Select Committee on Health Written Evidence


Evidence submitted by Alan Shackman (EPR 38)

EXECUTIVE SUMMARY

  E1.  This submission focuses solely on progress on the development of the core Local NHS Care Record Service, CRS, the area from which the vast majority of the benefits of NPfIT will be delivered.

  E2.  Not only is delivery of core CRS at least 2 years behind schedule but, as of early 2007, there remains no definitive timescale for introducing the clinically focused software that would take functionality in any significant way beyond the basic patient administration functionality that was available to the NHS when NPfIT began in 2002.

  E3.  Deployment of CRS cannot be said truly to have begun at any NHS organisation in the North West & West Midlands, North East, and East clusters because patient administration system (PAS) solutions that have been implemented under NPfIT are interim and will have to be replaced. Deployment of CRS proper is not expected to take off until 2009-10. Even this date cannot be assured given the as yet unresolved financial problems of iSoft, the supplier of core software, and the risk that development of the Lorenzo system will not be completed. these clusters

  E4.  The situation in London and South clusters is more positive now that there is a real indication that Cerner, the core software supplier in those clusters, has successfully anglicised the PAS element of its Millenium product for acute trusts. This at least gives hope that deployment of the clinical elements of CRS will not be long further delayed.

  E5.  The key objective of CRS to provide a seamless service across all care settings—GPs, community, mental health and acute hospitals—is in danger of being lost now that the original intention to have a single integrated system in each cluster has been abandoned. It has been agreed that GPs can have their system of choice; and, at any rate in London, an additional core software supplier has been brought in to provide for the specific needs of mental health trusts and PCTs. Whilst there is little doubt that a solution can be found, there are as yet no plans for how a cross-organisational, joined up CRS is to be obtained.

  E6.  There is no evidence that NHS organisations are committed to changing working practices in order to reap the benefits of CRS as it begins to be deployed.

  E7.  The first major theme in suggested ways forward is to bring additional suppliers of core CRS software into LSP consortia. This would have a dual purpose: to move core CRS forward more quickly particularly in the North West & West Midlands, North East and East clusters where progress to date has been negligible; to provide choices locally with a view to creating greater local ownership and thereby helping to obtain commitment to change working practices.

  E8.  It is suggested that current LSP contracts be reassigned from the Secretary of State to SHAs or PCTs in order to give those now being given responsibility for implementing NPfIT systems the full authority and power to enable them to succeed.

  E9.  The final suggestion is to make use of work undertaken under "Information for Health', the national programme that preceded NPfIT, to provide guidance on achieving cross-organisational information sharing.

THE SUBMITTER

  Alan Shackman has over 20 years experience as an independent consultant to the public sector, principally to the NHS, specialising in the business/user focused elements of preparing for and implementing IT systems. He is an expert in the usage of IT at grass roots level in the NHS, the majority of his assignments having been directly with NHS trusts covering all sectors—acute, mental health, community and primary. Over the past 15 years his work has focused on patient administration (PAS) electronic patient record systems. In that time he has prepared business cases and detailed definition of requirements, led procurements of PAS and electronic patient record systems at major acute trusts and across local health communities, developed benefits strategies and realisation plans, and facilitated the management of change.

  Alan is familiar with the products being offered by the two suppliers of core CRS software to NPfIT having worked on PAS replacement projects in both the South and North West and West Midland clusters. During 2004 and 2005 he acted as NPfIT programme facilitator for the north east sector of Greater Manchester comprising an acute trust, a mental health trust and five PCTs. Prior to that he helped two local health communities in Greater Manchester and Lancashire develop and implement their strategies under the "Information for Health" initiative.

  At national level, Alan led the development of a national output based specification for electronic patient record for acute trusts as part of the NHS IM&T Procurement Review of 1999. Earlier in the 1990s he was a member of the NHS Information Management Group's panel of consultants advising trust boards on electronic patient records. He was also a member of the team that reviewed the national resource management programme.

  He has recently been acting as an advisor on NHS IT matters to Richard Bacon MP of the Public Accounts Committee.

