Select Committee on Health Written Evidence


Evidence submitted by Statis Ltd (EPR 05)

STALIS LTD

  Our credentials for making this submission to the Select Committee are that Stalis Ltd, based in Oxfordshire, has for the past 25 years provided a range of IT systems and services to the NHS whose long standing clients include Moorfields Eye Hospital NHS Trust, The Oxford Radcliffe Hospitals NHS Trust and Sheffield Children's NHS Trust as well as the independent Capio hospital group.

  Following the introduction of the NPfIT Stalis has majored on assisting Trusts and their LSPs with Data migration, cleansing and the provision of interim Patient Administration Systems (PAS). Over the past three years Stalis has undertaken contracts with BT (for 9 London PCTs to migrate and archive data from legacy Child health systems), Accenture (for 4 Essex based PCTs to migrate and archive data from legacy Child health systems) and Fujitsu (directly contracting with 4 NHS Hospital Trusts to migrate, cleanse and archive data from PAS, A&E, Theatres and Maternity modules). We are also in the final stages with Moorfields of replacing their mission critical PAS due to the fact that BT and its main systems partner IDX (and now Cerner) could not provide an adequate solution to meet the Trust's needs.

  Based on this past and current experience of working with LSPs, their system suppliers and NHS Trusts we respectfully submit this assessment as evidence of both the failings with the NPfIT and the opportunities for the programme to be salvaged for the benefit of the NHS, tax payers and patients. Specifically the response addresses the item:

  Current progress on the development of the NHS Care Records Service and the National Data Spine and why delivery of the new systems is up to two years behind schedule.

INTRODUCTION

  1.  The purpose of this submission is to provide a synopsis of the background to and lessons that might be learned from the NPfIT and its management by Connecting for Health (CfH). It further indicates how the current problems with the failure to deliver Care Record Services (CRS) to NHS hospital Trusts can be turned round within the current investment levels.

  2.  As one of, if not the, most ambitious public sector ICT project ever undertaken it is not surprising that NPfIT has so far fallen far short on its overall delivery goals, and in particular, the Care Record Service (CRS). In 2006 the National Audit Office report, indicated that the programme is at least two years late. This is not to say all aspects are suffering the same delays but the key components of the National Spine, Choose & Book and, most of all, the Care Record Service (CRS) for acute hospitals is significantly adrift from its original goal.

Reflections on NPfIT so far

THE CONTRACTING PROCESS

  3.  Given the magnitude of the undertaking and the history of failure with previous public sector IT projects (Passport Office, Child Benefits etc) the programme was placed in the hands of an externally recruited senior IT figure—Richard Granger from Deloitte & Touche. With a launch budget of £2.3 billion and a timescale of approximately two years to put in place all the necessary suppliers and contracts, NPfIT was launched. This was exceedingly ambitious by any standards and the "haste" contributed to a serious lack of NPfIT, supplier and solution due diligence. The speed of procurement also precluded user (Trust and specifically Clinician buy in to the solution). This lack of buy in caused much of the delay during the early months of deployment.

  4.  It is to Mr Granger's (and the CfH team) credit that he achieved the early "political" goals in that contracts were placed more or less within the two years and the total contract value was held within the £2.3 billion). However, all this was accomplished at a price and against some ill founded concepts as set down below:-

  5.  Mr Granger had never undertaken a programme approaching this magnitude of scale and complexity—in fairness, few if any have—and had no prior knowledge of the healthcare IT requirements within the NHS.

  6.  From the outset Mr. Granger, and those within government directly involved, appeared to believe that all current systems operating within the NHS were in need of replacement. (At a public meeting with the IT industry at the outset of the programme Mr Granger was heard to describe current systems as "rubbish") and that no UK suppliers had the capability of meeting the needs. Furthermore, Mr Granger told the supplier industry that "UK companies had not served the NHS well and so could not expect much business". This demonstrated the lack of understanding at the time that was instrumental in guiding the programme.

