Written evidence from the Department of
Health
SECTION 1—INTRODUCTION
AND CONTEXT
Introduction
This document is a follow-up to the Public Accounts
Committee (PAC) hearing on 23 May 2011 into the NHS National Programme
for IT.
The structure of this document is as follows:
— Section
2: notes requested by the PAC.
— Section
3: responses to written questions received
from Mr Richard Bacon on 19 May 2011.
— Section
4: additional clarifying notes provided
to the PAC.
— Section
5: the Department's formal response to
a letter sent to the PAC on 26 May 2011 by the Chairman of CSE
Healthcare Systems.
Context
The National Audit Office (NAO) report entitled "The
National Programme for IT in the NHS: an update on the delivery
of detailed care record systems", was published on 18
May 2011. This report was not agreed by the Department.
The PAC hearing took place on 23 May 2011 to consider
the NAO report. The PAC recognised that the majority of the National
Programme had been delivered and the focus of the hearing was
on the detailed care record systems, where progress has been more
disappointing.
SECTION 2—NOTES
REQUESTED BY
THE COMMITTEE
2.1 Note on Central Programme Costs
Figure 3 (page 7) of the NAO report sets out total
expenditure on the Programme, including what it describes as "programme
management" costs of £1.19 billion. The PAC requested
a breakdown of these costs which are not all programme management
costs but include activities such as testing and deploying systems,
technical design, finance and commercial management, as well as
organisational overheads such as buildings and IT. Industry averages
suggest that programme management costs typically account for
10-20% of the total cost of a programme of this scale and complexity.
The table below provides a breakdown of central costs
by type, including the itemisation of legal costs requested at
the PAC hearing.
Figure 1
EXPENDITURE ON NPFIT (AT 2004-05 PRICES)
| | Total Acutal Expenditure to 31.03.11
| 2011-12 forecast | 2012-13 forecast
| 2013-14 forecast | 2014-15 forecast
| 2015-16 forecast | Total Programme Cost
|
| Category | (£m)
| (£m) | (£m)
| (£m) | (£m)
| (£m) | (£m)
|
| Internal Staff | 262 | 38
| 37 | 25 | 21 |
21 | 405 |
| External Contractors | 267 |
15 | 11 | 9 | 7
| 7 | 317 |
| External Consultancy | 83 |
8 | 4 | 3 | 3
| 3 | 104 |
| Supplier Contracts | 53 |
40 | 18 | 9 | 6
| 6 | 131 |
| Buildings | 67 | 7
| 8 | 7 | 8 |
7 | 104 |
| IT Costs | 53 | 4
| 2 | 2 | 2 |
2 | 65 |
| Legal | 36 | 7
| 7 | 7 | 7 |
8 | 74 |
| Income | (4) | (1)
| (2) | (1) | (1)
| (1) | (10) |
| Total Central Programme Costs | 817
| 119 | 87 | 62
| 54 | 52 | 1,190
|
| Total Programme Costs | 6,354
| 1,084 | 1,179 | 918
| 797 | 1,068 | 11,400
|
Central Programme Costs as % of
total
| 13% | 11% | 7%
| 7% | 7% | 5% |
10% |
This reduction represents a 25% saving in central programme costs
(down from £1.599 billion to £1.190 billion) since the
last NAO report in May 2008 and represents a 46% reduction in
central expenditure from 31 March 2010 onwards.
Figure 1
DEFINITIONS
| Category | | Definition
|
| Internal staff | | Permanent staff salary costs plus associated costs, for example training and travel.
|
| External Contractors | |
Professional services temporary resources plus associated expenses which includes admin and clerical, interim managers and specialist contractor within established departmental posts.
|
| External Consultancy | |
The provision of management, objective advice and assistance relating to the strategy, structure, management or operations of an organisation in pursuit of its purposes and objectives. Such assistance is provided outside the business as usual environment when in house skills are not available and will usually be time-limited.
|
| Supplier Contracts | | Non LSP third party supplier costs for direct frontline service provision, for example IT Hosting and Rental charges and the Public Information Programme contract.
|
| Buildings | | Rent, rates and associated costs for accommodation for NPfIT resources.
|
| IT Costs | | Internal costs associated with Hardware, Software and Licences for NPfIT resources.
|
| Legal | | Legal fees to support the NPfIT contracts.
|
| Income | | Invoiced income received for National IT Services provided to the Department of Health and NHS organisations by the Systems and Service Delivery team on a not for profit basis.
|
2.2 Note on the Costs of Millennium in the South "Greenfield"
Sites relative to London
Purpose
At the Public Accounts Committee on 23 May the Chair requested
a note on why the Department disagrees with the National Audit
Office conclusion that the price of Cerner Millennium in the three
"Greenfield" sites in the South is 47% higher than in
London.
Extract from the Summary of the NAO Report
"The costs of delivering three care records systems in acute
trusts under this contract are some 47% higher than the cost of
delivering the same system in London, although BT advises that
the system is being delivered in a different way" [page 10,
paragraph 14].
Departmental Response
The Department does not accept the NAO statement that the price
of Cerner Millennium in the South is 47% higher than in London,
as the NAO is not comparing like with like.
The NAO comparison was based on London CCN2, which the Department
believes is an inappropriate baseline as:
— The
BT delivery model for Cerner has evolved significantly in the
three year period between London CCN2 (May 2007) and the agreement
of the Greenfields CCN (March 2010).
— The
Greenfields trusts were of a significantly bigger scale and complexity,
had a different underlying technical solution and had richer clinical
functionality than delivered to London trusts under CCN2.