  Alan is a Chartered Engineer and Member of the Institution of Engineering & Technology. In an earlier phase of his career he was a member of the UK Industrial Space Committee and represented the UK on international telecommunications standards and regulatory forums.

COMMENTS ON PROGRESS ON THE DEVELOPMENT OF THE NHS CARE RECORD SERVICE, CRS

Scope and context

  1.  This submission focuses on progress on the development of the core Local NHS Care Record Service, CRS. This where the overwhelming majority of NPfIT funding is allocated and it is from the core Local CRS that the vast majority of the benefits set out in the NPfIT Business Case will be delivered. The submission excludes consideration of Picture Archive and Communication Systems (PACS) because these were not originally included as core deliverables; for the same reason it also excludes the plethora of relatively minor acute and primary/community departmental systems that LSPs have implemented.

  2.  The submission shows that:

    (a)  not only is delivery of core CRS up to two years behind schedule but that, as of early 2007, there remains no definitive timescale for introducing the clinically focused software that would take functionality in any significant way beyond the basic patient administration functionality that was available to the NHS when NPfIT began in 2002;

    (b)    the way in which CRS is now being introduced has been significantly altered with the result that the original intention that CRS should "provide a... service accessible... by health professionals whether they work in hospital, primary care or community services"[107] is in danger of being lost;

    (c)  even when systems are introduced the danger has increased since the inception of the Programme that changes in working processes necessary to obtain the benefits from the investment in CRS will not be driven through.

Review of CRS deployment to date

  3.  By now, all 155 acute hospital trusts in England should have implemented new NPfIT patient administration systems (PAS) as the essential first step in the introduction of Local CRS. As of April 2006, according to the NAO Report, the actual number was nine hospitals. Since then, so far as I am aware, the number has increased by only six. [108]This gives the flavour of CRS deployment to date. The position is different in those clusters in which iSoft is the software supplier for core systems (North West & West Midlands, North East, and East) and those clusters (South and London) in which Cerner is core software supplier now that IDX the original supplier has been replaced. iSoft dependent and Cerner dependent clusters are therefore considered separately.

...in clusters where iSoft is core software supplier

  4.  iSoft was contracted as the Local CRS software provider on the basis of its proposal to develop a new product, Lorenzo. Phase 1 of Lorenzo was stated in iSoft's 2005 Annual Report to have been available in 2004. It was not. iSoft now states, as reported by e-Health Insider on 11 December 2006, that Lorenzo will be delivered to CSC, the Local Service Provider, LSP, for the three clusters, in the first quarter of 2008, but that it will then be some months before it becomes available to trusts and that thereafter its introduction will be gradual, supposedly to occur in the 2009/10 timeframe at the earliest. However, confidence that this will be achieved must be tempered in the light of iSoft's current difficulties as widely reported in the media: that the company's accounting practices are being investigated by the FSA, that its share price has collapsed and that it has yet to obtain the long term funding it requires to meet its commitments. [109]

  5.  In lieu of Lorenzo, the CSC has been offering to trusts existing pre-NPfIT, non-CRS iSoft products known as iPM and iCM. iPM is a PAS with no clinical functionality. iCM is an additional module which includes some clinical functionality relevant primarily to acute trusts eg ordering pathology tests and X-rays. Some 10 acute and mental health trusts with a pressing need to replace their existing PAS have successfully deployed iPM. Those without a pressing need—the vast majority—have decided against because, even with the cash releasing benefit to them of CfH picking up the recurring revenue costs, iPM is considered inferior to their current PAS and certainly not a good enough reason for taking the risk and disruption of replacing a current working system—all the more so since it has become clear that moving to a Lorenzo solution from around 2009 would effectively be another major replacement exercise, not just an upgrade.

