Fixing NHS IT

A Plan of Action for a New Government John Cruickshank March 2010

ISBN 978-1-907635-04-5

2020health 83 Victoria Street London SW1H 0HW E admin@2020health.org www.2020health.org

Published March 2010 © 2020health.org March 2010

Fixing NHS IT
A Plan of Action for a New Government John Cruickshank March 2010

Contents
Contents About This Publication About The Authors 1. 1.1. 1.2. 1.3. 1.4. 1.5. 1.6. Fig1.1 2. 2.1 2.2 2.3 3. 3.1 Fig3.1 3.2 3.3 3.4 3.5 3.6 4. 4.1 4.2 4.3 4.4 5. 5.1 5.2 5.3 5.4 5.5 Executive Summary Background Key Drivers The Programme in Overview Local Service Providers Under-exploited Opportunities beyond the Programme National/Local IT Services Plan for Action Introduction Background Government’s responsibility for Health IT This Report Where can Healthcare IT Offer most Opportunity? Electronic Health Records Organisational Challenges affecting the CRS Telemedicine Collaboration and Communication Technology Prescribing Value Chain Document & Record Management Shared Services NHS IT / NPfIT in Overview The NHS Needs for IT What NPfIT intended to do The Situation now Guiding Principles for the Future Localised NHS IT The Original LSP Model – in Concept Why have there been such Difficulties? LSP Progress and Recent Developments The LSP way forward What alternatives exist to the LSP model? Architecture Interoperability, Standards and Open Source Delivering Shared Care across Local Health Communities Procurement and Catalogues 4 6 7 9 9 9 9 9 10 11 11 14 14 14 15 A. 17 17 18 19 19 20 21 22 23 23 24 25 27 28 28 29 30 31 32 33 33 35 36 B. C. 6. 6.1 National Infrastructure & Organisation National Infrastructure and Services N3 (Contract: BT 2004-2011) NHSmail (Contract: Cable & Wireless 2004-2013) PACS Spine (Contract: BT 2003-2013) Choose and Book (CaB) (Contract: ATOS 2003-2009) EPS (Contract – part of BT Spine) HealthSpace - and Personal Health Records Future National IT Organisation & Structure Required Future National IT Organisations NHS IT Set-up Appendix: List of Contributors Appendix: Glossary Appendix: Relevant EC Communications on EHRs and Telemedicine The EHR IMPACT Study Telemedicine Appendix: Case Study - Transformation through Collaboration and Communication Technology Appendix: Case Study – Developing an ICP-based EPR system in the Independent Sector Appendix: LSP Recent History & Developments London LSP (BT as LSP) North Midlands East (CSC as LSP) South (formerly Fujitsu as LSP) Appendix: EPR Architectural Options Appendix: Open Source as an Option 39 39 39 39 40 40 42 42 43 44 45 46 47 48

6.2 Fig 6.1

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53 54 54 54 55 56 57 58

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G. H.

About 2020health

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About This Publication
In 2002, the National Programme for IT (NPfIT) was launched with high expectations for how it could improve the delivery of healthcare in the NHS. Eight years on, the Programme needs to be rescued. IT is an essential enabler in improving productivity and patient outcomes but the Programme cannot be fixed by cancelling projects or renegotiating contracts. The new Government would need to assess how to gain the best from IT investment in the NHS as we consider that a hiatus around NHS IT after the Election would be disastrous. In response, 2020health believed it would be helpful if we undertook a short, independent research project to map out an action plan for NHS IT, with a particular focus on NPfIT, to assist policy makers determine the way forward.

About The Authors
John Cruickshank – 2020health NHS IT Policy Chair and Report Author John Cruickshank is an independent expert in NHS IT, having been intimately involved in its development continuously over the last 25 years. His passion for healthcare IT began in the mid 1980s when he project managed one of the first successful NHS implementations of a hospital-wide electronic patient record. As a leading management consultant in the field, he has held leadership roles in the healthcare practices of major systems integrators and consultancies at UK and European level. During the 1990s, he founded, built and sold his own consulting practice, Pareto Consulting, which set the benchmark in independent client-side advice to NHS Trusts and the centre.

We are indebted to all our sponsors for their unrestricted funding, on which we depend. As well as enabling our ongoing work of involving frontline professionals in policy ideas and development, sponsorship enables us communicate with and involve officials and policy makers in the work that we do. Involvement in the work of 2020health.org is never conditional on being a sponsor. Julia Manning, Chief Executive March 2010 www.2020health.org

He has personally advised over 100 different NHS Trusts and acted as a core advisor at a national level to two published NHS IT strategies in the 1990s.

Through his work, he has gained deep experience of NHS culture, processes, people and systems. He also has an in-depth knowledge of the clinical IT market both in the UK and Europe, and of its effective and commercially practical application and implementation in different countries.

John is a graduate in economics and management science from St John’s College, Cambridge. Julian Wright – Supporting Editor and Author After graduating from Oxford, Julian joined ICI's Central Management Services department, rapidly reaching the role of system integration co ordinator of corporate accounting. He then joined Deloitte & Touche, where he provided consultancy services to a range of Healthcare, Central Government, Finance, Utilities and Industry clients. In 1992 Julian joined Cap Gemini with specific responsibilities for Government and Health consulting. In particular, Julian built a major healthcare consultancy business from scratch and was subsequently made responsible for all Public and Healthcare consulting business in the UK.

His personal focus area is IT-enabled business change in the Healthcare, Government and Defence sectors, where he works at senior levels supporting and reviewing transformation programmes, as well as providing strategic advice on change issues.

In 1998 Julian joined a major systems integrator with the remit to build a Government consulting practice, which subsequently merged with the other UK practices under his leadership, taking the team from less than ten to over three hundred. In 2007 he took over the 1100-strong EMEA-wide consulting practice and embarked on a transformation programme to improve financial performance and integrate the disparate groups. He now works as a freelance consultant.

Published by 2020health.org All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the publisher.
© 2010 2020health.org
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- Victoria Street 83 London SW1H 0HW T 020 3170 7702 E admin@2020health.org
2020health.org

Julia Manning – 2020health Chief Executive and Series Editor Julia Manning studied Visual Science at City University and became a member of the College of Optometrists in 1991. She was a founder member of the British Association of Behavioural Optometrists and her work has included being a visiting lecturer at City University, a visiting clinician at the Royal Free Hospital, London and a Director of the Institute of Optometry. Julia ran a specialist optometry practice for people with mental and physical disabilities until August 2009.

The views expressed in this document are those of the authors alone and may not reflect the views of any of the companies or individuals interviewed. all facts have been checked for accuracy as far as possible.
Disclaimer

Julia is a founder and Chief Executive of 2020health.org which she launched in 2006 as the first web-based Think Tank for Health and Technology. It uniquely focuses on bottom-up policy development by front line professionals and focuses on the core areas of public health, technology and sustainability. She has written on many health and technology issues and the history of her profession in 60 years of the NHS [St. James’s House].
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01 Executive Summary
Since the creation of the £12billion National Programme for Information Technology in 2002, the subject of NHS IT in England has been much commented on, not least because of its ambition, delivery record and cost. A new Government would need to assess how to gain the best from IT investment in the NHS and what should be done with the centrally run Programme. There is a risk of a hiatus around NHS IT after the Election.
1.1 Background

In response, 2020health believed it would be helpful if we undertook a short, independent research project to map out an action plan for NHS IT, with a particular focus on the Programme, to assist policy makers determine the way forward. The NHS is shifting more and more to a complex, federated system and away from a centralised hierarchical model. This has profound implications for IT.
1.2 Key Drivers

As the plurality of providers grows, IT becomes a vital prerequisite to enable patient-centric, joined up healthcare services. As care becomes more personalised, patients increasingly want access to their own health records, have control over who has access to them, and exercise informed choice over their care.

The perception that IT projects can be axed, or made successful simply by renegotiating contracts, is entirely false. Unless a new Government genuinely recognises that they must deliver massive change in the way health and care are provided, supported by IT, they will fail again. Localising / fragmenting the existing problems will only make things worse.
1.3 The Programme in Overview

A new Government must work IT planning intrinsically into its policy and strategy (not treat IT as a cost - it is an asset). A constant dialogue is needed on strategy, refreshed at least yearly, linking business / policy plans to IT investment priorities, governance, processes and capabilities that the NHS needs.

The Programme was conceived to address the problems of a highly fragmented IT situation across England. Its central feature is the NHS Care Records Service, with a central core (the NHS Spine, a national database of key information about patients’ health and care) supported by a national infrastructure. The two remaining Local Service Providers are responsible for the delivery of local care records solutions, which connect into the Spine.

While the delivery of the overall vision remains 5 or more years away, the Programme has had some success, especially in delivering infrastructure, defining standards and some local care records.
1.4 Local Service Providers

In retrospect it is clear that the Programme tried to do too much, too quickly, with a limited focus on early winners to gain credibility and acceptance with the NHS. There was a collective failure to get the Programme positioned as an enabler for transforming healthcare services, and gain full clinical engagement and local ownership.

The Programme’s most significant failure lies in acute hospitals where centrally provided solutions have been very late because the NHS does not conform to a ‘one size fits all’ model, and for a mixture of contractual, software delivery and deployment reasons. . There have been successive attempts to make the Local Service Providers model work better over the years through several contract resets, with some improvement. Both contractors are now in further contract resets, due
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01 Executive Summary
for conclusion by 31 March. As a starting point, a new Government must test the contractual arrangements and baseline plans against key criteria that we set out in the main body of the report. Without sight or knowledge of the commercial situation or current state of negotiations, we do not know how close the revised arrangements are to meeting these criteria. quality well ahead of where many are now. Over time, the NHS should therefore address consolidation opportunities, such as rationalising NHS data centres into either large-scale off-site facilities or a “cloud-based” provision, once established and safe. Furthermore, where feasible, IT staff should be organised into shared services aligned to the natural health communities that they serve. i.e. county or metropolitan level, to deliver more critical mass and offer career progression. Going forward these local organisations should take responsibility for strategy, integration with national programmes and play a leading role in the selection and implementation of front-line systems. Our view is a national approach to IT should only be taken when one or more of three principles can be met:
1.6 National/Local IT Services

Irrespective, there are elements of the local solutions that work well (e.g. infrastructure; shared care records in primary and community care; secure data centres) and these should continue in one form or another. In the hospital area, much has been invested in time and money, some sites are operational and we are told that both solutions are close to being fully ready.

The catalogue should be created and coordinated centrally, but be accountable to the NHS. To incentivise Trusts to use the catalogue, partial central funding should be available. Suppliers must show clear adherence to well defined interoperability standards. This would also allow fairness in those parts of the NHS which already fall outside the preserve of Local Service Providers (principally the South). A process is underway to provide local solutions here but there is a risk that contracts may be rushed through, resulting in a sub-optimal solution for the NHS. Adherence to standards here is a critical element but there is as yet no ‘magic bullet’. There is a vibrant community internationally, in which the centre participates on behalf of the NHS. Here we recommend that the centre take a more practical but informed approach, and follow international/ EU standards unless there is an overwhelming case otherwise.

In the event that the new Local Service Provider arrangements do not meet the criteria, the acute solutions should be exposed to competition with the small number of other viable solutions, through becoming part of an acute systems procurement catalogue. Local health communities could call-off what they need based on their own capability, maturity, starting point and plans.

• • •

to avoid redundant variation for infrastructure and back-office solutions on a once and once only basis; to provide economies of scale, associated with using NHS purchasing power; to meet the ‘national’ nature of NHS patient care, through essential central coordination or regulation, e.g. standards, security.

A new Government needs to consider carefully the potential of:
1.5 Under-exploited Opportunities beyond the Programme

• • •

telemedicine (to provide remote access to specialised care, extending the reach of clinicians into the domestic care setting, improving service and overall efficiency);

National IT organisation(s) would be needed to deliver relevant services in support of these principles. The presumption is that they should have a limited remit and be performance managed by the NHS. They need to exhibit a culture of transparency, pragmatism, and learning / promulgating lessons to support NHS-wide ITenabled change. A small, linked organisation is also needed to interpret policy as a bridge with the Department of Health and set a national direction for IT. Beyond this, and respecting any nationally agreed contracts already in place, local NHS organisations should be free to set their own strategy to take advantage of national assets, with far greater emphasis on local choice of front-line systems. A single IT strategy must be set at the local health community level (i.e. to match the scope of the local IT organisation - e.g. county-based), as opposed to a free-for-all which would be impractical. Foundation Trusts would not be mandated to participate but would be encouraged, in order to meet the local healthcare strategy.

A new Government would wish to do an urgent stock-take of NHS IT projects, assets and organisation against these principles and we set out specific recommendations in Figure 1.1. It shows our recommended plan for action for NHS IT for the new administration’s first 12 months in office. The timetable is explicitly tight, since long drawn out reviews are not what is required. We do not have access to accurate costing information, but believe the recommendations in totality will save more than £1bn and accelerate improvements to patient outcomes.

collaboration services (network technology, enabling productivity & mobility, as a platform for improving working practices); electronic document records management (scanned paper medical records).

Finally, the nature of the current provision at local NHS IT level is highly-fragmented, with limited resilience against failure. If the NHS is to get value out of IT, local IT services need to be transformed to a scale and
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Although the Programme is helping to address the matter of improving the prescribing value chain (i.e. the electronic linkage of patients, prescribers, dispensers and the reimbursement agency), a review is needed to secure clinical and administrative benefits in a timelier manner than the current plans.

In each case pilots have taken place and there is a need to define a national strategy based on best practice in the UK and elsewhere, including both technology and process change aspects. Where appropriate, enabling national infrastructure would need to be procured and/or establish call-off catalogue arrangements as required.

The totality of IT provision must support the delivery of joined-up care. The emphasis must be on technologyenabled service improvement aligned to the core process of delivering care to improve patient outcomes, as opposed to an over-emphasis on technology.

