NPfIT go-live at Barnet and Chase Farm - the facts

Are the effects on patients of NPfIT go-lives merely “teething”?

“All the risks are falling on patients,” says Shadow Health spokesman 

Whenever the results of NPfIT go-lives are highlighted in the media, the official line is that all difficulties are teething.  Teething implies short-term, inconsequential pain. Barnet and Chase Farm Hospitals NHS Trust went live with the Cerner R0 Millennium Care Records Service in July 2007 and is still not over the difficulties according to board papers dated July 2008.

Below we publish verbatim excerpts from some of the trust’s board papers, and a paper from the local primary care trust at Enfield.

Aside from the possible effects on patients of cancelled operations, delayed treatments and appointments which were temporarily lost, there have been long-term financial consequences of the go-live.  This is from a paper, which is dated July 2008, to the trust’s board:

“… The Trust faces an extremely serious situation and needs to take immediate action. Both income and expenditure are out of line with the budget and the risk to achieving the break-even target has increased month on month. It remains too early to draw absolute conclusions at this stage. The income figures are still subject to final confirmation as a result of issues regarding data quality and completeness.”

The paper adds that the ” Patient Administration System issues in 07/08 have certainly caused a significant loss of activity and whilst the issues which have resulted in patients going to alternative providers are mostly resolved, the loss of outpatient activity and the subsequent conversion into inpatients is knocking into 08/09…”

Barnet and Chase Farm Hospitals NHS Trust agreed to install the Care Records Service in good faith, under some political pressure, and in the knowledge that the system, though not its installation, would be “free”. The board did not realise how difficult it would prove marrying the complexities of the system with the way doctors, nurses and clerical staff work. There were also bugs.

Most of the papers to the trust board are dated last month but there’s one from March and another from May 2008. Asterisks in the excerpts are to make it clear that the text before and after the asterisks is from different parts of board papers.

The trust’s role in protection from child abuse – a national IT issue?

“… The Trust has participated in the serious case review of a child who died in Enfield, who had attended Chase Farm Hospital. A review of the case management by the Trust has been undertaken and submitted and the outcome and recommendations of the panel is awaited…”

**

” …The new Patient Administration System system has created difficulty in our current child protection procedures. e.g. prior to the implementation of the new PAS system a flag was printed on the A/E card to alert staff. On the new system the flag only appears on the screen, leaving the responsibility for alerting staff to the receptionist.

“Initially it was believed this could not be changed, however an IT solution has now been found. Unfortunately this change has not as yet been implemented. Other problems include data utilised by the Liaison Health Visitor i.e.lack of access to a daily A/E child attendances list, lack of mandatory fields for school data. These issues continue to be raised with the IT dept by A/E and the paediatric department…”

**

“… Principal Risk:  Failure to identify and protect children at risk of abuse

“Key Controls:  Availability of updated child protection registers from all local authority boroughs. Flagging system on A/E I.T system.

“Assurances on controls: Quarterly audit of computerised flagging system for child protection register.

“Gaps in control:  New PAS system does not print the flag. This is a National IT issue.

“Action and Risk treatment plan: Dec 07 Update: This issue has been raised with both Local Authorities and has been discussed at the Local Safeguarding Children Board, and the Pan-London group. Mar 08 Update: an IT solution has been found and it will be possible to have a flag printed on A/E card but this not as yet been implemented.

A large rise in complaints after go-live of patient administration system (PAS)

“The PALS [Patient Advice and Liaison] service had another busy year, helping over 14,000 people who contacted them with problems or concerns about care, treatment or access to Trust services. This was a significant increase on the 5,500 cases in the previous year and was due to difficulties following the implementation of the Trust’s new Patient Administration System.”

Knock-on effect of go-live of patient administration system on trust finances:

“… Currently, the Trust was investing more money than it was saving in 2008/09, which was perhaps redressing the balance of previous years’ savings programmes. For example the administrative posts which had been deleted in previous years were now being
reinstated as a result of the Patient Administration System implementation.”

**

 “[The interim IT Director] advised that the previous week the Trust had submitted monthly monitoring returns for the first time since the introduction of the new Patient Administration System and that this week the monthly activity reports would be submitted. Returns for the final quarter would also be submitted. Therefore, in terms of electronic reporting the Trust was back on track, but this had required significant additional resources to achieve. Currently agency staff were being used but it would clearly be more cost effective to use permanent staff and this was going though the business planning process.”

**

” … Agreements for 2007/08 income had still not been concluded with some PCTs, notably Brent and Harrow. This was disappointing in terms of showing a lack of support on Patient Administration System issues. The Essex PCT was taking the line that if the Trust had not provided data, then it would not be paid for activity.

**

[From a Barnet and Chase Farm board report dated 10 July 2008]

“… The Trust faces an extremely serious situation and needs to take immediate action. Both income and expenditure are out of line with the budget and the risk to achieving the break-even target has increased month on month. It remains too early to draw absolute conclusions at this stage. The income figures are still subject to final confirmation as a result of issues regarding data quality and completeness.

“Income & Expenditure Summary – the Trust income and expenditure position for May shows a cumulative income and expenditure deficit of £0.4m which is a deficit of £1.3m against the plan …Elective income – the Trust’s activity for inpatient and day-cases is significantly lower than contracted levels. The table below shows the cumulative position for April and May … There are two issues which together which make up the variance. The first is that the volume of activity is lower than expected. There are a number of factors which have created this problem:

“- the Patient Administration System issues in 07/08 have certainly caused a significant loss of activity and whilst the issues which have resulted in patients going to alternative providers are mostly resolved, the loss of outpatient activity and the subsequent conversion into inpatients is knocking into 08/09

“… The Trust has not yet finalised its income position for April and May [2008]. The Patient Administration System issues mean that a number of processes still need to be finalised …

Did IT-related problems drive patients away from the Trust?

