Appendix 1—Scope of Functionality
in LSP Contract (Eastern Cluster)
Note: Please refer to the PDF for an improved rendition of this table.
EXHIBIT
D
Evidence demonstrating that the National Programme
is operating outside the bounds of accountability
Background: The National Programme's
£6.2 billionn budget for IT supplier contracts was secured
from HM Treasury on the back of local NHS approvals. Each local
Trust Chief Executive was asked to approve the content of each
Phase of the National Programme. Thus, in 2003, each Chief Executive
was asked to sign a letter showing their approval for Phase 1
of the Programme, including its content and its deployment timetable.
The NP promised that further Phases (their content and timetable)
would also be approved by the local NHS, after all, these systems
were being procured on their behalf.
However, only Phase 1 was ever signed-off by
the local NHS and no further requests for approval of subsequent
Phases, were sought by the National Programme. This despite the
fact that the National Programme is already implementing Phase
2 elements.
Evidence: The document shown below is
the ATP2 letter, drafted by the NP, for London Cluster and shows
that an undertaking was made by the NP to go back to local management
for subsequent phases. (This document is available on the Royal
Free Hospital Trust website www.royalfree.org.uk).
The following quote is taken from this document:
"This local full business case agreement
for the first phase of ICRS implementation (and national elements)
is being completed and requires agreement across London before
a contract can be awarded to the preferred LSP. Approval is required
by the London ICT Programme Board (21 October 2003), London Trusts
(17 October 2003), and Department of Health and HM Treasury (by
21 November).
Future phases of ICRS will require further locally
developed ATP cases."
Problem: The problem is future phases
of ICRS (the previous name for Local CRS) have proceeded to be
developed by the LSPs across all 5 cluster WITHOUT THE EXPRESS
APPROVAL OF LOCAL NHS TRUST CHIEF EXECUTIVES. In fact, critical
decisions about the content, scope and delivery times for all
phases of the LSP contracts are being made by the NP management,
without any recourse to the local NHS senior executives or clinicians.
This means that the taxpayer monies, that were
originally appropriated in 2003 for IT systems on behalf of local
Trusts, are now being applied by NP senior managers without any
further involvement of the local Trusts. The local Trusts do not
know therefore what they are getting and when and most importantly,
what they are not getting but were expecting as part of the initial
scoping of the LSP specifications (see the Eastern Cluster's schedule
of 59 modules in part one above.
As the NAO report has demonstrated, no one is
in a position to assess the performance of the National Programme
except the National Programme themselves—and this means
they are only accountable to themselves.
How is it that Chief Executives of local NHS
Trusts are under such close scrutiny for their performance, including
public Board meetings, internal and external auditors and various
levels of management line reporting, when the NP senior executives
only seem to be accountable to themselves?
This is particularly wrong when one compares
the level of taxpayers' monies each is responsible for: the NP
controls some £12billion, including £1.6 billion to
run themselves and paying for expensive management consultants
for long periods of time, without any scrutiny. The NHS Trust
will control considerably less than this amount with far greater
levels of scrutiny.
What is needed is an open framework of accountability
whereby:
(a) what is to be delivered is confirmed
to local NHS leaders
(b) any changes to the scope is done with
the approval of local NHS leaders
(c) performance of the NP is measured against
the baseline targets set in the LSP contract schedules.
EXHIBIT B
Evidence demonstrating that the benefits required
by the NHS to justify the business case in the LSP contracts are
unlikely to be delivered
Background: The Eastern Cluster Business Case
(Approval to Proceed 2) (attached) contains explicit reference
to the benefits that were needed to justify the investment in
LSPs. In particular, the implementation of "cross-organisation"
(eg systems operating in an integrated way across separate acute
trusts) and "cross-setting" (eg systems operating in
an integrated way across primary, secondary and mental health
sector organisations) systems was required as essential benefits.