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01 Executive Summary
(The references relate to specific recommendations in the main report. The benefits to be derived from the activity are shown in italics.)
Figure 1.1 Plan for Action Theme Accelerate benefits 0-3 months
6.G Deploy no-cost patient access to GP systems, where practical (enable personalised care) 3.C Review, simplify (where feasible) and accelerate Electronic Prescriptions Service (back office savings, reduced fraud and wastage, patient safety) 3.B Leverage immediate opportunities for collaborative technology, using Nottingham as a case model (patient throughput and experience in A&E, clinical productivity)

3-6 months
3.D: Accelerate adoption of case notes scanning and record technology in hospitals. (clerical & clinical productivity, patient experience – fewer wasted visits from lost notes)

6-12 months
3.A: Telemedicine: Establish a national framework on how best to exploit its potential, based on best practice in the UK and elsewhere (patient experience and control over own care, remote access to clinical specialists, clinical productivity) 3.C Prepare coherent strategy to bring together a unified prescription record across primary and secondary care (patient safety, monitoring effectiveness nationally of treatment programmes)

Theme Enabling local IT

0-3 months
5.C: Interoperability and standards: Ensure centre is taking a practical, informed and transparent approach, adopting international/ EU ones unless there is an overwhelming case otherwise (enabling interoperability and local choice of systems)

3-6 months
5.B: Integration technologies: Initiate research and pilots to test out the viability and impact on business case of different local approaches (flexibility of IT approach, enabling market innovation, cost savings) 5.E: Local Health Communities: Review and establish best practice for local shared care records (patient safety and experience, clinical and clerical productivity) (6.E)

6-12 months
5.D: Open Source: Commission research around the potential of clinical Open Source solutions in the NHS, with a view to exploiting its potential in the medium term (improve collaboration, cost savings, transparency, remove high barriers to entry for innovative suppliers) 3.E: Local IT: Assess potential from consolidating NHS data centres and other local infrastructure management (4.A, 6.I) (economies of scale, improved service) 3.E: Local IT: Assess potential from consolidating local IT staffing (4.A, 4.B, 6.I) (economies of scale, improved service, more career progression for IT staff)

Develop & exploit

Retain and restate commitment to key national infrastructure: N3, NHSmail, PACS, Spine (excepting the Summary Care Record- SCR) (exploit sunk investment)

6.A: N3: Ensure N3 is capable of meeting bandwidth and other capability needs in the medium term, for exploiting telemedicine, collaborative technology etc (3.B) (platform for future) 6.B: NHSmail: Ensure the current and future service meets the needs of the largest Trusts. (reduce redundant variation across NHS) 6.C: PACS: Develop national business case on extending PACS into other imaging modalities, and to enable image sharing across NHS. (patient safety and experience, clinical productivity)

6.A: N3: Plan for N3’s successor, to meet tomorrow’s needs and fit into the evolving Public Sector Network (platform for future) 3.B: Collaboration and communications technology: establish a national framework on how best to exploit its potential (6.A) (clinical productivity and mobility, management of scarce resources – cost savings, patient experience) 6.B: NHSmail: Review options in advance of contract expiry (platform for future) 6.C: PACS: Assess possible service delivery options prior to contract expiry prior to contract expiry (cost savings)

Strategy & Organisation

4.B: Stock-take: Test the existing IT activities of the centre against the guiding principles in 1.6, to inform the future scope of national IT programmes and organisation(s) (purpose, effectiveness, efficiency)

4.A: NHS and social care IT strategy: Create and publish a new national strategy, in the context of new Government policy, setting out a clear direction of travel for informatics, including IT, and a costed plan. (on-going alignment of IT to policy objectives, clarity of direction)

6.I: National IT organisations: Rationalise and re-organise current central functions, to meet the new national organisational remit and required future functions (3.E, 4.B, 4.A) (aligned governance to NHS, effectiveness and cost savings)

Review, halt or repurpose

5.A: LSPs:Review of progress and contracts. Retain those elements that work well, e.g. infrastructure, primary, mental health and community care solutions. Halt acute deployments, pause and reflect on case for continuing with current approach (minimise hiatus, exploit sunk investment) 5.F: ASCC procurements in the South: halt and test the effectiveness of the procurements (ensure optimal route for NHS) 6.E: SCR: Halt SCR roll-out, initiate a review of it – covering clinical validation, architecture / security and business case – consider repurposing it as an ‘urgent care record’ (simplify, clarify purpose, address BMA and others concerns)

Depending on 5.A, 5.F: Look to create an acute systems procurement catalogue to open up competition and choice (cost savings, sharing of experience, avoid unwieldy or fragmented procurements) 6.F: Choose & Book: Review in context of new Government policy on choice (If to be retained, assess how to improve its ease of use and fit to local business processes) 6.G: HealthSpace: Review options in the light of decisions on SCR (6.E). Consider enabling connectivity to 3rd party PHR suppliers (enable patient access to their records, more personalised care, cost savings)

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02 Introduction
Since the creation of the National Programme for Information Technology (NPfIT) in 2002 , the subject of NHS IT in England has been much commented on, not least because of its ambition, delivery record and cost. In particular, the National Audit Office presented two reports on NPfIT (in 20062 and 20083) to the Public Accounts Committee (PAC) and in turn the PAC made evident its concern with NPfIT’s progress, given the planned expenditure of over £12 billion.
2.1 Background
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Indeed, the current Government has not adequately taken into account the cost and complexity of IT investment that its policies have created, before launching policy initiative after policy initiative (e.g. Choose & Book, 18 week wait).

To deliver savings to the taxpayer and enable improved patient outcomes, a new Government would need to consider profound changes to NHS IT and NPfIT. For example, the Conservatives commissioned an “Independent Review of NHS and Social Care IT” which, when it reported in summer 2009, suggested a new direction for NHS IT towards a more localised approach based on a clear interoperability framework. In response to this, the Conservative Party set out high level policy in terms of a move away from the current centralised model to one where local health organisations drive the IT that they require4. Likewise the Liberal Democrats have recently signalled that they see localisation as the way ahead5. On a wider basis, in January 2010, the Government published its Government Information Communications & Technology (ICT) strategy6 to “deliver a high quality ICT infrastructure…against a background of economic pressures…to enable the transformation of the way public services run”.

A new Government must work IT planning intrinsically into its policy and strategy (not treat IT as a cost - it is an asset). A constant dialogue is needed on strategy, refreshed at least yearly, linking business and policy plans to IT investment priorities, governance, processes and capabilities that the NHS needs. We return to and address these themes throughout our report.

Building on the 2020health seminar of May 2009 on “Using IT to deliver improved patient outcomes”, our work took place over an 8 week period between late January and March 2010. The work has explored a number of key issues:
2.3 This Report

Whatever its outcome, after the General Election there is a risk of a hiatus around NHS IT. In response, 2020health believe it would be helpful to map out a blueprint and high-level implementation plan for NHS IT, with a particular focus on NPfIT. This could assist policy makers (irrespective of who forms the next Government in 2010) in forming a view on the best way forward.

Arguably, the only means a new Government will be able to meet the demand and productivity targets that the NHS is facing, is for IT-enabled new ways of working.
2.2 Government’s responsibility for Health IT

As a short, sharp study, it was not practical to attempt to cover the full scope of a review that a new Government would no doubt require, and in particular time did not permit us to address such important matters as the following:

• • • • • • • • • •

where best IT can support the transformation of healthcare services; how local NHS IT should be taken forward, especially in hospitals; the guiding principles that should drive national approaches to IT;

the role of standards and procurement catalogues in enabling NHS IT; the way forward for current national IT infrastructure, services and organisation.

Over the last 20-30 years, centrally led NHS IT projects have more often than not resulted in technology for its own sake, with limited upward linkage to policy and forward integration into genuine business benefit for the NHS. The net result has frequently been additional cost, failure to meet the critical business needs, and sometimes new islands of technology.

The perception that IT projects can be axed, or made successful simply by renegotiating contracts, is entirely false. Unless a new Government genuinely recognises that they must deliver massive change in the way health and care are provided, supported by IT, they will fail again. Localising or fragmenting the existing problems will only make things worse.

Health, and health IT, is uniquely complex and requires expert leadership and interpretation. There is no such thing as a health "IT" project in isolation, its success depends on several integrated strategies and activities policy, business decisions and processes, clinical processes, organisation, employee engagement and technology.

NHS-social care interaction (a highly complex subject in its own right); back office systems;

GP computing (which, relative to the rest of NHS IT, is a success story and where the plan of action is clear); the role and effectiveness of NHS Enterprise-wide agreements; information governance.

Relevant stakeholders and industry specialists were consulted through a total of 30 interviews and workshops, many of them anonymous (see Appendix A). In total, the NHS viewpoint covered representative views from across the country, from a range of IT leaders and clinicians. This did not include NHS Connecting for Health (CFH). Industry input was received from a wide range of international and UK IT providers to the NHS. A number of other thought leaders were also consulted, including members of the ‘Independent IT Review’ team. 2020health gratefully acknowledges all the contributions which have made this report possible.

1. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4071684.pdf 2. http://www.nao.org.uk/publications/0506/department_of_health_the_nati.aspx?alreadysearchfor=yes 3. http://www.nao.org.uk/publications/0708/the_national_Programme_for_it.aspx 5. http://www.centreforum.org/publications/nhs-a-liberal-blueprint.html 6. http://www.cabinetoffice.gov.uk/cio/ict.aspx 4. http://www.conservatives.com/News/News_stories/2009/08/Conservatives_will_end_Labours_costly_central_plans_for_NHS_IT.aspx

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02 Introduction
The remainder of the report is structured as follows:

03 Where can Healthcare IT Offer most Opportunity?
“Information and communication technologies (ICTs) have the potential to transform radically the delivery of healthcare and to address future health challenges. Whether they actually do so will depend on the design and implementation processes sufficiently accounting for the users’ needs, and the provision of adequate support and training after their introduction. In 2006, the Royal Society commissioned a policy report on Digital Healthcare7. Its views resonate well four years later:

• • • •

Section 3 – Where does healthcare IT offer the most opportunity? – building on best practice nationally Section 4 – NHS IT / NPfIT in Overview – describes the key NHS requirements of IT, describes

and internationally as context.

Section 5 – Localised NHS IT – describes the current situation around the delivery of systems by Section 6 – National Infrastructure & Organisation – considers the way forward for the NPfIT

what NPfIT was intended to address, the current situation and proposes guiding principles for the future. Local Service Providers (LSPs) and what alternatives exist, especially in the delivery of IT to support the clinical operational needs of hospitals and local health communities.

In addition there are several supporting appendices, including a glossary of terms (Appendix B).

national infrastructure services and what should be the structure and remit of future national organisations. It also considers how best Personal Health Records may be delivered.

The single most important factor in realising the potential of healthcare ICTs is the people who use them. The end users of any new technology must be involved at all stages of the design, development and implementation, taking into account how people work together and how patients, carers and healthcare professionals interact. To deal with the complexities of the healthcare environment we strongly advocate an incremental and iterative approach to the design, implementation and evaluation of healthcare ICTs.”

For example, patients may be able to monitor chronic conditions such as asthma and diabetes in their own homes using modified mobile ‘phones to access and process their data, which may give greater convenience and better management of their conditions and reduce the need to visit their local health centre. Electronic health records (EHRs) should allow healthcare professionals access to patients’ data wherever they are in the country and potentially worldwide. This should allow the many different healthcare professionals with whom an individual interacts during their treatment (who are often in different locations) to share information and make better informed healthcare decisions.

In the course of our research project, we asked about our contributors where they most felt IT in healthcare should play a role. The following summarises them. As introduced above, EHRs provide the basis for cross-sector records sharing. They represent a common, universal vision. In 2009, the European Commission (EC) published a series of reports on the socio-economic impact of interoperable EHRs and ePrescribing systems in Europe and beyond8. The case studies represented projects which had been long running and several had close relevance to the NHS in England.
3.1 Electronic Health Records

We return to this in more detail in Section 5.

While these reports reference developments on cross-sector records sharing, many of the opportunities and challenges also remain valid in planning for the implementation of care record solutions within healthcare providers, typically referred to as Electronic Patient Records (EPRs). Essential organisational ingredients to implementing EPRs successfully include: clinical leadership, empowered to and able to assume an enterprisewide role; accountable senior responsible officers (SROs), ideally the Chief Executive; formal project gateway reviews; and effective benefits management. Figure 3.1 provides a case example in support of this.

“For all cases, the socio-economic gains to society from interoperable EHR and ePrescribing systems eventually exceed the costs, albeit quite often only after a considerable length of time. This is why investment in such systems is worthwhile, and justifies their net financial boost…the results of the EHR IMPACT study give grounds for optimism in the success, value and deployment of interoperable EHR and ePrescribing systems across Europe.”

Appendix C provides a summary of key conclusions of the report. They make for powerful reading. Overall, the authors conclude that,

7. http://royalsociety.org/General_WF.aspx?pageid=10771&terms=nhs+ict 8. www.ehr-impact.eu

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03 Where can Healthcare IT Offer most Opportunity?
Figure 3.1- Organisational Challenges affecting the CRS As an example of the serious organisational challenges associated with implementing CRS, David Kwo the then IT Director at Chelsea & Westminster NHS Trust spoke of experiences in implementing its EPR in the 1990’s: “Our experience was that the main EPR challenges were not really technological or funding-related (although the right technologies and budgets are essential), they are about clear vision and management resolve, particularly given the number of years it takes to realise the vision. Clinical leadership is essential to ensure that EPRs are driven by process redesign, benefits management and the movement to improve the quality of medical care through evidence-based medicine. Chief Executives, not IT specialists, are the prime movers of EPRs. The Chief Executive needs to drive personally the overall organisational change programme (i.e. modernisation) which EPR implementations can and should catalyse. Furthermore, EPRs take a long time to implement. They require the Chief Executive’s personal attention over a period of years, like a major building project. But, unlike building projects, EPRs cannot be ‘handed-over’ to a project manager to deliver because there are practically no EPR project managers in the NHS who have ‘done it all before’ to hire. EPRs are invasive. Constructing a building is less complicated than an EPR in terms of the deeprooted clinical/operational processes being redesigned which must therefore be Chief Executive driven. EPRs are hospital wide. Unlike departmental systems, like maternity or pathology systems, the Chief Executive cannot just approve the EPR business case and let the clinicians and IT specialists ‘get on with it’. EPRs are mandatory. Unlike other systems, clinical staff have no choice as to whether or not to use EPR as part of their jobs. Our doctors must use the EPR for their everyday activities, e.g. to order tests, to access results, to prescribe drugs, to find a bed, to book a clinic appointment, to schedule a physio, to pre-assess a surgical admission, etc. EPRs are pervasive. Practically every single staff member and patient that comes into contact with the organisation is affected by it. EPRs are dynamic and developmental and can go on to support new and changing clinical requirements long into the future, as any good adaptive system should do. EPRs should be the basis of clinical research because they are like any other powerful medical advance that has the potential to both do great harm and do great good: they need to be evidence-based and high quality clinical research is needed to prove or disprove their value as they evolve (we are only at the beginning of their development and deployment curve).”

In 2008, the EC sent a Communication9 to European organisations including the European Parliament on telemedicine for the benefit of patients, healthcare systems and society. Appendix C also provides a summary of key conclusions of the Communication. It concluded that
3.2 Telemedicine

While evident that Telemedicine can offer a great potential, it does create challenges, especially in terms of its funding and impact on current reimbursement schemes. There are also important legal and ethical issues to be addressed. These issues aside, by extending the reach of physicians into the domestic care setting, there is considerable scope for service improvement and more efficient delivery of care. Without clear direction from the centre, the risk is that a fragmented, point-to-point approach is adopted without taking advantage of common national infrastructure.

In contrast to EHRs which form part of NPfIT, the NHS in England has taken a very different approach to Telemedicine. Three large scale Whole System Demonstrators were established and a major national evaluation is due to be published later in 2010.