  6.  Few PCTs had any corporate system for helping them managing the community services they provide and a considerable number, perhaps 50, in the North West and West Midlands cluster according to its website have deployed iPM. Some, to my personal knowledge, have rolled the system out widely to the various community disciplines. At others, I am told, the deployment has been more limited, the apocryphal "a couple of podiatrists use it every other Thursday morning". iCM has some facility for recording clinical notes but otherwise offers little to community clinicians. PCTs will therefore have little opportunity to progress unless and until Lorenzo becomes available, and even then, as for acute trusts, they will presumably have to face another major replacement project, not just an upgrade.

...in clusters where Cerner is core software supplier

  7.  Release 0, essentially the PAS element, of the Cerner Millenium product, has now gone live at some five acute trusts in South cluster. This was after a false start, causing considerable operational difficulties at the trust involved (Nuffield Orthopaedic), resulting from the LSP's eagerness to begin deployment before, as it transpired, this product from the US had been properly anglicised. At the time of writing post implementation reviews are awaited from the two latest trusts to go-live (Milton Keynes and Mid Hampshire) but early reports are encouraging. Release 0 has not been implemented at any mental health trusts or PCTs in South cluster.

  8.  London, having completed just one PAS replacement using the IDX system, has not yet undertaken any PAS replacements at acute trusts with the Cerner Millenium system. However, the LSP (BT) has moved away from the concept of having a single supplier of core software and, in lieu of a suitable product from Cerner, has adopted CSE Servelec's RiO system as its strategic solution for mental health trusts and PCTs. RiO offers considerable core clinical functionality as well as PAS functions; it has now started to be deployed at a number of trusts.

  9.  GPs continue to use their existing systems and have been little affected by NPfIT.

  10.  It is noted that responsibility for managing further implementation of NPfIT is now being passed down through SHA level to PCT Chief Executives.

Absence of firm plans for introducing clinical aspects of CRS

  The position regarding the all-important clinical functionality of core CRS as at March 2007 is summarized as follows.

  11.  For acute and mental health trusts in the three "iSoft" clusters (North West and West Midlands, North East, and East). The 10 trusts who have taken iSoft's interim solution, iPM, have the opportunity to deploy its clinical counterpart, iCM, to obtain at least some core CRS clinical functionality in the medium term. Those waiting for Lorenzo—the vast majority—must wait probably until 2010-11, always assuming, of course, that Lorenzo development is completed.

  12.  For acute trusts in the two "Cerner" clusters (London and South). Little core clinical functionality is available until Release 1 of the anglicised Cerner Millenium product is available, timeframe as yet unclear. Fundamentally, however, Millenium is a clinically rich, proven product working successfully in the USA and at other overseas locations

  13.  For mental health trusts and PCTs in London Cluster. Considerable core clinical functionality is potentially available from the RiO product (see paragraph 8)

  14.  For mental health trusts and PCTs in Southern Cluster. Fujitsu, the LSP, is only offering Cerner solutions: therefore little core clinical functionality until Cerner development available, timeframe unknown.

  15.  GPs will continue in the medium term to enjoy the strong clinical functionality in their current standalone GP system. NPfIT's initial intent for the longer term was that the core systems being provided by the LSPs to the other care settings would also be deployed for GPs but this strategy has now been superseded by the GP System of Choice concept. My understanding is that there will shortly be a formal EU procurement which will result in CfH contracting with a number of GP system suppliers from whom GPs will then be free to choose.

The original CRS vision is being lost

  16.  The delay and continuing uncertainty of the timescale for introducing core clinical elements situation described in paragraphs 11 to 14 means that even if things go well from now on—by no means assured—it will only have been possible to deliver a fraction of the intended clinical functionality by the time NPfIT contracts expire.

  17.  But that is not the only concern. The central purpose of NPfIT to provide a Local Care Record with detailed clinical information and functions such as ordering tests and information easily and immediately available across all local care settings—GP, out-of-hours service, community, mental health, acute hospitals—is being lost. With GPs having, in effect, opted out no LSP will be able to deliver the original intent of NPfIT of a single, truly integrated system. Nor in reality does there appear much prospect of single systems serving the subset of acute, mental health and community applications. Fujitsu in the South cluster and CSC in the North West and West Midlands, North East, and East continue to cling to this ideal but in fact their respective software suppliers are nowhere near being able to deliver it. BT in London which is currently achieving relatively the most success in terms of introducing functionality of use to clinicians (referring to the RiO implementations) has done so by ignoring the original contracted plan to provide a single suite of integrated software and introducing a standalone system for PCTs and mental health trusts entirely separate from the Cerner system for acute trusts.

