Select Committee on Public Accounts Minutes of Evidence


  I understand that I should write to you if I wish to make any points to the Public Accounts Committee when it meets on 29 March to discuss the recent National Audit Office (NAO) report on bed management.

  I should begin by explaining by interest in this matter. I am a consultant surgeon and the leader of the hospital team that, since 1987 has gradually designed and assembled the computer system, known by the acronym CALM (Clinical Applications for Logistics Management), that was highlighted in the NAO report as a unique example of best practice where computing solutions are concerned. The NAO report highlighted the need for appropriate information tools as being paramount in effective bed management and suggested that steps should be taken to spread CALM or systems like it (currently there are none) more widely throughout the NHS. In making this recommendation, the NAO concurred with an earlier report by the Emergency Services Advisory Team, published in 1998, that suggested that a number of CALM pilots should be established within the NHS.

  My reason for writing is to gain support for such a project and engender some discussion about how we might move forward with it. The history of NHS clinical computing has taught us that there is generally a wide gap between what is promised and what is actually delivered. Expensive failures, such as the RM (Resource Management) and HIS (Hospital Information Support Systems) projects, loom large in our minds as particular examples—examples that have themselves reinforced a widespread and understandable scepticism about the value of clinical computing. Such scepticism has a powerful dampening effect on new computing initiatives. I am anxious that the wider use of CALM is not thwarted because of this. I cannot but reflect also on how susceptible the NHS is generally to internal factors and how often it is that the NHS fails to push through good ideas. It is the fear that the NHS may fail to capitalise on a genuinely good idea that has motivated me to write.

  CALM has been many years in development (the project started in 1987) and has proved itself, both technically and in the benefits it delivers. The generosity of Lord Wolfson has enabled us to move CALM from prototype status to an industrial strength product, running on a modern technical platform suitable for the largest hospital enterprise. An important recent development is that a commercial partner of real substance has come forward to support the new version of CALM. Rapid implementation in other hospitals is now entirely practicable.

  So far as benefits are concerned, the NAO report points to the significant reduction in cancellations of admission that CALM has brought about. We are now confident that CALM, properly deployed, can reduce cancellation rates to near zero. But if I had to pick a single example of the kind of benefits CALM can deliver, it would be that illustrated in the figure 1 above. Figure 1 shows how CALM protected the interests of cancer patients throughout the winter of 1997-98, at a time when the hospital was coping with the effects of a prolonged 'flu epidemic. The figure shows how CALM kept the median wait for cancer patients steady at around two weeks, despite an unusual increase in the number of cancer patients presenting to the hospital in the months of February and March and despite the transfer of more than 20 beds from surgery to general medicine.

  The cost of CALM to a 400-500 bedded trust is approximately £450,000 in the first year and £110,000 in subsequent years. I would suggest that this is a small price to pay in order to be able to make promises to patients in the nearly certain knowledge that those promises will actually be honoured, in the way that is expected of an airline or a package tour company. Remember too that CALM really does provide a methodology for dealing with extremes of emergency demand, eg the so-called winter pressures. In fact, the real cost of CALM is less than it seems because CALM enables very considerable efficiency savings. By way of a simple example, the Royal Shrewsbury Hospital is able to sustain bed occupancy rates in excess of 90 per cent without particular difficulty. As the report itself points out, occupancy rates much in excess of 80 per cent are generally a cause of chaos, with very high rates of cancellation. I would also like to draw your attention to the fact that the cost of CALM is artificially low because of the generosity of Lord Wolfson in funding much of the development work. Lord Wolfson wishes CALM to be made available to the wider NHS at affordable cost and has done much to make this possible.

  I would like to propose, therefore, that we find a way to introduce CALM into five more acute trusts during the next year. I suggest that this should be within the context of a formal project, allowing the evaluation of benefits and providing justification for wider spread in later years. A formal project would allow us to develop improved implementation methodologies, which would make it easier to achieve further roll-out.

  I realise that there is always some discomfort when it comes to a government agency favouring a single supplier. I would like to suggest that an initially small-scale project should not offend sensibilities in this matter. In any case, it would be very difficult to involve other suppliers to create competition in the short term. This is because the software solution is extraordinarily complex (it took 12 years to develop) and could not easily be replicated by anew supplier within anything less than two or three years. There is surely some comfort to be derived from the fact that the commercial partner is an Anglo-French company and a small boost to this company is a boost to the indigenous UK software industry in healthcare—an industry that is currently undergoing severe contraction and is, indeed, at risk of disappearing altogether.

  If the committee thought that my attendance might be helpful, I would be pleased to appear as a witness when it meets on 29 March.

  Finally, I think it only proper that I alert you to a potential conflict of interest, albeit trivial. The committee should be aware that Sema Group UK plc are in negotiation with my employers at Shrewsbury to create some kind of research fellowship to ensure that CALM work continues more rapidly. Any monies from Sema would be used to fund a clinical replacement for me. The committee might think that this possible relationship with Sema might endanger my objectivity.

Andrew Hay
Consultant Urological Surgeon and Clinical Director for Information
Royal Shrewsbury Hospitals

6 March 2000

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