“Telemedicine can improve access to specialised care in areas suffering from a shortage of expertise, or in areas where access to healthcare is difficult…Telemedicine will only realise its full potential if Member States engage actively in integrating it into their health systems”.

Recommendation 3.A: an incoming Government needs to establish a national framework on how best to exploit the potential of telemedicine, based on best practice in the UK and elsewhere. In particular, it needs to:

• • •

review and publish the results of the Whole System Demonstrators;

procure enabling national infrastructure and/or establish call-off catalogue arrangements as required; support the wider NHS in adapting their care processes and procuring the enabling technology.

We face an environment where there is a need to deliver dramatic improvements in productivity, safety and quality through reliable, repeatable processes in a knowledge industry that has many human-action processes. Health record applications are necessary but not sufficient here.
3.3 Collaboration and Communication Technology

• • • •

The Internet Protocol (IP) network provides a platform to deliver collaborative applications that can improve productivity, mobility and be a foundation for business transformation. By this is meant a variety of applications identified in Cisco’s ‘Network Architecture Blueprint for the NHS’, for example: video – learning, consultations, carbon savings; mobility – asset and people tracking, anytime, anywhere access to information;

communications, collaboration and messaging – improving links to Social Care and others, identifying expertise, instant referrals; intelligent buildings – lower capital costs, energy efficiency, improved estate security.

9. COM(2008) 689

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03 Where can Healthcare IT Offer most Opportunity?
Through rigorous analysis of current business processes, the technology can be exploited in line with new organisational design and practice to make dramatic clinical productivity and patient satisfaction improvements possible. Appendix D references a report just published (see www.accaglobal.com) on the audited evidence of the benefits gained from technology-enabled transformation in the A&E department at Nottingham University Hospital NHS Trust (NUH). As co-sponsors, the European Commission stated in the report’s foreword that it provides “a persuasive account of the huge impact the new communications infrastructure deployed at NUH has had on re-engineering the day-to-day working processes of its emergency department.” In particular, it shows a reduction in the patient journey time of 23% for adult patients and 33% for paediatric patients, and an increase in clinical productivity of 12%. support solutions available today. The Audit Commission report “A Spoonful of Sugar” in December 2001 offers some interesting statistics:

• • • •

10.8% of patients admitted to hospital experience an adverse event;

70% of these errors could be eliminated by the use of computerised prescribing and clinical information systems; 1,200 lives per year can be saved.

each adverse event leads to an average 8.5 additional days in hospital, costing the NHS around £500m per year;

• •

The report makes a compelling case to exploit IP-based communications and collaboration technology on a wider basis beyond busy A&E departments, e.g.: in acute hospitals, where process times are dependent on human-human, ungoverned processes that can be accelerated, made visible, repeatable and reliable. For example, the discharge of in-patients where ward, pharmacy and transport functions must collaborate efficiently to free up bed-space quickly; to assist the efficient execution of processes that cross professional or organisational boundaries e.g. in community nursing or provision of poly-services.

The Electronic Prescription Service (EPS) will enable prescribers - such as GPs and practice nurses - to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. When fully implemented, it is designed to connect with the reimbursement agency (Prescription Pricing Division). This would enable substantial back-office savings as well as providing a rich source of connected prescription information at a national level. The issue here is one of scope and urgency of the roll-out.
Recommendation 3.C: A full review of the existing EPS programme is needed with a view to securing clinical

the potential of collaboration and communications technology, based on best practice in the UK and elsewhere. The national role should be to establish best practice linked to a series of model business cases. Beyond this, further activity should follow a similar pattern to that of telemedicine regarding infrastructure and call-off arrangements linked to favourable NHS-wide pricing. However, as always the emphasis must not be on technology but instead on the realisation of benefits through more efficient working practices linked in turn to a sound business case.
3.4 Prescribing Value Chain

Recommendation 3.B: a new Government would need to establish a national framework on how best to exploit

The review should define a phased approach with increasing scope and maturity, for both primary and secondary care, taking into account the long-term needs of the prescribing stakeholder community and the benefits that can be secured by changes to both front-line and administrative processes. If the widespread adoption of EHRs represents tomorrow’s vision, then today’s reality in hospitals is paper case notes, the legacy cost of which will be with the NHS for many years to come. Many new hospital builds have no capacity for the storage of physical records.
3.5 Document & Record Management

and administrative benefits in a timelier manner.

Whilst the use of electronic prescribing in the primary care context is almost universal, in contrast the market penetration in acute sector is minimal. There is a small unit within CFH that provides helpful guidance on ePrescribing in hospitals. The economic benefits and patient safety issues are well suited to the hospital decision
20

Clinicians also pointed out to us the value of a complete medication record across primary and secondary care. A focus upon providing tools to raise the levels of acute prescribing to those of primary care and to provide for reconciliation and a local shared medication record would have an immediate and dramatic impact both upon acute sector patient safety and improved medication management and outcomes across the continuum.

Experience from other countries such as the US, where the prescribing value chain management is more mature, is that IT has the potential to: address the significant levels of fraud; help reduce drug wastage; improve control over prescribing habits (e.g. use of generics); and improve patient safety through a reduction in medication errors.

Primary care prescribing is a multi-billion pound industry, the supply chain is supported by a series of point information technology solutions and a large and expensive central administrative infrastructure.

The key driver on the path towards being paperless or ‘paperlite’, is the role of Electronic Document Record Management (EDRM) solutions in respect of the paper case notes. EDRM provides a way to scan, digitise and store the paper records, so that the clinician not only can see the electronic information from the point of implementation through the EPR but also an integrated scanned view of the historic record. It is essential that EDRM solutions fit well with clinical practice and must meet patient safety and information governance requirements. EDRM solutions were not included as a core LSP service at the outset. The view of some we spoke to is that the technology has now matured to the point where it is robust, scalable, affordable and quickly deployable. More work needs to be done on its business case and to learn lessons from early pilots. The potential benefits are significant around clerical and clinical productivity for notes that are regularly accessed, as well as the patient care benefits from the avoidance of cancelled appointments due to lost notes, and the savings in the space needed to store paper files.

Recommendation 3.D: A review is needed of EDRM experience to-date, to establish both the maturity of the

technology solutions and the associated business case, with a view to accelerating its adoption in hospitals.

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03 Where can Healthcare IT Offer most Opportunity?
It may be that the national role should be to establish best practice linked to a series of model business cases, and in time associated national pricing and call-off arrangements. In addition, guidance should be shared on the necessary front-line and back office process changes needed to secure the associated benefits. The NHS itself has a highly varied estate of data centres and computer rooms. At the top end, the NPfiTprovided services come from highly resilient, state-of-the-art Data Centres. At the other extreme, by extrapolation there are at least 500+ local NHS computer rooms, some of which would fail rudimentary health and safety checks (e.g. we heard of one centre with rat infestations).
3.6 Shared Services

04 NHS IT / NPfIT in Overview
Self-evidently, IT needs to respond to the business and clinical needs of its users and not be an end in itself. In this section we introduce some of those needs, describe what NPfIT was intended to address, what the current situation now is and propose what should be guiding principles for the future. Since the advent of NPfIT, sadly there has been no published, overarching health informatics strategy10 that sets out clearly the clinical and business objectives that IT needs to support, and explains how the different elements of the IT architecture fit together now and in the future in support of these objectives, providing a realistic expectation of future plans. Crucially an active link is needed between NHS policy makers and those responsible for informatics11.
4.1 The NHS Needs for IT

The NHS has examples of IT-related shared business service programmes. The most noteworthy are the Electronic Staff Record (ESR) which provides a single NHS-wide HR and payroll system, and the Shared Business Services (SBS) which delivers a finance and accounting shared service to about 120 trusts. While each is rightly regarded as a success in its own right, at a local IT level, there are complaints because they operate separate engagement and service delivery models to NPfIT. Although both run on Oracle platforms, there is minimal integration only at the file transfer level. The unit of organisation of NHS IT staff varies from the small hospital-level IT functions to county or SHAwide shared service provision. In many cases these organisations are below critical mass in scale and unable to attract/retain the range and depth of IT skills required. However local knowledge, accountability and ownership is essential for successful implementation of frontline clinical systems. If the NHS is to get value out of IT, local IT services need to be transformed to a scale and quality well ahead of where many are now.

We take it as a starting point that all political parties are committed to the NHS being and remaining a publicly funded health service, with healthcare largely free at the point of delivery, based around a federated model of healthcare provision. The recent trend is for it to become more federated, as provider plurality increases and patients exercise more choice. The NHS is shifting more and more to a complex adaptive system and away from a centralised hierachial model. This has profound implications for IT.

Most recently, the NHS guidance on Informatics Planning guidance 2010/11 states, “to support the NHS in a coordinated national approach, an updated strategic direction for informatics will be developed over the coming months in collaboration with the NHS and its partners, to move from a ‘replace all’ to a ‘connect all’ philosophy.”

Recommendation 3.E: Assess what economies and improved service can be gained from consolidating NHS data centres and local IT staffing:

Reinforced by the economic constraints facing the UK, and in the context of an ageing population, future healthcare will most likely entail a further substantial shift of resources away from highly expensive acute care to more localised provision including polyclinics and home based care, with an increased emphasis on public healthcare and self-care.

1. 2. 3.

where appropriate, and if agreed to by affected Foundation Trusts, IT staff should be organised into shared services aligned to the natural health communities that they serve. i.e. county or at most SHA level. Consideration should be given to national career ladders and professional development paths, together with staff exchange programmes to the benefit of all concerned. In future, these local organisations should take responsibility for strategy, integration with national programmes and play a leading role in the implementation of front-line systems, following national guidance. They should work under the local clinical leadership of IT-enabled change programmes, reducing time, cost and local variability in selecting clinical systems locally.

the ESR and SBS Programmes to be examined for potential integration into the wider NHS infrastructure;

where practical, NHS data centres to be consolidated into either large-scale facilities or a “cloud-based” provision, once established and safe.;

The full IT implications of this shift in care provisioning priorities are difficult to predict. As the plurality of providers grows, IT becomes a vital prerequisite to enable patient-centric, joined up healthcare services at the point of care. It has a key role in measuring performance and enabling patient participation through the use of information produced as a by-product of data collected in supporting core care processes12.
10. The most recent comprehensive NHS IT strategy dates from 2001 – “Building the Information Core: Implementing the NHS Plan”, which drew heavily on a more comprehensive terms of the procurement and management approaches. The 2008 Health Informatics Review signaled a new direction in certain useful areas such as clinical engagement and leadership but limited detail was given on the IT or future plans. 11. The implementation of the 18 week wait (referral to treatment) in 2006 was a case in point where policy implementation commitments were reputedly made without full regard

At the same time, and in response to the Darzi Next Stage Reviews, the NHS is demanding an increased focus on delivering quality – for example, the Commissioning for Quality & Innovation (CQUIN) framework is intended to “reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers.”

For example, the Transforming Community Services Programme aims to improve community services so that they can “provide modern personalised and responsive care of a consistently high standard”. It will involve significant reprovisioning of current PCT-provided services, potentially leading to more providers. And in London, for example, 130 ‘poly-systems’ around polyclinics are being developed, which will radically change not only primary and community care, but remove substantial parts of current care provision from acute hospitals.

review in 1998 (‘Information for Health’). The 2002 document “Delivering 21st Century IT Support for the NHS” focused on setting out the basis for a national Programme, in

of the practical organisational and IT difficulties involved. to Great - DH December 2009

12. “We will make more use of information-based technologies to design new models of care as well as improving the performance of existing services. We will integrate information around the patient, deliver relevant information at the right time to clinicians and use technology to drive efficiency for both patients and clinicians” NHS 2010–2015: from Good

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04 NHS IT / NPfIT in Overview
To that regard, any single organisation providing NHS care services cannot have a monopoly over its patient information. Its reimbursement must be based not only on adhering to quality metrics but in its adherence to nationally agreed record sharing standards, subject to confidentiality and privacy constraints. Other key components or work streams within the NPfIT are:

Recommendation 4.A: A new national strategy is needed for NHS and social care IT, in the context of new

As individuals become more information aware and empowered through the web 2.0 revolution, the desire for more personalised care is rapidly growing. Patients increasingly want access to their own health records and control over who has access to them. Not only do they want to connect with other patients with the same condition, they want to connect with their GPs and other clinicians13.

The future Government needs to give early priority to setting a clear direction of travel for informatics and IT in the NHS and so give clarity to all stakeholders, within the context of its aspirations for the NHS and new policy environment. The resulting strategy must support the policy and clinical agenda with due regard to transformational change and overall cost of ownership. This needs to be consistent with and support the recently published Government ICT strategy. The aim of NPfIT was to assist the NHS in providing better, safer care, by delivering modern computer systems and services that improve how patient information is stored and accessed. CFH was formed in 2005 as a Department of Health (DH) Directorate charged with delivering NPfIT.
4.2 What NPfIT intended to do

Government policy.

• • • • • • • •

a national broadband IT network for the NHS (N3);

‘NHSmail’ – a central email and directory service for the NHS; ‘Choose and Book’, an electronic booking service (CaB); an Electronics Prescription Service (EPS);

‘Picture Archiving and Communications Systems’ (PACS);

IT supporting GPs including a system for GP to GP record transfer.

A constant feature over the last 20-30 years has been that NHS Informatics has struggled with organisational alignment in two senses:
4.3 The Situation now

between a remote, central function and sub-scale IT departments in Trusts (except now in larger FTs and some county Health Informatics Services); the split between information and IT, including at the centre, has led, in many cases, to a dysfunctional approach to collecting and processing information.

The detailed background and chronology behind the creation and execution of NPfIT has been well documented elsewhere and is not repeated here. In outline, the central feature is the NHS Care Records Service (CRS), comprising central and local elements. The central core is the NHS Spine, which provides a unique reference point for patient demographic and summary clinical information, and the security and access controls to central patient based data. LSPs are responsible for the delivery of care records locally, which connect into the Spine.

NPfIT was also conceived to address the problems of a highly fragmented IT situation across England14.

Over many years, the NHS has developed and deployed a number of key national information assets (e.g. a common format NHS number, Read codes, NHS Central Register, NHSnet, Secondary Uses Service as the commissioning clearing service) which all had their origin long before NPfIT. All of these needed proper management, control and development and these were brought in and transformed under CFH. It is now responsible for all nationally coordinated major IT programmes across the NHS.

If each provider now had an integrated EPR system as intended through the LSP Programme, the information collection could flow as a by-product of the operational systems. Instead, the problem of IT silos has if anything got worse and has militated against a strategic approach to IT at local level. Turning to the Programme itself, NPfIT sought both to specify and direct the central infrastructure (as enablers for joined-up care the NHS) and to fix the local operational IT problem, especially in hospitals, community and mental health services.

In regards to the latter, particularly with the demands for quality information, as one NHS IT Director commented to us, “The NHS has developed an increasing and ravenous demand for information with little regard for how it will be collected and at what cost”. This issue applies to requirements for information emanating both from the centre and from commissioners, leading to multiple short term local and national initiatives.