The Department believes that, although still difficult
to draw a direct comparison, a more representative baseline would
be London CCN3 which was agreed during March 2010, along with
the Greenfields CCN, and had a similar delivery approach and core
functional scope. If average prices are compared (noting the Departments'
view that taking an average is a crude comparison as all trusts
are different) then the NAO would have noted that the unit price
of the Greenfields is 24% less expensive than London CCN3 (£23.6
million as compared with £31 million) with the primary difference
in price being that the London deal included optional, additional
functionality such as; pathology, radiology, pharmacy stock control,
electronic document management, clinical dashboard and clinical
benchmarking which trusts would be charged for additionally under
the Greenfields contract. BT's cost model at CCN3 was independently
verified by KMPG who concluded in November 2010 that "BT
has provided sufficient underpinning evidence to support the agreed
delivery costs".
2.3 Note on the Verification Exercise relating
to the costs of RiO
Purpose
At Question 224, the Public Accounts Committee asked
for "a clear written account" of how the value for money
of the RiO prices was assessed.
Assessing the value for money of the RiO prices was
part of the CCN3 negotiation process. This note explains that
process and the subsequent verification exercise carried out by
KPMG.
CCN3 Negotiations Process
The CCN3 negotiation process was lengthy and involved
many iterations challenging the component parts of the BT cost
model. This included ensuring that rates offered were competitive
and that the effort ascribed to various activities was justifiable.
Taken together, competitive rates and reasonable
effort comprise value for money. BT was required to provide numerous
iterations of financial models. These models were reviewed in
detail by the Authority, resulting in multi-million pound savings.
The Authority negotiated reduced day rates on all
of the BT labour within the contract. In addition, BT's profit
margin on the contract was also significantly reduced. Other commitments
were also obtained by the Authority, in particular around sub-contractor
pricing; for example, Cerner has confirmed that the pricing provided
to the Authority (via BT) is the best it provides to any of its
customers.
The Authority then requested further financial assurances
and agreed with BT that a requirement of signing CCN3 would be
that a verification exercise would be conducted by third party,
independent financial experts (KPMG).
KPMG Verification Exercise Process
In October 2010 KPMG were requested by the Authority
to verify the costs presented by BT, including those for RiO,
in the CCN3 Financial Model.
The approach adopted by KPMG was as follows:
— Their
work focussed on the Cost Data sheet within the CCN3 Financial
Model and was conducted on a sample basis, designed to provide
a high coverage of costs with a reasonable sample size.
— The
cost elements for potential duplicate entries were reviewed.
— The
cost rates associated with BT labour were validated to cost rate
cards and payroll records.
— The
hours presented in the Model associated with BT labour were reviewed
for reasonableness.
— Sub-contractor
and other supplier costs were validated to the agreements entered
into by BT with their suppliers.
— Cost
elements and supporting documentation requested from BT were sampled
to substantiate the costs provided.
Conclusion of the Verification Exercise
On 3 November 2010 KPMG concluded that "BT has
provided underpinning evidence to support the agreed delivery
costs" and that "no proposed adjustments are required
for Agreed Delivery Costs".
2.4 Note on the Listening Exercise
Purpose
The Public Accounts Committee asked for a note (Question
276) about the responses received as part of the "listening
exercise" in respect of the National Programme for IT.
Departmental Response
The Department can confirm that it has not had any
responses relating directly to, or mentioning, the National Programme
for IT. There have been a very small number which note the need
to harness IT to facilitate information flows, but these tend
to be generic references.
SECTION 3—RICHARD
BACON QUESTIONS
AND ANSWERS
DETAILED CARE
RECORDS SYSTEMS
3.1 What are the maximum payments to which
NPFIT would be exposed for contract cancellation of the detailed
care records systems, for each of the LSP providers?
We are not able to reveal specific numbers as that
is likely to lead to suppliers expecting those amounts should
we attempt to terminate for convenience. Also, at this stage,
all figures are subjective, although they are informed by our
experiences with Fujitsu.
The maximum payments would occur if the whole
of the contracts were cancelled for convenience. In that scenario,
taking into account contractual costs, potential damages to suppliers,
the costs to procure replacement systems, transition costs, the
costs of "uplifting" ongoing services, legal and professional
fees, we believe that the maximum payments could be
in excess of the currently anticipated costs to complete the BT
and CSC contracts.
If we were to terminate in part (only services for
Acute) then the maximum payments might reduce by approximately
50%.
These costs do not include the deployment or operational
costs of any new systems that the NHS would need to procure. The
NHS cannot continue without replacing the systems now covered
by these contracts.
The categories are explained as follows:
— Contractual
costs: The minimum amount the supplier is allowed to receive under
these circumstances.
— Damages
paid to suppliers: This would include covering some of the suppliers'
unrecovered costs to date and pre-accrued claims at the point
of termination.
— Transition
and Uplift Costs: The costs of providing the ongoing services
post termination. It is likely that suppliers will seek to increase
these ongoing costs in an attempt to improve their financial position
(Fujitsu, for example, doubled the service charges claiming they
would turn the systems off unless we paid).
— Procurement
of replacement systems costs: The costs of running the procurement
for the live services to be supported and developed.
— Legal
and professional fees: The costs of supporting the termination,
transfer and investigation of the facts around termination.
