There’s something extraordinary about the IT-related difficulties at Milton Keynes General Hospital.
We are not so surprised at the allegations made by 79 doctors, nurses and secretaries who have signed a letter criticising a Care Records Service system installed under the NHS’s National Programme for IT [NPfIT]. The system is based on “Millennium” software from US healthcare IT supplier Cerner. The same basic system is due to be installed at NHS sites across Southern England.
According to a local paper, MK News, a doctor at Milton Keynes General Hospital, Richard Butterworth, told the trust’s board in March 2007 that the new system has proved a nightmare in outpatients where there were no case notes for 40 patients. One of the main justifications for the £12.4bn NPfIT is that lost case notes are supposed to be a thing of the past.
We’re not so surprised either that the trust’s finance director Rob Baird told his board that the system’s users trained on software that was different to the product installed. This was a complaint made by some delegates from other trusts at the Healthcare 2007 IT conference at Harrogate.
We are surprised, however, that the service at Milton Keynes General Hospital deteriorated to the extent that end-users signed a letter calling for it to be withdrawn. They do not want the system installed elsewhere and they suggest it may be unredeemable.
It could be that the users are going through the pain of change and are over-reacting to the sort of software glitches that always irritate people when complex new systems go live.
On the other hand it’s clear that clinical care has been disrupted, the results of which we do not even know. Baird did not appear to know the full implications. He said: “The service to our patients in some areas has diminished in this period. At the moment we have quite a confused situation and it’s like everyone had started a new job.”
At Oxford’s Nuffield Orthopaedic Centre staff filed a “Serious Untoward Incident” after a Care Records Service based on Cerner’s Millennium system went live in December 2006. Treatment for some patients was delayed and there were allegations of lost patient records. Hospital executives were concerned that the shortcomings of the new system had reduced the safety of patients; and the trust’s board blamed system difficulties for Nuffield’s loss of status as a top-performing hospital.
Milton Keynes and Nuffield have been among the first five sites to go live with the NPfIT Care Records Service. There have been complaints from other trusts. The Cerner system is said to be a good US-built product but it’s proving difficult to anglicise it. Cerner has products and user demands in other countries and it may be that there’s only so many people and so much money that can be allocated to adapting its Millennium product for the UK’s needs.
Cerner’s predecessor, US-based IDX, pulled out of the NPfIT – NHS staff say IDX wasn’t sacked but decided to withdraw – as it fought with the challenge of anglicising its product to meet the needs of the national programme.
We have also learned that before Milton Keynes went live, another Buckinghamshire trust that had installed the Cerner-based Care Records Service, had warned that the performance of the system was giving rise to such concern that it was being considered as a possible showstopper. Indeed the Buckinghamshire trust had warned, portentously as it happens, about the problems of going live at Milton Keynes. We do not know if the warning was passed on.
So are the lessons from early implementations of the Care Records Service really being learned? Why are they not published? And if these lessons are being learned, why did Milton Keynes go live before it was ready to?
We wonder whether trusts, which are under pressure to replace old technology and in practice can buy only NPfIT systems, are being put in the indefensible position of having potentially to sacrifice the quality of patient care or treatment to test in live use systems that have not been checked thoroughly first.
But none of this is as extraordinary as the policy decision at Milton Keynes General Hospital to remain silent about the letter from the 79 staff, to remain silent about the missing case notes, and to say nothing about the allegations that the system is awkward, unaccommodating and should be withdrawn. Instead the hospital’s spokesman is referring media inquiries to an employee at public relations specialist Bell Pottinger.
Bell Pottinger has a particular expertise in crisis management. It is working for NHS Connecting for Health, an agency that is running the NPfIT.
It may be the preferred modus operandi of Bell Pottinger to ensure that Connecting for Health, and not the hospital’s spokespeople, answers all external questions on the problems at Milton Keynes.
But it is by no means certain that the views of Connecting for Health and those of the trust will coincide.
We asked the trust’s media representative: can Connecting for Health’s spokesman speak for the hospital?
The spokesman replied: “No he can’t, no.”
We then asked: could we have a statement from the trust as to where you are with your patients, lost notes, reporting ability, rather than looking at it from a Connecting for Health point of view, which is from a distance?
“No – we are coordinating this [media inquiries] through one point. The trust’s position is reflected in whatever they [Connecting for Health] are saying.
Does Connecting for Health know what is going on in the trust?
“We talk to them,” replied the trust’s spokesman.
They are an organisation you may well have disagreements with?
“We may well do, yes.”
“Can they therefore speak for you?”
“I am not the person to answer that question. It’s a policy decision.”