However, in retrospect it is clear that NPfIT tried to do too much, too quickly, with a limited focus on early winners to gain credibility and acceptance with the NHS. NPfIT has had a number of notable successes, including: the delivery of central infrastructure services; in the roll-out of PACS across the country; in improving the professionalism of IT services in the NHS; in assurance processes to warrant systems connecting in with the national infrastructure; and in the delivery of IT solutions in many primary, community and mental health organisations. In directing a central push of IT solutions to the NHS, the perception was formed that NPfIT was trying to impose IT (especially in that clinical engagement was limited initially). There was a collective failure to get NPfIT positioned as an enabler for transformation of services. (During our work, we met with UK Specialist Hospitals Limited, which operates four independent treatment centres in the South West. Although on a much smaller scale, their approach started by developing the Integrated Care Pathways (ICPs) for each procedure to
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13. “Our plans to transform care for patients with long-term conditions will involve people being offered personalised care planning and support for self-care. This will help them to intervene early to prevent deterioration and avoid hospital admissions.” NHS 2010–2015: from Good to Great - DH December 2009 manage their condition and cope with any exacerbation of symptoms. New systems of care and technology will allow them, their carers and their professionals to monitor their care, 14. “In the past, individual NHS organisations procuring and maintaining their own IT systems and the procurement and development of IT within the NHS has been haphazard,

with individual NHS organisations procuring and maintaining their own IT systems, leading to thousands of different IT systems and configurations being in use in the NHS. These the NHS’s IT systems infrastructures have been built up to create silos of information, which, with few exceptions, are not shared or shareable even when, for example, different GP practices use the same GP system. As a result, the information required for safe and efficient care may be absent. This directly impacts on clinicians’ ability to deliver holistic and and increase the rate of take-up of advanced IT” (NAO report on NPfIT 2006) safe care. The Department did not consider this approach to have been successful, and one of the aims of the Programme has been to provide strong central direction of IT development, are provided by hundreds of different suppliers, with differing levels of functionality in use across the country. The large number of different and incompatible systems has meant that

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04 NHS IT / NPfIT in Overview
be undertaken, and then integrating them into an EPR system shared across the centres (see Appendix E). In 2007, the NPfIT Local Ownership Programme (NLOP) was introduced, promoting a shift in governance towards NHS ownership over NPfIT, with CFH acting more in a supporting role. However, these arrangements are neither fully centralised (with authority to match) nor fully decentralised (local responsibility) and represent a half-way house which lacks clear responsibilities and accountability. One aspect that NPfIT has successfully addressed was the historic low level of investments in IT, averaging less than 2% of NHS revenue. The most recent survey conducted by CFH shows a projected NHS IT spend in 2009/10 (revenue and capital) totalling £4bn, of which NPfIT’s share is £1.8bn17. This represents 3.15% of total NHS revenue spend, and 25% of NHS capital spend.

What is required is a clear demarcation of responsibilities for business implementation, standards, procurement / sourcing and process design. Some elements need to be national or ‘corporate’ (done once), some things need a ‘collaborative, opt-in’ approach (with local responsibilities), and others purely local. We return to this in Section 4.4 below.

Furthermore, each LSP was given exclusivity around a set of core functionality within a set geography15 (five regional clusters were defined, with four main contractors) such that local NHS Trusts had no choice over the solution they were to receive.

The original vision was for an “integrated care records service” (ICRS), with LSPs responsible for deep integration across the NHS around single enterprise instances of clinical systems. As this has proved enormously difficult to deliver, the LSP contracts have gradually shifted towards more traditional, organisational-centric solutions with thinner integration capabilities cross-sector.

In summary, the delivery of the overall vision for the Care Records Service remains at least 5 years away, based around some major failures, especially in the LSP arena around the delivery of modern EPR-like capability in hospitals.

In contrast, it was pointed out to us that in the South, where there is now no LSP, this onus has been lost and some Trusts are reluctant to invest in a sufficiently professional approach. In many areas outside the Programme, ICT remains highly fragmented and variable, with many home grown solutions remaining supported by a ‘man in a van’, a long way from the aspirations set out in the Government ICT strategy of hosted solutions in the G-Gloud. In 2020health’s view, a national approach should only be taken when one or more of three guiding principles can be met:
4.4 Guiding Principles for the Future

As commented earlier, CFH has driven a more standardised and professional approach to ICT, both nationally and locally. For example, the National Infastructure Maturity Model (NIMM) Programme has provided a useful capability maturity tool used for benchmarking local IT infrastructure services. Additionally, the LSP Programme set a useful mandate to ensure Trusts invest sufficiently to create a warranted technical environment.

1.

there is an overwhelming case for doing something once and once only across the NHS to avoid redundant variation and provide a baseline model for local business cases (e.g. infrastructure and back-office solutions). National systems run centrally would also fit into this category (e.g. NHSmail, ESR) but would be typically back office or infrastructure related, leaving the wider NHS to select and implement front-line systems applying available national guidance and interoperability standards;

The contracts provided for the eventuality of failure by one LSP, allowing another to step-in. (This was the situation in 2006 when Accenture withdrew from the NE and East clusters, and CSC stepped in from its neighbouring NW and W Midlands cluster to form a complete NME pan-SHA cluster).

In the meantime, many hospitals continue to rely on core Patient Administration Systems (PAS) that emanate from the 1980s, with a limited amount of integration between the core and departmental systems, and islands of information, especially in more automated parts of the hospital such as Intensive Care Units (ICU) and theatres. Many hospitals have been in ‘wait and see’ mode since the Programme’s inception, in some instances for much longer because EPR procurements in train prior to 2002 were cancelled by NPfIT. Applications commonly implemented in hospitals internationally have yet to fully penetrate the acute sector, e.g. order communications and ePrescribing. Investment has in many cases been made in ‘interim’ point systems, albeit some of them highly functional, which in turn may become the ‘new legacy’.

Due to LSP exclusivity, the market for local IT in these core areas was locked-up. The barriers to entry have stifled the innovative drive of suppliers outside the Programme and a lack of available, new suppliers to provide a competitive market still remains. This is now recognised nationally16.

2. 3.

Where pursuing national approaches, a clear approach of evolution should be adopted, i.e. robustly test out the concepts and ideas in a demonstrator; learn and assimilate lessons; get the model business case established; and then plan for a wide roll-out. This would need to include recommended process changes, stakeholder management, senior clinician change leadership and comprehensive training for affected staff at all levels from consultant to nurses, junior doctors and administrative staff.

to meet the ‘national’ nature of NHS patient care, through essential central coordination or regulation, e.g. standards, security.

there are clear, unequivocal economies of scale so that the NHS purchasing power can be maximised – e.g. enterprise wide agreements for licences;

Outside these, and respecting any nationally agreed contracts, 2020health believes that the principle should be that local NHS should be free to decide on its own approach to IT, consistent with the needs of its organisation and to support the delivery of joined-up care locally and nationally.
Recommendation 4.B: a new Government should test the existing activities of the centre, with respect to NHS

IT & NPfIT, against these principles, which in turn will inform the future scope of national IT Programmes and organisation(s).

15. The East of England was an exception with the LSP having no exclusivity

health care IT market to new suppliers and new technological developments, to inject more pace into the Programme. Our aim is to help trusts configure systems to best meet their local needs, as well as taking advantage of market developments to make more use of the information they hold.”

16. Mike O’Brien, Health Minister, commented in parliament on 2009, “The Department's Chief Information Officer has recently made clear our commitment to opening up the

17. Source: http://www.connectingforhealth.nhs.uk/resources/imtstaff/survey

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05 Localised NHS IT
This section looks in more detail at the LSP delivery of solutions to the local NHS, where and why there have been difficulties and what the way forward ought to be. It also considers how to move forward outside the LSP environment, notably the South, in terms of interoperability, procurement and shared care records. As stated in Section 4, a core element to NPfIT was the delivery of an Integrated Care Record Service (ICRS) at the local level. The intent was to provide modern operational systems across a core range of functionality in an integrated fashion across a whole health community.
5.1 The Original LSP Model – in Concept

Much has evolved since the LSP contracts were signed in 2003/04, changing the baseline NHS environment and so affecting the IT requirements.
5.2 Why have there been such Difficulties?

• • • • • • • • • • • •

Without seeking to attribute blame, it is evident that there have been difficulties on both sides. In our view, the main reasons include: while the CRS Programme was conceived as a change project, it quickly was repositioned and driven as a large scale IT deployment challenge, with change management reduced in priority;

The country was divided into five clusters, each with a LSP acting as prime contractor for the delivery of the full ICRS scope. Each LSP would have exclusivity around a core set of functionality.18 There was also an additional services catalogue allowing Trusts to call off other services. Requirements were defined by the CRS Output-Based Specification (OBS). (There was a crucial assumption that requirements could be standardised across the NHS, leading to a standardised process model.)

clinical engagement and leadership were lacking at the outset, and although clinicians locally were initially enthusiastic, the repeated delays in the delivery of solutions have eroded NHS confidence; the NHS does not conform to a ‘one size fits all’ model around a standardised process model; large scale deployment in an environment with a high degree of complexity has proved very challenging;

Although specialist healthcare application software would underpin the service, as leading global IT service providers, the LSPs were selected to act as prime contractors and orchestrate the ‘heavy lifting’, e.g. programme management, hosting, software configuration, environment management, systems integration, large scale deployment. “The role of national Programme local service providers (LSPs) is to deliver information technology (IT) systems and services across the National Health Service within defined groups of strategic health authorities. LSPs ensure the integration of existing local systems and, where necessary, implement new systems so that the national applications can be delivered locally, while maintaining common standards. All LSPs have contracted to develop and deliver a fully integrated NHS care record solution.” The contracts were successfully negotiated on the principle that the NHS would only pay when solutions were delivered and benefits realised: The on-going responsibility of LSPs in this regard was recently reaffirmed by Ministers19,

there was no direct relationship between customer/user (Trust) and application provider. The contractual relationship is between CFH and LSP, with cluster and SHA leadership as intermediaries. Trusts were frustrated that they did not have direct access to the product specialists. Ensuring all parties remained aligned proved very difficult;

there has been limited local ownership over the solutions, in part because Trusts have had no choice in the solutions they receive (in four out of five clusters, LSPs had exclusivity);

there were boundary issues over which party has responsibility for what, such as interfacing, data migration, change management; local IT environments are disparate, affecting the ease of integration;

The actual models enshrined in contracts differed from one cluster to another, and these differences have increased rather than decreased.

“NHS Connecting for Health bought the systems at a fixed competitive price transferring financial and delivery risk to the suppliers, and it does not pay suppliers until services are proven to be delivered and working. So, although there have been delays in delivering the NHS Care Records Service, the suppliers have borne the cost of overcoming difficulties in delivering the software and not the taxpayer.”20

the original OBS was generic and not specific enough to baseline the requirements. There were many different and valid opinions about the requirements, which has led to serious change control issues;

serious technical, organisational and commercial complexities emerged in delivering a single domain model (i.e. one shared application / database straddling a widely dispersed health community);

the work needed for the core software to comply with requirements has been much more extensive than ever envisaged;

Many of these points are understood and accepted by all parties involved, and there has been a gradual approach to address them over recent years through successive contract resets, with some improvement.
19. Mike O’Brien, Health Minister - Hansard 21 May 2009 18. as defined in the 2003 Output–Based Specification (OBS)

a ‘big bang’ approach to roll-out was chosen initially, rather than an approach of implementing the full solution at one or more pilot sites to iron out all the issues, prior to roll-out.

20. NAO 2006 report On NPfIT

For example, the ‘iSOFT 7’ (seven Trusts in London and the South who already had iSOFT systems) is one example of a contract variation from the standard LSP mode. Here the framework allowed for aligned opt out which carried forward the broad thrust of the Programme’s aims but is less prescriptive about how. In another
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05 Localised NHS IT
case, to speed up delivery of solutions, the enterprise-wide approach to ICRS was broken up, replaced by organisational-centric solutions and a level of prioritisation - at least within the acute space - around the ‘Clinical 5’21. However, the early releases of Cerner in the South were problematic, with gradual improvements with successive deployments. However, when contract reset terms could not be agreed with Fujitsu about the future deployment and configuration models, CFH terminated the contract in May 2008. A termination settlement has yet to be reached.

Finally, it is difficult to determine whether the LSP model is delivering value for money (compared to a more localised procurement approach). It needs more consideration, particularly in terms of the unit prices for software licence and deployments as compared to similar procurements elsewhere22. We return to this point later. It needs to be benchmarked against the costs of Trusts who have opted out of the Programme, and against other UK and international pricing. [The history of developments around the LSP Programme has been documented in detail elsewhere. What follows is our interpretation on events].
5.3 LSP Progress and Recent Developments

Both LSPs are now in further contract resets as discussed below. The question remains is whether the model is fixable, and on this the jury is out.

Following the second NAO review on NPfIT in 2008, the PAC stated in early 2009 that they expected to see demonstrable CRS product delivery within the next 6 months . In response, CFH announced a series of tests that both products should meet by 30th November 2009 .

The remaining two LSPs (BT for London and CSC for NME) are again in contract reset. As health minister Mike O’Brien MP confirmed on 2nd March , the resets have in part the objective of achieving £600M savings already announced by the Government, with the intent of signing Memoranda of Understanding by the end of March. Recent LSP developments in London and NME are discussed more in Appendix F. There appear to be some common features across the current contract resets. For example, both are considering options such as: some level of Trust opt-out (i.e. local choice, to a degree); revised delivery models; greater inter-operability around the prescribed solutions; and some reductions in functionality with a view to the suppliers saving cost through a reduced scope and associated risk.

Initially, in 2004, two of the four winning LSPs (BT in London and Fujitsu in the South) relied on hospital software from a leading US provider, IDX, while the other two (CSC and Accenture) planned to use solutions from a leading UK supplier, iSOFT. Significant difficulties ensued.

In the case of the latter, iSOFT intended that a brand new product (Lorenzo) would be designed and built to meet the full scope of the ICRS requirements. This proved much more time consuming and protracted than planned so that both LSPs chose to deploy working ‘interim’ solutions: in CSC’s case around iSOFT’s legacy iPM and iCM products (PAS and enterprise clinical solutions) in the acute space; in Accenture’s case, primary care and community software from TPP. As a result of these changes, significant numbers of large scale product deployments of ‘interim’ solutions into secondary, community & mental health have created a platform for shared care, and enabled improved workload and case management.

As a starting point, a new Government must test the LSP contractual arrangements and baseline plans against key criteria such as the following: 1. 2. 3. 4. 5. 6. are the future deployment plans credible and realisable? Do they match up to the evidence of recent deployments? Have the products and deployment approach been fully stress tested?;

By the time a new Government is in place after the Election, the LSP contract resets may or may not have been successfully concluded. Either way, it will provide a baseline to work from, and for a new Government to do its own full scale review. Likewise the success of the Lorenzo deployment at Morecambe Bay will be known, assuming it has gone live on time.
5.4 The LSP way forward

Meanwhile, the IDX software that was to be used as a common solution set across the South and London, proved unable to meet the UK requirements. During 2005 and 2006, Fujitsu and in turn BT replaced IDX with another US clinical software provider, Cerner, also a recognised leader in the US market. This was on the basis that an ‘as is’ version of the Cerner system already deployed in the Newham and Homerton hospitals would be taken, which could be readily deployed as Release 0 elsewhere. A design process would be followed to meet the full ICRS requirements through subsequent releases of Cerner.

