Patrick Kesteven, a consultant haematologist at Freeman Hospital, Newcastle, has a succinct explanation for a decision by his trust board to break away from the £12.7bn National Programme for IT in the NHS,
“The National Programme was taking forever,” he told Computer Weekly. He is not even sure that the National Programme for IT [NPfIT] – the UK government’s biggest IT investment – will ever work as originally intended.
Kesteven is no renegade: he is ensconced in Newcastle’s medical establishment. He chairs a programme board which is planning for a system of e-records to start going live at three hospitals in Newcastle upon Tyne in May next year.
Executives at the 11,000-strong Newcastle Upon Tyne Hospitals NHS Foundation Trust have given up waiting indefinitely for comprehensive e-record systems from the NPfIT. They want as soon as possible to give doctors and nurses systems which, with a single log-on, provide an overview of patients’ treatments and histories, who is supervising them, where they are in the hospital and whether, for example, they have just had an adverse reaction to a general anaesthetic.
The trust also wants better information to ensure it is paid for all it does: when patients are given extra treatment unrelated to their initial problem, this work may go unrecorded on existing payment-related systems
The NPfIT is specified to provide the solutions. But the government had promised it would happen by 2006: when they announced the NPfIT in 2002 ministers promised that patients would have a national electronic health record by the end of 2005. That hasn’t happened, nor is it expected to happen for years: the National Audit Office says it will be 2015 before a national e-records scheme will be rolled out across England. Even that may be optimistic says the audit office.
So the board of Newcastle Upon Tyne Hospitals NHS Foundation Trust has decided to buy its systems from the US University of Pittsburgh Medical Center which has introduced an integrated e-records system at its 20 hospitals.
The purchase cuts out CSC, the national programme’s local service provider to NHS organisations north of Oxford. It also sidelines NHS Connecting for Health, the 1,100-strong bureaucracy in the Department of Health which is running parts of the NPfIT.
Newcastle and the Pittsburgh Medical Center have formed a joint venture whose directors hope to sell licences and implement systems in NHS organisations.
Other foundation trusts have been inquiring about Newcastle’s approach to major IT investment, says a report to the trust’s board. Foundation trusts have the freedom to buy outside the NPfIT if they have good financial reasons for doing so. Non-foundation trusts must buy their main hospital system – the patient administration system – under the NPfIT, though there are exceptions.
Monitor, the regulator of Foundation Trusts, is aware of Newcastle’s plans to buy outside the NPfIT. Newcastle’s board has been told that Monitor “understood that the Trust could not wait until 2012/13 for the national programme to provide the required systems”.
If many foundation trusts diverge from the NPfIT, the government’s plan of having England’s trusts supplied by a small group of appointed IT companies – local service providers – will disintegrate further. Already non-foundation trusts in the south of England are considering “interim” systems that are not from the scheme’s two remaining local service providers, BT and CSC. Trusts in the south are losing their NPfIT local service provider Fujitsu, the company’s contract having been terminated.
Tola Sargeant, an NPfIT expert at market analyst, says there is a “lull” in the NPfIT, mainly in the south, creates opportunities for suppliers other than CSC and BT. “…Some trusts may decide they cannot afford to wait for an LSP [local service provider] system and instead procure an interim or replacement system from alternative suppliers … However, competition for any such contracts will be stiff and small UK SMEs .. will be competing against much larger international rivals that are also targeting the UK market.”
Kesteven and Newcastle Upon Tyne Hospital NHS Trust recognise they are taking a risk by going it alone. No figure has been announced for the cost of its break-away investment in electronic medical records system from the University of Pittsburgh Medical Center but Computer Weekly understands that the investment is £15m over two years. This includes a payment in advance for seven years of Cerner software licences – pre-ordered licenses and any more they decide to buy within the seven years – and all support and maintenance, but not consultancy.
The Newcastle foundation trust is the first organisation outside the US to invest in the Pittsburgh Medical Center’s e-records technology, which is based on the “Cerner” system.
Kesteven recognises that not all staff at the University of Pittsburgh Medical Center are enamoured with all aspects of the Cerner system. “But would they go back to how things were before? They couldn’t imagine it.”
There is also the challenge of making an American system work in the UK. “Anglicisation would be the key,” Newcastle’s trust has been told.
If the implementation at Newcastle goes badly – as has a basic version of the Cerner system when it was deployed at some NHS trusts in London in the south of London – there may be health officials in Whitehall who will say: “Serves you right. You should have waited for systems from the NPfIT. The software and hardware wouldn’t have cost anything [being centrally funded] and we would have supported you until everything worked well, even if that took some time.”
