Long-term NPfIT users lacked confidence in CRS data

Some long-term users of the Cerner Care Records Service – which is due to be rolled out to hospitals across the south of England – have “little confidence in the information generated”, according to an external, independent audit report.

The criticisms by users at Weston Area Health Trust in Weston-super-Mare, North Somerset, are despite nearly two years of intensive remedial work on the Cerner Millennium system.

The difficulties at Weston show that problems arising from an e-records go-live under the NHS’s National Programme for IT [NPfIT] can last years, despite claims by the Department of Health and NHS Connecting for Health that problems with Cerner installations in the south of England are only teething.

The undue length of the problems at Weston and at some other NPfIT “early adopters” may cause concern among some hospital executives because the Cerner Care Records Service is due to be rolled out to all major trusts in London and the south of England.

MPs given impression in 2006 that Weston was satisfied with the NPfIT system 

Weston installed the basic R0 version of the Cerner Care Records Service in July 2006. Weeks after the go-live the Department of Health cited Weston as an example of a satisfied NPfIT site which had learned from problems at Nuffield Orthopaedic Centre, which installed the Cerner system six months earlier.

The Department of Health told the Public Accounts Committee in 2006:

 “We will support the local NHS and ensure the problems are not repeated. Indeed, the Chief Executive of Weston Area Health NHS Trust wrote to us expressing his thanks for our support during the recent deployment there. In particular he thanked us for the support ‘that was provided in a number of ways, including production testing, contract assurance and infrastructure assurance’.”

But nearly two years later, the Audit Commission has, after an annual audit of the 2007/8 accounts and work at Weston, had little positive to say about the Trust’s Cerner Care Records Service.

In a report dated September 2008, the Commission found that the trust has a “significant way to go before it will have a system that is well regarded by its staff”.

Care Records Service “never going to deliver what the NHS needed”

Earlier this year the trust’s Audit and Assurance Committee heard that the Care Records Service – the most important part of the £12.7bn NPfIT – was “never going to deliver what the NHS needed”.

Work to improve the Cerner system at Weston included the installation of version 7.03 of the system in August 2007. This “resolved some of the flaws in the system and has allowed the Trust to start to address reporting problems”, said the Audit Commission which also said:

“Continuing problems with the Cerner system have resulted in work around systems still having to be used. The system is difficult and overly complicated to use, training needs to be improved and users have little confidence in the information generated.”

The Commission carries out annual audits of the accounts and work of some NHS trusts including Weston. It found that the Trust, which includes Weston General Hospital, had gone live before the problems at the Nuffield Orthopaedic Centre had been fixed. Nuffield went live with Cerner Millennium a few days before Christmas 2005.

Not enough time allowed to fix problems  – and too much faith in suppliers

The Audit Commission said that Weston had allowed six months for the problems at Nuffield to be fixed – but this delay proved “insufficient”. Weston’s executives had placed too much faith in the ability of the suppliers, Cerner and Fujitsu, to correct the problems at Nuffield.
Auditors concluded that the problems at Weston “resulted in significant disruption to service deliverability at the Trust”.

Weston Area Health Trust is among 12 NHS hospitals in the south which have installed R0 of Cerner Millennium. Three trusts in London have also installed Cerner as part of the NPfIT but in a form tailored for use in the capital. A further two trusts in London, Homerton and Newham, bought the Cerner system directly from the supplier, outside of the NPfIT.  Most of the trusts have had serious problems.

Audit Commission comments on Weston

The Audit Commission said of Weston:

“The Trust identified that the development of the National Care Records Service (NCRS) was a significant risk to the Trust’s services both in its ability to treat its patients on a day-to-day basis, and to the general administration of the hospital services. This was confirmed by problems experienced at another trust which had adopted the system in January 2006.

“Whilst the [Weston] Trust implemented the system six months later in July 2006 this delay was, with hindsight, insufficient to resolve the outstanding problems with the system. These problems have resulted in significant disruption to service deliverability at the Trust.

“The overall remit of our review was to assess how the Trust has and is managing the business risks associated with the implementation of the NCRS and to identify to what extent the information provided by the Trust can be relied upon for management decision making.

“Our review considered the key project management information and control documentation the Trust used to manage the project to a go live date and beyond. This was supported by a Trust wide survey and interviews with staff involved in the management and usage of the system.

