The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee Contents

Examination of Witnesses (Question Numbers 60-79)


16 June 2008

  Q60  Geraldine Smith: Can I also ask what sort of support they will get? They are obviously one of the first of three early adopters. What sort of help and support is there? It is a massive exercise for them in staff training.

  Mr Hextall: It is. They have support from CSC, as the supplier, and iSOFT, who are keen to make sure that the product works. So they are getting a substantial amount of support. Connecting for Health has a deployment support team helping, and the way that the early adopters are doing it in the North, Midlands and East, the two who are next are going to be helping in the Morecambe Bay area so that they can learn the lessons from Morecambe Bay, for Bradford and South Birmingham, who are the next ones to go.

  Q61  Geraldine Smith: I hope there are not too many lessons to be learned.

  Mr Hextall: There are always lessons to be learned.

  Q62  Geraldine Smith: I hope they get it right first time, because it does have such serious repercussions for patient care. Most of the problems we have had in the past in our area are down to poor administration so I think it is essential that we get it right. Is three months enough of a time gap before you start rolling it out to all the trusts? That does not seem very long to me.

  Mr Hextall: If everything went well, it would be enough time. Again, we need to be quality-driven rather than date-driven as far as that release key milestone, that then will sign off the release for the remainder of the trusts to be able to take. If everything goes according to plan, the three months will be okay. It will be clearly monitored on a weekly basis during that period.

  Q63  Geraldine Smith: From the demonstration last week, it did look very good. I hope it works as well as it appeared to in that demonstration. Can I ask, is it just going to be the hospitals that hold this information or is there that link with the GPs, or is it going to be gradual?

  Mr Hextall: It will be gradual. There are four releases currently planned of the Lorenzo software and that is one thing that was a change, one of the lessons from the review that Mr Bacon enquired about that we commissioned last year. The four releases have increasing levels of functionality and the GP integration is in the fourth release, so it is right at the end.

  Q64  Geraldine Smith: What sort of time delay is that? How long are you talking about?

  Mr Hextall: I think it is 2010. I would need to check.

  Mr Nicholson: Spring 2010.

  Q65  Geraldine Smith: One of the things again from the demonstration that I found very useful was that there appeared to be an alert system as well, so there was a lot of information available for GPs who may be prescribing a drug that may interfere with someone's condition that they may not be immediately aware of.

  Mr Hextall: They certainly have elements of prompts and decision support built into the system to try and prevent people doing the wrong thing, yes.

  Q66  Geraldine Smith: Can I ask about security of data, because, of course, everyone is concerned about that. Can you reassure me?

  Mr Hextall: Yes. As with all the Connecting for Health systems, patient confidentiality is ensured by anybody using the system having to access the system with a smartcard, and you can only get a smartcard on production of evidence of identity, typically a passport, and evidence of residence, typically a utility bill. Your smartcard would then contain details of your role-based access, and there are different roles that can be set into the card so you would only be able to use it for the purpose that it was given to you, and again, only if you have a legitimate relationship with the patient. That is the same kind of level of security which is known as e-GIF level 3 in government terminology, which is the highest that we could aspire to.

  Q67  Geraldine Smith: Mr Nicholson, can I ask you, just changing the subject slightly. We touched on trusts doing their own thing, having different systems. I do not think they should be able to. We still have a National Health Service and I think if you have an IT system it should be linked nationally. One of the problems is if you have a great many different systems operating. That is bound to cause problems, I would have thought.

  Mr Nicholson: The way that we are trying to operate is that they will all take the same system in a particular LSP area. I personally have a different constitutional relationship with foundation trusts than I do with NHS trusts. I cannot direct NHS Foundation trusts to take it but what I can do is to make sure that the processes are in place to make it much more likely that they will.

  Q68  Geraldine Smith: Do you think you should be able to direct them?

  Mr Nicholson: All I would say on it is that the only place I have been where they have seriously looked at this is Bradford. They went through a process of looking at the alternatives and came to the conclusion that the national system was by far the best one for them, and they are absolute advocates for it now. By telling them to do something, you would not have got the kind of advocacy and the commitment they have to implementing that they have now. So I think if they come to it under their own conclusion, that is a much more powerful way of taking it forward.