“… April’s case mix was very low and has improved in May but the average is still low. It is possible that the Patient Administration System issues in 07/08 and the difficulty of patients accessing the Trust has resulted in the more complex patients being more likely to have gone to other Trusts due to the nature of their condition. There is no direct evidence for this however and we will need to see more data to draw firm conclusions.”

 ” … The Patient Administration System problems meant there was a lack of activity data and although there appeared to be lower levels of activity it was difficult to assess whether this was due to patients choosing to go elsewhere or the impact of PCT demand management initiatives…”

The Trust did not know of patients waiting for treatment who slipped through the net

“…The introduction of a new Patient Administration System meant the Trust was unable to produce monthly waiting time data between July 2007 and January 2008. Unfortunately the production of the waiting time data in February revealed a significant number of waiting time breaches which had occurred… there were 23 breaches of the outpatient guaranteed waiting time (if a person’s wait is more than 1 month than the target time it counts as a second breach) …. There were 63 inpatient breaches: 26 were from Enfield…”

“… The technical problems have now been resolved, but the production of contemporary data has revealed a much higher number of long waiters than estimated.

**
“The Director of Operations – Emergency Care advised that the breaches [in waiting time targets] were mainly related to migration issues between the old and new Patient Administration System systems.

**

“Cancelled operations – 272 elective operations were cancelled by the hospital at the last minute for non-clinical reasons which is less than the 0.8% national threshold proportion of total elective activity for the year. However 20 of these patients in Q4 were not re-admitted within 28 days – therefore this part of the target is under-achieved. The reason for this relates to the surveillance system for tracking 28 day cancelled operation which was not operational in the new Patient Administration System. A new system is now in place which will prevent these breaches going forwards.

The Trust has contacted patients whose treatment was delayed

– “Barnet and Chase Farm has contacted and offered appointments to all the patients concerned and many of these have now been treated.

– “[It has] developed a new reporting system to capture data quality issues and identify incomplete data, which will be managed and monitored by the Trust’s Information Team…

– “The Trust will maintain the submission of monthly reports to the Department of Health and is now able to produce and maintain a Patient Tracking List which ensures that appointment dates are set within target waiting times

**

The trust has given a formal explanation to the NHS’s regulator, the Healthcare Commission, of the problems after the Cerner PAS go-live

“Core Standards Declaration – Healthcare Commission Core –  and Development Standards – 8 May 2008

“The Trust was the first in London to implement the Cerner RO Patient Administration System on 19th July 2007. Following the implementation, the Trust experienced challenges to ensure that all clinics had notes for all patients and that all records keeping and retrieval systems were accurate during Q2 and Q3. The Trust was also unable to provide some of the mandatory external datasets and external reports for these quarters with full and complete accuracy.

**

“Areas of Risk to our stated performance on Targets:  The Trust was the first in London to implement the new Connecting for Health PAS solution. The Trust could not assure external bodies that all activity for Q2 and Q3 were sufficiently accurate for external reporting and therefore did not submit monthly activity returns. The implications for the Healthcare Commission during the forthcoming data validation period are that they will not have all of the necessary activity data that determines the overall size of the Trust for comparison with our well-estimated targets performance on the:
– Number of In-patients waiting longer than standard,
– Number of Outpatients waiting longer than standard,
– Number of Cancelled Operations at the last minute
– The reduction in Emergency Bed-days

“The Trust is in discussion with the Healthcare Commission to mitigate the risk

Despite delays for patients, the trust had under-used capacity [which is likely to mean emptier-than-usual wards and operating theatres]

“… the ongoing technical patient administration system issues have caused problems with scheduling and admission of patients. In April and May the Trust had unutilised capacity arising from this issue …

The problems and the Trust’s application to become a Foundation Trust:

“Application for NHS Foundation Trust status…There remained significant issues in the following areas:

• Financial capability …
• Human Resources management …
• Quality and suitability of IT systems and quality and use of underlying data – recognising the problems of introducing the new PAS system. Although much progress has been made, an FT application will be heavily reliant on a robust IT system and data …

Comment:

Barnet and Chase Farm should be congratulated for the timely publication of comprehensive board papers. It should be said that the Department of Health and NHS Connecting for Health publish no board papers at all. 

Are the protracted problems the fault of the trust? Alex Nunes, of the trust’s recently disbanded Patient and Public Involvement Forum, said:

“You can’t blame a trust for a system that it didn’t develop and was put in at the behest of the Government.” 

But Stephen O’Brien MP, the Conservative’s health spokesman, made an equally valid point. He said of the London NPfIT go-lives: “All the risks are falling on patients.”

Links:

Bucks had MRSA control issues for 18 months after Cerner go-live – E-Health Insider, Aug 2008 

Barts delays urgent cancer visits after NPfIT go-live – IT Projects blog, June 2008

Barts NPfIT go-live ends up in The Sun – IT Projects blog April 2008

Big problems hit Royal Free Cerner roll-out – Computer Weekly, Aug 2008

Minister defensive over Cerner NPfIT sites – IT Projects blog – February 2008

NHS Connecting for Health, Bell Pottinger and a hospital [Milton Keynes] in trouble – IT Projects blog, 2007 

Whitehall officials pledge not to repeat troubles of Care Records Service go-live at Nuffield hospital – but similar problems have already occurred at another hospital – IT Projects blog, 2007 

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