Fixing nhs

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Fixing nhs

  1. 1. Fixing NHS IT A Plan of Action for a New Government John Cruickshank March 2010 ISBN 978-1-907635-04-5 2020health Published March 2010 83 Victoria Street © 2020health.org March 2010 London SW1H 0HW E admin@2020health.org www.2020health.org
  2. 2. Fixing NHS IT A Plan of Action for a New Government John Cruickshank March 2010
  3. 3. Contents Contents 4 About This Publication 6 About The Authors 7 1. Executive Summary 9 6. National Infrastructure & Organisation 39 1.1. Background 9 6.1 National Infrastructure and Services 39 1.2. Key Drivers 9 N3 (Contract: BT 2004-2011) 39 1.3. The Programme in Overview 9 NHSmail (Contract: Cable & Wireless 2004-2013) 39 1.4. Local Service Providers 9 PACS 40 1.5. Under-exploited Opportunities beyond the Programme 10 Spine (Contract: BT 2003-2013) 40 1.6. National/Local IT Services 11 Choose and Book (CaB) (Contract: ATOS 2003-2009) 42 Fig1.1 Plan for Action 11 EPS (Contract – part of BT Spine) 42 HealthSpace - and Personal Health Records 43 2. Introduction 14 6.2 Future National IT Organisation & Structure 44 2.1 Background 14 Fig 6.1 Required Future National IT Organisations 45 2.2 Government’s responsibility for Health IT 14 NHS IT Set-up 46 2.3 This Report 15 A. Appendix: List of Contributors 47 3. Where can Healthcare IT Offer most Opportunity? 17 3.1 Electronic Health Records 17 B. Appendix: Glossary 48 Fig3.1 Organisational Challenges affecting the CRS 18 3.2 Telemedicine 19 C. Appendix: Relevant EC Communications on EHRs 3.3 Collaboration and Communication Technology 19 and Telemedicine 50 3.4 Prescribing Value Chain 20 The EHR IMPACT Study 50 3.5 Document & Record Management 21 Telemedicine 50 3.6 Shared Services 22 D. Appendix: Case Study - Transformation through Collaboration 4. NHS IT / NPfIT in Overview 23 and Communication Technology 52 4.1 The NHS Needs for IT 23 4.2 What NPfIT intended to do 24 E. Appendix: Case Study – Developing an ICP-based EPR 4.3 The Situation now 25 system in the Independent Sector 53 4.4 Guiding Principles for the Future 27 F. Appendix: LSP Recent History & Developments 54 5. Localised NHS IT 28 London LSP (BT as LSP) 54 5.1 The Original LSP Model – in Concept 28 North Midlands East (CSC as LSP) 54 5.2 Why have there been such Difficulties? 29 South (formerly Fujitsu as LSP) 55 5.3 LSP Progress and Recent Developments 30 5.4 The LSP way forward 31 G. Appendix: EPR Architectural Options 56 5.5 What alternatives exist to the LSP model? 32 Architecture 33 H. Appendix: Open Source as an Option 57 Interoperability, Standards and Open Source 33 Delivering Shared Care across Local Health Communities 35 About 2020health 58 Procurement and Catalogues 36 4 5
  4. 4. About This About The Publication Authors 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 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 enabler in improving productivity and patient outcomes but the Programme cannot be fixed by cancelling 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 projects or renegotiating contracts. hospital-wide electronic patient record. The new Government would need to assess how to gain the best from IT investment in the NHS as we consider As a leading management consultant in the field, he has held leadership roles in the healthcare that a hiatus around NHS IT after the Election would be disastrous. In response, 2020health believed it would practices of major systems integrators and consultancies at UK and European level. During the be helpful if we undertook a short, independent research project to map out an action plan for NHS IT, with a 1990s, he founded, built and sold his own consulting practice, Pareto Consulting, which set the particular focus on NPfIT, to assist policy makers determine the way forward. 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 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 ongoing work of involving frontline professionals in policy ideas and development, sponsorship enables us Europe, and of its effective and commercially practical application and implementation in communicate with and involve officials and policy makers in the work that we do. Involvement in the work of different countries. 2020health.org is never conditional on being a sponsor. He has personally advised over 100 different NHS Trusts and acted as a core advisor at a Julia Manning, Chief Executive national level to two published NHS IT strategies in the 1990s. March 2010 John is a graduate in economics and management science from St John’s College, Cambridge. www.2020health.org 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. 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. 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. - Victoria Street 83 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 London SW1H 0HW of Optometrists in 1991. She was a founder member of the British Association of Behavioural T 020 3170 7702 Optometrists and her work has included being a visiting lecturer at City University, a visiting E admin@2020health.org 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 Published by 2020health.org 2009. 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 All rights reserved. No part of this publication may be The views expressed in this document are those of the © 2010 2020health.org Disclaimer development by front line professionals and focuses on the core areas of public health, reproduced, stored in a retrieval system, or transmitted authors alone and may not reflect the views of any of technology and sustainability. She has written on many health and technology issues and the in any form or by any means without the prior written the companies or individuals interviewed. all facts have history of her profession in 60 years of the NHS [St. James’s House]. permission of the publisher. been checked for accuracy as far as possible. 6 7
