Confidential NHS paper on the health of the National Programme for IT

Published exclusively on this blog is a confidential NHS paper on the £12.4bn National Programme for IT [NPfIT].

The paper is important because it is an objective analysis of the strengths and weaknesses of the NPfIT by senior IT executives on the front line. Its authors work for the Leeds Teaching Hospitals NHS Trust, which is the largest NHS trust in the UK.


At Computer Weekly’s request, the Leeds Teaching Hospitals NHS Trust has kindly allowed this blog to make the paper available.

First I have reproduced some excerpts from the paper. Second I comment on some specific parts of it. Then the paper is reproduced in full.

Excerpts from the Leeds paper:

“THE LEEDS TEACHING HOSPITALS NHS TRUST

TRUST BOARD – 5 OCTOBER 2006

“Update on Connecting for Health (CFH) and the national IT programme (NPfIT)

“The delivery of new systems to the NHS via Connecting for Health has been split into national and local elements, with the later focused on five geographic ‘clusters’ led by principle-contractor “Local Service Providers” (LSPs). Some key elements of national delivery have progressed well, notably: electronic prescription transfer to pharmacies; Choose and Book (GP system); the new national broadband network (“N3”); national software licence deals (e.g. Microsoft, Oracle and Novell); a national patient demographic and NHS number tracing database; and systems to support Payment by Results.

“However, there has been slow progress with electronic patient records and the national care record – despite shrinkage to its scope so that it currently essentially covers only allergies and recent GP prescribing.

“Local system provision has varied across the country. The implementation of GP systems has generally been a success, including in Leeds. Good progress has also been made with Community and Child Health systems. However, little has been achieved in providing strategic systems for secondary care (acute and mental health) – especially in the North East and East of England (where Accenture is the LSP). In particular, Patient Administration Systems replacement projects for several West Yorkshire Trusts are now running at least 2 years late.

“Other than PACS (digital Radiology), there are no strategic clinical systems on offer in Yorkshire and the Humber. Connecting for Health is increasingly announcing ad hoc developments, e.g. blood tracking and oncology e-prescribing systems, not least as a means of increasing clinician engagement in the national programme. However, such initiatives are invariably under-funded and over-ambitious.

“The costs of the national IT programme at the end of the 10-year implementation, initially estimated as £6.2bn, are now thought to be closer to £12.4bn, once NHS costs are accounted for.

“Impact of late delivery and increased costs

“Much of the cost of implementing Connecting for Health systems – including change management, process redesign, data conversion and training – will fall to the service itself. Pressure on central Department of Health budgets has cut Connecting for Health resources and increased cost transference to the NHS.

“The lack of new Patient Administration Systems means that many Trusts (and Primary Care Trusts) will be unable to meet national e-booking targets and will struggle to meet other national policy requirements. Trusts, including Bradford, Airedale and mid-Yorkshire, are increasingly looking to procure new Patient Administration Systems outside the national programme.

“Connecting for Health has concentrated the IT supplier market by creating several large contractor conglomerates; smaller, often more innovative companies have struggled to survive. LSPs and their sub-contractors are not keeping up with the scale and complexity of the national programme.

“Existing supplier offerings are obsolescent, as major policy initiatives – notably the 18 weeks waiting times target and Choose and Book – arrive with inadequate Department of Health allowance for the significant informatics and associated change management consequences.

“Connecting for Health made pre-payments last year against existing Trust contracts – including The Leeds Teaching Hospitals NHS Trust’s contract with iSoft. The Leeds Teaching Hospitals NHS Trust formally registered concerns that this had been done without regard to supplier performance and the associated withholding of payments; this has been addressed by Connecting for Health this year …

“The Leeds Teaching Hospitals NHS Trust’ is well advanced with the delivery of its Informatics Strategy. Our approach is consistent with – but not reliant upon delivery of – the national strategy… We are, however, being affected by the Connecting for Health-induced changes to the NHS IT market.

“For example, when the Trust recently wished to explore extending its existing Picture Archiving and Communications contract to provide a Trust-wide solution, our supplier would only do business through the Connecting for Health and LSP route. Reduced supplier competition will almost certainly cost the Trust more in the longer term.