Wider Impacts
Both BT and CSC have been clear that they are not
willing simply to walk away. Therefore, it is safe to assume that
some form of dispute will occur and that both suppliers will seek
to recover costs. Legal advice provided to the Department indicates
there is a risk of some unquantifiable "collateral damage"
to the Fujitsu existing claim and the risk of suppliers working
in unison against the Department is significant.
Delivery of replacement or new services would also
be required, and the time taken to procure can be extended by
factors outside of the Department's or Trusts' control.
3.2 Have you now ascertained the cost of RiO
outside of the National Programme and compared it to the cost
within the National Programme?
We have obtained comparative data from three trusts
(as set out in Figure 2 below), which have purchased RiO outside
of the National Programme: Bradford District NHS Care Trust, a
mental health trust; Somerset Partnership NHS Foundation Trust,
also a mental health trust, and Nottinghamshire Healthcare NHS
Trust, which provides mental health, learning disability and community
health services, as well as managing two medium secure units and
the high secure Rampton Hospital near Retford.
Figure 2
COMPARATIVE ANALYSIS OF RIO COSTS
| Bradford District Care Trust
| Nottinghamshire Healthcare NHS Trust
| Somerset Partnership NHS Foundation Trust
| Trusts provided by NPFIT |
| Deployment Charge | 590K |
1596K | (see note 1) | 1395K
(see note 2)
|
| Annual Service Charge | 160K
| 335K
(see note 3) | 139K
| 353K |
Total Cost
(over a normalised 48 month term)
| 1230K | 2936K | 556K
| 2797K |
Notes:
1. There was no deployment charge as a special development
relationship existed between CSE and the trust.
2. Deployment charges for RiO vary from £925k to £1.6m
depending on care setting and software version. The figure provided
is an average.
3. Nottingham has additional specialised modules of functionality
because of the services provided by the trust.
Figure 3
COMPARATIVE ANALYSIS OF RIO SERVICE OFFERINGS
| Bradford District Care Trust
| Nottinghamshire Healthcare NHS Trust
| Somerset Partnership NHS Foundation Trust
| Trusts provided by NPFIT |
| License | For contract term
| For perpetual use | For contract term
| For contract term |
| Hardware | No | No
| No | Yes |
| Hosting | No | No
| No | Yes |
| Application Support | Yes |
Yes | Yes | Yes
|
| Disaster Recovery | Partial
(see note 4)
| Partial
(see note 5) | No
| Yes |
| Spine connectivity | No |
No | No | Yes |
| Product Development | No |
No | No | Yes
(see note 6)
|
Notes:
4. The disaster recovery process is managed by the supplier
on trust owned and managed infrastructure which is capable of
holding 25% of the capacity of the live service.
5. The disaster recovery process is managed by the supplier
on trust owned and managed infrastructure.
6. There has been significant product development already
funded through the NPfIT. This will continue and trusts have the
ability to influence enhancements to the RiO software with 3,
significant, trust defined, functional upgrades to the deployed
software included in the price.
Summary
None of the trusts consulted had purchased the same RiO product
offering and all trusts varied significantly from the offering
provided to NPFIT trusts, making a direct price comparison difficult.
However, trusts within the programme typically had significant
advantages to those outside the programme, namely:
— The
ability to influence the functionality of the product.
— Centrally
provided and hosted hardware.
— Centrally-provided
disaster recovery with 100% capacity and availability.
— No
additional development costs for subsequent releases.
— Spine
connectivity.
BT estimate that the monthly charge for hardware,
disaster recovery, service management and Spine connectivity to
be in the region of £42,500 per month or just over £2
million of value over a 48 month contract term.
Additional Functionality
Furthermore the NPFIT investment in the development
of the RiO has significantly enhanced the functionality of the
product to the benefit of all trusts. Examples of functionality
in the latest deployed version (v5) and soon to be deployed (R1,
2011) of RiO include:
— Standard
assessment forms.
— Care-plans
and reports.
— Spine
connectivity, enabling integration with central demographics services,
and functionality to support smart cards and role based access
controls.
— Waiting
lists.
— Results
reporting.
— Prevention,
screening and surveillance.
— SNOMED.
— Inpatient
prescribing.
— Functionality
to support multi-disciplinary care planning.
CERNER MILLENIUM
A NORTH
BRISTOL, OXFORD,
AD BATH
3.3 How much is NPfIT paying in total to deploy
Cerner Millennium at each of the following 3 sites: North Bristol,
Oxford, and Bath - inclusive of licence, hosting/central
infrastructure and deployment charges?
3.4 What is the annual cost, every year for
the remainder of the BT contract, for each of the 3 sites?
The table below provides the overall cost, inclusive
of licence, hosting/central infrastructure and deployment charges,
of deploying Cerner Millennium at North Bristol, Oxford and Bath.
Figure 4
GREENFIELDS ONE-OFF AND RECURRING COSTS
| £'000
|
| Bath | Oxford
| North Bristol | Total
|
| Overall cost | 21,000 | 23,800
| 24,300 | 69,100 |
| Deployment charge (one off) | 13,100
| 15,700 | 15,200 | 44,000
|
| Annual service charge (£/y) | 1,700
| 1,900 | 2,000 | 5,600
|
| Forecast service months | 56
| 51 | 54 | |
The service charge for North Bristol is higher (despite having
fewer users than Oxford), as the Oxford infrastructure is shared
with the Nuffield Orthopaedic Centre NHS Trust (ie a shared domain).
Service charge is payable only for the months that the system
is in use (i.e. it is not a fixed charge).
3.5 What will the annual cost be for each of the 3 sites
after the BT contract finishes?