  5. 5. 01 Executive Summary Since the creation of the £12billion National Programme for Information Technology in 2002, the subject of 1.1 Background 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. 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 1.2 Key Drivers model. This has profound implications for IT. 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. 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 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. The Programme was conceived to address the problems of a highly fragmented IT situation across England. Its 1.3 The Programme in Overview 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. 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. 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. The Programme’s most significant failure lies in acute hospitals where centrally provided solutions have been 1.4 Local Service Providers 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 9
  6. 6. 01 Executive Summary for conclusion by 31 March. As a starting point, a new Government must test the contractual arrangements and quality well ahead of where many are now. Over time, the NHS should therefore address consolidation baseline plans against key criteria that we set out in the main body of the report. opportunities, such as rationalising NHS data centres into either large-scale off-site facilities or a “cloud-based” provision, once established and safe. 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. 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 Irrespective, there are elements of the local solutions that work well (e.g. infrastructure; shared care records in progression. Going forward these local organisations should take responsibility for strategy, integration with primary and community care; secure data centres) and these should continue in one form or another. In the national programmes and play a leading role in the selection and implementation of front-line systems. 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. In the event that the new Local Service Provider arrangements do not meet the criteria, the acute solutions 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 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 • to avoid redundant variation for infrastructure and back-office solutions on a once and once only basis; own capability, maturity, starting point and plans. • to provide economies of scale, associated with using NHS purchasing power; 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 • to meet the ‘national’ nature of NHS patient care, through essential central coordination well defined interoperability standards. or regulation, e.g. standards, security. This would also allow fairness in those parts of the NHS which already fall outside the preserve of Local Service A new Government would wish to do an urgent stock-take of NHS IT projects, assets and organisation against Providers (principally the South). A process is underway to provide local solutions here but there is a risk that these principles and we set out specific recommendations in Figure 1.1. It shows our recommended plan for contracts may be rushed through, resulting in a sub-optimal solution for the NHS. 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, Adherence to standards here is a critical element but there is as yet no ‘magic bullet’. There is a vibrant but believe the recommendations in totality will save more than £1bn and accelerate improvements to community internationally, in which the centre participates on behalf of the NHS. Here we recommend that patient outcomes. the centre take a more practical but informed approach, and follow international/ EU standards unless there is an overwhelming case otherwise. 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 IT- enabled change. A small, linked organisation is also needed to interpret policy as a bridge with the Department A new Government needs to consider carefully the potential of: of Health and set a national direction for IT. 1.5 Under-exploited Opportunities beyond the Programme • telemedicine (to provide remote access to specialised care, extending the reach of clinicians Beyond this, and respecting any nationally agreed contracts already in place, local NHS organisations should be free into the domestic care setting, improving service and overall efficiency); 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 • collaboration services (network technology, enabling productivity & mobility, as a platform for organisation - e.g. county-based), as opposed to a free-for-all which would be impractical. Foundation Trusts would improving working practices); not be mandated to participate but would be encouraged, in order to meet the local healthcare strategy. • electronic document records management (scanned paper medical records). The totality of IT provision must support the delivery of joined-up care. The emphasis must be on technology- enabled service improvement aligned to the core process of delivering care to improve patient outcomes, as In each case pilots have taken place and there is a need to define a national strategy based on best practice in opposed to an over-emphasis on technology. 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. 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. 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 10 11