“Conclusions

“Connecting for Health has significantly changed the face of NHS informatics. While much has been achieved nationally, and in primary care, progress is slow for the acute sector. The Trust has to work within this new landscape but must maintain its self-sufficiency to guard against the various risks.

My comments on specific parts of the paper:

I have not seen it stated so clearly in an NHS board paper that there has been shrinkage in the scope of the national electronic patient record. No announcement has been made on scaling back of the original plan. The electronic patient record is the chief objective of the £12.4bn NPfIT programme.

Innovative systems are welcome but if such initiatives are under-funded and over-ambitious this suggests they are high risk and may fail, in which case this underlines the need for more accountability and visibility, ideally in the form of an independent, published review.

Also I have not seen it stated so clearly before in any trust board paper that the pressure on the budgets of the Department of Health has increased costs to the NHS.

If more costs are transferred to the NHS from the centre, this could make the local implementations unaffordable in the medium and long term. Again, it’s a cause for concern, and a further reason for an independent review of the programme.

The paper also claims that Local Service Providers and their sub-contractors are not keeping up with the scale and complexity of the national programme. If this is true, and the indications are that it may be, this could cause the programme to fail and again highlights the need for an urgent review. One answer would be to reduce the scale and complexity of the NPfIT – but could this be done without compromising the original objectives of the programme?

Again, if the Leeds paper is right, and major policy initiatives such as a target for an 18-week waiting times target and Choose and Book arrive with inadequate allowance for the significant informatics and associated change management consequences, there could be serious implications. Lack of planning over changes in working practices are cited by the National Audit Office as contributory factors in project failures such as the Libra scheme for magistrates’ courts.

The paper says it is significant that, for the North-East of England, Connecting for Health does not have a roadmap for delivering an electronic care record; nonetheless, the Trust continues to make tangible progress.

My comment: It is more than four years since the national programme was launched and nearly three years since contracts worth £6.2bn were signed. One would have expected clear plans for an electronic health record to have been finalised long before now.

Nobody reading the Leeds paper should continue to have a Panglossian view of the national programme.

**

The paper is reproduced here, with the permission of Leeds Teaching Hospitals NHS Trust.

THE LEEDS TEACHING HOSPITALS NHS TRUST

TRUST BOARD – 5 OCTOBER 2006

Update on Connecting for Health (CFH) and the national IT programme (NPfIT)

1. The delivery of new systems to the NHS via CFH has been split into national and local elements, with the later focused on five geographic ‘clusters’ led by principle-contractor “Local Service Providers” (LSPs). Some key elements of national delivery have progressed well, notably: electronic prescription transfer to pharmacies; Choose and Book (GP system); the new national broadband network (“N3”); national software licence deals (e.g. Microsoft, Oracle and Novell); a national patient demographic and NHS number tracing database; and systems to support Payment by Results.

2. However, there has been slow progress with electronic patient records and the national care record – despite shrinkage to its scope so that it currently essentially covers only allergies and recent GP prescribing.

3. Local system provision has varied across the country. The implementation of GP systems has generally been a success, including in Leeds. Good progress has also been made with Community and Child Health systems. However, little has been achieved in providing strategic systems for secondary care (acute and mental health) – especially in the North East and East of England (where Accenture is the LSP). In particular, PAS replacement projects for several West Yorkshire Trusts are now running at least 2 years late.

4. Other than PACS (digital Radiology), there are no strategic clinical systems on offer in Yorkshire and the Humber. CFH is increasingly announcing ad hoc developments, e.g. blood tracking and oncology e-prescribing systems, not least as a means of increasing clinician engagement in the national programme. However, such initiatives are invariably under-funded and over-ambitious.

5. The costs of the national IT programme at the end of the 10-year implementation, initially estimated as £6.2bn, are now thought to be closer to £12.4bn, once NHS costs are accounted for.

Impact of late delivery and increased costs

6. The lack of progress, especially in secondary care, and increasing ‘true’ costs to the NHS have been the subject of intense media interest and a formal review by the National Audit Office. A long-awaited NAO report was published in June amid suggestions – including from members of the Parliamentary Public Accounts Committee – that criticisms had been toned down. A further NAO review has just been announced.