  Q69  Geraldine Smith: Can I just ask about how the Choose and Book system is going? It appeared a bit mixed in my own area. I think people like the booking part. I am not so sure they think there are real choices there or that they want the choice. I am getting into policy areas. How is the actual IT system going?

  Mr Nicholson: The IT system itself works well. In fact, 90% of GP Practices at one stage or another use it. So it does work. I think some of the operational ways that people work underneath it are sometimes quite difficult. For example, if you want to book a date, the implication is that there is a clinic there for you to book, so the hospital has to be absolutely on top of the way that they manage and pre-book clinics. That is not absolutely in place everywhere and it just takes time to make that happen, but it does give you the opportunity, whether you take it or not, to have the kind of choice that people now have through free choice. As you know, people can now choose secondary care, can choose any hospital that will do services at NHS quality for NHS tariff in the country when you are making a referral. So whilst we do not force people, if they do not want to make that choice, it is available and increasingly I think people will take it up.

  Q70  Geraldine Smith: In my experience, people just want their local hospital to be good. They do not want six choices or three choices. They just want their own hospital to be good. That is the priority for them.

  Mr Nicholson: Yes, I agree.

  Q71  Geraldine Smith: Finally, with Choose and Book, what is the feedback from GPs? Are they satisfied with it? Do they think it is going reasonably well?

  Dr Braunold: From my understanding from my colleagues—and I have spent a lot of time talking to my colleagues about Choose and Book—there are those of us who are lucky enough to work in areas where our configuration of our services, our computers on our desks, are working well. Choose and Book is working well for us and I scream blue murder when it is down actually, because I do not like going back to the old system. I like the fact that I know about the different hospitals in London and the different services that are there, and my vulnerable patients, who do not speak good English, are able to leave the room with the date of their consultation with the clinician. We do not have any of that coming back to me, "When is my appointment coming?" There are other colleagues for whom it is not working as well. The local configuration of their computers is not working so well or they have some kind of real objection to doing some of the extra work that I personally believe I advocate to do in my consulting room. I have spoken to a colleague, for instance, a friend of mine, who was actually very anti doing the work, but he was totally transformed by the relationship improvement with his patients of enabling them to get their appointment. So he feels that, even though it takes longer, he prefers to do that. It takes time to move the population of GPs along but the tool is working, the tool is deployed and it works.

  Q72  Keith Hill: Mr Nicholson, this is obviously a fabulous and very exciting programme, which will presumably confer hugely valuable benefits on patients in England. Is it being attempted anywhere else in the world?

  Mr Nicholson: I do not know whether it is. Certainly there is lots and lots of interest in it from Australia, from Spain, from the rest of Europe. We recently had some people over from France. There are lots of people very interested in the way we are doing it but I do not know whether there is actually anywhere else doing it in exactly the way that we are.

  Mr Hextall: From the discussions we have had with other countries, I am sure that everybody is doing the same thing but nobody is doing it on the same scale. Typically, Australia and America are doing it on a state-based system and Switzerland is doing it on the canton-based system but the same functions of having patient information available, electronic booking and the electronic prescriptions ...

  Q73  Keith Hill: It is the sheer scale and centralisation of the National Health Service which makes it possible.

  Mr Hextall: Yes.

  Q74  Keith Hill: Personally, it seems to me very difficult to think of what else would be a more compelling thing that you would want to do for the National Health Service going forward into the 21st century.

  Mr Nicholson: An interesting thing to me is if you take something like picture archiving, which is digital x-rays and all the rest of it. Four or five years ago we were quite behind the rest of Europe in terms of implementation of picture archiving. Now we are the first G8 country to have it completely implemented across the whole of the country, enabling digital x-rays and images to be moved between departments, between hospitals, and between services. We were able to do that because of the nature of the system, because of the way we were implementing it. We would never have been able to do that if we had left it to individual organisations to decide when to do it and how to do it.