This figure is to be determined, as it would be subject to a separate
procurement exercise. It will be determined by factors including:
— Whether
the Trusts' procurement results in the Trusts staying with Cerner
Millennium.
— Whether
the systems are transferred to a new hosting provider.
— Whether
the Trusts wish to continue being part of a consortia where there
are synergies and therefore cost reductions by sharing certain
support services between trusts, or "go it alone".
— Whether
they wish to maintain the very rigorous service level agreements,
with penalty payments where services are not met.
— The
usual reduction in the total cost of IT ownership over time.
3.6 What original delivery dates were given
for each of the 3 sites when the BT contract reset was first signed?
3.7 How many changes have been there been
to those delivery dates for each of the 3 sites since then? Please
list.
3.8 What are the current planned go-live dates
for North Bristol, Oxford, and Bath?
The table below provides answers to each of these
questions:
Figure 5
DELIVERY DATES FOR THE "GREENFIELDS"
SITES
| Bath | Oxford
| North Bristol |
A) Outline delivery date agreed with BT at contract reset, prior to local detailed
planning
| 28-May-11 | 10-Sep-11 | 04-Jun-11
|
| B) Formally contracted delivery date following local detailed planning
| 01-Jul-11 | 19-Nov-11 | Yet to baseline
|
| C) Current planned delivery date | 29-Jul-11
| 19-Nov-11 | Yet to baseline |
| Number of changes in delivery date (between A and C)
| 2 | 1 | 2 |
| Variation between formally contracted and current delivery dates (between B and C)
| 1 month | None | N/A
|
| Planned project duration from project start to go-live
| 16 months | 20 months | 21 months
|
The implementation of a Cerner system is a significant change
management exercise within a Trust. Accepted good practice for
the IT element within a large scale change programme is to determine
the dates as part of the wider planning exercise. Fixing dates
too early and driving to meet those dates can introduce unnecessary
risk to the project. As the project progresses dates move from
being tentative (or "outline") to becoming fixed as
part of a detailed implementation plan.
When the dates have been fixed in the detailed implementation
plan, the supplier can be penalised for failure to meet the date—similarly
the Department of Health would be penalised if the slip was caused
by an NHS Trust.
Outline delivery dates were agreed with BT at the point of contract
reset reflected by point A in the table above—these delivery
dates were not contractually baselined at that stage. Dates were
contractually baselined following detailed planning between the
Trust and the Supplier and these are reflected by point B above.
This method of agreeing implementation dates is in line with best
practice on large IT programmes
Historically, Oxford and Bath had initiated projects with Fujitsu.
Changes at Bath
1. Detailed planning led to the outline delivery date of 28
May 2011 being contractually baselined at 1 July 2011.
2. On 15 April 2011 BT notified the NHS of a delay to the
project resulting in a re-baselined delivery date of 29 July 2011.
Contractual delay deductions in the order of £500K have been
applied to BT for this delay.
Changes at Oxford
1. Detailed planning between the Trust and the supplier led
to the outline delivery date of 10 September 2011 being contractually
baselined at 19 November 2011. There is not expected to be any
financial implication from this change.
Changes at Bristol
1. The detailed planning led to the outline delivery date
of 4 June 2011 being revised to 2 July 2011, but this was not
formally baselined and is now subject to further revision. This
change was as a result of the Trust wanting to move an interim
milestone that would impact the go-live date. This was in part
due to the Trust receiving a Delay Event Notice issued by BT in
September 2010. BT have, to date, not associated any cost with
this Delay Event Notice.
2. Detailed re-planning discussions are currently ongoing
between the supplier and the Trust to establish a new contractual
delivery date.
Comparisons of delivery timeframes
By comparison in London, Kingston took 18 months, St Georges took
18 months, and Imperial is forecast to take 20 months. All these
durations exclude the delays caused by the four month "pause"
in London deployments between Oct 2008 and January 2009, following
the Royal Free go-live in July 2008.
Outside of the programme, where Trusts have contracted either
directly with Cerner or via a third party (such as University
Pittsburgh Medical Centre), deployments take a similar duration.
Newcastle took 19 months to go-live and the Wirral took 24 months
after contract signing.
COMPUTER SCIENCES
CORPORATION
3.9 How many iSoft iCM licences i) have been paid for by
NPfIT since it began? And ii) at what total cost?
The answer provided to this question includes iPM, as well as
iCM licenses. iPM was deployed in Primary Care, Mental Health,
Acute and Tertiary settings between April 2005 and August 2010.
To date the Authority has procured a total of 6 iCM licenses and
83 iPM licences. Within the current contract, the Authority has
paid £1.4 million for all 89 iCM and iPM licences combined.
This covers the licence cost until iCM and iPM are de-commissioned.
Figure 6
DEPLOYMENT AND SERVICE CHARGES FOR IPM
| Cluster | Deployment Charge per site (£'000)
| Annual Service Charge per site (£'000)
| Total Annual Service Charge (£'000) for all IPM Deployments
| Acute | Mental Health
| PCT |
| NE | 470 | 226
| 1,353 | 22
| 14 | 47
|
| NWWM | 500 | 152
| 8,156 | | |
|
| EEM | 564 | 274
| 4,111 | | |
|
| Average | 511 | 217
| 13,621 | |
| |
Figure 7
DEPLOYMENT AND SERVICE CHARGES FOR ICM
| Contract | Deployment Charge per site (£'000)
| Annual Service Charge per site (£'000)
| Total Annual Service Charge (£'000) for all ICM Deployments
| Acute | Mental Health
| PCT |
| NE | 564 | 113
| 113 | 5 |
0 | 1
|
| NWWM | 610 | 78
| 234 | | |
|
| EEM | 564 | 108
| 216 | | |
|
| Average | 579 | 100
| 563 | | |
|
As can be seen, the contracted costs vary by Cluster. As clusters
were originally offered as individual contracts, potential contractors
offered discreet bids for each individual region that reflected
the contractor's view of charges necessary to recover their costs
and achieve margin. An average value is included above for simplicity.