“Overall, the Trust’s processes to project manage the implementation of the NCRS proved insufficient to secure an effective implementation of the system. This was principally due to the failure by the suppliers to deliver a system that was fit for purpose. However; the Trust had placed too much reliance on the suppliers correcting the problems found at the other trust and there were weaknesses in level of testing and documentation of the system.

“The Trust’s staff have responded well to the need to implement compensatory procedures and systems to address operational needs. There has been a need to implement significant workarounds to address system weaknesses and shortcomings. These were intensified by the constant changes to the system undertaken to resolve the problems.

“A significant watershed was the implementation of version 7.03 of the system in August 2007. This has resolved some of the flaws in the system and has allowed the Trust to start to address reporting problems. However, from the user survey conducted as part of this review, the Trust has a significant way to go before it will have a system that is well regarded by its staff. Further investment in training and support will therefore be required to embed the system.

“We have agreed with the Trust that we will undertake a further staff survey in the coming months. Recommendation: The Board should monitor the implementation of the action plan resulting from our review of the implementation of NCRS.”

Weston’s comment to us last week

The trust told Computer Weekly that staff were now more confident “in the use of” the system but the spokesperson did not confirm that staff had more confidence in the system.

The trust’s statement said:

“The Annual Audit letter refers to 2007/08. Earlier this year we upgraded to an improved version of Millennium which has enabled better statutory reporting and more efficient use of the system. The Trust has been working closely with Cerner and Fujitsu staff to make further improvements which have resulted in better data quality and staff are now more confident in the use of the system.”

The spokesperson said the statement was based on “informal staff feedback at present” and that a follow-up survey of staff satisfaction was “currently being undertaken”.


NPfIT harmed by poor communications – IT Projects blog, Dec 2008

Evidence mounts for NPfIT review – Computer Weekly, Nov 2008

World’s largest programme cutting quality corners? – Colin Beveridge November 2008

Department of Health statements to the Public Accounts Committee on Weston are in this 2006 report (Department of Health written evidence to the committee)

Audit Commission – Annual Audit Letter for Weston – September 2008 

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A very interesting article, however who is it that reassures the Board of the Trust implementing Cerner R0 that all previous problems are resolved?

There seems to be an unholy alliance of the supplier,CfH and the Strategic Health Authority operating here!

Good point. There's no individual who's giving the over-optimistic assurance that problems have been solved.

Those working on the programme have a professional interest in giving the impression that all is well. Nobody on the programme is admitting to the existence of any serious problems - and when journalists point them out, at least so that trusts boards can understand what is really happening, officialdom accuses us of lowering morale and being against the NPfIT.

Pretending all is well when it isn't harms the NPfIT - and perhaps patients - much more than any media coverage.

Tony Collins

Homerton - which installed Cerner's Millennium outside NPfIT - appears to have had no problems and be happy with the system.

What is the difference?

And if their implementation was successful but the NPfIT ones have had problems, is this to do with the version of the software or something else?

Rather than NAO saying things are awful (I paraphrase) wouldn't it be more useful to look at what makes the difference between successful and problematic implementations of the same software?

Why am I not surprised?

The Audit Commission report on NHS reporting and recording systems indicated error rates of up to 40% with the systemic falsification of those used for performance measurement being commonplace.

As for security ...

I have to keep track of over around two dozen passwords. Luckily most are static and few access material of any serious value: to me or anyone else.

A typical medical consultant, servicing a number of NHS and other hospitals might have to keep track of over 50, each changing every three months with re-use not permitted, and those who might be able to help with lost passwords commonly working a 9 - 5 day while they are on call. Little black books and post-it notes are the only option if you are not to resort to the ultimate sin of shared pass-words - when your professional indemnity insurance (and thus your future employability let alone your reputation) depends on what is done in your name.

The growing gulf between medical practitioner and the Alice in Wonderland world of NHS management makes such a crisis of confidence inevitable.

Even the supposed "success" of on-line x-rays comes at a considerable price: when the system time out every 20 minutes during an eight hour operation and you have to log back, let alone when the network goes does down (at least once or twice a month in most hospitals, albeit usually out of hours so "only" those on call are affected so it does not show in the "all-important" management performance stats) or the low resolution of the screeen fails to show up a hair line fracture etc. etc.

The message I was asked to pass on to you from those at the medical party I attended just before Christmas was "Keep up the good word Tony - and don't fall ill or have an accident - lest you "accidentally" fall through the cracks in the system."