On pages 92 to 95 of this document, the text
shown below entitled "Qualitative comparison of benefits—Should
Cost v LSP" is provided in the Economic Case section of the
ATP2 for the Eastern Cluster.
Qualitative comparison of benefits—Should
Cost v LSP
1. The previous discussion was concerned
with justifying the total quantum of expenditure on ICRS core
functions. While that discussion indicates that there is likely
to be substantial financial benefit from the LSP solution over
and above that available from the should cost option, the empirical
evidence estimating such benefit is largely acute based.
2. A qualitative approach has therefore
been adopted to the comparison of "should cost" and
LSP cases and benefits have been scored by assessing the extent
to which the "should cost" and LSP options scenarios
would deliver the investment objectives described within the Strategic
Case, as a basis for comparing the Should cost option with the
LSP solution.
3. This has been achieved by using a weighting
and scoring system, the results of which are presented below.
4. The LSP option presents a clear advantage
over the "should cost" option in terms of the ability
to meet investment objectives and so deliver the overall benefits
sought.
Figure 1—Benefits—Should Costv LSP
| |
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|
|
|
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|
|
Individual Trust
procurements
("should cost") |
Cluster ICRS
procurement |
|
Overall aim + subsidiary
"SMART" objectives |
Notable ICRS phase 1 & 2 functionality
required locally |
Relative
weight |
Raw
score |
Weighted
score |
Raw
score |
Weighted
score |
Commentary |
1. Improve the experience of patients at all stages of care from the initial contact, through referrals, to scheduled treatment and back home as described in the NHS plan |
By 2005, patients should expect that an NHS organisation providing care already have any existing demographic information it needs for care to hand. They should only be asked to confirm personal demographics (name address etc). Any changes that are made to this record should automatically update the record for any future episodes of care. |
Integration across cluster organisations, and with PDS, Spine
| 9 | 1 | 9 |
3 | 27 | Cross boundary issues likely with 'should cost'
|
| From 2005, patients will be able to securely access their own records through a range of channels.
| Many components plus integration across cluster organisations
| 5 | 1 | 5 |
2 | 10 | More difficult with 'should cost' to provide access to comprehensive records
|
| From 2006, every patient requiring an elective procedure will be given a choice of provider, whenever it is practical, depending on the patient's condition and treatment required, in accordance with National policy.
| Integration with
e-bookings | 7
| 1 | 7 | 3 |
21 | High risk with "Should cost" of lack of integration between primary and secondary care and within each care setting
|
| From 2005, every patient requiring an outpatient clinic or day case appointment will be provided with a confirmed date, time and place, at the time of referral or through the booking management service, in accordance with National policy.
| Integration with
e-bookings | 7
| 1 | 7 | 3 |
21 | High risk with "Should cost" of lack of integration between primary and secondary care and within each care setting
|
| From 2007 all test results (Pathology and Radiology as a minimum) should be held electronically (Including those tests that are performed at remote locations from where the patient's treatment is performed).
| Order entry, results reporting | 9
| 2 | 18 | 2 |
18 | Risk will remain in place for both options as it will rely on total integration
|
| From 2007 all order for all tests should be recorded electronically. Including those tests that are performed at remote locations to where the patient's treatment is preformed.
| Clinical correspondence, assessments, scheduling, results reporting, PACS
| 8 | 2 | 16 |
3 | 24 | Higher chance of information falling between the cracks with 'should cost'
|
| From 2007, patients who need to make a series of visits for investigations and treatments, will be able to agree and book a mutually convenient schedule of contacts, based around the clinic, theatre schedule of the relevant clinicians.
| Scheduling, E-booking | 7 |
2 | 14 | 3 | 21
| Risk with "Should cost" of lack of integration between primary and secondary care and within each care setting
|
| From 2007, clinical interventions should never be postponed to another date because the information required for treatment is unavailable in electronic format.
