Below is the result of my interview with Brian James, Chief Executive of Rotherham NHS Foundation Trust, which is shortly to buy its main hospital e-record systems outside of the NHS’s £12.7bn National Programme for IT [NPfIT].
James answered all my questions with an openness which is rare in the NHS.
Background to the interview.
The Rotherham NHS Foundation Trust Health Informatics Strategy 2006 – 2011 speaks to the importance of electronic health records. It says:
“The primacy of the clinical record is acknowledged, and with this the importance of clinical ownership of the quality of that record from which all other information is derived – if this is incorrect or incomplete then all other information derived from it for whatever purpose is compromised.”
Before settling its IT strategy, the trust did what Downing Street and the Department of Health didn’t do before embarking on the NPfIT: it asked managers and “key clinical staff” what they wanted from IT. Questions included:
– What do you need from IT and Information to achieve your key service objectives?
– Do you believe it would be worth investing in IT and Information additionally if it could achieve the above – i.e. do you think there is an economic case for doing so?
– Do you think clinical staff should be more involved in the IT and Information strategy and would you support their time required to be involved?
Rotherham’s main system is McKesson’s Totalcare. The trust had decided to replace this patient administration system via NHS Connecting for Health during the financial year 2006/7. This did not happen because the software was not ready.
Meanwhile the McKesson contract was renegotiated nationally. One result, says the trust, is that its PAS hardware will have to be replaced so that the supplier can support its software for longer than planned. The trust’s board says of the delays in the supply of the NPfIT Lorenzo system from local service provider CSC:
“In effect the existing systems of hospitals must live past their intended operating lifecycle.” It adds that the delays have “forced trusts to consider tactical alternatives to deliver much needed automation or improved efficiency”.
Even so, Rotherham says it is committed to the NPfIT in the long term because national systems [note use of future tense]:
– will be free of service charge as far as it understands
– will be to national standards for information integration
– will be upgraded to accommodate central NHS requirements and policy changes
– will be consistent across clinical networks
– will allow greater integration across communities and pathways
Since Brian James joined Rotherham as chief executive nearly four years ago, the trust’s ratings of fair for quality and good for resources have risen to excellent.
James said one fundamental change was giving doctors genuine management roles. In each specialty doctors are in charge of all their staff and budgets and told they can reinvest a large chunk of any surplus. Most executive directors are doctors.
In his interview, James said the trust has gone out to tender for new systems outside of the National Programme for IT [NPfIT], for several reasons.
“Perhaps the most pressing one is that we have been given advice by Mckesson, the current provider of our PAS [patient administration system], that they intend to withdraw the product that we are using.
“They intend to do this by 2010. Even if we could get an extension to that, which we believe would be possible for a short while, it’s our view that this presented too big a risk to this organisation. Therefore we needed to move outside the existing programme that is supposed to provide us with the CSC Lorenzo system in this area.
“We have been unable to get any firm dates for the delivery of Lorenzo. We did as much investigation as we felt practical as to whether it would be deliverable in a form that would be acceptable to us by 2010 and our assessment was that it would be possible but looked unlikely.”
What do you mean by acceptable?
As a full PAS?
“Yes – and the rest. Our business assessment of our needs has identified the fact that we need quite a wide range of systems for this hospital, really because of the uncertainty around the delivery of the Lorenzo product, and therefore the uncertainty about all of the additional systems that we would need to attach to that product, even if supported by the LSP [local service provider], it just left us with, in our view, too big a risk for us to absorb.”
What did CSC [the local service provider and supplier of Lorenzo] say about your decision not to buy a PAS from them?
“We are not dealing with CSC. We are dealing through the Strategic Health Authority [Yorkshire and Humber] who are active as the customer for the service. Although we have had dealings with the SHA they can’t give us any guarantees [on the delivery of Lorenzo].”
What does the SHA say – that if you wait a bit longer they’ll give you a guarantee?
“We have been getting that kind of comment now for quite a few years. We were unable to elicit from them an absolute definite on delivery, in time for us to be able to make a different decision. We knew that if we couldn’t get an answer on this before about March  we could not afford to wait any longer before commencing an alternative course of action which would be an external procurement.”
Have you had any assurances since March 2008?
So the position with Rotherham is that you must pay for whatever PAS you choose whereas it would be free from NPfIT but no guarantee it will arrive?
“That sums it up correctly. We have also done an assessment of the business and financial risks to us. We are quite keen to get the benefits of the system quickly. We want to move to paperless as quickly as possible.
“In all of our discussions with potential suppliers we have been very clear that we will need a system that is fully EPR/spine compliant. We have never gone away from the fundamentals of the national programme in terms of compliance required for connectivity. We have built that into our specification. We see this as a necessary step for us although who knows what will happen longer term.
“If Lorenzo does produce something that’s as good as or better than the systems we are looking at, that may give us a future direction of travel. On that basis we probably acknowledge that this [non-NPfIT choice] may be an interim system. But if it is , it may well be one that’s interim for a good eight years or so. For us that is an investment worth making.”
Have you had any warning from the SHA that if you don’t buy from CSC, your local service provider, other trusts may have to pay more for Lorenzo? [The Department of Health has given CSC and the other local service provider BT a contractual promise of compensation if trusts fail to deploy their systems.]
“No. They [the SHA] told us we would probably have to pay more. We would have to pay for the system they would have given us (in addition to anything we buy).”
Does your business case allow for paying for two systems given all the business risks?
“It would still from a financial perspective pay us to do that. But we have agreed that we are progressing this as an interim solution because as far as we are concerned we have a burning platform on our hands and we must do something.
“In taking that interim system clearly we don’t want to have to replace it very quickly. So we have advised the health authority that we would recognise we would need to go to the back of the national programme, or be scheduled for the tail end of the national programme roll-out of Lorenzo if that’s what is going to happen. That’s at least eight years away where we are now.”
James said that as Rotherham is buying an interim system it should not have to pay for Lorenzo as well. I asked whether the SHA has accepted that whatever Rotherham chooses will be an interim system.
“They have accepted that as an argument. There seems to be an acknowledgement from the centre that some organisations are going to need to implement interim systems and we are certainly one of those.
“We are progressing along that route. I am sure some others will be in the same position. What solutions they may pursue may not go as far as we have done. They may look to see whether there is another PAS that can be provided in some way via the national programme but we felt it was in our best interests to go for a fully-integrated EPR at this stage rather than try and do short-term fixes.”
Brian James – short biography.
Appointed Chief Executive of Rotherham General Hospitals NHS Trust in February 2005, and led the organisation through its successful application to become a foundation trust.
In 1993 he was at Darlington Memorial Hospital in County Durham, in charge of Strategy, Business Development, IM&T and all operational and clinical services. This involved going live with one of three national IM&T pilots of Hospital Information Support Systems. He has a Masters in Health Information Management.
Foundation trusts tender outside of the NPfIT – E-Health Insider
Department of Health threatens hospitals bypassing the NPfIT – Computer Weekly
Newcastle’s break-away foundation trust: “NPfIT was taking forever” – on website of Richard Bacon MP
NHS head defends major IT delays – Silicom.com