PART OF A LETTER FROM ANDREW HAY, CONSULTANT
UROLOGICAL SURGEON AND CLINICAL DIRECTOR FOR INFORMATION, ROYAL
SHREWSBURY HOSPITALS NHS TRUST, TO THE CLERK OF THE COMMITTEE
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.
THE EPR (ELECTRONIC
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
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 agoat
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 Systemthe 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 businessthat 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.
Consultant Urological Surgeon and Clinical Director for Information
Royal Shrewsbury Hospital NHS Trust
25 May 2000