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Fixing NHS ITA Plan of Actionfor a New Government

John Cruickshank

March 2010

ISBN 978-1-907635-04-5

2020health83 Victoria StreetLondonSW1H 0HWE admin@2020health.orgwww.2020health.org

Published March 2010 2020health.org March 2010

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Fixing NHS ITA Plan of Actionfor a New Government

John CruickshankMarch 2010

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6. National Infrastructure & Organisation 39

6.1 National Infrastructure and Services 39N3 (Contract: BT 2004-2011) 39

NHSmail (Contract: Cable & Wireless 2004-2013) 39

PACS 40

Spine (Contract: BT 2003-2013) 40

Choose and Book (CaB) (Contract: ATOS 2003-2009) 42

EPS (Contract part of BT Spine) 42

H ea lthS pa ce - a nd Pe rs onal H ea lth Reco rd s 4 3

6.2 Fu ture Nati onal IT Organ isati on & Structure 4 4

Fig 6.1 Required Future National IT Organisations 45

NHS IT Set-up 46

A. Appendix: List of Contributors 47

B. Appendix: Glossary 48

C. Appendix: Relevant EC Communications on EHRs

and Telemedicine 50

The EHR IMPACT Study 50

Telemedicine 50

D. Appendix: Case Study - Transformation through Collaboration

and Communication Technology 52

E. Appendix: Case Study Developing an ICP-based EPR

system in the Independent Sector 53

F. Appendix: LSP Recent History & Developments 54

London LSP (BT as LSP) 54

North Midlands East (CSC as LSP) 54

South (formerly Fujitsu as LSP) 55

G. Appendix: EPR Architectural Options 56

H. Appendix: Open Source as an Option 57

About 2020health 58

5

Contents 4

About This Publication 6

About The Authors 7

1. Executive Summary 9

1.1. Background 91.2. Key Drivers 9

1.3. The Programme in Overview 9

1.4. Local Service Providers 9

1.5. Under-exploited Opportunities beyond the Programme 10

1.6. National/Local IT Services 11

Fig1.1 Plan for Action 11

2. Introduction 14

2.1 Background 14

2.2 Governments responsibility for Health IT 14

2.3 This Report 15

3. Where can Healt hcare IT O ffer most Opportunity? 17

3.1 Electronic Health Records 17

Fig3.1 Organisational Challenges affecting the CRS 183.2 Telemedicine 19

3 .3 Co lla bo ra tion a nd C ommunica tion Te ch no lo gy 1 9

3.4 Prescribing Value Chain 20

3.5 Document & Record Management 21

3.6 Shared Services 22

4 . NHS I T / NPf IT i n O ve rview 23

4.1 The NHS Needs for IT 23

4.2 What NPfIT intended to do 24

4.3 The Situation now 25

4.4 Guiding Principles for the Future 27

5. Localised NHS IT 28

5.1 The Original LSP Model in Concept 28

5.2 Why have there been such Difficulties? 295.3 LSP Progress and Recent Developments 30

5.4 The LSP way forward 31

5.5 What alternatives exist to the LSP model? 32

Architecture 33

I ntero pe ra bili ty, S ta nd ard s a nd O pe n S ource 3 3

Delivering SharedCare acrossLocalHealthCommunities 35

Procurement and Catalogues 36

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Contents

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In 2002, the National Programme for IT (NPfIT) was launched with high expectations for how it could improvethe delivery of healthcare in the NHS. Eight years on, the Programme needs to be rescued. IT is an essentialenabler in improving productivity and patient outcomes but the Programme cannot be fixed by cancellingprojects 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 wouldbe helpful if we undertook a short, independent research project to map out an action plan for NHS IT, with aparticular focus on NPfIT, to assist policy makers determine the way forward.

We are indebted to all our sponsors for their unrestricted funding, on which we depend. As well as enabling ourongoing work of involving frontline professionals in policy ideas and development, sponsorship enables uscommunicate with and involve officials and policy makers in the work that we do. Involvement in the work of2020health.org is never conditional on being a sponsor.