  Q75  Keith Hill: When I asked the question first, I deliberately referred to patients in England but we are a United Kingdom and we do still have reasonably porous borders. What are the opportunities going to be for Wales, Scotland and Northern Ireland?

  Mr Hextall: Certainly Wales and Scotland have similar schemes. They were given an opportunity when we placed the adverts for the contract for procurement in 2003 to join in with the national programme for IT, and either were not able to respond quickly enough or had their own ideas. Certainly Wales and Scotland are doing very similar initiatives about making patient information available where it is needed and we are collaborating with both of those jurisdictions at the moment.

  Professor Thick: I attend a European forum of those who are developing electronic records, and I think the general observation is that boundaries are very dangerous places because you go across, you get ill and how are your records going to follow? We are putting a great deal of effort into making sure that the standards that we implement are international, that the summary records that we develop are inter-operable precisely in order to make patient safety the prime issue.

  Q76  Keith Hill: This is all good news.

  Mr Nicholson: I was recently, for a completely different reason, visiting the Armed Forces in Afghanistan. I was in a hospital in Helmand province where they were able to send digital images from the middle of Helmand province right into the University Hospital Birmingham, so that by the time the injured member of the Armed Forces got into the hospital all the images and all the details were with the doctors, which I thought was fantastic.

  Q77  Keith Hill: It is fantastic. It is very sad about the individual soldier of course, but this is very impressive stuff. Let me take you into slightly more detailed questions now, because as the NAO remarks, this will only succeed if you can engage the support and enthusiasm of clinicians and other NHS staff. There are obviously issues which emerge from the NAO report about a certain dissatisfaction—I think you may have alluded to it earlier—about the realism of progress reporting and communications. How can you make progress reporting and communications about the programme more open and realistic to staff?

  Mr Hextall: I must admit I was puzzled when I saw that comment originally in the report but I now understand it, because we have a plethora of information to be able to manage the programme, so from a programme management perspective there is not anything we do not know. What we are not particularly good at is making that available in lay terms so that the public can understand how individual trusts perhaps are progressing. It typically takes 12 months for a trust to prepare and then implement a patient administration system as part of the national programme. There is a lot of preparation, a lot of data migration that needs to happen. We have not been very good at being able to measure that to make it visible. For the future, taking that recommendation on board, we are looking at being able to turn the plethora of information that we use to manage the programme internally into external facing information for the public.

  Q78  Keith Hill: That is for the public but let me just put you an issue which is raised by the NAO about the surveys you do with staff and ask you if there is any significance in the fact that in the latest survey you carried out you decided not to ask staff about how favourable they were towards the programme.

  Mr Hextall: That was the MORI survey, I think. We have done the MORI survey in three waves. In the first couple we asked the same questions virtually, I think. What happened between the first two waves and the third one was that we went through an NPfIT local ownership programme where we were putting more ownership and accountability on the NHS so that they felt they could pull the systems and they owned them rather than feeling that perhaps they were being delivered to them. As part of that process we consulted with the strategic health authorities on what they wanted out of the survey by way of stakeholder engagement and communication to inform their engagement and communications. So the questions were actually formed out of discussions with the strategic health authorities and shaped in that way. So if there was a question dropped, that would be why it was dropped.

  Q79  Keith Hill: Let me turn to something which has already been raised, which is the issue of clinical functionality. How can you convince staff of the benefits of the programme given the limited clinical functionality currently available?

  Professor Thick: You are quite right. In the first implementations in the south it has been disappointing perhaps that there is such a limited amount of clinical functionality in the Cerner product that was deployed. I think that has resulted in great expectations in the clinical community there which have been let down, so they feel cross. Also, if you put in a new PAS system into a hospital you necessarily change the processes of the way people work and, as far as the clinicians were concerned, they saw their everyday work being changed around in a way that they did not understand, and perhaps with a limited amount of consultation. So their perception inevitably was that the system did not work because it did not do what they normally do. We are going to have to turn that around considerably by accelerating the amount of clinical functionality that goes into particularly the south. It is not quite so true in the North because the clinical functionality is there in the first place. We are putting a great deal of effort into making sure it becomes available before then very quickly and in particular, order communications.

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