  7.  The original concept was that all legacy systems would be replaced in a few years—a feat that was never realistic and demonstrated a total lack of understanding within NPfIT / CfH. The "Legacy Systems Team" within CfH quickly came to recognise the value of the existing systems and the magnitude of the task facing the NHS in replacing these. CfH then renamed the team to "The Existing Supplier Team" reflecting that some/many legacy systems are strategic and will need to be retained for many years.

  8.  CfH made clear that they considered only companies with no previous track record in the NHS were likely to be successful, and in particular, US companies. This view prevailed during the early stages of the procurement process thus encouraging companies to participate who would otherwise have seen their lack of experience as a material weakness (rightly) in any such project.

  9.  Only large global service companies (Local Service Providers—(LSP)) would be considered as main contractors as they were the only ones likely to have the human resources to scale up for the projects and the balance sheets to take on contracts with severe financial penalties. The issue of whether they had NHS IT experience was not viewed as key at the final selection/contract stage.

  10.  Because Mr Granger had no previous experience in healthcare he initially failed to appreciate the complexity and diverse nature of the requirements. Similarly, none of the LSPs had in-depth healthcare IT expertise in the UK, or really understood the needs of the NHS. Thus for the first three years of the programme (two years of procurement and the first year of implementation) NPfIT was driven in an environment of ignorance of the true NHS environment.

  11.  The funding for the projects did not include the provision of funds for the migration and cleansing of data from existing systems to the CRS or even acknowledge the significance of this part of the program. In many cases, it was not even understood that data migration into the new systems would be required as part of the ongoing support of the Trusts' operational systems. NHS patient data is generally of a poor standard with most hospitals having electronic records that contain many duplications, incomplete fields of data and data stored in areas of the systems for which the systems were not designed. Trusts have records spanning between 10 and 20 years so the need to clean these is significant to the success of NPfIT and the CRS.

IMPLEMENTATION EXPERIENCE

  12.  The LSPs commenced the programme with little or no experience in UK healthcare and little experience anywhere of the systems required by the NHS. Although this has improved with some LSPs it is not consistent across the NHS and remains an issue today.

  13.  The LSPs appeared to place their reliance on what their sub-contractors committed to deliver and placed their trust in the contract terms to hold them safe. LSPs also fell into the trap of believing the NHS would accept the systems without question and would abide by project timescales imposed by the LSPs. The naivety of this contributed to the early implementation experiences when it became apparent Trusts would not accept (and could not for resource and operational reasons) inferior systems compared to what they already had.

  14.  There was little experience of the existing "legacy" systems. In conjunction with this, there was little appreciation of the number and variety of systems to support clinical applications that were "held together" by the existing legacy Patient Administration Systems (PAS) due to be replaced.

  15.  The LSPs built project teams very quickly in the naive belief that the NHS would accept their delivery schedules and that the software would be ready. They, the LSPs did not have the skill or experience to evaluate the software suppliers, hence many of the problems with iSOFT, IDX and Cerner, are systemic and continue to this day—the US company Cerner cannot provide the reporting capabilities necessary to support NHS Trusts (as is evidenced from the early users in the Southern Cluster).

  16.  Both IDX and Cerner systems have never been successfully implemented in the UK, being systems configured for the US market (which is one focussed on patient billing in discrete establishments rather than the UK model of focus on administrative/clinical systems over multiple site establishments).

  17.  Large teams of project staff worked to a rigid methodology that was ill fitted to the NHS and the implementation of clinical systems. Many Trusts acknowledged that there was a huge culture gap between the NHS approach and the LSP approach.

  18.  The NHS was not prepared for the magnitude of change required, and is still not after more than three years. Trusts are unprepared for the tasks required by NPfIT to create a secure patient information system and for the data migration involved.

  19.  Because of the delays and the unsuitability of the CRS software especially at the hospital level, Trusts have lost three years of progress and are now being forced into implementations where they may lose important functions in their systems.