Julia Manning, Chief Executive

March 2010www.2020health.org

-

2020health.org

83 Victoria StreetLondon SW1H 0HWT 020 3170 7702E admin@2020health.org

Published by 2020health.org

2010 2020health.org

All rights reserved. No part of this publication may bereproduced, stored in a retrieval system, or transmittedin any form or by any means without the prior writtenpermission of the publisher.

Disclaimer

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

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About ThisPublication

John Cruickshank 2020health NHS IT Policy Chair and Report AuthorJohn Cruickshank is an independent expert in NHS IT, having been intimately involved in itsdevelopment continuously over the last 25 years. His passion for healthcare IT began in themid 1980s when he project managed one of the first successful NHS implementations of ahospital-wide electronic patient record.

As a leading management consultant in the field, he has held leadership roles in the healthcarepractices of major systems integrators and consultancies at UK and European level. During the1990s, he founded, built and sold his own consulting practice, Pareto Consulting, which set thebenchmark in independent client-side advice to NHS Trusts and the centre.

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

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

John is a graduate in economics and management science from St Johns College, Cambridge.

Julian Wright Supporting Editor and AuthorAfter 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 Healthconsulting. In particular, Julian built a major healthcare consultancy business from scratch andwas 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 Governmentconsulting practice, which subsequently merged with the other UK practices under hisleadership, taking the team from less than ten to over three hundred. In 2007 he took over the1100-strong EMEA-wide consulting practice and embarked on a transformation programmeto improve financial performance and integrate the disparate groups. He now works as afreelance consultant.

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

Julia Manning 2020health Chief Executive and Series EditorJulia Manning studied Visual Science at City University and became a member of the Collegeof Optometrists in 1991. She was a founder member of the British Association of BehaviouralOptometrists and her work has included being a visiting lecturer at City University, a visitingclinician at the Royal Free Hospital, London and a Director of the Institute of Optometry. Juliaran a specialist optometry practice for people with mental and physical disabilities until August2009.

Julia is a founder and Chief Executive of 2020health.org which she launched in 2006 as the firstweb-based Think Tank for Health and Technology. It uniquely focuses on bottom-up policydevelopment 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 thehistory of her profession in 60 years of the NHS [St. Jamess House].

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1.1 Background

Since the creation of the 12billion National Programme for Information Technology in 2002, the subject ofNHS 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 shouldbe 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 tomap out an action plan for NHS IT, with a particular focus on the Programme, to assist policy makers determinethe way forward.

1.2 Key Drivers

The NHS is shifting more and more to a complex, federated system and away from a centralised hierarchicalmodel. This has profound implications for IT.

As the plurality of providers grows, IT becomes a vital prerequisite to enable patient-centric, joined uphealthcare services. As care becomes more personalised, patients increasingly want access to their own healthrecords, 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 isan asset). A constant dialogue is needed on strategy, refreshed at least yearly, linking business / policy plans toIT 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 entirelyfalse. Unless a new Government genuinely recognises that they must deliver massive change in the way healthand care are provided, supported by IT, they will fail again. Localising / fragmenting the existing problems willonly make things worse.

1.3 The Programme in Overview

The Programme was conceived to address the problems of a highly fragmented IT situation across England. Itscentral feature is the NHS Care Records Service, with a central core (the NHS Spine, a national database of keyinformation about patients health and care) supported by a national infrastructure. The two remaining LocalService 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 earlywinners to gain credibility and acceptance with the NHS. There was a collective failure to get the Programmepositioned as an enabler for transforming healthcare services, and gain full clinical engagement andlocal 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.

1.4 Local Service Providers

The Programmes most significant failure lies in acute hospitals where centrally provided solutions have beenvery 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 yearsthrough several contract resets, with some improvement. Both contractors are now in further contract resets, due

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quality well ahead of where many are now. Over time, the NHS should t herefore address consolidationopportunities, such as rationalising NHS data centres into either large-scale off-site facilities or a cloud-basedprovision, once established and safe.

Furthermore, where feasible, IT staff should be organised into shared services aligned to the natural healthcommunities 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 withnational programmes and play a leading role in the selection and implementation of front-line systems.

1.6 National/Local IT Services

Our view is a national approach to IT should only be taken when one or more of three principles can be met:

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 coordinationor regulation, e.g. standards, security.