The total cost of deployment and service charges of these interim
systems to end March 2011 is approximately £105 million.
The local cost of a deployment of iCM is approximately £150,000
and the estimated local cost of an iPM deployment is £5 million.
3.10 When will the next Lorenzo go-lives take place? And
at which sites?
There will be no decision on the next Lorenzo site to go live
until after the outcome of the Major Projects Review is known
by the Department.
We do know that there are 80 Trusts in the North, Midlands, and
East of England whose PAS systems will become unsupported in the
next 2-3 years and who will, therefore, need either to extend
non-strategic systems or re-procure systems.
3.11 What is the demand for Lorenzo?
The original contract committed 223 Trusts to take NPfIT systems
in NME. This includes 161 Trusts committed to Lorenzo. In December
2010 we wrote to you saying that, at that time, the Memorandum
of Understanding (MoU) expectation was that these numbers would
reduce to 187 Trusts taking systems, with at least 127 expected
to take Lorenzo. These numbers were based on returns from the
SHA CIOs. We would expect to repeat this exercise if the terms
of the MoU are accepted by the Department.
3.12 How many Trusts are signed up to take Lorenzo?
Under the current contracts in the North East & North West
and West Midlands, 161 Trusts are committed to take Lorenzo. The
East and East Midlands Cluster does not have a commitment due
to the contract's non-exclusivity in that Cluster.
3.13 How many will sign up to take it? How do you know?
The number of Trusts that will take Lorenzo is under review as
part of the current MoU discussions with CSC. We have previously
carried out a consultation exercise with trusts to establish demand
and we would expect to repeat this exercise if the terms of the
MoU are accepted by the Department. The Department is clear that
demand will depend on the quality of the product.
3.14 How long does it take to deploy Lorenzo at one site?
The deployment "cut-over" takes a weekend.
The deployment project, which delivers all the necessary local
design, build, testing, data migration, and related clinical and
process change, varies in duration depending on the size of the
organisation, the scope of the deployment, and its complexity.
The actual project durations for the three Release 1.9 Lorenzo
Care Management deployments to date have been:
— Bury
PCT: Project Initiation Document (PID)
Sign Off—March 2009; Care Management—Go-Live—03
November 2009; PID to go-live duration 8 months.
— University
Hospitals Morecambe Bay: PID Sign Off—February
2009; Care Management—Go-Live—31 May 2010; PID
to go-live duration 15 months.
— Birmingham
Women's Hospital: PID Sign Off—January
2009 but Project Engagement started March 2010; Care Management—Go-Live—31
October 2010; PID to go-live duration 22 months, Project engagement
to go-live 8 months.
Evidence from CSC's delivery of other products suggests
that these timeframes will be reduced as CSC refines its delivery
process in the light of lessons learned from previous deployments.
Delivery timeframes for Lorenzo modules:
The Lorenzo product is designed to be deployed in
modules or stages. The list below shows the expected time to deploy
these modules.
— Care
Management, Mental Health, Care Plans and Inpatient Prescribing
(IPP) deployment units each have a deployment profile of 12
months.
— Request
and Results is 11 months.
— Clinical
Documentation is eight months.
— To
Take Out (TTO) and Advanced Bed Management is six months each.
— Day
Care is four months.
— Emergency
Care is four months (with Care Management).
Comparative Data
Cerner Millennium Deployments—by
comparison, Cerner Millennium deployments in London at Kingston
took 18 months, at St Georges 18 months, and Imperial is forecast
to take 20 months. All these durations exclude the delays caused
by the four month "pause" in London deployments between
October 2008 and January 2009, following the Royal Free go-live
in July 2008.
Outside of the programme, where Trusts have contracted
either directly with Cerner or via a third party (such as University
Pittsburgh Medical Centre), deployments take a similar duration.
Newcastle took 19 months to go-live and the Wirral took 24 months
after contract signing.
Pre-NPFIT Projects—the
South West Shires Consortium May 2003 implementation plan assumed
an average roll-out of 30 months per Trust.
The Kensington, Chelsea and Westminster Business
Case in April 2002 for the implementation of IDX included a "strategy"
stage of 3-12 months, a procurement stage of 18-24 months and
an implementation stage of 21-42 months.
SECTION 4—ADDITIONAL
NOTES PROVIDED
TO THE
COMMITTEE
4.1 Note on Role Based Access Control
Introduction
The aim of this paper is to clarify answers given
(in response to questions 173-186) at the Public Accounts Committee
hearing on 23 May in respect of access to care records.
The different types of health records discussed in
this paper include:
— detailed
care records held locally;
— records
held in prescription, referral and other local systems; and
— Summary
Care Record of key information which can be accessed anywhere
in England should a patient need treatment away from home, out
of hours or in an emergency.
Detailed care records
Every NHS organisation keeps a detailed record of
every patient they care for.
There is more than one single electronic health record
for each patient—these records used to be a combination
of electronic and paper but increasingly they are becoming electronic.