But Newcastle’s executives see the risks as worth taking. They have learned the main lesson from the troubled installations of the NPfIT Care Records Service Care in London and the south of England: that the customer must in control of the supplier, the contract, the software’s functionality and the changes in the day-to-day working practices of doctors and nurses.
Homerton and Newham hospitals in London have ended up with stable Cerner systems – but it took years to resolve problems, which they did through a contract with Cerner, and without a local service provider acting as middleman, and without the involvement of NHS CfH.
The NPfIT trusts which have run into serious and enduring problems have not been in direct control of the suppliers. They include Barts and The London, the Royal Free Hampstead, Nuffield Orthopaedic Centre, Barnet and Chase Farm, Buckinghamshire Hospitals NHS Trust, and Weston Area Health NHS Trust.
As they have no direct contractual relationship with their suppliers, NPfIT trusts cannot sue over a failed installation. Contracts for NPfIT installations are between the Secretary of State for Health and the local service providers, on behalf of trusts. So when NPfIT trusts want changes to the Cerner or “Lorenzo”, they must usually put their requests to a committee, which may be granted eventually and then incorporated months or years later in a general software upgrade. The local service providers and CfH are perceived by some NHS executives as unnecessary middlemen.
Even with their own IT contracts in place, Newcastle’s directors know that it is going to be difficult enough trying to combine information on its patients, which is now held in up to 100 legacy systems across its various sites.
Andre Snoxall, e-record programme director at the Newcastle foundation trust who is a former CIO at trusts in New Zealand, says that with the most favourable conditions and contracts, it’s still an enormous task to bring about a comprehensive view of a patient with a single log-on.
He said: “It takes an extraordinary amount of effort to try and get a full picture of a patient’s history”.
He added that the biggest challenge for the trust has less to do with technology than inspiring people, engaging them, and “getting them working towards a common goal”.
Achieving a single patient view at one large trust alone will be hard enough – but the government’s aim is for the national programme to achieve this at all hospitals across England, with standardised systems, with most trusts having no contract with their suppliers, having little control over changes to the software, and amid delays of at least four years so far.
Kesteven will gain some sympathy among some NHS IT executives for his view that the NPfIT may never be achievable – which should be a prompt to the government to re-think the plan. Or conduct a high-level review of the programme – which it has repeatedly refused to do.
How will Newcastle Upon Tyne Hospital NHS Foundation Trust avoid the problems at Cerner NHS sites in south of England?
Andre Snoxall, e-record programme director at the Newcastle foundation trust, told Computer Weekly: “Knowing the problems there are is half the battle. We have partnered with UPMC [University of Pittsburgh Medical Center] who I believe are the largest single Cerner customer in the world.
“Therefore we believe they have got – and this is part of the reason we partnered with them – a tremendous amount of clout with Cerner. They have the ability to influence the way that product is developed. We are hoping that through that relationship we will hopefully get a version of the product that’s more advanced than the ones that have currently been implemented.
“However we are not putting all our eggs in that basket. We recognised that organisations such as Barts and the Royal Free have encountered a number of issues largely because of deficiencies largely in the way the product handles the 18-week pathway [a target to treat 95% of outpatients and 90% of inpatients within 18 weeks of being referred by their GPs].
“We will look at how we may avoid [these problems] through workarounds and through whatever means are available. We have more time, another nine months, to try and get that right. Hopefully we won’t end up with all the same sorts of problems. Now that’s not to say we expect everything will be perfect from day one. We don’t think it will. But forewarned is forearmed.”
He added: “A lot of problems are down to the fact that you need more people to be able to manage the patients than would be optimal.”
Dr Patrick Kesteven, Consultant Haematologist at the Freeman Hospital, Newcastle – a short biography:
He grew up in Rome, where his father worked for the United Nations. When he was 10, his family moved back to Australia where he completed his education.
Medical training was at Sydney University and then St Vincent’s Hospital in Sydney. The latter led to completion of his physician training. He moved to St Thomas’ Hospital in London to undertake haematology training. At St Thomas’, he completed his pathology training and a PhD on the problems of anticoagulation during open heart surgery.
This led to his appointment at the Freeman Hospital in Newcastle, a major cardiothoracic centre, as Consultant Haematologist. Since then his research has been centred around the problems of anticoagulation and of pathological venous thrombosis.
NPfIT break-away trust reveals business case details – IT Projects blog, September 2008
Newcastle chooses Pittsburgh for EHR – E-Health Insider