  20.  The project approach by the LSPs has been to deliver to an implementation plan which has been ratified by the NHS at the cluster level, but with no recourse or discussion with existing suppliers. The existing system suppliers have also been held at arms length from the LSPs and their partners delivering the replacement systems thus ensuring that communication is at best convoluted or at worst, non- existent. We have had experience of this as a supplier of data migration services, not contracted through the LSP, being prevented from direct communication with the system supplier, and we believe this has also been the case for the Trusts. The situation has improved in some areas but largely due to local initiatives rather than a deliberate policy.

  21.  Although the UK healthcare IT supplier industry contained a wealth of skill, experience and useful systems these were largely ignored by the LSPs in the first two years of implementation. This has changed somewhat but is still far from ideal in that the LSPs do not make communication with outsiders easy. This may be due to the conflict of interests in areas where suppliers are in direct competition with the LSP for additional services.

Lessons for future success of NPfIT

  22.  Attempt to introduce any major IT programme against political led time schedules is fraught with danger and should not be the basis for any future implementation timescales. Although projects need targets, and there is nothing wrong in having challenging timescales, project goals must be realistic and those for NPfIT in general and CRS in particular were not.

  23.  Governments, of whatever political persuasion, will likely wish to change their strategies on public sector health care and so continually alter the data set and reporting requirements—as evidenced by the 18 week wait policy. Specification creep is a nightmare for NPfIT, Trusts and IT suppliers to deal with in a project of this magnitude. Such changes also underpin the need for NHS specific Patient Administration Systems rather than non UK solutions which are designed for very different healthcare environments such as the US.

  24.  Most healthcare systems vary significantly country to country especially in respect of administrative, billing and HR rules and requirements. It is these issues that cause the most problems for healthcare providers and their suppliers. Systems are typically designed for their home markets and not for a multi country/world model approach.

  25.  The US healthcare market is very different from the public sector systems found in the UK, Ireland and parts of continental Europe. As such, any systems built in the US face the prospect of the greatest changes.

  26.  Replacing working PAS and the like is counterproductive. It is better to leave the PAS functions to local suppliers whereas clinical applications are more widely applicable and so can be added and allow faster progress to be made.

  27.  Centrally driven projects are rarely successful. It would have been far better (as supported by the BCS) for CfH to set the standards, control the national applications like the Spine, and allow the Trusts to choose from an accredited supplier portfolio who meet the national standards (as advocated for GP systems). This would have created local impetus, ownership of the solution, and a vibrant competitive UK industry in which the overseas firms could have competed but not dominated.

  28.  The success to the implementation of systems is not having large global corporations. It is recognising that the software must be fit for purpose and that this can come from small companies with appropriate healthcare expertise within the local economy. Large resources in service companies for volume roll-out can be trained.

Impact assessment

  29.  Overall the programme remains in place despite all the setbacks and failures. It is to the Government's credit that they continue to support NPfIT and give encouragement to all stakeholders to stay the course. The message that NPfIT is material to the NHS and its reforms remains an essential underpinning of the investment

  30.  For the NHS as a whole and its staff, NPfIT has shown few benefits with the exception of improved networking (part of the original plan) and GP payments, email and PACS (all added later). By contrast many NHS Trusts have been significantly disadvantaged by having to wait for the delivery of systems that could have been provided by smaller UK suppliers (iSOFT notwithstanding).

  31.  Although the "central" message is that the tax payer has been protected this is not true in that ultimately the tax payer picks up the cost of delay and the increased cost of the programme (now estimated at £12 billion). Delays to delivery, the waste of NHS resources due to repetitive work following inadequate software deliveries, and the lack of progress in improving workflows all has a cost to the NHS and thus the tax payer

  32.  The failure to modernise the NHS to the extent required is in part due to the fact that NPfIT has not met its objectives. However, NPfIT is not wholly at fault. The NHS has not applied itself to the programme due in part to the series of NHS re-organisations during the past four years.

  33.  NHS staff have and continue to suffer from the burden of having inappropriate systems "not fully fit for purpose" forced on them. The NPfIT made no allowance for the fact that NHS staff and clinicians are under pressure and have little time to devote to the magnitude of the change especially when LSP's are forcing delivery dates on them as they now are due to the financial pressures caused by non payment. It is well known that the LSPs are faced with significant losses which exacerbates the pressure on Trusts to "go-live" with systems that are not fit for purpose nor rigorously tested.