The majority of electronic detailed care records
held by NHS organisations in England are stored in iPM, SystmOne,
Lorenzo, Cerner, RiO and EMIS.
Summary care record
Patients have a choice whether or not to have a Summary
Care Record (SCR). Every patient aged 16 and above is written
to at least 12 weeks before any information is sent to the Summary
Care Record from the patient's GP practice record. Any patient
who chooses to opt out will not have an SCR created.
Access to records
Regulatory bodies have made it clear that they expect
the NHS to put in place the strongest possible safeguards. The
commitment to achieving this is set out in the NHS Constitution
and in the NHS Care Record Guarantee.
By law, everyone working for, or on behalf of, the
NHS must keep all information about a patient secure. Healthcare
staff have a legal, ethical and, in some cases, professional obligation
to respect patient confidentiality.
These choices may vary between different NHS organisations
depending on the local systems they use. All systems connected
to the Spine have a range of technical controls in place to allow
detailed care records to be safely and securely shared across
NHS organisations.
NHS Smartcards
Healthcare Staff must have an NHS Smartcard (like
a bank card and PIN) to access systems and access to a patient's
medical record is only available to those healthcare staff who
have the appropriate access controls added to their Smartcard.
Staff who do not need to have access to medical records will not
have the appropriate access controls added to their Smartcard
and will not be able to access a patient's medical record.
In order to ensure that Smartcards are issued to
appropriate individuals, Smartcards are issued by Registration
Authorities locally in the NHS, so it is not possible to give
an accurate figure of the number of NHS staff who will have access
to SCRs.
Legitimate Reason
Access to a patient's medical record is only available
to staff with a legitimate reason. This is enforced in the system
through a mix of both stringent technical controls and operational
processes. Access to a patient's record requires a legitimate
relationship to be established in the system, which requires the
involvement of at least two members of staff to register the patient
on the system. Any access without this would generate an alert,
for investigation by the local NHS Privacy Officer, whose role
it is to investigate any inappropriate accesses.
In the context of GPs, each GP practice functions
as a workgroup and will generally have access to the records of
a patient of that practice in the appropriate context (for example,
for a patient consultation). This access is fully audited.
All GPs must use smartcards when interacting with
national services such as the Personal Demographic Service, Summary
Care Record, Choose & Book and Electronic Prescriptions Service.
Smartcards are not mandated for general system access; however,
many GP systems do provide the capability to use the smartcard
as a method of authentication. Additionally, under the Local Service
Provider contract, TPP is obliged to provide smartcard authentication
as the primary authentication mechanism for its GP systems.
Permission to View
Access to a patient's Summary Care Record requires
the patient to give their permission for the clinician to view
their Summary Care Record. Any access that is made without permission—eg
accessing a patient's SCR in an emergency—generates an alert
which is sent to the local NHS Privacy Officer to investigate.
In an acute setting such as a hospital the patient
would consent to the clinical team providing care for them to
have access to their record at the point of entry.
Audit of accesses
All accesses to a patient's medical record are audited,
including the details of the time and date of the access and the
details of the individual who made the access.
Transparency of accesses
Patients can request to see both the information
held about them but also who has been looking at their Summary
Care Record. This commitment to the public is included in the
NHS Care Record Guarantee.
Not all system users can access all information,
for example administrative staff would only be allowed to see
a patient's demographic information. This principle is known as
role based access control (RBAC). These functions are authorised
by the local NHS Information Governance lead known as a Registration
Agent.
User Numbers
The number of users by Cluster is shown in Figure
8.
Figure 8
USER NUMBERS BY NPFIT CLUSTER
| Number of Users |
| North Midlands and East | 200,000
|
| London | 53,000 |
| Southern | 35,000 |
— The
total number of registered smartcard users is currently 843,000.
— The
number of unique users authenticating during March 2011 was 378,811.
— Currently
12,500 staff have the appropriate roles on their NHS Smartcard
to view Summary Care Records.
— A large
Mental Health Trust would have approximately 3,000 users.
— Another
61,721 healthcare staff also access detailed care records using
Ambulance, Child Health, Maternity, digital x-rays and scans (PACS
and RIS), Accident and Emergency, and Theatre systems.
4.2 Note on Clinical Benefits and Exploitation
Introduction
NHS IT systems support the NHS in providing better
care for patients. This document provides practical examples of
how NHS IT systems are being exploited to improve: patient experience,
clinical efficiency, clinical safety, clinical effectiveness,
research and education.
Patient experience
Integrated software allows the doctor to demonstrate
result and diagnostic findings directly on screen to the patient.
As examples, Cerner Millennium can be used to show laboratory
data and to graph sequences of data in front of the patient in
the clinic. This allows the patient to see the effect of a treatment
or procedure and improves both the level of understanding of the
patient as well as their level of engagement.
Using the screen to demonstrate information to patients
is a first step towards patients having control of their own record,
as it improves familiarity and understanding of medical terminology.
Millennium also allows the printing of any page so
that the doctor can share legible and easily deciphered information
with the patient at any point of their journey. Millennium additionally
allows the doctor or nurse to review information from other providers
in the presence of the patient and check accuracy, as well as
developing patient confidence in the medical or care information
held about them.
With patient agreement, it is also possible to add
patient generated digital information, for example, e-mails about
their condition, to the detailed care record.
Healthspace and Communicator (although only available
to a small number of clinicians at the moment) provide a platform
for patients to communicate with their GP or specialist through
a secure e-mail route. The doctor can add information to the patient's
Healthspace account. As an example, a consultant in haematology
at Barts and the London Hospital has a patient on an oral chemotherapy
drug for a chronic bone marrow condition. The consultant sends
blood results to the patient using this route. Other patients
on the move use this route to ask the consultant questions about
their appointments and their condition.