  7. 7. 01 Executive Summary (The references relate to specific recommendations in the main report. The benefits to be derived from the Figure 1.1 Plan for Action activity are shown in italics.) Theme 0-3 months 3-6 months 6-12 months Theme 0-3 months 3-6 months 6-12 months Accelerate 6.G Deploy no-cost patient access to 3.D: Accelerate adoption of case notes 3.A: Telemedicine: Establish a national Enabling 5.C: Interoperability and standards: 5.B: Integration technologies: Initiate 5.D: Open Source: Commission research benefits GP systems, where practical (enable scanning and record technology in framework on how best to exploit its local IT Ensure centre is taking a practical, research and pilots to test out the viability around the potential of clinical Open personalised care) hospitals. (clerical & clinical productivity, potential, based on best practice in the informed and transparent approach, and impact on business case of different Source solutions in the NHS, with a view patient experience – fewer wasted visits UK and elsewhere (patient experience adopting international/ EU ones unless local approaches (flexibility of IT to exploiting its potential in the medium 3.C Review, simplify (where feasible) and from lost notes) and control over own care, remote there is an overwhelming case otherwise approach, enabling market innovation, term (improve collaboration, cost savings, accelerate Electronic Prescriptions Service access to clinical specialists, clinical (enabling interoperability and local cost savings) transparency, remove high barriers to (back office savings, reduced fraud and productivity) choice of systems) entry for innovative suppliers) wastage, patient safety) 5.E: Local Health Communities: Review 3.C Prepare coherent strategy to bring and establish best practice for local 3.E: Local IT: Assess potential from 3.B Leverage immediate opportunities for together a unified prescription record shared care records (patient safety and consolidating NHS data centres and other collaborative technology, using Nottingham across primary and secondary care experience, clinical and clerical local infrastructure management (4.A, 6.I) as a case model (patient throughput and (patient safety, monitoring effectiveness productivity) (6.E) (economies of scale, improved service) experience in A&E, clinical productivity) nationally of treatment programmes) 3.E: Local IT: Assess potential from consolidating local IT staffing (4.A, 4.B, Develop Retain and restate commitment to key 6.A: N3: Ensure N3 is capable of meeting 6.A: N3: Plan for N3’s successor, to meet 6.I) (economies of scale, improved & exploit national infrastructure: N3, NHSmail, bandwidth and other capability needs in tomorrow’s needs and fit into the evolving service, more career progression for PACS, Spine (excepting the Summary Care the medium term, for exploiting Public Sector Network (platform for future) IT staff) Record- SCR) (exploit sunk investment) telemedicine, collaborative technology etc (3.B) (platform for future) 3.B: Collaboration and communications technology: establish a national Strategy & 4.B: Stock-take: Test the existing IT 4.A: NHS and social care IT strategy: 6.I: National IT organisations: Rationalise 6.B: NHSmail: Ensure the current and framework on how best to exploit its Organisation activities of the centre against the guiding Create and publish a new national and re-organise current central functions, future service meets the needs of the potential (6.A) (clinical productivity and principles in 1.6, to inform the future strategy, in the context of new to meet the new national organisational largest Trusts. (reduce redundant mobility, management of scarce scope of national IT programmes and Government policy, setting out a clear remit and required future functions (3.E, variation across NHS) resources – cost savings, patient organisation(s) (purpose, effectiveness, direction of travel for informatics, 4.B, 4.A) (aligned governance to NHS, experience) efficiency) including IT, and a costed plan. (on-going effectiveness and cost savings) 6.C: PACS: Develop national business alignment of IT to policy objectives, case on extending PACS into other 6.B: NHSmail: Review options in advance clarity of direction) imaging modalities, and to enable image of contract expiry (platform for future) sharing across NHS. (patient safety and experience, clinical productivity) 6.C: PACS: Assess possible service delivery options prior to contract expiry prior to contract expiry (cost savings) Review, halt 5.A: LSPs:Review of progress and Depending on 5.A, 5.F: Look to create or repurpose contracts. Retain those elements that an acute systems procurement work well, e.g. infrastructure, primary, catalogue to open up competition mental health and community care and choice (cost savings, sharing of solutions. Halt acute deployments, pause experience, avoid unwieldy or fragmented and reflect on case for continuing with procurements) current approach (minimise hiatus, exploit sunk investment) 6.F: Choose & Book: Review in context of new Government policy on choice (If 5.F: ASCC procurements in the South: to be retained, assess how to improve halt and test the effectiveness of the its ease of use and fit to local business procurements (ensure optimal route processes) for NHS) 6.G: HealthSpace: Review options in 6.E: SCR: Halt SCR roll-out, initiate a the light of decisions on SCR (6.E). review of it – covering clinical validation, Consider enabling connectivity to 3rd architecture / security and business case – party PHR suppliers (enable patient consider repurposing it as an ‘urgent care access to their records, more record’ (simplify, clarify purpose, address personalised care, cost savings) BMA and others concerns) 12 13