7. Much of the cost of implementing CFH systems – including change management, process redesign, data conversion and training – will fall to the service itself. Pressure on central DH budgets has cut CFH resources and increased cost transference to the NHS.

8. The lack of new PAS means that many Trusts (and PCTs) will be unable to meet national e-booking targets and will struggle to meet other national policy requirements. Trusts, including Bradford, Airedale and mid-Yorkshire, are increasingly looking to procure new PAS outside the national programme.

9. CFH has concentrated the IT supplier market by creating several large contractor conglomerates; smaller, often more innovative companies have struggled to survive. LSPs and their sub-contractors are not keeping up with the scale and complexity of the national programme. Existing supplier offerings are obsolescent, as major policy initiatives – notably the 18 weeks waiting times target and Choose and Book – arrive with inadequate DH allowance for the significant informatics and associated change management consequences.

10. CFH contracts, paying suppliers by results, have resulted in substantial losses of income for some LSPs (e.g. Accenture) and their sub-contractors (e.g. iSoft). Accenture has recently written off £260m against its two major CFH contracts. It has also now reportedly stopped acute sector systems implementations, including withdrawing support part way through a troubled PAS implementation at Scarborough Trust. There is open speculation about iSoft’s survival and Accenture’s possible withdrawal from the national programme.

11. CFH made pre-payments last year against existing Trust contracts – including LTHT’s contract with iSoft. LTHT formally registered concerns that this had been done without regard to supplier performance and the associated withholding of payments; this has been addressed by CFH this year. The media have picked up on this issue and its governance implications.

12. The withdrawal of, say, Accenture from the national programme would be significant but any gap would be filled by another existing LSP: such a change has already happened in London. More critical for LTHT would be if iSoft ceased trading (see below).

Impact on LTHT

13. LTHT is well advanced with the delivery of its Informatics Strategy. Our approach is consistent with – but not reliant upon delivery of – the national strategy. Numerous departmental systems have been rationalised and integrated; and true clinical systems are being implemented, notably the new Clinical Information System and PACS – the first LTHT implementation of an NPfIT system. A report on the Trust’s progress is at Annex A.

14. We are, however, being affected by the CFH-induced changes to the NHS IT market. For example, when the Trust recently wished to explore extending its existing PACS contract to provide a Trust-wide solution, our supplier would only do business through the CFH and LSP route. Reduced supplier competition will almost certainly cost the Trust more in the longer term.

15. iSoft is a major supplier of systems to LTHT (PAS, Theatres, Pathology, Radiology) and the wider NHS. The company has gone from being a market-leader, with a large user base, to a company with open financial problems due to its inability to meet CFH demands and whose accounting practices are under investigation by the Financial Services Authority. Given iSoft’s assets and NHS user-base it is very likely that the company would be taken over before any complete collapse; indeed, it is difficult to conceive that CFH could allow otherwise. While Trust iSoft systems will continue to function operationally, there could be issues on the responsiveness of support and development, and possibly costs.

Issues and Risks

• Personnel issues: Agenda for Change and other national HR polices are constraining the development of 24×7 technical support arrangements. Recruitment and retention of technical specialists is becoming an issue, with strong competition from the Leeds-based CFH, Information Centre for Health and Social Care and DH, as well as Accenture and other private sector bodies.

• Technical capacity: ASR and Wellcome Wing service moves, and the NOW are currently all competing for limited technical networks, telephony and IT technical resources; there is a also a 9-12 month waiting list for new IT systems.

• CMT capacity: new systems require disciplined use. Data quality remains a serious issue for financial, access and clinical governance.

• External information demands: the burden of DH, Healthcare Commission and audit requirements continue to spiral unchecked. New demands in relation to the 18 weeks waiting times target are especially onerous.

• 18 weeks waiting times target: the “rules” continue to change and DH is still focused on central monitoring rather than on systems to support delivery. CFH is not expected to deliver any systems solutions before target comes into force in 2008.

• Data Protection/Caldicott: there are significant information governance issues for new clinical pathways crossing organizational and professional boundaries.

