Select Committee on Public Accounts Minutes of Evidence



I would like to take the opportunity, if I may, to comment on issues that emerge from the evidence of 29 March and that are apparently associated with some element of confusion. In the final part of this letter, I have presumed to make comments of a more general nature.


  Of course, good information management cannot make up for inadequate bed resources. High rates of emergency flow, particularly during the winter months, must have an adverse effect on the waiting list position, at least in the short term. It is not true to say, however, as is suggested in the PAC minutes, that high rates of emergency flow must necessarily translate into high rates of cancellation. CALM has demonstrated conclusively that it is possible to develop a statistical model of likely future rates of emergency flow, to reserve capacity sufficient to deal with that projected flow and thus avoid cancellations. CALM forces surgeons to recognise the hospital's true capacity to treat patients and prevents them from making promises that the hospital cannot ultimately fulfil. CALM also forces the hospital to favour patients with high clinical priority when resources are scarce.

  I would repeat that even at times of extreme pressure from emergencies, the set of rules within CALM will reduce cancellation rates by around 50 per cent in a mediocre implementation, and get them close to zero in a high quality implementation.

  Proper information management will spare patients much uncertainty. It will also allow more efficient use of finite resources and thus enable us to treat more patients (and the most needy) in the context of a generally insufficient resource. CALM has enabled the Royal Shrewsbury Hospital to run at much higher levels of bed occupancy than has been possible elsewhere. CALM has also enabled us to protect the interests of cancer and other high priority patients.


  It is suggested in the minutes that current work on the EPR, as proposed within the White Paper Information for Health (IfH), should lead to improved scheduling solutions. I think that this could be the case if IfH had made explicit the need for a scheduling backbone to underpin the EPR. Unfortunately, nowhere in IfH is there overt mention of scheduling. As I stated in an earlier Submission, I believe a revision of IfH is appropriate in this regard. Trusts, in seeking to implement EPR level III, as they are required to do, need to recognise the need to place EPR within the context of a capable scheduling engine. Currently, they have been diverted from the need to attend to this with the certain result that the present distressing state of affairs in regard to cancelled admissions will continue in the longer term.


Widespread interest in CALM but significant barriers to spread

Throughout 1998-99, we presented CALM, in response to invitation, at a number of national conferences, organised variously by ESAT, BAMM (British Association of Medical Managers) and HSMC (Health Services Management Centre). As a result, more than 25 acute sector trusts expressed apparently genuine interest in the CALM methodology and began to seek ways of transferring the CALM solution to their own hospitals. During recent weeks, interest has been expressed by a yet larger number of trusts following our Beacon demonstrations. (Interestingly, Aintree, singled out as another example of good practice by Sir Alan Langlands, was very keen to take CALM following my visit there two years ago—at the behest of ESAT.) Despite all this interest, no other trust has made serious steps to invest in CALM. This is because there are some significant barriers to roll-out.

  For a hospital to take CALM, it has to take a new PAS (Patient Administration System—the hospital's core information system), going through the usual laborious procurement procedures demanded of public service bodies. This is thoroughly off-putting. Furthermore, because scheduling is not an explicit element within the IfH definition of the EPR (Electronic Patient Record) and because trusts are greatly concerned just how to meet EPR level III requirements, they have focused on other, more obviously clinical, aspects of their computing needs. The quality of PAS is now an unimportant element within their IM&T thinking. This is a disastrous development because it means that hospitals have temporarily forgotten about an information need that actually is crucial to their daily business—that is, high quality scheduling. This means that they will continue to fail in this area with the appalling consequences for patients that we are so familiar with.

  Sir Alan Langlands is correct in suggesting that because CALM has been taken up by a major supplier it should become available to other trusts if they want it (and are prepared to overcome the procurement hurdle). But CALM does have to be available long term. My worry is that as matters currently stand, CALM may not have a long term future. I fear that senior management at Sema are not committed to a project that the NHS is not yet demonstrably serious about. It is by no means certain that Sema will support CALM beyond 2000 without clear evidence that CALM can make its own way in the financial sense. This is one of the reasons why I have proposed five new sites within the context of an R&D project, in order to achieve a footprint for CALM that is large enough to make it financially self-sufficient.

  I do want to endorse Sir Alan's comments on the need for change management. As he says, just installing software alone is not enough. In effect, though he did not exactly word it thus, Sir Alan identifies how the inherent conservatism and insularity of trusts is such a barrier to modernisation of the NHS and will thwart any real progress until it is overcome. He alluded to the "not invented here" attitude that acts as a barrier to rapid uptake of solutions that have been proven elsewhere. This is why any project that we create to take pilot sites forward must include a significant component of change management and must to some extent be imposed (although we have no lack of acute trusts that want to take up CALM). CALM gets at the very core of the NHS' big problem. A laissez-faire approach to CALM is not appropriate when set against the scale and urgent nature of the problem and the real opportunity to solve it by a progressive programme of change.


  I feel that I must once again emphasise the unique nature of CALM. CALM has been 13 years in the making. It has a richness of functionality and an underlying intellectual rigour (using new ways of thinking) that has not been achieved elsewhere, to my certain knowledge, and could only be replicated after many years' effort. Of course, there are systems that can schedule booked admissions for outpatient and day case treatments, and there are systems that can give a reasonably accurate picture of the current bed state. I would humbly suggest that these systems, whilst meritorious, are addressing relatively easy problems that may not even need the application of IT in every case.

  I have written recently to Alan Milburn, Secretary of State for Health, to express concern that so little progress has been made with CALM. After all, in 1998, ESAT, an important and influential NHS body, recommended strongly that CALM should be piloted in other NHS trusts. In 1999, the NHS awarded CALM Beacon status and this year CALM received glowing tribute from the independent NAO report. I confess to wondering what more must I, as a clinician with a full surgical workload, do to get the unique and proven benefits of CALM into other hospitals? And what message does my frustration give to other innovative clinicians? After all, we are told that the future of the NHS lies with clinicians who want to change and to modernise, yet when we show that we can do so, we are not supported.

  I enclose a copy of the proposal that accompanied my letter to the Secretary of State.

Andrew Hay
Consultant Urological Surgeon and Clinical Director for Information
Royal Shrewsbury Hospital NHS Trust

25 May 2000

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Prepared 25 January 2001