It also
sidelines NHS Connecting for Health, the 1,100-strong bureaucracy
in the Department of Health which is running parts of the
NPfIT.
Newcastle and Pittsburgh Medical Center have formed a joint
venture whose directors hope to sell licences and implement systems
to NHS organisations.
Other foundation trusts have been inquiring about Newcastle's
approach to major IT investment, says a report to the trust's
board. Foundation trusts have the freedom to buy outside the NPfIT
if they have good financial reasons for doing so. Non-foundation
trusts must buy their main hospital system - the patient
administration system - under the NPfIT, although there are
exceptions.
Monitor, the regulator of NHS foundation trusts, is aware of
Newcastle's plans to buy outside the NPfIT. Newcastle's board has
been told that Monitor "understood that the trust could not wait
until 2012/13 for the national programme to provide the required
systems".
If many foundation trusts diverge from the NPfIT, the
government's plan to supply England's NHS trusts through a small
group of appointed IT companies - local service providers - will
disintegrate further. Already, non-foundation trusts in the south
of England are considering "interim" systems not supplied by the
scheme's two remaining local service providers, BT and CSC
the contract of the third provider, Fujitsu, was
terminated.
Tola Sargeant, an NPfIT expert at market analyst Ovum, says that
the "lull" in the NPfIT, mainly in southern England, creates
opportunities for suppliers other than CSC and BT.
"Some trusts may decide they cannot afford to wait for a local
service provider system and instead procure an interim or
replacement system from alternative suppliers," she says. "However,
competition for any such contracts will be stiff and small UK SMEs
will be competing against much larger international rivals that are
also targeting the UK market."
Kesteven and the Newcastle trust recognise they are taking a
risk by going it alone. No figure has been announced for the cost
of its investment in a US electronic medical records system but
Computer Weekly understands that the investment is £15m over two
years. This includes a payment in advance for seven years of Cerner
software licences - pre-ordered licences and any more they decide
to buy within the seven years - and all support and maintenance,
but not consultancy.
The Newcastle trust is the first organisation outside the US to
invest in Pittsburgh Medical Center's Cerner-based e-records
technology.
Kesteven recognises that not all staff at Pittsburgh Medical
Center are enamoured with all aspects of the system. "But would
they go back to how things were before? They couldn't imagine
it."
There is also the challenge of making a US system work in the
UK. Anglicisation will be the key, Newcastle has been told.
If the Newcastle implementation goes badly - as did a basic
version of the Cerner system when it was deployed at some NHS
trusts in London in the south of London - health officials in
Whitehall may say it serves the trust right for not waiting for the
free (because centrally funded) NPfIT systems.
But Newcastle's executives see the risks as worth running. They
have learned the main lesson from the troubled installations of the
NPfIT Care Records Service in London and the south of England: that
the customer must be in control of the supplier, the contract, the
software's functionality and the changes in the day-to-day working
practices of doctors and nurses.
Homerton and Newham hospitals in London have successfully
installed Cerner systems. But it took years to resolve problems,
which they did through a contract with Cerner, and without a local
service provider acting as middleman or the involvement of
Connecting for Health.
Those NPfIT trusts that have run into serious and enduring
problems have not been in direct control of the suppliers. They
include Barts and the London, the Royal Free, Nuffield Orthopaedic
Centre, Barnet and Chase Farm, and Weston Area Health
Authority.
As they have no direct contractual relationship with the
suppliers, NPfIT trusts cannot sue over a failed installation.
Contracts for NPfIT installations are between the health minister
and the local service providers. So when NPfIT trusts want changes
to the Cerner or "Lorenzo", they usually have to put their requests
to a committee. Any variations may be granted eventually and
incorporated months or years later in a general software
upgrade.
Little wonder then that local service providers and Connecting
for Health are seen by some NHS executives as unnecessary
middlemen.
Even with their own IT contracts in place, Newcastle's directors
know it will be difficult trying to combine information on its
patients, given that data is held in up to 100 legacy systems
across its various sites.
Andre Snoxall, e-record programme director at the Newcastle
trust and a former CIO at trusts in New Zealand, says that even
with the most favourable conditions and contracts it is still an
enormous task to bring about a comprehensive view of a patient with
a single log-on.
"It takes an extraordinary amount of effort to try and get a
full picture of a patient's history," he says. He adds that the
biggest challenge for the trust is not so much technology as
inspiring people, engaging them and "getting them working towards a
common goal".
And if achieving a single patient view at one large trust alone
is hard enough, the government aims to do it for all hospitals
across England. Standardised systems, no contractual relationship
between most trusts and their suppliers, little customer control
over changes to the software, and delays of at least four years so
far are just some of the obvious problems.
Kesteven will gain some sympathy from some NHS IT executives for
his view that the NPfIT may never happen. That should be a prompt
to the government to rethink the programme or conduct a high-level
review, which it has so far repeatedly refused to do.
NPfIT: expert views >>
Newcastle's case for breaking away from the NPfIT
The go-it-alone costs of hardware and software are higher for
the Newcastle Upon Tyne Hospitals NHS Foundation Trust than if it
installed systems under the NPfIT. NPfIT hardware and software are
paid for by the government's £6.2bn worth of contracts with local
service providers, and are therefore free to NHS trusts.
But the Newcastle trust points outs that maintenance and support
are cheaper outside the NPfIT. Overall, according to the details of
Newcastle's business case seen by Computer Weekly, the costs are no
higher outside the NPfIT than within it.
Newcastle says of its joint venture with the University of
Pittsburgh Medical Center to install e-record systems at Newcastle
and to offer licenses and implementation to other NHS organisations
that:
the implementation costs are higher than the NPfIT
but the implementation [and associated costs] come sooner
and "hard and softer savings and benefits are ultimately similar
in magnitude, although planned and expected to be achieved much
sooner"
The trust also says the NPfIT option "requires more ongoing
system maintenance, service desk and lifecycle costs, which erodes
into the recurrent savings achieved". It adds that there are
"marginal differences between the ongoing additional infrastructure
staffing requirements" between the NPfIT and joint venture
options.
"Based upon the above it is considered that from a value for
money perspective then the joint venture option was
preferable."
The trust is currently using the McKesson system, which will be
gradually replaced with Pittsburgh's Cerner system.
How will Newcastle avoid the problems at Cerner NHS sites in the
south of England?
Andre Snoxall, e-record programme director at the Newcastle
foundation trust, says, "Knowing the problems there are is half the
battle. We have partnered with University of Pittsburgh Medical
Center, who I believe are the largest single Cerner customer in the
world.
"Therefore we believe they have got - and this is part of the
reason we partnered with them - a tremendous amount of clout with
Cerner. They have the ability to influence the way that product is
developed. We are hoping that through that relationship we will get
a version of the product that's more advanced than the ones that
have currently been implemented.
"However we are not putting all our eggs in that basket. We
recognised that organisations such as Barts and the Royal Free have
encountered a number of issues largely because of deficiencies in
the way the product handles the 18-week pathway [a target to treat
95% of outpatients and 90% of inpatients within 18 weeks of being
referred by their GPs].
"We will look at how we may avoid [these problems] through
workarounds and through whatever means are available. We have more
time, another nine months, to try and get that right.
"Hopefully, we won't end up with all the same sorts of problems.
Now that's not to say we expect everything will be perfect from day
one. We don't think it will. But forewarned is forearmed.
"A lot of problems are down to the fact that you need more
people to be able to manage the patients than would be
optimal."
See
IT Projects blog for full interview with Snoxall >>