After accumulating losses of over $300 million, Accenture withdrew in September 2006 and with the agreement of CFH, their contracts were novated to CSC for the whole of the three clusters forming NME.

where necessary and demanded by the Trusts, is there a satisfactory direct ‘customer’ relationship between Trust and application supplier? (So that the specific expertise of the application provider is directly and readily available locally);

is the value add of the LSP model worthwhile (e.g. programme management, technology infrastructure, systems integration)?; to what degree is local choice enabled and on what basis might other application providers compete?; how will Trusts who opt-out of the LSP Programme be handled? Are the alternative arrangements equitable?;

and sophisticated reporting; (2) Order Communications and Diagnostics Reporting (including all pathology and radiology tests and tests ordered in primary care); (3) letters with 22. The reputed deployment charge per Trust is between £20-£30m, as against £3-5M in Scandinavia. The contract value for the recent award for Patient Management Systems in Scotland was “in excess of £44m” for five NHS Boards. coding (discharge summaries, clinic and A&E letters); (4) scheduling (for beds, tests, theatres etc.); (5) e-Prescribing (including ‘To Take Out’ (TTO) medicines).

21. The 2008 Health Informatics Review suggested an initial focus should be around the “Clinical 5” : (1) Patient Administration System (PAS) with integration with other systems

7. 8.

do the arrangements represent value for money, benchmarked against other UK and international procurements?; how will local configuration be allowed to meet specific Trust needs?; is there a workable, practical and cost effective split of responsibilities between Trust and contractor, particularly in areas such as data cleansing, data migration and training?;
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9. 10. what flexibility exists in the implementation roadmaps and integration of existing systems? Can Trusts chose a model that meets their own capability and maturity? Does it provide an open, low-cost platform that other specialist application providers can readily leverage?; In outline, a hospital-wide EPR solution must meet the following broad requirements: rich functionality; deep integration; fast response times; a full view of all relevant clinical information as a basis for intelligence /decision support; an intuitive user interface; and the use of IT-supported ICPs. It must also be able to drive out and report on the NHS quality agenda and other key information needs.
Architecture

If the view is taken that the revised LSP arrangements do not pass these criteria, the LSP contracts would need to be deconstructed in a carefully planned fashion retaining what is best and transferring the hospital EPR elements into a catalogue. Whatever emerges, those LSP elements that work well (e.g. delivery of primary, community and mental health CRS solutions; PACS; resilient hosting services) should continue in one form or another.

Without sight or knowledge of the LSPs commercials or current state of negotiations, we do not know how close the revised arrangements are to meeting these criteria.

how will the arrangements enable and bring about joined-up care (around the detailed sharing of records) at the local health community level?

In the hospital EPR area, much has been invested in time and money, some sites are operational and we are told that both solutions are close to being ready. To test this and ensure they offer value for money, we believe that the acute solutions from Cerner and iSOFT should be exposed to competition through becoming part of an acute systems catalogue (discussed at the end of Section 5). Trusts could call-off what they need based on their own capability, maturity, starting point and plans.

The Cerner solution is an example of the single database approach and clinicians we spoke to saw it as being well ahead of alternatives in terms of the depth of its functionality and its ability to generate task lists and prompt alerts across the enterprise. There is also an emerging view that an alternative ‘surround and replace’ strategy is viable, based on progress in other countries. This is discussed more in Appendix G. It potentially represents a more flexible, perhaps lower cost way of meeting the requirements. On the other hand, it is not proven in the NHS. In our view, the approach is worthy of closer research and validation.

There are many who are convinced that the only way to achieve this level of integration and benefits now is through a ‘monolithic’ solution, around a single supplier database. Such integrated hospital systems were around long before NPfIT and were implemented from the 80’s onwards – for example, at Winchester, Wirral and Burton. While delivering high levels of in-built integration, there may be compromises in the level of functionality in specific modules as compared to a best of breed approach, especially in relation to PAS.

Clinicians need absolute confidence in the integrity of the electronic record if they are to move away from reliance on paper case notes. Only in this way can the full benefits of an EPR be gained.

Recommendation 5.A: A full review is needed of the LSP progress and contracts using the specified criteria.

This would also allow fairness in those parts of the NHS which already fall outside the preserve of LSPs (principally the South).

The catalogue should be created and coordinated centrally, but be accountable to the NHS. To incentivise Trusts to use the catalogue, partial central funding should be available. Suppliers must show clear adherence to well defined interoperability standards.

Interestingly, in Scandinavia, open integration standards to enable “incremental evolution around a common platform” have been prevalent for some time. Here, we understand that the trend has gone back towards single supplier EPRs on the basis that multiple suppliers add cost, complexity and management overhead.

Retain those elements that work well. Halt acute deployments, pause and reflect on the case for continuing with the current approach. Consider exposing the acute solutions to direct competition in a specific acute systems catalogue.

Recommendation 5.B: more research is needed, and potentially pilots, into the viability of other local integration technologies and approaches such as ‘surround and replace’, and the resulting impact on business cases. It should endeavour to address the circumstances when such approaches may be more fruitful than a traditional approach of ‘rip and replace’. Interoperability, Standards and Open Source

Beyond the LSP model, there are at least four aspects to consider:
5.5 What alternatives exist to the LSP model?

The EU usefully describes ‘interoperability’ as: “the ability to exchange, understand and act on patient and other health information and knowledge, among linguistically and culturally disparate clinicians, patients and other actors, within and across jurisdictions, in a collaborative manner”. “Full record sharing requires at least two levels to be achieved: 1. 2. Separately, the EU has identified that:

• • • •

the architectural approach - what alternatives exist beyond the LSP approach of ‘rip and replace’ (or versions around it); interoperability and standards – both within and across organisations; shared care records at the Local Health Community Level; procurement and catalogue alternatives.

Semantic interoperability is essential for automatic computer processing to underpin real value-added EHR clinical applications, such as intelligent decision support, care planning, etc. What is at stake here is not only exchanging data and information but reusing and processing them. The degree to which information can be re-used and processed is the measure of semantic interoperability.”
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semantic interoperability: the ability for information shared by systems to be understood at the level of formally defined entities, so that the receiving system can process the information effectively and safely.

functional and syntactic interoperability: the ability of two or more systems to exchange information (so that it is human readable by the receiver);

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The mechanisms that are used to implement interoperability must meet Information Governance (IG) requirements, as driven by legislation and rules that implement that legislation. Amongst those we interviewed, it was felt that a more pragmatic mandate is needed around the CFH standards agenda for it to be more informed but practical, reflecting an appropriate and valid need for patient safety to be balanced against the need for progress and a vibrant market open to new and innovative suppliers. The concept of ‘good enough’ is important, to avoid over-engineered solutions that make their usability less than optimal. There is also a need for more transparency on where to locate authoritative versions of current standards. Furthermore, the NHS should follow international / EU standards unless there is an overwhelming case otherwise. For example, confusion was expressed on NHS-driven initiatives such as the Logical Record Architecture whose purpose and remit needs clarifying, and its relationship to well-established international initiatives such as OpenEHR and IHE.

Although falling outside the scope of our work, it is worth noting that CFH has developed significant and comprehensive policies around IG. From both the NHS and industry viewpoint, questions were raised about whether the balance is right between protecting privacy and ensuring solutions are usable. For example, in interviewing leading GPs from the iSOFT primary care user group (see www.isug.co.uk), they commented, “connecting to the Spine to check patient demographic details, to make CaB referrals, or to issue the new-style prescriptions with bar codes may only have an overhead of ten seconds each, but the frequency with which these operations are done throughout the working day means a huge amount of clinicians’ time is wasted each week”.

At the technical standards level, there is a vibrant community internationally not only at EU and US levels, but increasingly global. The NHS has been active in this community for some time, and CFH has built significantly on this. Within this context, CFH’s Data Standards team works at several levels to agree authoritative standards:

• • •

professional practice standards – covers generic medical record keeping standards, such as those developed by the Royal College of Physicians. It has also driven the GP2GP solution, enabling the transfer of electronically held information on GP systems when a patient moves; operational standards - that directly support implementation of operational systems, such as in the definition of message standards with the Spine and secondary use datasets; fundamental standards - components out of which operational standards are constructed. These include SNOMED CT (Clinical Terminology)26 and ICD10 (Disease Classification).

Recommendation 5.C: A review is needed to ensure that the centre is taking a more practical but informed

In passing, it is worth noting that the whole environment around EPRs and interoperability standards is developing rapidly due to the massive stimulus to health IT in the US. Incentive funding is being provided to hospitals that ‘meaningfully use’ electronic records, and are compliant with a comprehensive layered set of standards, which suppliers must meet27. In realigning the CFH standards work, much could be learnt from the US model.

A related relevant factor concerns whether open source solutions have a place to play in the EPR market. A brief analysis is presented in Appendix H. While the open source technology solutions market is already vibrant, a market in clinical applications is starting to emerge, particularly in the US. There is clear engagement from leaders in the international standards community. Open source solutions are particularly suited to collaborative environments such as healthcare. The main other potential advantages of open oource relate to: reduced total cost of ownership (10-20%); the avoidance of vendor lock-in; transparency; and the removal of high barriers to entry.

approach to technical and IG standards, and that the NHS is following international/ EU standards unless there is an overwhelming case otherwise.

In practical terms, the NHS Spine and associated national services represent interoperability mechanisms across NHS organisations. In 2009, CFH announced the creation of an ‘NHS Interoperability Toolkit’ (ITK) to “incorporate a national and a local approach to encourage interoperability, provide standards and governance, allow users to get more value from their systems and to innovate. The toolkit provides a framework and standards for local integration within and between NHS trusts for better integration between Spine and non-Spine accredited systems.”

The governance around data standards is provided by the Information Standards Board which has close engagement with the Royal Colleges. They are responsible for Information Standard Notices (ISNs). While taking a valuable role, there is concern that those who have to implement ISNs (e.g. Trusts, suppliers) are not as well engaged in the process as they might be.
26. One example of central use is "The dictionary of medicines + devices (dm+d)" which provides, among other things, medicines with codes and terms linked to SNOMED CT concepts.” It is a key platform for the delivery of the EPS.

While recognising that it is potentially a valuable initiative, some we consulted with were confused about the ITK’s precise purpose and mandate. This could usefully be clarified and transparent plans publicised.

The initial scope of the ITK is to enable third party integration with LSP systems. This is now extending into Proof of Concept work in areas such as discharge summaries. Some of the complexity around interoperability is illustrated by a comment we received from one Trust IT Director, “Asking doctors to type in a history in a large hospital is futile. Our discharge summary is not just a document with some pharmacy workflow. It pulls data from the operation notes and previous co-morbidities”.

In the medium term, open source clearly has enormous potential applicability to the NHS, perhaps through developing complimentary services around the NPfIT core and specific clinical solutions, subject to strict compliance with standards. It is not a short term panacea. It should continue to be actively explored, with pilots promoted in specific clinical areas, to assess whether it can be a realistic solution. These explorations should look carefully at the business case and long term benefits. solutions, based around pilots and learning lessons.

Recommendation 5.D: Commission on-going active research around the potential of clinical open source

As the LSP model has shifted away from delivering an overall ICRS across large cluster(s) towards a more organisational-centric approach, the way in which IT can support shared care and treatment across a local health community (LHC) becomes more challenging. At its simplest level, it involves supporting messaging
Delivering Shared Care across Local Health Communities
goal will reduce health costs for the federal Government by over $12 billion over the next 10 years….our approach to the adoption of standards, implementation specifications, and certification criteria is pragmatic, but forward looking…we believe it will allow those who adopt Health Care IT (HIT) to choose from a variety of offerings ranging from subscription Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Interim Final Rule” Department of Health and Human Services, 13 January 2010 services, to vendor-based products, to open source products. An innovative and competitive HIT marketplace needs to exist much like the marketplace for consumer electronics…we 27. “Recovery funding has been designated to modernize the health care system by promoting and expanding the adoption of health information technology by 2014. Achieving this

believe that it will be common in the near future for Certified EHR Technology to be assembled from several replaceable and swappable EHR Modules.” Excerpts from Health

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and communication between local GPs and Trusts, with a focus around key transactions such as referral letters, clinical correspondence and hospital discharge summaries. At a higher level, the requirement relates to supporting cross-sector ICPs and more complex record sharing and functionality. significantly work against delivering joined-up care across the NHS and would represent a return to the fragmented approach of the 1990’s. Then, while some Trusts with clear and engaged leadership had successful EPR projects, many others without such capabilities were unable to proceed far.

As a rough guideline, 95% of the patient flows reside within such areas (i.e. metropolitan or county levels). There are however important exceptions such as clinical networks (especially cancer). Independent sectorprovided services pose particular challenges in terms of integration of patient related data. Many ISTCs are part of geographically dispersed chains so the IT provision is based on organisational efficiencies not on integration with different local health economies. In the NME case, TPP SystmOne is effectively providing such a care record across a wide geographic health area, at least across primary, community and child health sectors, which also enables workload and case management. CSC is committed to providing ‘click through’ functionality across SystmOne and Lorenzo in the acute space. And as mentioned elsewhere, London planned on its own ‘London Care Record’ as part of CCN2, but now is looking to use the Summary Care Record integration capabilities. We return to this in Section 6.

In response to the PAC criticism about lack of contingency around LSPs, in 2007/08 CFH ran a procurement called Additional Supply Capability and Capacity (ASCC) to create a four year framework of available additional supply. Its aim was to have available additional Systems Integrator capacity and services available on standby, and to allow Trusts to acquire point clinical solution services. As described in Appendix F, an accelerated process is underway under the ASCC framework to procure centrally funded point applications in community, ambulance and acute trusts in the South. CFH have stated that central funding will be available until 2015, presumably being left over from the previous LSP contract. As part of the process, CFH is aggregating demand across the Trusts and is looking for products which are immediately available for deployment. This has come about as an understandable reaction to the difficulties with the LSP arrangements. Contracts are intended to be let from March onwards. From the NHS side, our discussions suggest that trusts appreciate the well-intended nature of the procurement, and are keen to receive centrally funded systems. There is more concern and scepticism from the supplier side. Several key issues remain need clarifying:

Some form of collaborative procurement would be much better, ideally facilitated by appropriate catalogues of reputable suppliers to choose from.

Outside NPfIT, some LHCs have been pursuing shared record initiatives. For example, Hampshire’s Health Record28 has been running for some time based on document sharing technology across all sectors and, although relatively limited, the system is widely used. Kent has more ambitious plans through their Bluebird project for cross-sector functionality to enable many-to-many communications, for example to allow the reconfiguration of pathology services. The approaches in Wales and Scotland also have parallels here. The development of interoperability standards internationally is especially helpful here, such as IHE.