  8. 8. 02 Introduction Indeed, the current Government has not adequately taken into account the cost and complexity of IT investment that Since the creation of the National Programme for Information Technology (NPfIT) in 2002 , the subject of its policies have created, before launching policy initiative after policy initiative (e.g. Choose & Book, 18 week wait). 2.1 Background 1 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 A new Government must work IT planning intrinsically into its policy and strategy (not treat IT as a cost - it is Accounts Committee (PAC) and in turn the PAC made evident its concern with NPfIT’s progress, given the an asset). A constant dialogue is needed on strategy, refreshed at least yearly, linking business and policy plans planned expenditure of over £12 billion. to IT investment priorities, governance, processes and capabilities that the NHS needs. To deliver savings to the taxpayer and enable improved patient outcomes, a new Government would need to We return to and address these themes throughout our report. 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 Building on the 2020health seminar of May 2009 on “Using IT to deliver improved patient outcomes”, our work 2.3 This Report centralised model to one where local health organisations drive the IT that they require4. Likewise the Liberal took place over an 8 week period between late January and March 2010. The work has explored a number of Democrats have recently signalled that they see localisation as the way ahead5. key issues: On a wider basis, in January 2010, the Government published its Government Information Communications • where best IT can support the transformation of healthcare services; & 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”. • how local NHS IT should be taken forward, especially in hospitals; Whatever its outcome, after the General Election there is a risk of a hiatus around NHS IT. In response, • the role of standards and procurement catalogues in enabling NHS IT; 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 • the guiding principles that should drive national approaches to IT; in 2010) in forming a view on the best way forward. • the way forward for current national IT infrastructure, services and organisation. As a short, sharp study, it was not practical to attempt to cover the full scope of a review that a new Government Arguably, the only means a new Government will be able to meet the demand and productivity targets that the would no doubt require, and in particular time did not permit us to address such important matters as the following: 2.2 Government’s responsibility for Health IT NHS is facing, is for IT-enabled new ways of working. • NHS-social care interaction (a highly complex subject in its own right); 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 - • back office systems; policy, business decisions and processes, clinical processes, organisation, employee engagement and technology. • GP computing (which, relative to the rest of NHS IT, is a success story and where the plan The perception that IT projects can be axed, or made successful simply by renegotiating contracts, is entirely of action is clear); 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 • the role and effectiveness of NHS Enterprise-wide agreements; will only make things worse. • information governance. 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 Relevant stakeholders and industry specialists were consulted through a total of 30 interviews and workshops, NHS. The net result has frequently been additional cost, failure to meet the critical business needs, and many of them anonymous (see Appendix A). In total, the NHS viewpoint covered representative views from sometimes new islands of technology. 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 4. http://www.conservatives.com/News/News_stories/2009/08/Conservatives_will_end_Labours_costly_central_plans_for_NHS_IT.aspx 5. http://www.centreforum.org/publications/nhs-a-liberal-blueprint.html 6. http://www.cabinetoffice.gov.uk/cio/ict.aspx 14 15
  9. 9. 02 Introduction 03 Where can Healthcare IT Offer most Opportunity? The remainder of the report is structured as follows: 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 and internationally as context. “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 • Section 4 – NHS IT / NPfIT in Overview – describes the key NHS requirements of IT, describes for the users’ needs, and the provision of adequate support and training after their introduction. what NPfIT was intended to address, the current situation and proposes guiding principles for the future. For example, patients may be able to monitor chronic conditions such as asthma and diabetes in their own homes using modified mobile • Section 5 – Localised NHS IT – describes the current situation around the delivery of systems by ‘phones to access and process their data, which may give greater convenience and better management of their conditions and reduce Local Service Providers (LSPs) and what alternatives exist, especially in the delivery of IT to support the the need to visit their local health centre. Electronic health records (EHRs) should allow healthcare professionals access to patients’ clinical operational needs of hospitals and local health communities. 