Memorandum submitted by Thomas J Brooks
I am writing to offer evidence to the Committee
of Public Accounts on the National Programme for IT in the Health
Service (NPfIT).
I am a management consultant who specialises
in supporting the effective management of healthcare. I have worked
with the NHS in England, Wales & Scotland and with health
& social care in Hong Kong, Singapore, Norway and the USA.
Between 1995 and 1997, I was seconded to the NHS Executive in
Leeds where I led the NHS Number project, the last successful
national IT based project to be delivered fully in England and
Wales. I have first hand experience of the national programme
for IT, through supporting trusts in various parts of England
to improve their NHS IT services despite the challenges thrown
up by Connecting for Health.
As well as being a member of the Worshipful
Company of Information Technologists Medicines and Health Panel,
I am a member of the all party Parliamentary IT Committee where
I serve on the programme committee assisting MPs and Peers with
their liaison with healthcare bodies and organisations. However,
I write this letter in an entirely personal capacity.
I have read the paper produced by Richard Bacon
MP & John Pugh MP entitled "Information Technology In
The NHS: What Next?" I strongly support the approach suggested
in their paper in respect of the provision of IT systems and services
to local NHS trusts. However, I question whether MPs have fully
understood the scale of the national "spine" infrastructure
issues. I also make observations in this letter on the poor quality
of the negotiation of the NPfIT contracts by Mr Granger and his
team and the resultant effect of the inadequacy of the negotiated
contracts.
THE REPLACEMENT
OF LOCAL
SYSTEMS AT
HOSPITALS AND
GP PRACTICES
The view that central procurement would produce
systems that met local requirements was indeed a fundamental error.
Globally the real value of IT systems to healthcare is realised
when IT is available at the point of care to support the care
of the patient presenting. The freedom of GPs to select their
own systems from 1995 onwards built on this approach. GPs selected
systems whose style suited their manner of interfacing with the
patient presenting. Clinicians in hospitals also need a system
that suits their style of working and the range of services that
they provide. Clinical preferences in one hospital are rarely
identical to those expressed by their neighbouring hospitals.
Choice at the local level is essential.
Three London hospitals "opted out"
of the national programme from the beginning. Homerton University
Hospital Trust and Newham University Healthcare Trust both deploy
Cerner Millennium. Their implementation is at a much more advanced
state than any trusts in the National Programme. The same is true
of University College Hospital London that selected and installed
the IDX system independently of the National Programme.
In each of these cases the NHS Trust contracted
directly with the system manufacturer. Local choice and implementation,
together with a direct supplier relationship, unencumbered by
the having to work through an LSP and a Connecting for Health
Cluster Office, has proven to be the more successful route.
There is no evidence to date that LSPs have
added any value to the national programme and a cluster wide contract
has not delivered any identifiable benefits
None of the local Trust systems delivered to
date by the LSPs have any meaningful clinical support software
in use. The software modules delivered so far focus largely upon
patient administrative tasks. There are no timescales published
in either the Connecting for Health Cerner release schedule or
in the iSoft Lorenzo system schedule for when each specified clinical
support feature will be released. Nor is there a published description
of what each clinical support feature will actually contain if
it is eventually released.
There are systems available with strong clinical
point of care support features. The industry assessor, KLAS Enterprises,
lists eleven "fully assessed" vendors of systems that
are marketed as strong in clinical support features, including
the Cerner and the IDX products of course. The iSoft Lorenzo system
is not listed. The list includes Misys, a British owned company
and McKesson, which has a well established British customer base.
This demonstrates that there is a considerable quantity of choice
of system available to local trusts.
THE CENTRAL
INFRASTRUCTURE
MPs are mis-informed if they view the central
infrastructure as "making reasonable progress". The
delivery promises for the three application areas that depend
on the central spine (choose & book, the care records service
and e-prescribing) have all been missed. As a means of creating
a pretence that choose & book targets are about to be achieved,
a range of semi-automated alternatives has been launched.
The key central infrastructure item was planned
to be the patient data repository. In the view of many informatics
engineers this has been doomed from the start. Connecting for
Health has never been able to define and publish any detailed
data architecture for the patient record depository and for local
records.
One option considered was to hold only a national
record for each patient. This would include all of the patient's
healthcare history in electronic format. Every NHS and social
care organisation nationwide would be able to share access to
the patient's details through this national record.
A calculation of the potential size of such
a record structure, made during the procurement process, showed
it was beyond that realistically implementable on current technology.
Further, a calculation of the volume of messages that would need
to be supported if everyone in the NHS depended upon a central
patient data depository for their patient records, also provides
a performance demand well beyond the capability of current day
technology.