However as the technology scope extends beyond thin, portal-like capabilities, so the need for strong, secure supporting infrastructure is more essentially. This makes a business case more complex and potentially unaffordable. Tools such as Map of Medicine (available nationally) are being successfully used to address total cost and quality of provision across the full cycle of care and have the potential to support inter-organisational working around ICPs more widely. The NHS needs to determine how best to exploit its potential, for example its full effectiveness can only best be realised when integrated into operational systems.

• • • •

responsibilities – there is no single point of contact and Trusts may end up holding the integration risk (with separate contracts in place for applications, deployment services, integration support and hosting);

funding - what national business case exists, with what level of approval to spend and when;

integration - how a participating Trust can be sure it will receive bundled, integrated solutions, for example if it requires several of the Clinical 5 components. As one supplier commented, NHS Trusts may receive a ‘bag of bits’; configuration - the extent of local configuration possible.

Recommendation 5.E: LHC shared care initiatives need active encouragement nationally, in the context of

Although far from straight-forward, organisational engagement and buy-in is probably more readily dealt with at an LHC level rather than at a national level, provided there is visible leadership. future plans for the SCR.

If there were to be no national contracts or catalogues, the NHS would revert in full back to a ‘free for all’ with each Trust following its own separate procurement. This would be a significant retrograde step. It would
28. http://www.hantshealthrecord.nhs.uk/welcome/

As discussed earlier, parts of the NHS already fall outside the preserve of LSPs. This principally applies in the South following Fujitsu’s termination in 2008. However some FTs had already broken away from NPfIT (e.g. Wirral, Royal Berks, Rotherham and Newcastle). Most have a strong executive and clinical leadership around the value that the EPR can bring the Trust, and have selected single supplier, single database EPRs.
Procurement and Catalogues

There is an alternative approach which links in with the discussion at the end of 5.3. This would involve creating a catalogue framework specifically around acute sector EPRs, resulting in a small number (six or less) of kitemarked suppliers. It would have consistent adherence to a national agreed vision and standards, while enabling local choice. Care would be needed since there is already a proliferation of frameworks. The model could be along the lines of GPSoC and have the following features:

There is a risk that contracts may be rushed through, resulting in a sub-optimal situation for the NHS.

• • • •

rigorously vetting nationally around an updated OBS (so Trusts do not have to each repeat the process) around a minimum set of core functionality (for example, ‘the clinical five’ as a start); compliance to standards mandated; transparent pricing;

lead application supplier responsible for systems integration and deployment;
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• •
allow easy call-off by Trusts based on their capability, maturity, starting point and plans;

06 National Infrastructure & Organisation
As discussed in Section 4, perhaps the greatest criticism of NPfIT is that it attempted to do much, too soon through a centralised approach. This over-ambition meant that many useful national initiatives have since become - rather unfairly - tarred with the brush of ‘NPfIT failure’.

Funding incentives would be available to Trusts only if they were to follow these standards. One idea to be explored would be that funding is provided only on a pro rata basis rather than absolute, for example being proportional to the Trust’s size. This ensures that the Trust has proper ‘skin in the game’.

performance managed by linking to commissioner targets (e.g. 24 hour discharge summaries).

This section therefore takes a dispassionate view on how the key national projects have progressed and makes recommendations for a new Government to consider. It also looks at what central / national informatics function is needed to support this and enable the successful local adoption of IT, as described in section 5. In section 4 we discussed the guiding principles to be applied to the major national components of the NPfIT Programme. We begin to apply these in this section.
6.1 National Infrastructure and Services

Recommendation 5.F: Halt and test the effectiveness of the ASCC Southern procurements, particularly against

It would be important to support these catalogues with appropriate knowledge management tools. To make it transparent as possible, a Wikipedia-type approach could be considered as a means to store templates, repositories of common specifications, best practice guidelines and so on.

an alternative acute systems catalogue model.

In this sub-section, the material includes discussion on N3, NHSmail, Spine, CaB, EPS and PACS. Time precluded us addressing important other national IT areas such as national screening and registry systems, and NHS Choices. The NHS N3 national broadband network is a success story. It provides a managed service allowing Trusts easy connection to services. In certain cases, Community of Interest Networks (COINs) have enabled local health communities to work collaboratively with N3 for the delivery of higher function local Wide Area Networks (WANs). The service has been developed and extended continually, for example a national videoconference services over N3 was recently offered. It is an essential enabler to exploit the full potential of telemedicine, and the collaboration and communication technologies discussed in Section 3.3
N3 (Contract: BT 2004-2011)

As the service develops, there are important considerations about its future requirements in advance of contract renewal. For example:

• • • • •

how N3 should fit relative to the overall Public Sector Network (PSN); the potential from using thin client technology; the delivery of Voice Over IP (VOIP) services or a national basis;

the support of technology at the edge of the network, whether services to mobile or disconnected users (outside 3G coverage); the future requirement for bandwidth and switches to support the on-going explosion of images (PACS and beyond) and the need for their sharing.

Recommendation 6.A: Build on N3’s success, extend and develop in the context of new technology requirements

and the evolving Public Sector Network.

NHSmail is the secure email and directory service for NHS staff in England and Scotland, approved for exchanging patient data with NHSmail and Government Secure Intranet (GSi) users. There are 500k users with NHS.net addresses. Most small NHS organisations use it as their internal email services but take-up has been slower amongst larger Trusts. It was upgraded in 2007 to Microsoft Office Exchange.
NHSmail (Contract: Cable & Wireless 2004-2013)

The head of the NHSmail programme recently stated that he wants “most” NHS organisations to have migrated to NHSmail by the time its current contract expires in July 2013.
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However there is a vigorous debate amongst the IT community about whether this meets local Trust requirements especially in terms of running a local Active Directory, the use of it as an archiving tool, the limitations of relying on N3 bandwidth for the local exchange of images, and the mobile connectivity requirements of Blackberry’s and the like.
Recommendation 6.B: Retain NHSmail and review in advance of contract expiry. The current and future

service must meet the needs of the largest Trusts.

Outside the SCR, there are a number of less controversial aspects, in particular:

concerns. GPs have repeatedly expressed concern about it as a clinical and performance management tool, and more recently the British Medical Association (BMA) has criticised the pace of the SCR roll-out. Its architecture and security have also received heavy criticism, and in response, extensive efforts have gone into building in clear consent models.

Picture Archiving & Communications Systems (PACS) were a late addition to the LSP contracts in 2005.
PACS

• •

At that stage, it was a relatively mature technology, with a well proven business case (starting from cost savings through the removal of X-ray films), a clear implementation roadmap and a relative isolated change impact (compared to EPRs). About a quarter of NHS Trusts already had PACS installed through direct supply from the small number of leading global suppliers. The LSP PACS contracts allowed for a common service hosted locally within each Trust, with off-site LSP data centres providing access to archived solutions and some level of business continuity. By 2007, all sites had been implemented. In this regard, the PACS Programme has seen to be highly successful. In our view, the main considerations about the future of a nationally provided PACS service relate to: the relatively high running cost of the service. We were told that the cost of LSP-provided PACS services typically exceed those which are directly supplied in comparable Trusts, reflecting some degree of extra service. Given that some of the LSP PACS contracts run out in 2013, the value of this extra service needs considering or whether it would be more optimal to return to a model with each Trusts (or LHC) having a direct contracts with their PACS supplier; nationally, a business case needs considering to extend PACS into additional modalities, for example ultrasound, endoscopy, colonoscopy, mammography and pathology;

• • •

between security and usability. The review should consider ways to improved clinical adoption such as : how logon speed can be improved; how contactless smartcards should be supported to aid use of portable devices at the point of care delivery; and whether a Single Sign On solution(s) should be offered as an option to ease security burdens.

Recommendation 6.D: The NHS needs to review policy around smartcards to ensure an appropriate balance

smartcards and security: Access to the Spine is provided through smart card readers which authenticate the user. There are significant operational issues about the level of security versus the usability of the system;

the Patient Demographic Service (PDS) is centred on the patient’s NHS number and is a successor service to earlier generations of centrally provided demographic services such as the NHS Central Register and the Strategic Tracing Service. It is fully operational and covers all 50M patients in England; The PDS should remain a fundamental part of any future NHS IT infrastructure.

• •

secondary Uses Services (SUS): Provides valuable anonymised management and reporting information. This enables Payment by Results, processing an estimated £34bn of financial transactions for 2009/10; SUS should be retained and developed.

Recommendation 6.C: Continue and fully exploit the existing PACS national services. Develop a national

the original LSP contracts did not support inter-organisational transfer of PACS images (the XDSi protocol is the international standard for image exchange protocol). This is an essential enabler for cross-site reporting and the rationalisation of reporting services. Elsewhere, Wales and Scotland are already embarked down this route, and Scandinavia is also well ahead in this regard. Latterly CFH has procured an approach (Burnbank) which allows images to be pushed out to requesting services, however this falls short of the full requirements. The NHS needs actively to determine the benefits and costs of moving to a full image exchange service.

It is mainly used by out of hours services. There are 1.2m records live today, which may rise to 2M by the end of 2010.

The current version of the SCR contains GP summary data, including allergies and medications information. The first release of the SCR went live in pilot form in 2007, with further sites following in 2008. A team from University College London formally evaluated progress on these early adopters and their report was published in April 200829.

the Summary Care Record or PSIS (Personal Spine information Service): this was originally conceived as a means to provide a ‘thin’ central record about key clinical information regarding the patient. The initial vision was that it would provide key static and event clinical information, and would be fed by compliant primary and secondary care systems.

business case on extending PACS into other imaging modalities, and to enable image sharing across NHS. Assess prior to contract end whether services should be provided via LSPs or directly contracted from PACS vendors.

The NHS Spine provides a national messaging and database, intended to provide a single, authoritative repository of demographic and clinical information about the patient across the NHS. It provides a platform for other services such as CaB and EPS (discussed below). The Spine is now fully operational, although it continues to be developed.
Spine (Contract: BT 2003-2013)

Further releases including some pilot schemes in Bournemouth and Bury are intended to broaden out the record to include clinic letters and discharge summaries – i.e. requiring a feed from other sectors, such as Cerner and iSOFT in the acute space. Transaction message structures are governed by the Message Implementation Manual (MIM). Further releases may widen the integration capabilities, possibly to support ICPs across care settings.

A plan is in place to send out 34m Patient Information Packs (PIPs) by the end of April to 105 PCTs, to alert patients that their records are planned to be loaded onto the SCR and give them the opportunity to provide consent or not. The BMA has recently objected to the speed of the planned roll-out30. To date, the level of optouts has been less than 0.7%.

At one level, the Spine has been misunderstood by both the public and politicians, for example in references to the ‘NHS Computer’. Most of the attention has been around the Summary Care Record (SCR) and its privacy

29. http://www.ucl.ac.uk/media/library/screvaluation

30. http://www.healthcarerepublic.com/news/989166/BMA-demands-summary-care-record-roll-out-suspension/

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In our view, the SCR has suffered from a lack of clarity of purpose, causing confusion. As time has progressed, more ideas have been added in and its precise purpose is now rather opaque. Its true value may only be apparent when summary GP data from across the whole country is loaded onto the database. Our suggestion is that, for now, it be repurposed as an ‘urgent care record’ and kept as a thin record until there is full national take-up. The case for a much broader national record needs clarifying particularly in the context of local shared care records, which as discussed in Section 5 are worthy of encouragement. It will enable automated repeat dispensing, a significant benefit for some patients. In time, it will link up with the PPD providing significant productivity savings as well as the potential for much improved and timely information around medicines management.

Recommendation 6.E: The SCR needs a full review by a new Government, with consideration given to repurposing it as an ‘urgent care record’. This needs to cover both a clinical validation of the SCR (to establish its worth beyond doubt), a review of the architecture and security of the Spine, and a review of its business case.

Clinicians also pointed out to us the value of a complete medication record across primary and secondary care.
Recommendation: as per 3.C

Experience from other countries such as the US where such a service is mature is that it has the potential to: address the significant levels of fraud; help reduce drug wastage; improved control over prescribing habits (e.g. use of generics); and improve patient safety through a reduction in medication errors.

CaB is a national application service (NASP) that runs off the back of the Spine.
Choose and Book (CaB) (Contract: ATOS 2003-2009)

It was originally planned and named as ‘eBooking’ to enable the passing of referrals and first appointment booking information from primary to secondary care. As the Government then introduced a choice policy (giving patients the right to choice of where to go for secondary care treatment), the service was renamed and reconfigured as ‘Choose and Book’.

With certain GP systems, the GP-end of CaB involves additional effort on the part of the doctor during the consultation. They criticise its usability for that reason. There are operational issues, for example a CaB booking should be accompanied by a referral but is often delayed. Furthermore, hospitals have chosen to implement in different ways, in some cases through their own service. The original contract with ATOS expired in 2009. Its future needs to be tested against what the policy choice needs are – now and in the future – e.g. greater plurality of suppliers, as how the service can be improved.

GPs receive incentive payments to use the service. The original intent was that 90% of first referrals nationally would use CaB, but latest usage figures show this at about 50%. The system involves a booking agent on the primary care software, linking into a central application, which in turn communicates with hospital appointment scheduling software, usually part of the PAS.

However, PHRs are but one element of using IT to deliver more personalised care through new interactive channels to communicate with the patient and provide them with self-service capability. Nor are they a substitute for investment in care records to support the clinical and operational processes in and across healthcare organisations. There is a strong body of evidence that patients want to be more in control of their health records and who has access to them. For patients managing chronic conditions, they provide a valuable tool to track and manage the condition. But equally they can enable the ‘well’ to manage their health better, and potentially not use avoidable healthcare treatment. There is a wealth of authoritative sources of healthcare information available to patients. The PHR market for solutions is developing rapidly with much innovation, with many freely available tools. There are genuine questions about whether a state-driven development of a PHR (i.e. HealthSpace) can keep up with the full innovation of the market. It is of note that HM Treasury reputedly rejected a CFH business in 2009 to invest a further £100M to create a HealthSpace 2 service.

As discussed in Section 3, a PHR is a key enabler towards more personalised healthcare, opening up health records to the patient and empowering the patient with tools, information sources and informal networks. There is a growing body of evidence for the use of PHRs and how they can improve patient care.