A new Government would wish to do an urgent stock-take of NHS IT projects, assets and organisation againstthese principles and we set out specific recommendations in Figure 1.1. It shows our recommended plan foraction for NHS IT for the new administrations first 12 months in office. The timetable is explicitly tight, sincelong 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 topatient outcomes.

National IT organisation(s) would be needed to deliver relevant services in support of these principles. Thepresumption is that they should have a limited remit and be performance managed by the NHS. They need toexhibit 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 Departmentof Health and set a national direction for IT.

Beyond this,and respecting anynationally agreed contracts already inplace,local NHSorganisationsshouldbe freeto settheirownstrategyto takeadvantageof national assets, with fargreateremphasis onlocalchoice of front-linesystems. A singleIT strategy must beset atthe local healthcommunity level(i.e.to matchthe scope of thelocalITorganisation - e.g. county-based), as opposedto a free-for-all which wouldbe impractical. Foundation Trustswouldnot be mandated to participate but would be encouraged, in order to meet the local healthcare strategy.

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, asopposed to an over-emphasis on technology.

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for conclusion by 31 March. As a starting point, a new Government must test the contractual arrangements andbaseline 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 howclose the revised arrangements are to meeting these criteria.

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

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

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

This would also allow fairness in those parts of the NHS which already fall outside the preserve of Local ServiceProviders (principally the South). A process is underway to provide local solutions here but there is a risk thatcontracts 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 vibrantcommunity internationally, in which the centre participates on behalf of the NHS. Here we recommend thatthe centre take a more practical but informed approach, and follow international/ EU standards unless thereis an overwhelming case otherwise.

1.5 Under-exploited Opportunities beyond the Programme

A new Government needs to consider carefully the potential of:

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

collaboration services (network technology, enabling productivity & mobility, as a platform forimproving working practices);

electronic document records management (scanned paper medical records).In each case pilots have taken place and there is a need to define a national strategy based on best practice inthe UK and elsewhere, including both technology and process change aspects. Where appropriate, enablingnational 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. theelectronic linkage of patients, prescribers, dispensers and the reimbursement agency), a review is needed tosecure 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 resilienceagainst 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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Figure 1.1 Plan for Action

(The references relate to specific recommendations in the main report. The benefits to be derived from theactivity are shown in italics.)

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01 ExecutiveSummary

Theme 0-3 months 3-6 months 6-12 months

Acceleratebenefits

6.G Deploy no-cost patient access toGP systems, where practical (enable

personalised care)

3.C Review, simplify (where feasible) andaccelerate Electronic Prescriptions Service(back office savings, reduced fraud andwastage, patient safety)

3.B Leverage immediate opportunities forcollaborative technology, using Nottinghamas a case model (patient throughput andexperience in A&E, clinical productivity)

3.D: Accelerate adoption of case notesscanning and record technology inhospitals. (clerical & clinical productivity,

patient experience fewer wasted visitsfrom lost notes)

3.A: Telemedicine: Establish a nationalframework on how best to exploit itspotential, based on best practice in theUK and elsewhere (patient experience

and control over own care, remoteaccess to clinical specialists, clinicalproductivity)

3.C Prepare coherent strategy to bringtogether a unified prescription recordacross primary and secondary care(patient safety, monitoring effectiveness

nationally of treatment programmes)

Develop& exploit

Retain and restate commitment to keynational infrastructure: N3, NHSmail,PACS, Spine (excepting the Summary CareRecord- SCR) (exploit sunk investment)

6.A: N3: Ensure N3 is capable of meetingbandwidth and other capability needs in

the medium term, for exploitingtelemedicine, collaborative technology etc(3.B) (platform for future)

6.B: NHSmail: Ensure the current and

future service meets the needs of thelargest Trusts. (reduce redundantvariation across NHS)

6.C: PACS: Develop national businesscase on extending PACS into otherimaging modalities, and to enable imagesharing across NHS. (patient safety andexperience, clinical productivity)

6.A: N3: Plan for N3s successor, to meettomorrows needs and fit into the evolvingPublic Sector Network (platform for future)

3.B: Collaboration and communicationstechnology: establish a nationalframework on how best to exploit its

potential (6.A) (clinical productivity andmobility, management of scarceresources cost savings, patientexperience)