  34.  Ruling out the UK supplier industry from the programme was a fundamental mistake and all but destroyed the sector. This has meant that much of the ICT skills and software development potential that could have help build our health IT industry into a world class industry was handed to mainly US companies (Cerner, IDX, Accenture, CSC). Now, due to the delivery slippage and underperformance the value of UK suppliers and their systems is being recognised and has the potential to save the programme.

  35.  The belief that only large companies could handle the programme was flawed. It is true that large volumes of human resources are needed for managing and implementing multiple concurrent projects. However, the production and supply of NHS specific software does NOT require large companies. On the contrary the majority of successful systems in the NHS come from relatively small suppliers. If NPfIT had appreciated that the basic software could be provided by UK suppliers the LSPs could have been trained to implement the software to meet the CRS requirements.

The Way ahead

  36.  The NPfIT has achieved some considerable and measurable improvements in the provision and application of modern IT systems for the benefit of the NHS and its patients. Most notable among these are PACS (imaging systems), the BT provided N3 broadband network, and some GP/Community systems. Choose & Book and the Spine have made some progress but both remain some way from their original goals. It is noteworthy that the most progress towards Choose & Book has been made by Trusts enhancing their existing PAS, not replacing for one of the new NPfIT solutions.

  37.  The Care Record Service (CRS) is the one programme within NPfIT that has the worst record of delivery and yet it is, perhaps, the most needed. Although LSP CSC continues to implement the legacy iSOFT system to the benefit of those Trusts with archaic legacy systems it is not the modern futuristic solution (Lorenzo) originally contracted. Likewise, in the London and Southern clusters, both Fujitsu and BT are underperforming due to the Cerner Millennium product needing far more change than expected, and there are doubts that it can ever meet the underlying and changing needs of the NHS for a robust NHS workflow related PAS which underpins CRS.

  38.  However, much of the time that has been lost could be made up if the strategy was changed. What we respectfully suggest is that consideration be given to the following:-

  39.  There are many Trusts with perfectly adequate PAS that could be supported for many years to come. Instead of replacing these they should be retained and clinical systems added to them. This offers significant benefits

    (a)  Although the data cleansing would still need to be undertaken there would be no data migration

    (b)  The Trust's operational support is unaffected and resources are not wasted on a one year cycle of replacement

    (c)  Clinical systems can be implemented to the benefit of clinicians and patient care far sooner than with the current programme

  40.  Those Trusts that need to replace their PAS should use pre existing UK developed systems (of which there are several) that already meet the NHS requirements especially for reporting. This strategy would allow BT and Fujitsu particularly to recover lost ground and would provide a sound IT platform on which to implement the Cerner clinical applications. It would also overcome the lack of reporting capability in the Cerner product.

  41.  CSC has demonstrated with iSOFT that, despite the latter's inability to deliver its new system Lorenzo, the deployment of a UK built PAS (iPM) can meet NPfIT needs. CSC has implemented more PAS than the rest of the LSPs combined (including Accenture prior to their departure). CSC is showing that a UK PAS with a separate solution for clinical applications is viable (the iSOFT iCM product originated from the US).

  42.  Such a strategy would also save the programme significant new expenditure. We understand that when CfH/DoH requires changes (usually known as Data Set Change Notices—DSCNs) the charge made by Fujitsu/Cerner for even minor amendments is substantially in £six figures—this would be avoided.

  43.  Trusts should be free to choose which PAS suits them best from an approved list of suppliers which are committed to meeting the mandatory standards of the NPfIT .

  44.  With this approach the modernisation of IT within the NHS can gather pace—without this the CRS programme will continue to under-perform to the detriment of the NHS, its patients and tax payers.

R Roger Wallhouse

Chairman, Stalis Ltd

March 2007





 
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Prepared 25 April 2007