The statement from Connecting for Health answers none of the specific concerns of doctors nurses and other end-users, as expressed in the letter. And it is silent on Dr Butterworth’s statement to the Milton Keynes board that records had gone missing.
Instead Connecting for Health’s comment is about the IT only:
“Milton Keynes Trust identified some unacceptable problems with the newly installed system and raised these initially with Fujitsu (the supplier). The trust first contacted NHS Connecting for Health (NHS CFH) senior management on Friday 30th March 2007. We responded immediately and met with the Trust and the SHA on Monday (2 April).
“It is clear that there are some issues at the Trust which need immediate attention and we share their disappointment that they have experienced these problems. Ensuring this is resolved and normal service is resumed is a top priority. We have assembled a dedicated team to work with Fujitsu, the Trust and the Strategic Health Authority to resolve the problems as quickly as possible. This team will continue to work together until the system is working to the satisfaction of the doctors and other staff at the Trust.
“Like the doctors and staff at the Trust, we want to ensure that the system starts to work smoothly as quickly as possible so that disruption can be minimised and everyone concerned can start to benefit as a result.
“There will be no payments made to Fujitsu until the system is working satisfactorily. This is standard practice.
“The new system at Milton Keynes replaces a 20 year old Patient Administration System and some clinical functionality. We are confident that when the current issues are resolved, it will help to deliver better, quicker, safer care for patients.”
Fujitsu emerges from the difficulties with some credit. It is described in the letter from doctors, nurses and others at the trust as “heroic”. Fujitsu’s statement on the difficulties concedes that the difficulties have had a “high impact” on the hospital’s work.
“The system which has been installed by Fujitsu at Milton Keynes is the foundation release of the Cerner Millennium software. Its purpose is to provide an electronic record of a patient’s medical history and treatment and to support hospital administration functions. Milton Keynes is the fifth organisation in the South of England to go live with the new system.
“It is normal for new IT systems to have a bedding down period where issues are dealt with before it becomes a part of everyday working life. However, it is clear that in this case there have been some high impact problems and we regret any inconvenience that this has caused to patients and clinicians.
“There were 16 issues that needed addressing after the “go-live” date. Of these 16, six were identified as being of greater priority. They included case note tracking, re-scheduling out-patients and missing data fields. Five of the six, have been resolved and the one remaining is due to be resolved by the middle of April. Of the lower priority issues, three remain under investigation and an on-site team from Fujitsu and Cerner are currently working with the Trust to resolve them.
“We continue to work closely with NHS Connecting for Health to rectify any issues as soon as possible. There are lessons to be learned from this particular deployment and we will ensure that these are taken on board for the future.”
One of the lessons is about having good communications at a time of crisis. The mouthpiece should be a representative of the organisation in trouble not a totally different government agency that operates at a distance to the one in difficulty. Indeed NHS Connecting for Health could be at odds with Milton Keynes General Hospital.
A further point is that NHS Connecting for Health is perceived to be a poor communicator.
More than two years ago, in November 2004, John Clayton, Programme Manager at Southern Cambridgeshire National Programme for IT, wrote a report that described some of the major problems that could prevent the programme achieving the objectives set for it. One of these was “perceived NPfIT secrecy and limited communication”.
By January 2005, the British Computer Society said in a statement: “NPfIT is unnecessarily secretive … Secrecy actually damages NPfIT by encouraging the substitution of rumours for hard news. If corrective measures are not taken, NPfIT will find itself spending a disproportionate amount of its time fire fighting and becoming even less likely to achieve successful outcomes from its huge investment.”
By December 2006 the British Computer Society, which has thousands of members working in support of the frontline care of patients, published a paper that was largely positive about the NPfIT but said of communications that political pressure constrains the NPfIT to “deny problems and to defend the indefensible.”
Though they support the idea of a shared patient record, many clinicians are uncertain whether, at a cost of £12.4bn, the programme can be justified. And today, as in 2002 when the programme was launched, there are still more questions than answers. There is also a perception that bad news is being heavily managed.
The success of the programme hinges on the support of doctors, nurses and NHS trusts. That is why officials at the Department should be trying to do all they can to build credibility for the programme and the way it is being handled.
The control of information over the difficulties at Milton Keynes and other “early adopter” sites will deepen distrust and cynicism. If clinicians continue to believe that bad news is being slickly managed, they may be predisposed to resent NPfIT systems. And that could be disastrous for the programme.
Letter from 79 doctors, nurses and secretaries – here
Interesting comments on E-Health Insider on the letter – here
Milton Keynes goes live with elecronic records – here
British Computer Society paper – here