  18.  Local CRS will remain a collection of independent systems, not in any sense joined up, unless steps are taken to introduce what is usually termed in IT-jargon as an "integration engine", the function of which is to sit over standalone systems and expedite information sharing between them. No plans such plans have been announced. (The National Spine, it should be noted, is designed neither to contain detailed clinical information nor to provide the facility, for example, for GPs to order hospital services such as pathology tests, and is therefore not suitable for this integration engine function.)

Benefits delivery

  19.  Connecting for Health is focused on delivering the systems. As and when software that supports clinical functions is introduced it becomes essential if expected benefits are to be obtained that all NHS organisations get to grips with the management of change. To begin with it requires commitment at trust Board level, commitment which it has to be said is increasingly lacking as confidence in Connecting for Health's ability to deliver ebbs. Assuming this can be turned round, there is then the need for resource not only in the form of funding but also in freeing local staff time. First and foremost it requires local "clinical champions" to be made available at grass roots level. These people have to be allowed significant time away from their normal day-to-day duties to take charge of winning local support and actually making things happen. It requires a number of senior administrators and clinicians to think carefully through changes to processes and procedures. It requires all staff to be released for training. It requires organisations to be given the "space' in their perform targets over the period of change. It requires some measure of external, expert facilitation. Particularly in the current financial climate it remains unclear where this resource is to come from.

  20.  In 2002 the Department stated[110] that "we will work closely with the Modernisation Agency to change working practices so that IT is used effectively". The Modernisation Agency ceased to exist in March 2005.

CONCLUSIONS

  21.  The Local Care Record Service in the North West & West Midlands, North East, and East clusters is dependent upon iSoft successfully completing the development of Lorenzo. According to present plans, mass deployment of the patient administration (PAS) element of Lorenzo will begin in the 2009-10 timeframe, presumably with the all important clinical elements to follow, say, from 2010-11. Given iSoft's track record in developing Lorenzo and the company's unresolved financial problems, the Department cannot be confident that this timescale will be met.

  22.  Implementation of the Local CRS cannot be said truly to have begun at any NHS organization in the North West and West Midlands, North East, and East clusters. The majority of acute and mental health trusts have implemented nothing. Some 10 acute and mental health trusts and a considerable number, around 50, PCTs have deployed as an interim measure an old, pre-NPfIT iSoft PAS known as iPM. iPM has successfully filled an immediate administrative need and with the addition of iCM may provide some clinical functionality albeit primarily for acute trusts only. Organisations which have implemented iPM have not, however, taken any meaningful step towards CRS because moving from iPM to Lorenzo (assuming Lorenzo development is completed) would not be a simple upgrade but would in fact take on many of the characteristics of a full PAS replacement.

  23.  There is now a real indication that Cerner is coming good for acute trusts in the South and London clusters and that deployment of clinical functionality in the Millenium product will quickly follow that of the PAS deployments achieved so far. But it must be emphasised that as yet the delivery of clinical elements of CRS for acute trusts has not begun, nor has any timetable for doing so been published.

  24.  It is not known when Cerner plans to develop functionality within Millenium for mental health and community (PCT) applications. Until such time mental health trusts and PCTs in the South cluster will not be able to begin implementing CRS. They have, however, been able genuinely to set out on the CRS path in London because BT, the LSP, has adopted the CSE Servelec product, RiO, as its strategic solution rather than wait for Cerner development. Incidentally, the approach adopted in London reveals what an opportunity is being lost, particularly to PCTs, in the North West & West Midlands, North East, and East clusters with the decision to use iSoft's iPM/iCM systems as interim solutions when much more clinically rich alternatives are available.