Connecting for Health has not published any
calculation details that it has made to demonstrate that the scale
of the implementation is technically achievable. The NASP contract
for the "spine" signed with BT is understood never to
have warranted that it could handle a fully detailed central patient
data depository
The current proposal for shareable patient records
on the "spine" is an ill-defined fudge. The detail of
what patient data items would be held on the national spine has
changed frequently and only a "first step" "summary"
is defined currently. Clinicians are broadly agreed that the current
"first step" "summary" detail is of extremely
limited value to them.
One challenging question is whether clinicians
should rely upon the data in their local records when a patient
presents or rely on the nationally held detail. Which is the more
likely to be correct and which should take precedent when the
details are not identical?
MATCHING THE
NPFIT ARCHITECTURE
WITH THE
NHS ORGANISATION
The national spine was an ill-conceived venture
in that it does not support adequately the legal framework of
the national health service in the UK, nor does it have parallels
overseas.
There is no corporate body called the NHS. The
1977 Health Act clarified the legal relationship between the patient
and the national health service as that between the patient and
the (family) health authority. The core of that legal relationship
was preserved in the subsequent health legislation. Each patient
is registered with one, and only one, primary care trust. The
primary care trust is responsible for providing the patient with
a GP, and with a dental practitioner. The primary care trust maintains
contracts with a range of GPs and with dental practitioners. (It
also maintains contracts with community pharmacists and ophthalmologists.)
The primary care trust receives an annual sum
per patient registered with it from which to commission and pay
for the patient's care. The primary care trust contracts with
a range of acute, mental health, children & `older people'
and other care service providers for elective healthcare for the
patients registered with it. The primary care trust is at the
heart of financial management in the NHS.
The annual capitation contribution is weighted
by age, deprivation and many other factors. The primary care trust
has the responsibility for ensuring that what it spends on health
care for its patients balances the needs related funds that it
receives for those patients. The primary care trust, similar to
the health maintenance organisation in the USA and provident funds
in some commonwealth countries IS the hub of the care delivery
process. Yet under the national programme central infrastructure
arrangement, the primary care trust plays no significant role.
If the next attempt to modernise patient care
and administration in England centred upon the primary care trust
and its legal relationship with its patients, the resultant information
and IT architecture would so closely model most parts of the world
that many `off the shelf' software solutions become immediately
available.
THE INADEQUACY
OF THE
NPFIT PROCUREMENT
Computer Weekly revealed in May 2004, that "only
five months after the deal was signed" it had "run into
contractual issues". Quoting from a leaked BT document, CW
reported the issues as arising from "detailed definition
of requirements and practical deployment not envisaged at the
Effective Date of the Agreement".
The reason that BT (and other LSPs) faced up
to "detailed definition of requirements and practical deployment
not envisaged" is that after the contracts were signed, the
Contractors had to produce a substantial amount of detail on an
"agree to agree" basis. In different contracts, post
signature documents were required for "Service Level Specifications",
Help Desk Interworking Procedures', Detailed Annual Implementation
Plans, Component System Descriptions, Quality Plans, Disaster
Recovery Plans, Module testing plans and specifications, etc,
etc. The NAO did not appear to uncover the extent of the contractual
holes at contract signature nor to examine how much the absence
of these documents in early 2004 led to the subsequent rescheduling
and delays.
The NAO complimented CfH for delivering the
advantages of "swift procurement". But the NAO's own
report demonstrates the extent of the inadequacy of the CfH procurement,
which was undertaken in haste with the commercial deal still not
agreed fully when the contract signatures had dried.
The delivery details for the National Data Spine
contract had to be "reorganised and replaced" as early
as December 2004. The core care records element of the Accenture
contract was revised "into four releases" the last of
which was "13 months later that the original target date".
CSC customers fared even worse with a "five release"
rescheduling, the last element of which will be nearly two years
late.
Nor was the quality of analysis work undertaken
by the procurement team impressive. During the procurement the
Cerner solution, which was included in a shortlisted consortium,
was examined and rejected. Apparently it was considered to be
less suitable than the other computer software offerings. The
once rejected Cerner is now the `great hope' of Connecting for
Health.
The implementations in the southern cluster
to date (Nuffield Orthopaedic Centre, Weston and the delayed Milton
Keynes implementation) have demonstrated how difficult it is to
`build' and implement Cerner Millennium without very close interaction
between Trust clinical staff and Cerner technicians in Kansas.
The LSP and Cluster team structure gets in the way of that necessary
very close interaction.
The iSoft "Lorenzo" offering was selected
from paper descriptions with minimal demonstrations of prototype
software elements. Lorenzo is still not available from the development
laboratories in India. When it is ready, iSoft have stated that
they will evaluate it first in Germany and Singapore. Neither
of these two countries requires solutions that mirror England.
A full examination of all the procurement facts
would illustrate that the procurement process and the LSP contractual
structure was the root cause of many of the problems that exist
today.
5 November 2006
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