HealthSpace is an online personal health organiser, free to the public, to help manage people’s health, developed and managed by CFH. It has also been developed to allow patient access to the SCR, currently only available to patients in the early adopter areas. As such, it provides the basis for a personal health record (PHR).
HealthSpace - and Personal Health Records

choice. Once its future purpose is clear, the fit between the IT systems and local operational practices, in particular the impact on the GP consultation process, need assessing. As discussed earlier in section 3, the Electronic Prescription Service (EPS), will enable a prescriber - such as a GP or practice nurse - to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. When fully implemented, it is designed to connect with the reimbursement agency (Prescription Pricing Division - PPD). Access to the EPS is tightly controlled through the use of smartcards and pin numbers which give users different levels of access appropriate to their role.
EPS (Contract – part of BT Spine)

Recommendation 6.F: The original CaB policy intent needs to be reviewed in the context of the policy on

Release 1 involved placing a bar code on the paper prescription at the GP end, which then avoids the need for the dispenser to rekey the information. EPS also tracks whether the patient has picked up their medication. All GP and pharmacy systems are now compliant and the service is operational. Release 2 involves the removal of the paper prescription provided that both prescriber and dispenser are both live. The respective GP and pharmacy systems are still proceeding through CFH technical accreditation and roll-out approval, so - beyond some pilot sites - the service is not yet operational,
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In time, these approaches could provide secure messaging, patient questionnaires, PCT surveys based on clinical conditions, links to voluntary /carer organisations, distribution of patient leaflets, as well as plug-in applications. Understandably, there are concerns among some GPs about the impact of opening up their records, particularly at the practical level of managing access but also at the wider level of how it will change the relationship with the patient and how they use the service. Such fears may or may not be groundless. Thoughtful management of the process may be able to minimise any such risks. One aspect worthy of central consideration concerns eConsultations. In certain situations, a face-to-face visit to the doctor could be avoided if there is a shared record with the patient. But there are important ethical and reimbursement considerations that the centre would need to consider and address.

Outside NPfIT, software already exists to enable the patient to have access to their primary care record with some of the major solutions. Many patients already benefit from booking GP appointments and ordering repeat medications in this way. Some 50 or so GP practices have provided full patient access to view their record and the capability exists for it to be activated on a much more widespread basis.

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06 National Infrastructure & Organisation
A range of possibilities need looking at by a new Government concerning the development of future PHRs:

• • •

Figure 6.1 – Required Future National IT Organisations Function 1. Strategy, leadership and direction setting Key Activities On-going engagement on the informatics implications of policy. Determining where collective investment makes senses. Top level clinical engagement with Royal Colleges etc. 2. NHS IT Design Authority and standard setting Technology roadmap and policies Standard setting Organisational Location & Behaviour A small unit, straddling DH and NHS. The DH Informatics unit formed after the 2008 NHS Informatics Review provides the basis for this but currently has too low a profile and is not transparent. (e.g. there is no public DH Informatics web site)

broaden access to the SCR via Health Space. This could be slow and limiting;

broaden access to the SCR by specifying a range of interoperability and governance standards and allow third party vendors to connect in. Approved PHRs would be kitemarked. Patients would have the choice on which PHR to use and select. The role for HealthSpace would be limited or none at all. This approach could be a no cost option to the NHS; in the short term, enable access to the GP record through established software packages that offer a patient front-end (as described earlier) to leading GP systems.

Recommendation 6.H: Review PHR and HealthSpace options in the light of decisions on SCR. Look for an early opportunity to enable no-cost patient access to GP systems, where feasible.

Largely done by the CFH Technology Office now – some elements may now fall within DH Informatics. Need to ensure practical rather than purist approaches are taken regarding implementation of IG and technical standards, and ensure international/EU standards are applied/enforced within the NHS where relevant. Could logically be integrated with Function 1.

On the basis of the earlier discussion and recommendations about local and national NHS IT provision and the guiding principles established in 4.4, we now turn our attention to how NHS IT should be organised nationally and how this fits to the current set-up.
6.2 Future National IT Organisation & Structure

In our view, there remains a strong case for national organisation(s) to coordinate national IT and deliver national IT services, but we would suggest some important changes to the current model. Figure 6.1 sets out our view on the four main functions needed to promote connectivity, transparency and security:

3. National IT Infrastructure and Services Delivery

Central contract management. Operations management. Programme Office.

To cover the essential national services and nationally run contracts on a business as usual basis Possible case for the function to be outsourced. Needs to be NHS-facing and accountable. Need not be centrally provided, but possibly through regionalised NHS resources provided by different HIS functions or specialist contractors, with extensive use of eLearning and knowledge management.

4. Helping the NHS deliver IT enabled business change

Enabling the NHS to deliver better on localised IT, e.g. EPR, telehealth. Establishing national catalogues for hardware, services and solutions. Maximising purchasing power through enterprise-wide agreements. Providing specialist deployment support and project management resources. Developing and promulgating worthwhile guidance on enabling NHS IT through R&D, capability maturity models, promoting pilots, learning and promulgating lessons, model business cases, clinical engagement models.

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06 National Infrastructure & Organisation
While Functions 1 and 2 are not far from the current model, there are important behavioural differences. What is needed is clear transparency, leadership and a practical mindset on setting achievable and realistic targets and standards.

A Appendix: List of Contributors
The following lists the contributors to the work. There were many others who contributed on an anonymous basis.
Steering Group 2020health 2020health Independent Consultant Ascribe (WCI)* University of the West of England, Bristol NHS Contributors Kings College Hospital NHS Foundation Trust Oxford Radcliffe Hospitals NHS Trust The Rotherham Foundation Trust Primary Care iSOFT User Group NHS Connecting for Health Industry Contributors Ascribe (WCI)* Cambio CSC dbMotion HP Independent consultants* Map of Medicine PAERS Steria Tolven Tribal

Elements of functions 3 and 4 are addressed by CFH but the roles seem blurred. Crucially Function 4 in our opinion must get its mandate from the NHS and be accountable to them. The presumption should be that the organisations should be small and nimble31, with a relatively small span of projects. We did not gain access to CFH during the work so did not have the opportunity to discuss these views.

Recommendation 6.I: A full review is needed of current central functions (including DH Informatics and CFH) to meet the new national organisational remit and required future functions.

Julia Manning (CEO, Chair of Steering Group and Series Editor) John Cruickshank (NHS IT Policy Chairman and Principal Author) Julian Wright (Supporting Editor and Author) Tim Giles Dr Tony Solomonides

Given the emphasis in the Government ICT strategy, there is a strong case for aggregating IT delivery into shared service organisations like the Health Informatics Services. Here they could serve (some of) the IT needs of organisations across a local health community. Their scale could be large enough to be professional, provide economies of scale for service delivery (especially around 24/7 service), but close enough to the users and offer a career structure to the IT professionals involved. A wider range of mature, capable local NHS IT organisations would facilitate greater devolution of responsibility from the centre. A network of these organisations could facilitate work in the national interest in collaboration with a future central NHS IT body.

As mentioned in Section 3, in many parts of the NHS, the organisations are simply too small to be effective, especially in relation to infrastructure services.
NHS IT Set-up

Dr Hugh Cairns (Consultant Nephrologist) Dr Paul Altmann (Consultant Nephrologist – also Clinical Director of Health Informatics, South Central SHA) David Kwo (Deputy Director of EPR) Dr John Lockley (Chair) and Dr Peter Harris Invited to contribute but no response was forthcoming

Tim Giles, Carl Adler Tomas Mora-Morrison Andrew Spence Johan Hjord Craig Wilson, Mark Vincent, Ruth Gardiner, Jo Watts, Julia Hopper Nat Billington Dr Brian Fisher Nick Wensley & colleagues Neil Cowles Prof Matthew Swindells (BCS Health Chair)

Other Contributors Independent IT Review members Dr Glyn Hayes (Chair), Gail Beer UK Specialist Hospitals Limited Fiona Calnan (CEO) * speaking in an individual capacity rather than as company representatives.

31. The most recent figures for CFH (January 2009 – source Hansard) show 1,465 FTE emplyees and contractors.

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B Appendix: Glossary
A&E ASCC BMA CaB CCN CEO CfH CIO CMM COTS CQUIN CRS DH DSCN EC ED EDRM EHR EPR EPS ESR EU FT FTE GP GPSoC GSi HealthSpace HIS HIT HL7 HR ICN ICP ICRS ICT ICU IG IHE IM&T IP ISB ISN ISTC ITK IT LHC LPfIT LSP MIM
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Accident & Emergency Additional Supply Capability and Capacity British Medical Association Choose and Book Contract Change Notice Chief Executive Officer Connecting for Health Chief Information Officer Capability Maturity Model Custom-Off-The-Shelf Solution Commissioning for Quality and Innovation Care Records Service Department of Health Data Set Change Notice European Commission Emergency Department Electronic Document and Records Management Electronic Health Record (straddles across health organisations) Electronic Patient Record (to support treatment within an organisation) Electronic Prescriptions Service Electronic Staff Record European Union Foundation Trust Full-Time Equivalent General Practitioner GP Systems of Choice Government Secure Intranet On-line personal health manager, and patient window into the SCR Health Informatics Service Health IT Health Level 7 interoperability standard Human Resources Information Change Notice Integrated Care Pathway Integrated Care Records Service Information Communications Technology Intensive Care Unit Information Governance Integrating the Healthcare Enterprise Information Management and Technology Internet Protocol Information Standards Board Information Standards Notice Independent Sector Treatment Centre NHS Interoperability Toolkit Information Technology Local Health Community London Programme for Information Technology Local Service Provider Message Implementation Manual

N3 NAO NLOP NHSmail NIMM NME NPFIT NHS NHSmail NUH OBS OGC OpenEHR OPCS PAC PACS PAS PCT PDS PHR PIP PPD PSIS RBAC ROI SBS SCR SOC Spine SDS SHA SNOMED SOA SRO SUS TCO TCV VOIP UKSH WAN XDS

NHS National broadband Network National Audit Office NPFIT Local Ownership Programme NHS email service NHS Infrastructure Maturity Model North Midlands East pan-SHA National Programme for Information Technology National Health Service NHS-wide email service Nottingham University Hospital NHS Trust Output Based Specification Office of Government Commerce Open standards specification of an EHR Office of Population, Censuses & Surveys Public Accounts Committee Picture Archiving & Communications System Patient Administration System Primary Care Trust Personal Demographic Service Personal Health Record Patient Information Packs Prescription Pricing Division (NHS Business Services Authority) Personal Spine information Service Roles Based Access Return on Investment Shared Business Service Summary Care Record Systems of Choice Single NHS-wide reference point for patient information Spine Directory Services Strategic Health Authority Systematized Nomenclature of Medicine Service Oriented Architectures Senior Responsible Officer Secondary Uses Service Total Cost of Ownership Total Contract Value Voice over IP UK Specialist Hospitals Ltd Wide Area Network Cross-Enterprise Document Sharing

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C Appendix: Relevant EC Communications on EHRs and Telemedicine
This Appendix provides key extracts from: the European Commission EHR Impact study (www.ehr-impact.eu) to investigate the socio-economic impact of interoperable EHR and ePrescribing systems in Europe and beyond, and a Communication (COM(2008) 689) to European organisations including the European Parliament on telemedicine for the benefit of patients, healthcare systems and society. “EHRs and ePrescribing are not quick wins, they are sustainable wins. It takes at least four, and more typically, up to nine years before initiatives produce their first positive annual socio-economic return, and six to eleven years to realise a cumulative net benefit.
The EHR IMPACT Study

Telemedicine can improve access to specialised care in areas suffering from a shortage of expertise, or in areas where access to healthcare is difficult.

Plans to invest in EHRs and ePrescribing systems should have a clear focus on achieving changes at the right time; neither too late, nor too early. It comes as a paradox that in the complex environment of EHR and ePrescribing systems, longer time scales are generally associated with lower risk of failure.

Despite the potential of telemedicine, its benefits and the technical maturity of the applications, the use of telemedicine services is still limited, and the market remains highly fragmented. Although Member States have expressed their commitment to wider deployment of telemedicine, most telemedicine initiatives are no more than one-off, small-scale projects that are not integrated into healthcare systems.

Telemonitoring can improve the quality of life of chronically ill patients and reduce hospital stays. Services such as teleradiology and teleconsultation can help to shorten waiting lists, optimise the use of resources and enable productivity gains.

The sub-analysis of financial, or cash, impacts underlines the extensive reliance on executives’ and managers’ skill and expertise in organisational change and resource redeployment to realise financial returns.

• • •

Telemonitoring is a telemedicine service aimed at monitoring the health status of patients at a distance. Telemonitoring is particularly useful in the case of individuals with chronic illnesses. It can contribute to re-organisation and re-deployment of healthcare resources, for instance by reducing hospital visits, thus contributing to the greater efficiency of healthcare systems.

Healthcare provider organisations bear most of the costs and are the main beneficiaries. Long phases of engagement, planning and design lead to net socio-economic costs followed by net benefits at later stages. Citizens, healthcare professionals and third parties tend to reach a net benefit quicker.

EHRs and ePrescribing bring about considerable strategic gains for healthcare and should be approached as a clinical venture, not as an ICT project. Using EHRs and ePrescribing as part of successful change in clinical and working practices is an essential component of improving health services delivery and performance. By taking the socio-economic perspective, initiatives can achieve returns of close to 200% on their total investment, and an average of about 80% over some nine years. The EHR IMPACT study identified two not to miss opportunities for all EHR and ePrescribing systems. One is to organise engagement and a productive dialogue between users and ICT experts preceded spending large sums of money on actual solutions. Continuous engagement with healthcare professionals from the outset is essential and time-consuming, but must not be avoided. If it is, it has bigger costs downstream.

Policies have to create the right climate and incentives for Health Provider Organisations to pursue the required investments. This includes a political commitment to goals such as improving the quality and increasing the efficiency of healthcare, and the removal of potential regulatory and other system barriers. The second plea to policy makers is to allow investors, project teams and stakeholders enough time to achieve net socio-economic returns.

The EHR IMPACT cases show that interoperability is a prime driver of benefits from EHR and ePrescribing systems. Benefits rely on access to information regardless of place and time. Local, closed ICT systems lacking interoperability would not release these substantial gains.

It has proven to increase quality of care for patients, in particular chronically ill patients. In the context of an ageing population and an increasing burden of chronic diseases, the benefits its wider deployment can provide are crucial. It requires a coherent approach and partnership involving patients, health professionals, healthcare providers, payers and the industry, to ensure sustainability of the services.

Most telemonitoring services are still limited to the status of temporary projects without clear prospects for wider use and proper integration into healthcare systems. Member States are responsible for the organisation, provision and funding of national healthcare. The leadership of their health authorities in achieving wider deployment of telemedicine is essential. Collecting evidence and sharing good practice on implementation of telemedicine services and reimbursement schemes are therefore critical in order to secure the necessary acceptance and commitment on the part of the health authorities.”

The other opportunity is to use interoperability is a prime driver of benefits. It makes life easier for users and provides gains that rely on access to information regardless of place and time, and from re-using information for multiple purposes. Without the meaningful sharing and exchange of information, the gains would be marginal and not justify the cost of investments.”
Telemedicine

European citizens are getting older and are increasingly living with chronic diseases. Their health condition often requires enhanced medical attention. Medical support may not be available in remote areas and for certain specialities as easily or as frequently as their health condition would require.
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“Telemedicine encompasses a wide variety of services. Those most often mentioned in peer reviews are teleradiology, telepathology, teledermatology, teleconsultation, telemonitoring, telesurgery and teleophthalmology. Other potential services include call centres/online information centres for patients, remote consultation/e-visits or videoconferences between health professionals.