  25.  The key objective of CRS to provide a seamless service across all care settings—GPs, community, mental health and acute hospitals—is in danger of being lost now that the original intention to have a single integrated system in each cluster has been abandoned. It has been agreed that GPs can have their system of choice; and, at any rate in London, an additional core software supplier has been brought in to provide for the specific needs of mental health trusts and PCTs. Whilst there is little doubt that a solution can be found, there are as yet no plans for how a cross-organisational, joined up CRS is to be obtained.

  26.  There is no evidence that NHS organisations are committed to changing working practices in order to reap the benefits of CRS as it begins to be deployed.

SUGGESTIONS ON THE WAY FORWARD

  27.  Before formulating any suggestions for the way forward it is worth observing that the following principles have been established by Connecting for Health:

    (a)  that a non-performing software supplier will not be tolerated: witness the dismissal of IDX from the Fujitsu-led LSP consortium in South cluster;

    (b)  that an LSP can have more than one core software supplier: witness BT now using CSE Servelec in addition to Cerner;

    (c)  that trusts may be offered choice: witness plans for establishing a catalogue of additional systems suppliers. [111](My understanding is that CfH may be intending that this catalogue be used only for non-core systems but there is no reason in principle why choice should not also be available for core CRS.)

  Bearing in mind the principles set out in paragraph 27 and the conclusions of paragraphs 21 to 26 the following questions need to be asked and the results of more detailed investigation acted upon.

  28.  What is the benefit to the NHS in keeping iSoft as core CRS software supplier to CSC in the North West & West Midlands, North East and East clusters given the company's inability to date to deliver any CRS systems and that the future availability of Lorenzo is by no means assured? Even if iSoft is retained, why are NHS organisations not being offered the option of an alternative supplier with a more proven product?

  29.  Should both other LSPs (Fujitsu and CSC) be encouraged to follow BT's example in bringing a specialist supplier of mental health and community (PCT) applications into its consortium?

  30.  Can funding from NPfIT can be justified for any further implementations of iSoft's interim iPM solution given that iPM cannot truly be said to be a step towards CRS? In the event that Lorenzo development is not successfully completed, what would be the consequence to those trusts and PCTs which having already implemented iPM are now tied in to iSoft?

  31.  Should the putative catalogue of additional systems be extended to core systems thereby enabling local communities to choose the core CRS supplier or combination of suppliers of their choice? Would so doing create a greater feeling of local ownership and thereby help obtain commitment to changing working practices in order to reap the full benefits of CRS?

  32.  Can the current LSP contracts be reassigned from the Secretary of State to SHAs or PCTs in order to give those now being given responsibility for implementing NPfIT systems the full authority and power to enable them to succeed?

  33.  Might the Local Information Strategy (LIS) plans developed under "Information for Health', the national programme that preceded NPfIT, provide guidance on achieving cross-organisational information sharing? (It should be noted that LIS work was very much focused on sharing information across entire local health communities and that a number of local communities were well on the way to getting systems in place when projects were put on hold in 2002.)

  34.  Some of the questions in paragraphs 28 to 33 overlap; all are difficult to answer. A working party should be set up as a matter of urgency. It should be chaired by a senior member of the Department. It should be drawn from expert witnesses who have made submissions to the Health Select Committee and to the Committee of Public Account's pending report on NPfIT, representatives of the NHS at SHA and trust level, representatives of Connecting for Health.

Alan Shackman

March 2007










107   Connecting for Health Business Plan 2005-06. Back

108   The way in which information on the progress of implementation is presented in the Connecting for Health website is poor. Users are directed to the individual Clusters' sites for detailed data. Such data, however, either does not appear or is in too summary a format. It is not possible, for example, to obtain detail of which precise elements of the Local Care Record Service has been implemented, and where and when. Back

109   "We have secured bank funding until late 2007, but it is clear that if the business is to prosper we must soon put in place long-term funding arrangements", quote from Chairman's report, iSoft interim results 11 December 2006. Back

110   "Delivering 21st Century IT Support for the NHS", Department of Health, 2002. Back

111   As reported in E-Health Insider on 1 March 2007. Back


 
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