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 • Section 6 – National Infrastructure & Organisation – considers the way forward for the NPfIT informed healthcare decisions. 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 In addition there are several supporting appendices, including a glossary of terms (Appendix B). 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.” 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, 3.1 Electronic Health Records 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. Appendix C provides a summary of key conclusions of the report. They make for powerful reading. Overall, the authors conclude that, “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.” 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 enterprise- wide 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. We return to this in more detail in Section 5. 7. http://royalsociety.org/General_WF.aspx?pageid=10771&terms=nhs+ict 8. www.ehr-impact.eu 16 17
  10. 10. 03 Where can Healthcare IT Offer most Opportunity? In 2008, the EC sent a Communication9 to European organisations including the European Parliament on Figure 3.1- Organisational Challenges affecting the CRS 3.2 Telemedicine 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 As an example of the serious organisational systems, like maternity or pathology systems, the challenges associated with implementing CRS, Chief Executive cannot just approve the EPR “Telemedicine can improve access to specialised care in areas suffering from a shortage of expertise, or in areas where access to David Kwo the then IT Director at Chelsea & business case and let the clinicians and IT healthcare is difficult…Telemedicine will only realise its full potential if Member States engage actively in integrating it into their Westminster NHS Trust spoke of experiences in specialists ‘get on with it’. health systems”. implementing its EPR in the 1990’s: EPRs are mandatory. Unlike other systems, clinical In contrast to EHRs which form part of NPfIT, the NHS in England has taken a very different approach to “Our experience was that the main EPR challenges staff have no choice as to whether or not to use EPR Telemedicine. Three large scale Whole System Demonstrators were established and a major national evaluation were not really technological or funding-related as part of their jobs. Our doctors must use the EPR is due to be published later in 2010. (although the right technologies and budgets are for their everyday activities, e.g. to order tests, to essential), they are about clear vision and access results, to prescribe drugs, to find a bed, to While evident that Telemedicine can offer a great potential, it does create challenges, especially in terms of its management resolve, particularly given the number book a clinic appointment, to schedule a physio, to funding and impact on current reimbursement schemes. There are also important legal and ethical issues to of years it takes to realise the vision. pre-assess a surgical admission, etc. 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. Clinical leadership is essential to ensure that EPRs EPRs are pervasive. Practically every single staff are driven by process redesign, benefits member and patient that comes into contact with the Without clear direction from the centre, the risk is that a fragmented, point-to-point approach is adopted without management and the movement to improve the organisation is affected by it. taking advantage of common national infrastructure. quality of medical care through evidence-based medicine. EPRs are dynamic and developmental and can go Recommendation 3.A: an incoming Government needs to establish a national framework on how best to exploit on to support new and changing clinical the potential of telemedicine, based on best practice in the UK and elsewhere. In particular, it needs to: Chief Executives, not IT specialists, are the prime requirements long into the future, as any good • movers of EPRs. The Chief Executive needs to drive adaptive system should do. review and publish the results of the Whole System Demonstrators; personally the overall organisational change • programme (i.e. modernisation) which EPR EPRs should be the basis of clinical research procure enabling national infrastructure and/or establish call-off catalogue arrangements as required; implementations can and should catalyse. because they are like any other powerful medical • advance that has the potential to both do great harm support the wider NHS in adapting their care processes and procuring the enabling technology. Furthermore, EPRs take a long time to implement. and do great good: they need to be evidence-based They require the Chief Executive’s personal attention and high quality clinical research is needed to over a period of years, like a major building project. prove or disprove their value as they evolve (we are But, unlike building projects, EPRs cannot be only at the beginning of their development and We face an environment where there is a need to deliver dramatic improvements in productivity, safety and 3.3 Collaboration and Communication Technology ‘handed-over’ to a project manager to deliver deployment curve).” quality through reliable, repeatable processes in a knowledge industry that has many human-action processes. because there are practically no EPR project Health record applications are necessary but not sufficient here. managers in the NHS who have ‘done it all before’ to hire. 