| Scheduling, Results Reporting, Order entry |
6 | 2 | 12 | 3
| 18 | Medium risk for "should cost" of systems not all being integrated
|
2. Improve the quality of care by enabling standards to be implemented across the NHS and Clinical and Social Care networks
By 2006, patient level information will routinely be available to support clinical governance relating to NSF's which span care settings.
| Decision support as part of ICPs, order entry, Clinical correspondence etc.
| 9 | 1 | 9 |
2 | 18 | Risk with "should cost" of systems not all being integrated
|
| By 2007, ICRS will have had a significant impact in reducing the impact of clinical error. This will arise from the improved quality of records and access to them, legible clinician orders and use of defined order sets, together with the increasing use of clinical decision support.
| Clinical correspondence, Order Entry, Decision Support, results reporting
| 10 | 2 | 20 |
3 | 30 | Some risk with "should cost" of information not being available regarding previous tests conducted at another organisation
|
| By 2010, ICRS will have reduced the number of avoidable adverse incidents arising from medications management.
| e-prescribing | 9 | 2
| 18 | 3 | 27 |
In "should cost" some risk of not picking up interactions with drugs recorded on other organisations' systems
|
| By 2006, investigations will not need to be repeated because information relating to earlier tests is not available in electronic format. (Pathology and Radiology as a minimum).
| Results reporting, clinical correspondence |
9 | 2 | 18 | 3
| 27 | Some risk with "should cost" of information not being available regarding previous tests conducted at another organisation
|
| By 2005, provide all clinical staff will have the infrastructure made available to them to quickly and easily access the latest evidence and best practice.
| Access to electronic reference material |
9 | 3 | 27 | 3
| 27 | Both options will provide this functionality
|
| By 2007, patient's medical records from their registered GP practice will be available to clinicians at an acute or community hospital where routine medical treatment is provided
| Many components plus integration across cluster organisations
| 8 | 0 | 0 |
2 | 16 | High risk for "Should cost" due to legacy systems and lack of spine record
|
3. Enable effective access to clinical and administrative information across care providers and locations to support NHS clinical priorities
By 2007, a summary of a patient's recent medical history from acute or community hospitals will be available to clinicians at within the community.
| Integration across cluster organisations + with PDS, Spine
| 8 | 1 | 8 |
3 | 24 | More difficult with "should cost" to provide access to comprehensive records
|
4. Reduce the fragmentation of care through improved consistency and coherence of systems and records
By 2005, provide clinical staff with fast and convenient access to the summary of previously electronically recorded healthcare interventions delivered (regardless of by whom) for any one patient and to the detail about patients in their care and which are held on the National Spine.
| Integration & messaging across cluster organisations + with PDS, Spine
| 5 | 1 | 5 |
3 | 15 | More difficult with 'should cost' to provide seamless information exchange during referrals, discharges & transfers
|
| By 2010, General Practitioners and others actively providing care (eg within a clinical network) will be able to access and maintain a consistent and detailed patient record irrespective of care location.
| ICPs within and between organisations | 8
| 1 | 8 | 3 |
24 | More difficult with "should cost" to provide integrated pathways across different organisations
|
| By 2008, ICRS should contribute to a 25% reduction in nurse's administrative workload.
| Many components plus integration across cluster organisations
| 6 | 2 | 12 |
3 | 18 | More risk with "should cost" due to lack of full integration
|
| By 2008, ICRS should contribute to a 20% reduction in doctor's administrative workload.
| Many components plus integration across cluster organisations
| 6 | 2 | 12 |
3 | 18 | More risk with "should cost" due to lack of full integration
|
| By 2006, significantly reduce the time spent obtaining missing/lost patient information during referrals, discharges and transfers
| Clinical correspondence, integration across communities
| 5 | 1 | 5 |
2 | 10 | More difficult with "should cost" to pull together information from different organisations
|
5. Improve health policy development and health research through increased availability, improved quality and speed of retrieval of data
By 2010, facilitate the operation of multi-disciplinary and multi-organisational integrated care pathways
| Facilities for the abstraction, management and reporting of information
| 3 | 2 | 6 |
3 | 9 | More difficult with "should cost" to pull together information from different organisations
|
| By 2008, provide up to date, accurate and fully anonymised patient data for policy development where the source data is less than 3 months old at time of making it available.
