Barts: we underestimated impact of NPfIT go-live

Barts and The London NHS Trust says it underestimated the impact on its operations of going live with the Cerner LC0 system under the NHS’s £12.7bn National Programme for IT [NPfIT].

The problems have led to operating theatres and clinics being unused at times – despite a demand for them – because of difficulties in scheduling patients for appointments.

The trust is also funding from its reserves £930,000 for extra temporary staff, in part to cope with the backlogs of work following the NPfIT go-live. It is also facing a further £1.5m shortfall in income because it may not have enough accurate information on which to bill its local primary care trust for the patients it sees and treats.

A Barts and The London spokesman told Computer Weekly that an “intensive programme of measures is in place” which “will allow us to return to our previous performance levels as quickly as possible”.

He added that trust has “apologised publicly to patients, GPs and staff for the difficulties they have experienced”.

The spokesman was responding to Computer Weekly’s questions after the trust published board papers on its website which described as “significant” ongoing problems after the implementation of the Care Records Service, based on Release 0 of a patient administration system from US supplier Cerner and BT, London’s NPfIT local service provider.

The trust has had difficulty maintaining an overview of which patients have been treated for what. In its latest published board papers the trust warns that income may be less than expected.

A financial paper to the board on the first quarter of the trust’s 2008/9 year says:

“There are ongoing recording issues arising from the implementation of CRS [the NPfIT Care Records Service] which may impact on activity and associated income.”

The paper adds:

“The Trust is working with BT [and] Cerner to correct these issues in time to ensure that Quarter 1 [of 2008/9] income can be accurately invoiced. To reflect the high risk around income the trust has provided £1.5m against the first quarter’s income.”

The paper adds: “There are also known system errors where data which has been entered into CRS [the Cerner Care Records Service system] has not been reflected in the data warehouse and therefore is missing from SLAM [Service Level Agreement and Monitoring system]. These issues have caused [a] significant understatement of both inpatient and outpatient activity and income”.

With fewer than expected patients being booked correctly into hospital systems, clinics and operating theatres have been under-used.

The paper says: “There is some evidence that April activity was reduced due to the implementation issues of CRS. Clinics were reduced in some areas and issues with bookings meant that in some areas the clinics and operating theatres were not operating their usual capacity”.

The trust has directed nearly £1m from central reserves to ICT to “fund additional temporary staff costs relating to the implementation and subsequent validation of CRS”.

Two other London trusts, Barnet and Chase Farm and the Royal Free Hampstead have also had significant and protracted problems after going live with the Cerner system. There have been difficulties at go-lives of trusts outside London too. But the government and the Department of Health want trusts to accelerate plans for trusts to deploy NPfIT systems.

A spokesman for Barts and The London said: “The Trust anticipated that there would be a greater degree of fluctuation in activity levels in the period before and after the CRS [Care Records Service] go-live in April, but we underestimated the level of impact that CRS would have on our operations.”

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Barts and The London is one of the UK’s top teaching hospitals. The trust comprises St Bartholomew’s (Barts) in the City, The Royal London in Whitechapel and The London Chest in Bethnal Green.

The trust has the UK’s biggest heart attack centre and is home to London’s air ambulance.

In October 2007 the trust announced that the Healthcare Commission had awarded it the highest possible quality rating for the second year running.

Comment:

Barts and The London deserves credit for admitting the seriousness of the trust’s problems. There is political pressure on some trusts to pretend publicly, and particularly to staff, that the problems are merely teething. This enforced lack of honesty makes it difficult for the trust’s executives to put all that’s necessary into preventing crashes, fixing bugs, reducing workarounds and ensuring that staff change the way they work. The local service provider is a large part of remedy when it comes to the technology – but do trust executives have the authority to apply pressure on the supplier? Probably not.

Barts also has the honesty to question the way it protrayed its problems initially as teething. It’s difficult to blame Barts for the difficulties. Its board was under great political pressure to go live, as are other London trusts, which will already have realised that they need to enter into deployments with eyes wide open.

These are our questions to Barts and its answers:

Question: If clinics and operating theatres are under-used this suggests that people have not had operations when they needed them and people have not been seen in clinics when they needed treatment. Any comment on this please?

Answer: “The Trust anticipated that there would be a greater degree of fluctuation in activity levels in the period before and after the CRS go-live in April, but we underestimated the level of impact that CRS would have on our operations. An intensive programme of measures is in place to address this, which will allow us to return to our previous performance levels as quickly as possible.”

Question: What will be the effect on the trust’s finances of an “underperformance on income of £3m for the year”? Does this mean cuts in budgets elsewhere in the hospital’s operations, recruiting, equipment or staff?

Answer: “Barts and The London is now reporting break-even figures on our operational income, as at the latest information available. This represents a significant improvement on figures reported in June and is encouraging news for the Trust. The next report on Trust finances will be published at an upcoming public meeting of the Trust board, on 24 September.”

Question: Do you still think it accurate to use in public communications the word “teething” to summarise all problems arising from the go-live when your board reports use the word “significant” to describe some of the difficulties? Does this instil trust in the honesty candidness of the trust’s communications?