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D Appendix: Case Study - Transformation through Collaboration and Communication Technology
This appendix references extracts from a report entitled “Collaboration and communication technology at the Heart of Hospital Transformation”, published on 15 March 2010 by the Association of Chartered Certified Accountants (ACCA) in collaboration with Nottingham University Hospitals NHS Trust (NUH) and the European Commission Information Society Directorate – General. As Florin Lupescu, Director, ICT Addressing Societal Challenges at the European Commission comments in the Foreword:

E Appendix: Case Study – Developing an ICP-based EPR system in the Independent Sector
UKSH UKSH is a leading edge independent sector healthcare company with a first class record of delivering quality results, innovation and efficiency. UKSH operates four treatment centres across the South West in Bristol, Wiltshire, Somerset and Gloucestershire and has treated over 40,000 NHS patients to date.

“The report provides a persuasive account of the huge impact the new communications infrastructure deployed at NUH has had on re-engineering the day-to-day working processes of its emergency department. The report highlights the role of communications tools in creating a more efficient, streamlined and peaceful working environment in which NUH can deliver high quality care to patients.” Key extracts from the report now follow: “This report tells the story of how one acute teaching hospital, Nottingham University Hospitals NHS Trust (NUH), has embraced ICT and used it to engineer change and to begin to revolutionise service delivery across its emergency department – one of the largest and busiest in Europe.

The challenge for UKSH was to harness technology to enable the patients to receive their care and aftercare interchangeably across multiple sites. The EPR system had to follow a clinically led model. In 2008, UKSH embarked on a process of developing detailed evidence based integrated care pathways (ICPs) for each procedure that would be undertaken at the new centres. UKSH led this work with its own clinical workforce and input from Vanderbilt University Medical Center.

With new facilities opening in November 2009 at three locations across the South West and a clinical workforce who would be travelling and working across the various locations, UKSH needed strong systems and infrastructure in place to ensure high quality care and effective patient management. In planning the service delivery, UKSH identified the use of an electronic patient record (EPR) system as the key enabler to drive high quality care.
Background

Utilising telephony services provided by fixed and portable handsets, the new system enables staff to instantly contact any other member of the ED team – wherever they are located within the department and beyond. The new processes make finding and speaking with people much more efficient and add governance to person-person process steps. These changes have fostered a more collaborative working environment with all staff working together to ensure the new system’s success. They have also resulted in an increase in patient satisfaction due to shorter waiting times and improved comfort levels. Having taken the decision to make a significant investment in both new processes and new technologies the Trust was committed to assessing the benefits. This report begins that process. At the time of writing the new collaboration technology had only just been introduced to the emergency department of NUH. However, significant improvements are already evident, including: a reduction in the patient journey time of 23% for adult patients and 33% for paediatric patients

• • •

an increase in productivity of doctors treating minor injury patients equating to a potential time saving of over seven hours per day or one doctor per year cost containment that will allow a full return on investment in the new technology to be realised in just 14 months.

The IMS MAXIMS electronic health record architecture enabled UKSH to load the detailed ICPs and integrate them into their advanced electronic patient record system which includes: Patient scheduling Choose and book integration Patient flow management Theatre management Patient and referrer correspondence PACs ordering and review Pathology and pharmacy ordering and review Detailed clinical metrics, tracking and reporting capabilities

These ICPs followed the full pathway from referral, pre-assessment, procedure, inpatient/ day case and discharge through to follow up. The ICPs were then extensively reviewed by a panel of experienced NHS consultants to ensure compliance with the highest UK standards. All evidence supporting the ICPs is referenced and can be accessed by clinicians to review relevant articles and research that support the pathway. At the same time, UKSH looked at the various technology solutions available and sought to identify a system that met its needs. In April 2009, when the ICPs were agreed and completed, UKSH began the process of integrating them into an electronic patient record system developed with its IT provider, IMS MAXIMS.
Developing the system

Overall the new system has been a great success. Indeed it has been such a success that, just six weeks after roll-out during a planned four hour system outage, staff complained that without the phones, despite the established fall back procedures, they could not do their jobs properly.”

“We consistantly focus on delivering high quality results for our patients. Our new clinically led system is driving a standardised care approach, high quality outcomes and delivering detailed data and metrics. For UKSH the technology is an enabler rather than a controller of activity and feedback from clinicians has indicated that the system works for them in an effective and seamless way to support high quality patient care.” Fiona Calnan, CEO, UKSH

The chosen system was built up from the clinical perspective with every aspect of the pathway integrated into one seamless, robust and accessible platform. Before going live the system was extensively tested to make sure it could manage the patient’s treatment from start to finish. The web based system features high levels of security, user identification and locks down, and allows clinicians to access the patient information they need whichever site they are on. This integrated electronic solution also ensures complete and up to date patient information is available.

The system went live in November 2009 to support the opening of UKSH’s three new sites in the South West.

The clinical approach taken from the outset made the system more intuitive for the clinicians to use and manage and training across all skill levels meant staff were engaged and understood the system and its value to the patient pathway.

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F Appendix: LSP Recent History & Developments
BT was awarded the London LSP contract in December 2003, based on using the IDX software around a single database and instance of the software. During 2005, when it became evident that IDX would not be available for some time to support GP and community care, a decision was made in CCN1 to bring in specialist solutions (respectively INPS and Rio). These deployments have been a success with all but one community trust now using Rio. Subsequently, and in view of similar developments in the South, a decision was made in CCN2 in 2006 to switch the hospital system from IDX to Cerner, and create a London Shared Record to straddle across the care sectors in London.
London LSP (BT as LSP)

At the time their contract was terminated in May 2008, Fujitsu had deployed Cerner into 8 out of 41 acute Trusts in the South.
South (formerly Fujitsu as LSP)

A contract reset CCN3 is in process to formally recognise this new deployment model and reflect the new requirement to meet the emerging IT needs of Polyclinics, in the context of a Government requirement to save £100M from the TCV. After the 2006 exit of Accenture, further delays occurred to the development of Lorenzo resulting in more contract reset activity between CFH and CSC. Lorenzo was essentially a development project with difficulties on both sides.
North Midlands East (CSC as LSP)

However, like the Southern Cerner acute deployments, the early London deployments were problematic. The Royal Free problems received the highest profile, with the Trust reporting £8M in attributable losses following its implementation in 2008. There was more than a year’s delay before the next deployment of the improved Cerner system at Kingston Hospital in late 2009. This was based around a new delivery model, including: much more Cerner presence on site; working in a single domain; and a training system to match the live one. This new implementation passed the CFH ‘30 November 2009 deployment test’ and is now seen as a replicable model for the next planned deployments at St George’s and Imperial.

CFH subsequently agreed a contract Memorandum of Understanding for BT to take on these live Cerner sites (bringing them onto the same code base as the London version of Cerner), deploy four new ‘early adopter’ Cerner sites (N Bristol, Oxford Radcliffe, Bath and one other), together with a series of ROI deployments across the South. The contract was valued at £540M in September 2009. Fujitsu’s PACS responsibilities related to the GE system were in turn taken on by CSC.

In April 2009, the new NHS CIO announced that those Southern acute, community and ambulance Trusts remaining outside the LSP Programme would be able to receive centrally funded systems through the Additional Supply Capability and Capacity (ASCC) procurement framework established in 2008. She announced that a new procurement would start shortly.

The result from the contract reset signed in 2008 was a layered four release programme (‘Penfield’). The first deployment of Release 1.9 (covering the core Care Management functionality) went live in Bury PCT in late 2009 (a small community provider), with the first full deployment due at a large hospital (Morecambe Bay Trust) in late March 2010. After a gap to learn lessons, CSC plan 3 further early adopter Lorenzo implementations in summer 2010, followed by a further 12-13 sites during the remainder of the year. The practicality of these plans remains to be seen. Typically in the software industry, it takes 18-24 months after the initial α or β implementation before a complex software product is really ready for general release. CSC told us that while Lorenzo is not yet ready for general release, it is further ahead than a β release.

As with BT, the contract with CSC is in reset to achieve £400M in total savings. It appears to be dependent on the Morecambe Bay go-live being successfully achieved32.

Meanwhile, the TPP implementations in primary, community and mental health have been regarded as a success, with over 15 million patient records live in the North East and East. Trust contributors reported to us that they are evaluating using the product in hospital outpatients.

Although no public announcement was made, we understand that Lorenzo did pass the ‘30 November 2009’ deployment test based on the outcome of the Bury PCT deployment.

32. http://www.e-health-insider.com/news/5724/new_csc_deal_hinges_on_morecambe_bay

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G Appendix: EPR Architectural Options
[The material in this appendix is kindly provided by Ruth Gardiner, independent consultant] Prior to NPfIT, there were two schools of thought on architectural approaches around hospital EPRs:

H Appendix: Open Source as an Option
As part of this study, we took a brief look at the state of the open source industry as regards clinical IT systems, by speaking with key players internationally.

• •

‘rip and replace’ - involves the replacement of all major patient systems with a single EPR solution from a single vendor, sometimes managed by a systems integrator; ‘best of breed’ approach - involves procuring and using best in class systems for each departmental function, integrated through an integration engine.

The pro’s and con’s of each were heavily debated. However, while providing the opportunity for rapid, tactical progress, the generally accepted view was ‘best of breed’ was sub-optimal. Its level of integration was traditionally limited to data integration, with an inability to enable effective workflow to achieve optimised processes on an enterprise-wide level (such as ICPs). At least until recently, the LSP model fitted into the ‘rip and replace’ approach. There is now emerging a third alternative – ‘surround and replace’ - which some Trusts in the South are looking to pursue, which takes a middle ground and seeks to take the best from both approaches. It enables a more flexible approach, but is dependent on factors such as timescale, finance, risk and the starting point.

A number of the open source projects have reached a level of maturity that included referenceable deployments and many of the on-going developments are targeted at President Obama’s Recovery & Reinvestment Act in the US, which is providing funding for the adoption of “Meaningful Use” of EPR products33. The certification process will include mechanism for both proprietary and open source products. To become accredited. a number of open source projects are centred on the provision of standardised open infrastructure, repositories and application development frameworks around which clinical applications can be developed (similar in manner to iPhone applications).

In summary, we found that there is clear engagement around open source from leaders in the vibrant international standards community (see http://www.openhealthtools.org/index.htm) and commercial open source healthcare vendors.

Open source solutions are particularly suited to collaborative environments such as healthcare. The other main potential advantages of Open Source relates to reduced total cost of ownership (10-20%), the avoidance of vendor lock-in, transparency, and the removal of high barriers to entry.

Example suppliers of such integration products include Cambio, DBMotion, ICW, iSOFT, Orion and Tolven. Major questions remain on whether the ‘surround and replace’ strategy is truly viable. The major issue associated with all multi-vendor approaches is ensuring the parties can work together and as smaller niche solutions are acquired by larger vendors this becomes increasingly complicated. But as a means to enable choice and progress at Trust level, it represents an avenue worthy of consideration.
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The aim is to achieve seamless information flow integrating disparate application systems into a comprehensive distributed information system. This is difficult to achieve as individual applications typically are not designed to cooperate. The integration strategy must ensure data integrity and also enable the context or and meaning of data exchanged between systems to be maintained. It should also minimise the need to move between different systems for the user and ensure functionality is aligned to core business processes as closely as possible. Across the globe, there is a growing trend towards using emerging interoperability technologies to make better use of existing systems whilst moving forward with new and innovative solutions for specific tasks as they become available. This includes solutions that use Service Oriented Architectures (SOA) and internationally agreed standards for messaging and communications. These systems enable the linking of distributed systems either through a centralised hub or through a federated approach to data held in different databases.

In outline, the functional components need to be brought together through an effective enterprise wide integration platform that either incorporates or can work with a clinical decision support engine, workflow management and can provide a longitudinal view of patient interventions, outcomes and key clinical information.

It involves retaining some of the existing patient systems which are fit for purpose, and bringing other new systems either to replace some functionality or add new functionality. It uses more sophisticated integration technologies specifically designed for healthcare to enable interoperation between systems to give the appearance of one system. The key difference compared with the legacy approach to ‘best of breed’ is that the component systems are designed to support and optimise corporate wide processes or ‘lines of business’ such as enterprise scheduling. The departmental systems approach typically reinforced departmental ways of working and creates a barrier to improving efficiency and effectiveness across the organisation.

Custom-off-theShelf (COTS) vendors are increasingly choosing to build elements of their product stack based on open source technology (e.g., database, application server and operating systems) giving them access to the code and potentially easing multiple support problems. The next generation of COTS solutions are starting to include open source platforms and technologies beyond the use of core open source technologies seen today.

“We have already developed a powerful, open source specialty database (Renalware) at King’s College Hospital in the Renal unit and are now developing a parallel database within the Institute of Liver Studies. The experience within Renal indicates that the use of a specialty database — designed from the start around clinical need, under local control and continually evolving as data requirements change and core software develops — dramatically improves data quality whilst facilitating activity-based costing.

In the course of our work we also spoke with Dr Hugh Kairns, Consultant Nephrologist at King’s College Hospital, who spoke of their progress in the renal unit with a specialist clinical open source system:

In the medium term, open source clearly has enormous potential applicability to the NHS, perhaps through developing complimentary services around the NPfIT core and specific clinical solution, subject to strict compliance with standards. The discussion about PHRs in Section 6 is an example.

As with proprietary software, to avoid practical implementation issues associated with running open source software there needs to be organisations providing commercial support for open source solutions. In addition to this, the use of open industry standards is essential to ensure that integration with existing technologies is possible. For example, the NHS makes wide use of Microsoft products, such as Word which is the default standard for document preparation (e.g. clinic and discharge letters).

Clinicians and other staff have a primary interest in entering and maintaining an accurate database as they all derive specific and immediate benefit. User designed audit of outcome measures is now almost seamless in Renal and drives quality improvement. Current user-friendly software permits clinicians to develop rapidly additional clinical audit and costing analysis screens, which non-specialty hospital databases cannot possibly provide as they do not handle the relevant metadata.”

33. http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=1745

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About 2020health
Our Vision

2020health is a health and technology think tank with a vision of more people enjoying good health.
Our Mission

• • • •

We want to improve health through effective commissioning, competition and technology. We seek a level playing field between the public and private sector as the work to improve health outcomes. We search forways in which the workforce can take more responsibility in local healthcare. We examine the consequences of healthcare decisions on society, lifestyle and culture.

Our Method We are ‘professional’ led, ensuring all we do has the constant input of people working for and in the public services. Our unique emphasis is on giving people who work delivering healthcare, the ‘grass-roots’, the opportunity to use their experience and expertise to direct our work. Our partnership 2020health's work is made possible through partnership and sponsorship. Please do contact Julia@2020health.org if you would like to know more about getting involved in our work.

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