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 EPRs are invasive. Constructing a building is less identified in Cisco’s ‘Network Architecture Blueprint for the NHS’, for example: complicated than an EPR in terms of the deep- • rooted clinical/operational processes being video – learning, consultations, carbon savings; redesigned which must therefore be Chief • Executive driven. mobility – asset and people tracking, anytime, anywhere access to information; • EPRs are hospital wide. Unlike departmental 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 18 19
  11. 11. 03 Where can Healthcare IT Offer most Opportunity? Through rigorous analysis of current business processes, the technology can be exploited in line with new support solutions available today. The Audit Commission report “A Spoonful of Sugar” in December 2001 organisational design and practice to make dramatic clinical productivity and patient satisfaction improvements offers some interesting statistics: possible. • 10.8% of patients admitted to hospital experience an adverse event; 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 • each adverse event leads to an average 8.5 additional days in hospital, costing the NHS NHS Trust (NUH). around £500m per year; As co-sponsors, the European Commission stated in the report’s foreword that it provides “a persuasive account of • 70% of these errors could be eliminated by the use of computerised prescribing and the huge impact the new communications infrastructure deployed at NUH has had on re-engineering the day-to-day working processes clinical information systems; 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%. • 1,200 lives per year can be saved. The report makes a compelling case to exploit IP-based communications and collaboration technology on a The Electronic Prescription Service (EPS) will enable prescribers - such as GPs and practice nurses - to send wider basis beyond busy A&E departments, e.g.: 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 • in acute hospitals, where process times are dependent on human-human, ungoverned processes that substantial back-office savings as well as providing a rich source of connected prescription information at a can be accelerated, made visible, repeatable and reliable. For example, the discharge of in-patients national level. The issue here is one of scope and urgency of the roll-out. where ward, pharmacy and transport functions must collaborate efficiently to free up bed-space quickly; Recommendation 3.C: A full review of the existing EPS programme is needed with a view to securing clinical • to assist the efficient execution of processes that cross professional or organisational boundaries - and administrative benefits in a timelier manner. e.g. in community nursing or provision of poly-services. The review should define a phased approach with increasing scope and maturity, for both primary and Recommendation 3.B: a new Government would need to establish a national framework on how best to exploit secondary care, taking into account the long-term needs of the prescribing stakeholder community and the the potential of collaboration and communications technology, based on best practice in the UK benefits that can be secured by changes to both front-line and administrative processes. 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 If the widespread adoption of EHRs represents tomorrow’s vision, then today’s reality in hospitals is paper 3.5 Document & Record Management arrangements linked to favourable NHS-wide pricing. However, as always the emphasis must not be on case notes, the legacy cost of which will be with the NHS for many years to come. Many new hospital builds technology but instead on the realisation of benefits through more efficient working practices linked in turn to have no capacity for the storage of physical records. a sound business case. 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 Primary care prescribing is a multi-billion pound industry, the supply chain is supported by a series of point implementation through the EPR but also an integrated scanned view of the historic record. It is essential that 3.4 Prescribing Value Chain information technology solutions and a large and expensive central administrative infrastructure. EDRM solutions fit well with clinical practice and must meet patient safety and information governance requirements. 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 EDRM solutions were not included as a core LSP service at the outset. The view of some we spoke to is that over prescribing habits (e.g. use of generics); and improve patient safety through a reduction in medication errors. 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 Clinicians also pointed out to us the value of a complete medication record across primary and secondary care. are significant around clerical and clinical productivity for notes that are regularly accessed, as well as the patient A focus upon providing tools to raise the levels of acute prescribing to those of primary care and to provide for care benefits from the avoidance of cancelled appointments due to lost notes, and the savings in the space reconciliation and a local shared medication record would have an immediate and dramatic impact both upon needed to store paper files. acute sector patient safety and improved medication management and outcomes across the continuum. Recommendation 3.D: A review is needed of EDRM experience to-date, to establish both the maturity of the Whilst the use of electronic prescribing in the primary care context is almost universal, in contrast the market technology solutions and the associated business case, with a view to accelerating its adoption in hospitals. 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 21