Clinical efficiency
Millennium allows the doctor to review and endorse
GP referrals made via Choose and Book online. In this way the
doctor can redirect the referral if necessary to return it to
the GP with questions or comments. The process is faster than
paper based processes for accepting referrals in secondary and
specialist care.
Clinical staff at Morecambe Bay can also access the
GP records of the specific patients they are treating, as Lorenzo
is connected to the GP system in use locally.
Millennium also provides the clinician (nurse or
doctor) with immediate access to a group of test results. This
includes access to radiology, reports integrated with the PACS
image, other images such as ultrasounds and MRI scans, laboratory
results and patient measurements such as height, weight and vital
signs. Remote monitoring of conditions by testing at home and
uploading via e-mail is now also possible. Immediate access to
patient documentation, such as the referral letter, clinic letters,
discharge summaries and clinical notes is also available through
Millennium.
In summary, the digital record is always available
for clinical consultations at any networked PC within a trust
at any time of day or night. With VPN access the clinical professional
at home can also view the record securely and support decision
making by doctors based at the hospital. This has proved particularly
helpful, for example, at Barts in managing stroke patients in
the stroke unit.
The search for patients through the personal demographic
system has improved patient flows and access to information in
Accident and Emergency departments.
Depth of coding into International Classification
of Disease (ICD)10 codes and Health Resource Groups is improved
by access to problem lists populated with Systematised Nomenclature
of Medicine Clinical Terms (SNOMED CT). As wider use of SNOMED
is achieved through the use of Millennium and Lorenzo the ability
to plan services based on deeper levels of information will develop
rapidly.
Clinical safety
Immediate access to patient information including
coded diagnosis and problem lists improves decision making by
all staff in emergency situations. For example, coding of diabetes
in the digital record aids treatment in the emergency room of
confused or comatose patients. Emergency resuscitation of cancer
patient receiving chemotherapy is also improved by knowledge of
their blood counts.
Lorenzo and Millennium permit the use of Alerts to
manage patients with Infection Control problems such as MRSA and
C.diff, allergy status, vulnerable adults and child safeguarding
needs. At Morecambe Bay, infection prevention is now fully electronic
across the Trust using Lorenzo functionality and in Barts all
patients carrying MRSA are alerted to the clinician using Millennium.
The data is always available day or night.
The Royal Free has also created safety procedure
information in Millennium. For example, there was a serious untoward
incident in the trust, as a result of which bleeding guidelines
are now included in the system. Similarly, endoscopy data is now
held on the system, helping to address the issue that previously
only about a quarter of endoscopy data was available.
The software provides listing functions to support
patient handover at shift change times and to create work lists
for nights and weekends.
The software supports the production of legible and
meaningful discharge summaries for handing over care to GPs and
sharing information with patients and their families. This function
is particularly well developed in the current version of Lorenzo
at Morecambe Bay University hospitals where about 60% of patients
currently are sent home with a software generated summary. This
equates to 1500 Discharge Summaries being produced in April 2011,
compared to only 136 in January 2011.
The software provides tools for endorsing patient
results from the laboratories. This ensures that abnormal results
are not missed or if they are, the practitioner can be identified
and managed.
Patient protocols can be added to the patient record
to be used by any staff for treatment or care management. In Barts,
for example, all occupational therapy assessments are added to
the record. These can be printed out or e-mailed to other practitioners
either within the hospital or in the community. Protocols for
patients with haemophilia, sickle cell disease and multiple sclerosis
are other examples.
Clinical effectiveness
Clinical audit is strongly supported by the creation
of patient lists identifying groups of patients with particular
problems or diagnoses. These lists can be tracked in real time
and offer an immediate way of checking that patients are correctly
investigated and managed.
Patient tracking and outcomes assessment is advanced
by the use of SNOMED Clinical Terms.
The software supports decision making and management
of patients at all forms of multidisciplinary team meetings and
cancer review processes.
Research
Millennium gives the user immediate access to Medline,
an abstracts and research publication database. Searches are initiated
from a recognised clinical term and support both care and research.
The software suites allow the capture and transfer of clinical
data for research purposes.
Databases and protocols can be shared across health
systems to support complex research and network collaborations.
Education
Millennium provides access to BMJ Action sets in
a number of English Trusts. These are real time learning tools
for any grade of doctor and provide the doctor with decision support.
The patient listing functions allows educators to
review groups of similar patients with students on a class room
basis before visiting patients or where patients are only seen
rarely in outpatients. The stored clinical data provides an immediate
source of educational material for medical and nursing students.
Statistics relating to Lorenzo Exploitation at Morecambe
Bay
— 70%
of all staff are trained to use Lorenzo and are smartcard enabled
(4,200 out of 6,000) with a concurrency of 350-400 users at any
one time.
— Lorenzo
supports in excess of 1,200 unique logins per day; greater than
300 of those are by Doctors.
— Approximately
28% of all users login each day.
— In
addition to management and administrative teams, some 1,100 clinical
staff are now using the Lorenzo system at Morecambe Bay to admit,
transfer and discharge patients.
Statistics relating to Cerner Millennium
Exploitation at The Royal Free Hospital
During April 2011, Cerner processed the following
number of transactions:
— 93,655
appointments (3,122 per day);
— 71,906
registrations (2,397 per day);
— 321,320
orders opened (10,711 per day); and
— there
are over 1,300 smartcard enabled active users within the Trust
(700-800 concurrent at peak times).