Answer: “We acknowledge that the initial problems were characterised as such in our statements early on in the implementation, as this reflected the situation at that time. Barts and The London continues to be open and transparent in discussing the operational challenges concerning CRS. Trust performance reports are published on our website on a quarterly basis, and address CRS as well as all our other areas of operation. We have apologised publicly to patients, GPs and staff for the difficulties they have experienced.”

Excerpts from a finance report to Barts and The London NHS Trust, dated 23 July 2008, on the first three months of 2008/09.

“There are ongoing recording issues arising from the implementation of CRS [Care Records Service] which may impact on activity and associated income. Recommendation – outputs should continue to be validated and workflow issues should be communicated and addressed at the earliest opportunity…

“There remain significant data quality issues with the Trust’s activity and patient treatment activity and income information due to the implementation of CRS. The Trust is working with BT/Cerner to correct these issues in time to ensure that Quarter 1 income can be accurately invoiced. To reflect the high risk around income the Trust has provided £1.5million against the first quarter’s income.

“Inpatient and outpatient activity for Months 1 and 2 have been extracted and uploaded into the SLAM (Service Level Agreement and Monitoring) system. This shows a very significant underperformance against the Trust’s income budgets. There are however a series of known data quality issues, as detailed below, which as they are addressed should improve the reported activity and income position…

“There has been a significant switch from elective to non-elective activity due to staff failing to correctly follow the complex workflows for admitting elective patients. Action is underway to correct these errors for April and May patients and a further exercise will be carried out to correct these errors for June patients. There is evidence that this problem is ongoing and further training will be provided to address this.

“There are significant numbers of outpatient attendances which have not been checked out (signed off) and which have therefore not yet been reflected in the data warehouse or in SLAM. Action is ongoing to correct this.

“There are also known system errors where data which has been entered into CRS has not been reflected in the data warehouse and therefore is missing from SLAM. These issues have caused significant understatement of both inpatient and outpatient activity and income. An action plan has been agreed to correct these issues for retrospective data and BT/Cerner are working on solutions to stop further errors.

“There is some evidence that April activity was reduced due to the implementation issues of CRS. Clinics were reduced in some areas and issues with bookings meant that in some areas the clinics and operating theatres were not operating at their usual capacity. It is therefore possible that even when known data quality issues have been resolved the Trust will have underperformed against its activity plan in April.

“The Trust has agreed that it will supply North East London PCTs with an interim report on commissioned activity for April and May by July 18th. It will then supply a further report on activity and finance for April and May to North East London PCTs by the end of July. This report will need to reflect all April and May activity and give an accurate picture of the financial impact of that activity on North East London PCTs. The significant data quality errors for April and May therefore require resolution by the end of July. 

“Commissioners are likely to want robust activity and finance information for June by the middle of August. All significant data quality errors for Quarter 1 will need to be resolved by then.

“There remains a significant risk that the CRS data quality issues will not be resolved within the timescales given above. The Trust has therefore provided £1.5million against income to date to reflect the ongoing risk.

“As discussed above some of these data quality issues are ongoing. There are plans to correct these errors but the continuation of some of these errors may mean that there is a risk of income loss in future quarters. The Trust is therefore forecasting an underperformance on income of £3m for the year.

“The Trust should have more robust activity information available for Month 4 reporting though it will still be subject to some on going data quality issues…

“Due to ongoing issues with CRS the Trust has been reluctant to action the effect of activity over/under performance until all activity information exported from CRS into SLAM has been validated. Once this is complete, the appropriate financial adjustments will be actioned. As such, the net Directorates positions and forecasts do not include the impact of over/under performance …

“Reserves – the following amounts have been allocated from Central Reserves in Month 3: Connecting for Health – £930k transferred to ICT, non-recurrently, to fund additional temporary staff costs relating to the implementation and subsequent validation of CRS…”

 Links:

Official overview of the London Programme for IT – Powerpoint presentation

Barts delays urgent cancer visits after Care Records Service go-live – IT Projects blog, June 2008 

Barts NPfIT go-live ends up in The Sun – IT Projects blog April 2008

Royal Free considers compensation claim after Cerner implementation – Computer Weekly, Sept 2008

Barnet and Chase Farm Cerner go-live – the facts – IT Projects blog, Aug 2008

 

 

 

 

 

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If I read this article correctly, Barts is forecasting an additional spend of nearly £1M for temporary staff AND an income shortfall of £3M for this year. Which makes the unexpected cost of implementation almost £4M.

Of course these are provisional sums and estimates, which might go either way. Nevertheless these are frightening, direct on-costs of a system implementation. Money that will not be available for patient care.

However, money is not the only issue at stake. When it comes to treating patients, time is generally the predominant factor. For some people, system induced inefficiencies will be vital, in every sense of the word.

So far we have heard much about the programme cost control mitigation [water-tight contracts?] but very little about the true cost of failure. System providers might regard implementation weakness as annoying snags or glitches. To an NHS patient, these failures could be a matter of life or death

I thought the first rule of being in a hole was to stop digging so I genuinely hope that somebody somewhere is looking at the big picture and doing something positive to mitigate the risk of similar massive financial black-holes swallowing the NHS from within itself.

The question must be: is the Barts experience typical or atypical?

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