  12. 12. 03 Where can Healthcare IT 04 NHS IT / NPfIT in Overview Offer most Opportunity? It may be that the national role should be to establish best practice linked to a series of model business cases, Self-evidently, IT needs to respond to the business and clinical needs of its users and not be an end in itself. In and in time associated national pricing and call-off arrangements. In addition, guidance should be shared on this section we introduce some of those needs, describe what NPfIT was intended to address, what the current the necessary front-line and back office process changes needed to secure the associated benefits. situation now is and propose what should be guiding principles for the future. The NHS itself has a highly varied estate of data centres and computer rooms. At the top end, the NPfiT- Since the advent of NPfIT, sadly there has been no published, overarching health informatics strategy10 that sets out 3.6 Shared Services 4.1 The NHS Needs for IT provided services come from highly resilient, state-of-the-art Data Centres. At the other extreme, by clearly the clinical and business objectives that IT needs to support, and explains how the different elements of the extrapolation there are at least 500+ local NHS computer rooms, some of which would fail rudimentary health IT architecture fit together now and in the future in support of these objectives, providing a realistic expectation of and safety checks (e.g. we heard of one centre with rat infestations). future plans. Crucially an active link is needed between NHS policy makers and those responsible for informatics11. The NHS has examples of IT-related shared business service programmes. The most noteworthy are the Most recently, the NHS guidance on Informatics Planning guidance 2010/11 states, “to support the NHS in a Electronic Staff Record (ESR) which provides a single NHS-wide HR and payroll system, and the Shared coordinated national approach, an updated strategic direction for informatics will be developed over the coming months in collaboration Business Services (SBS) which delivers a finance and accounting shared service to about 120 trusts. While each with the NHS and its partners, to move from a ‘replace all’ to a ‘connect all’ philosophy.” 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 We take it as a starting point that all political parties are committed to the NHS being and remaining a publicly minimal integration only at the file transfer level. 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 The unit of organisation of NHS IT staff varies from the small hospital-level IT functions to county or SHA- patients exercise more choice. The NHS is shifting more and more to a complex adaptive system and away from wide shared service provision. In many cases these organisations are below critical mass in scale and unable to a centralised hierachial model. This has profound implications for IT. 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. 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 If the NHS is to get value out of IT, local IT services need to be transformed to a scale and quality well ahead to more localised provision including polyclinics and home based care, with an increased emphasis on public of where many are now. healthcare and self-care. Recommendation 3.E: Assess what economies and improved service can be gained from consolidating NHS data For example, the Transforming Community Services Programme aims to improve community services so that centres and local IT staffing: they can “provide modern personalised and responsive care of a consistently high standard”. It will involve significant re- provisioning of current PCT-provided services, potentially leading to more providers. And in London, for 1. where practical, NHS data centres to be consolidated into either large-scale facilities or a “cloud-based” example, 130 ‘poly-systems’ around polyclinics are being developed, which will radically change not only provision, once established and safe.; primary and community care, but remove substantial parts of current care provision from acute hospitals. 2. the ESR and SBS Programmes to be examined for potential integration into the wider NHS At the same time, and in response to the Darzi Next Stage Reviews, the NHS is demanding an increased focus infrastructure; 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.” 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 The full IT implications of this shift in care provisioning priorities are difficult to predict. As the plurality of level. Consideration should be given to national career ladders and professional development paths, providers grows, IT becomes a vital prerequisite to enable patient-centric, joined up healthcare services at the together with staff exchange programmes to the benefit of all concerned. In future, these local point of care. It has a key role in measuring performance and enabling patient participation through the use organisations should take responsibility for strategy, integration with national programmes and play a of information produced as a by-product of data collected in supporting core care processes12. 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. 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 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 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 of the practical organisational and IT difficulties involved. 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 to Great - DH December 2009 22 23
