When Computer Weekly began researching the cause of duplicate patient records at Manchester we contacted one of the trusts involved, the University Hospital of South Manchester NHS Foundation Trust.
The immediate reaction of a spokeswoman for the trust was to say that she had received a note about the incident a few days earlier from Connecting for Health, which runs the National Programme for IT [NPfIT].
“I am looking at it now,” she said. “It is saying: ‘if trusts have any press inquiries regarding the GM [Greater Manchester] Incident they should contact the Connecting for Health press office.”
The note was dated 27 April 2007, several days before Computer Weekly contacted the trust. It seemed, therefore, that neither Connecting for Health nor the trust had issued any statement on the problem of duplicate records in Greater Manchester. They were prepared, however, to make a statement if a journalist rang. This may appear at first to be effective crisis management but it’s not a good way to disseminate lessons.
We asked Connecting for Health whether it had asked some trusts not to comment on the Greater Manchester incident. An NHS CfH spokeswoman did not go as far as to deny categorically that the agency had approached trusts. She said that she (personally) was not aware of any “instructions” to trusts.
Computer Weekly also asked Connecting for Health whether it publishes details of its major incidents, of which there were around 200 in a four-month period between October 2006 and the end of January 2007. Connecting for Health says it does publish details. But we cannot find any evidence of publication.
We had asked Connecting for Health: “Isn’t there a case for Connecting for Health publishing the severity one and two incidents and the lessons learnt from them so that other trusts could gain from adversity?”
It replied: “Yes, we do this already. Details of all Higher Severity Service Incidents are already published throughout NHS Connecting for Health with the intention that these are then cascaded as appropriate to the wider NHS in order to provide the ability to identify trends or to pre-empt similar incidents occurring in other areas.
“In addition, analysis of Higher Severity Service Incidents and any underlying problems is undertaken by NHS Connecting for Health staff. In conjunction with suppliers, work-around, known error and root cause analysis information is circulated in order to help prevent re-occurrence of incidents or to mitigate potential risks to the live service.
“NHS Connecting for Health takes any and all opportunities to share lessons learnt. Every Higher Severity Service Incident is thoroughly reviewed after the event and any findings are fed into all affected processes and procedures. NHS Connecting for Health also promotes and supports a number of user groups to share best practice, common experience and lessons learnt.”
Since asking NHS Connecting for Health where it publishes details of its severity one and two incidents, we’ve heard nothing.
If the government seeks to control information on troubled go-lives of NPfIT systems, the likelihood is that it will deny instinctively that patient safety is ever at risk from implementations of national systems.
If government ministers do not feel any compulsion to tell the truth over NPfIT implementations, that is they do not feel any need to make public any serious incident arising from an NPfIT implementation, this lack of accountability could in itself present a danger to patients – a threat compounded by the absence of regulatory supervision of patient safety in the wake of NPfIT implementations.
With pressure from Whitehall for many more national systems to go live, it’s possible that software may be installed without having been thoroughly tested first.
If patches and releases are not well designed, patients may become guinea pigs for experimental implementations in which lessons are learned in an impromptu way.
It’s hardly a good strategy for winning the hearts and minds of clinicians.