4.3 Note on Advance Payments and Repayments
Description
Advance Payments are provided to suppliers as a method
to mitigate high financing costs that their projects would otherwise
attract using bank credit, and hence a higher cost to the Taxpayer.
Advance Payments are only made once a value for money
case has been made to the Treasury and their permission granted.
All Advance Payments are made against a Bond (and
Deployment plan) which is guaranteed by a reputable financial
institution, acceptable to CFH. CFH can call the Bond without
recourse to the supplier. No advance payment period exceeds one
year and all advance payments are reconciled at the end of the
term and unearned values are refunded within the term.
Advanced Payments and Repayments to date
The total of advance payments made to 31 March 2011
in respect of all contracts over the whole period of the Programme
is £2,532 million. The total of repayments to date is £1,085
million and suppliers have retained £1,328 million, as deliverables
have been met. The value of outstanding advance payments at 31
March 2011 was £119 million. The table below sets this out:
Figure 9
ADVANCED PAYMENTS AND REPAYMENTS TO DATE
| £ million |
| Total advance payments made | 2,532
|
| Of which: | |
| Total amount earned by supplier | 1,328
|
| Total amount repaid | 1,085 |
| Amount to be earned or refunded as AP not yet expired
| 119 |
SECTION 5—RESPONSE
TO LETTER
FROM CSE
5. Note for the Public Accounts Committee in response to
the letter received by the Public Accounts Committee from the
Chairman, CSE Healthcare Systems dated 26 May 2011
Purpose
Mr Alan Stubbs, the Chairman of CSE Healthcare Systems, wrote
to the Clerk of the Public Accounts Committee (PAC) on 26 May
2011 in response to evidence given by Ms Christine Connelly at
the PAC hearing on 23 May 2011.
This note is a formal response to the points raised in Mr Stubbs'
letter.
General Points
The evidence provided by Ms Connelly at the hearing in respect
of Bradford District Care Trust was based on written information
received by the Department from the Trust on 20 May 2011 in response
to specific questions asked of the trust by the Department.
Ms Connelly also sought, on the basis of the information received
from Bradford, to compare the RiO service provided at Bradford
with the RiO systems provided as part of the National Programme
for IT. She did not state that Bradford was receiving "a
lower standard of service" but did clearly state that there
is not a like for like comparison between the services provided
by CSE directly to Bradford and the services provided by BT to
Trusts receiving RiO through the National Programme for IT.
In order to make a broader comparison, the Department has, since
the PAC hearing, obtained information from two other trusts that
have deployed RiO outside of the National Programme for IT. The
findings are summarised in the answer to Question 2 from Mr Richard
Bacon (please see Section 3 of this document).
Specific Points raised in the CSE Letter
— Ms
Connelly did not state that Bradford does not get 24/7
support. She said, in response to Question 241, that
"we get 24/7 support". By "we", Ms Connelly
was referring to the trusts that take RiO inside the National
Programme
— Ms
Connelly did not state that Disaster Recovery was excluded
from the Bradford service. In fact, explicitly in response to
Question 239, Ms Connelly stated that Bradford do have Disaster
Recovery. However, she went on to point out the limitations of
the Disaster Recovery at Bradford and to contrast this, in response
to Question 241, to the fact that within the National Programme
full Disaster Recovery is provided and that the cost of full Disaster
Recovery is significant. To clarify, Bradford told the Department
that they have "local disaster recovery provision" with
CSE invoking Disaster Recovery remotely, onto local Bradford infrastructure
and that this operates "at 25% capacity". This contrasts
significantly with the NPfIT environment where components are
automatically recovered if they fail and, should the whole environment
fail, it is contracted to be completely recovered within two hours.
— The
Department acknowledges that there was no mention of Facilities
Management. Bradford told the Department that hosting and
infrastructure is provided by the Trust, with 24/7 support provided
by CSE via "dial-in" over N3. In NPfIT, facilities management
is provided directly by BT on infrastructure supplied by BT.
— Ms
Connelly stated in response to Question 237 that Bradford has
a 59 month contract duration, as the Trust told the Department
that their live service runs from 5 May 2009 to 31 March 2014.
— Ms
Connelly's comment re 25% availability, in response to
Question 239, was, as stated above, specifically in the context
of Disaster Recovery, not in respect of the service availability
as a whole. The Department did not request information from the
Trust on operational service levels achieved by CSE.
Figure 10
A COPY OF THE LETTER FROM CSE CHAIRMAN, ALAN
STUBBS.
SUBJECT: PAC meeting 23 May 2011 on the national
programme for the NHS
During the evidence presented by Ms Christine Connelly,
one of our contracts for RiO; Bradford Mental health Trust was
referenced.
Ms Connelly's statement was that Bradford is receiving
a lower standard of service than provided by BT in London and
hence the lower price charged by CSE Healthcare Systems to Bradford.
CSE healthcare Systems wishes to correct the evidence
given.
— Ms
Connelly stated that the services is NOT 24*7 hours—the
service is a 24*7 service.
— Ms
Connelly stated that Disaster Recovery (DR) was NOT included in
the service—a DR services is included.
— There
was no mention of Facilities Management—we provide remote
Facilities Management.
— The
service contract is for five years—not four years as stated.
— Ms
Connelly implied that the system only had 25% availability—our
records demonstrate that this is not true; the system is architected
to achieve an availability of over 99%.
June 2011
| 