| Facilities for the abstraction, management and reporting of information
| 5 | 2 | 10 |
3 | 15 | More difficult with "should cost" to pull together information from different organisations
|
| Total |
| | 246 |
| 438 | |
Key to relative weighting
| | Key to raw score
|
| 1 = least important | 0 |
Does not deliver goal at all |
| Through | 1 | Low delivery of goal
|
| To | 2 | Medium delivery of goal
|
| 10 = most important | 3 |
Maximum delivery of goal |
Problem: What is clear from this text is that the
benefits of the LSP solution (versus the "should cost"
meaning what would have been done if an LSP was not used but instead
a more traditional procurement approach taken), were highly centred
around "cross-organisational" and "cross-setting"
information systems being implemented by the LSP (see last column
in their table).
However, it is also clear that the current National Programme
approach to implementing Local CRS systems is purely "single-organisation"
based and not at all oriented towards "cross-organisation"
and "cross-setting" approaches. This means that one
of the main "radical" and innovative benefits of the
National Programme, which was intended to justify the high cost
of the contracts, will not be delivered by the Programme.
It is important to note that the National CRS Spine record
will not deliver these benefits as they require functionality
only available with Local CRS solutions containing the full and
detailed patient record and advanced and intelligent functionality,
as opposed to the Spine record, which is just a passive "bucket"
or repository of what will only ever be a subset of the patient's
medical record.
EXHIBIT C
Evidence demonstrating that the National Programme mis-managed
the implementation of the Local CRS solution at the first Southern
Cluster site and caused preventable local disruptions
Background: The Cerner solution was implemented at
the Homerton and Newham NHS Trusts in London in September 2004,
as part of a local NHS contract which pre-dated the National Programme
LSP contracts. The implementation encountered many difficulties
(reported in the London Evening Standard at the time), to the
extent that the local Primary Care Trust was forced to declare
a "Serious Untoward Incident (SUI)" as a result of the
fact that critical data for monitoring clinical activity by the
two trusts were made unavailable for several months and the Trusts'
paediatric outpatient waiting lists were persistently breached.
It was known at the time that the Cerner system did not have a
suitable reporting module, for producing the necessary activity
reporting to the local PCT and national bodies, and yet the local
managers decided to proceed with the implementation.
In December 2005, over a year later, the same Cerner solution
was implemented at the Nuffield Orthopaedic Centre (NOC) in Oxford,
as the first deployment of the Cerner solution in the National
Programme's delayed roll-out programme for Southern Cluster. It
is known from sources within the National Programme, that the
decision to go-live before the end of the 2005 calendar year was
politically motivated (ie the NP wanted to show a "success"
to counter the mounting delays to the Programme's implementation
schedule), despite internal concerns about readiness of the Cerner
product at the local trust.
In the event, the implementation at the NOC encountered very
similar difficulties to that of the London Trusts and, remarkably,
a Serious Untoward Incident was also declared as a result. An
investigation into the problems behind the SUI at the NOC was
apparently instigated but its report was never made public, despite
its importance to other Southern Cluster trusts.
Evidence: The report of the investigation into the London
Trusts' Serious Untoward Incident is available on the Newham PCT
website: www.newhampct.nhs.uk on pages 182-218.
Problem: The problem here is that, because of the politically
driven motives to show results "at any cost", the National
Programme management (a) failed to learn important lessons, as
documented by the report shown above, about shortcomings in the
Cerner software from the Homerton and Newham implementation in
2004, and (b) demonstrated poor management judgement by deciding,
despite such documented warnings, to implement the system at the
NOC thereby causing preventable deleterious effects on the patients,
staff and management of the NOC in 2005.
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