  13. 13. 04 NHS IT / NPfIT in Overview To that regard, any single organisation providing NHS care services cannot have a monopoly over its patient Other key components or work streams within the NPfIT are: 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. • a national broadband IT network for the NHS (N3); As individuals become more information aware and empowered through the web 2.0 revolution, the desire for • ‘NHSmail’ – a central email and directory service for the NHS; 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 • ‘Choose and Book’, an electronic booking service (CaB); condition, they want to connect with their GPs and other clinicians13. • an Electronics Prescription Service (EPS); Recommendation 4.A: A new national strategy is needed for NHS and social care IT, in the context of new Government policy. • ‘Picture Archiving and Communications Systems’ (PACS); The future Government needs to give early priority to setting a clear direction of travel for informatics and IT • IT supporting GPs including a system for GP to GP record transfer. 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. A constant feature over the last 20-30 years has been that NHS Informatics has struggled with organisational 4.3 The Situation now alignment in two senses: • between a remote, central function and sub-scale IT departments in Trusts (except now in larger FTs The aim of NPfIT was to assist the NHS in providing better, safer care, by delivering modern computer systems and some county Health Informatics Services); 4.2 What NPfIT intended to do 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. • the split between information and IT, including at the centre, has led, in many cases, to a dysfunctional approach to collecting and processing information. 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 In regards to the latter, particularly with the demands for quality information, as one NHS IT Director commissioning clearing service) which all had their origin long before NPfIT. All of these needed proper commented to us, “The NHS has developed an increasing and ravenous demand for information with little regard for how it management, control and development and these were brought in and transformed under CFH. It is now will be collected and at what cost”. This issue applies to requirements for information emanating both from the responsible for all nationally coordinated major IT programmes across the NHS. centre and from commissioners, leading to multiple short term local and national initiatives. NPfIT was also conceived to address the problems of a highly fragmented IT situation across England14. 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 The detailed background and chronology behind the creation and execution of NPfIT has been well got worse and has militated against a strategic approach to IT at local level. 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 Turning to the Programme itself, NPfIT sought both to specify and direct the central infrastructure (as enablers reference point for patient demographic and summary clinical information, and the security and access controls for joined-up care the NHS) and to fix the local operational IT problem, especially in hospitals, community and to central patient based data. LSPs are responsible for the delivery of care records locally, which connect into mental health services. the Spine. 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 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 roll-out of PACS across the country; in improving the professionalism of IT services in the NHS; in assurance 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, processes to warrant systems connecting in with the national infrastructure; and in the delivery of IT solutions intervene early to prevent deterioration and avoid hospital admissions.” NHS 2010–2015: from Good to Great - DH December 2009 in many primary, community and mental health organisations. 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 In directing a central push of IT solutions to the NHS, the perception was formed that NPfIT was trying to 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 impose IT (especially in that clinical engagement was limited initially). There was a collective failure to get 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 NPfIT positioned as an enabler for transformation of services. (During our work, we met with UK Specialist 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 Hospitals Limited, which operates four independent treatment centres in the South West. Although on a much 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, smaller scale, their approach started by developing the Integrated Care Pathways (ICPs) for each procedure to and increase the rate of take-up of advanced IT” (NAO report on NPfIT 2006) 24 25

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