Conclusions

16. CFH has significantly changed the face of NHS informatics. While much has been achieved nationally, and in primary care, progress is slow for the acute sector. The Trust has to work within this new landscape but must maintain its self-sufficiency to guard against the various risks.

17. It is significant that for the North-East of England, CFH does not have a roadmap for delivering an electronic care record; nonetheless, the Trust continues to make tangible progress. We have very positive and constructive relationships with the SHA IT team, who share our perspective.

18. The Board is asked to note the significant changes taking place across NHS informatics and progress with the LTHT Informatics Strategy.

Brian Derry Alastair Cartwright

Director of Informatics Deputy Director of Informatics

September 2006

Annex A: Trust Informatics Strategy Update

1. Trust-wide Informatics facilities supporting clinicians and managers

• Accident and Emergency: new Trust-wide A&E management system, with links to clinical patient monitoring devices

• Clinical Audit: multi-specialty system for local outcome measurement, research, pathway management being rolled out, starting with Orthopaedics in October

• Theatres: Trust-wide theatre management and booking system being implemented.

• Radiology: business case approved and implementation commencing of a Trust-wide Picture Archiving and Communications System (PACS) and Radiology Information System.

• Choose and Book: implementation of the national patient choice system and preparation for e-booking from GP surgeries.

• Leeds Dental Institute: replacement PAS on track for the autumn.

• Pagers: digital paging system being implemented across the Trust; pagers for oncology patients introduced.

• Results: GP access to e-results being rolled out. GP results ordering being piloted.

• Retinopathy: system implemented for capturing and managing digital retinopathy.

• CMT income: Service Level Agreements System enhanced to improve income recovery and to cover private patients.

2. Efficient processes and a trained workforce

• Patient pathway management: outpatient referral registration and booking centralised. Redesigning patient admin processes for pre-operative assessment, and for outpatient clinic, inpatient/Day Case waiting list and booking management. “Copying Letters to Patients” model agreed and being rolled out.

• Staff Libraries: LTHT achieved national accreditation. Trust staff can now use all Leeds NHS libraries. The Leeds-wide library catalogue will be available over the Internet. Plans progressing with Leeds University for joint library service at SJUH.

• e-Learning: implementations include budget management, hand hygiene, cannulation, patient administration and emergency medicine (winning a national award).

3. Infrastructure

• Major building schemes: IT, data networks and telephony services have supported some 300 Acute Service Reconfiguration schemes. Substantial planning and implementation work for the New Oncology Wing is underway.

• Network improvements: LGI network upgraded to the latest high-speed technology. SJUH upgrade completed apart from the old Lincoln Wing. Cookridge network made more robust and a high speed link installed to SJUH to enable remote medical equipment testing.

• Medical Records: 20,000 Gynaecology amalgamated to the single Trust folder in the last 6 months. Paediatric casenotes next, leading ultimately to a single set of notes for each patient. Electronic archiving of 150,000 health records.

• Payment by Results: further enhancements to LTHT service agreements system and links established to national PBR database (the “Secondary Uses Service).

• New national network (N3); LTHT now linked to national NHS ‘broadband’ facility, “N3”. This is providing high speed links to Wharfedale and Seacroft.

• Telephones: PABX being upgraded to increase capacity and enable use of new automatic call handling technology.

4. Use of information

• Clinical Coding: 100% coding completeness for the first quarter of 2006/7 (80% in 2004/5 and 95% in 2005/6). Depth of coding (average number of diagnoses per episode) up by 23% since March 2004. 9 coders now professionally accredited via the national exam.

• Modeling and analysis:

• Making Leeds Better – comprehensive affordability model developed.

• Change Programme – extensive support provided to PWC/Task Forces.

• Capacity planning – automated models developed to support CMT capacity planning, for service management and Choose and Book.

• Consultant appraisal – detailed comparative information produced for some 500 consultants and is on the Trust intranet.

• Market analysis – initial competitor and patient flow analyses produced.

5. Professional management and support services

• Major operational services improved, notably the Referral and Booking Service, information processing and analysis, medical records libraries, IT Help Desk, IT training, technical support and system management.

• A review of the management arrangements for CMT IT systems and staff is commencing, in line with an audit report by Robson Rhodes.

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