6.B: NHSmail: Review options in advanceof contract expiry (platform for future)

6.C: PACS: Assess possible servicedelivery options prior to contract expiryprior to contract expiry (cost savings)

Review, haltor repurpose

5.A: LSPs:Review of progress andcontracts. Retain those elements thatwork well, e.g. infrastructure, primary,mental health and community caresolutions. Halt acute deployments, pauseand reflect on case for continuing withcurrent approach (minimise hiatus,exploit sunk investment)

5.F: ASCC procurements in the South:

halt and test the effectiveness of theprocurements (ensure optimal routefor NHS)

6.E: SCR: Halt SCR roll-out, initiate areview of it covering clinical validation,architecture / security and business case consider repurposing it as an urgent carerecord (simplify, clarify purpose, address

BMA and others concerns)

Depending on 5.A, 5.F: Look to createan acute systems procurementcatalogue to open up competitionand choice (cost savings, sharing ofexperience, avoid unwieldy or fragmented

procurements)

6.F: Choose & Book: Review in contextof new Government policy on choice (Ifto be retained, assess how to improve

its ease of use and fit to local businessprocesses)

6.G: HealthSpace: Review options inthe light of decisions on SCR (6.E).Consider enabling connectivity to 3rdparty PHR suppliers (enable patient

access to their records, morepersonalised care, cost savings)

Theme 0-3 months 3-6 months 6-12 months

Enablinglocal IT

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 localchoice of systems)

5.B: Integration technologies: Initiateresearch and pilots to test out the viabilityand impact on business case of differentlocal approaches (flexibility of IT

approach, enabling market innovation,cost savings)

5.E: Local Health Communities: Reviewand establish best practice for localshared care records (patient safety andexperience, clinical and clerical

productivity) (6.E)

5.D: Open Source: Commission researcharound the potential of clinical OpenSource solutions in the NHS, with a view

to exploiting its potential in the mediumterm (improve collaboration, cost savings,transparency, remove high barriers toentry for innovative suppliers)

3.E: Local IT: Assess potential fromconsolidating NHS data centres and otherlocal infrastructure management (4.A, 6.I)(economies of scale, improved service)

3.E: Local IT: Assess potential fromconsolidating local IT staffing (4.A, 4.B,6.I) (economies of scale, improved

service, more career progression forIT staff)

Strategy &Organisation

4.B: Stock-take: Test the existing ITactivities of the centre against the guidingprinciples in 1.6, to inform the futurescope of national IT programmes andorganisation(s) (purpose, effectiveness,efficiency)

4.A: NHS and social care IT strategy:Create and publish a new nationalstrategy, in the context of newGovernment policy, setting out a cleardirection 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: Rationaliseand re-organise current central functions,

to meet the new national organisationalremit and required future functions (3.E,4.B, 4.A) (aligned governance to NHS,effectiveness and cost savings)

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Indeed,the currentGovernmenthas notadequatelytakeninto accountthe costand complexity of ITinvestmentthatits policies have created, before launching policy initiative after policy initiative (e.g. Choose & Book, 18 week wait).

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

We return to and address these themes throughout our report.

2.3 This Report

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

where best IT can support the transformation of healthcare services;

how local NHS IT should be taken forward, especially in hospitals;

the role of standards and procurement catalogues in enabling NHS IT;

the guiding principles that should drive national approaches to IT;

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 Governmentwouldno doubtrequire, andinparticulartimedid notpermitus toaddresssuchimportant matters asthe following:

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 planof 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 fromacross 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. Anumber of ot her thought leaders were also consulted, including members of the Independent IT Reviewteam. 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

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2.1 Background

Since the creation of the National Programme for Information Technology (NPfIT) in 2002 1, the subject ofNHS 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 2006 2 and 20083 ) to the PublicAccounts Committee (PAC) and in turn the PAC made evident its concern with NPfITs progress, given theplanned expenditure of over 12 billion.

To deliver savings to the taxpayer and enable improved patient outcomes, a new Government would need toconsider profound changes to NHS IT and NPfIT. For example, the Conservatives commissioned anIndependent Review of NHS and Social Care IT which, when it reported in summer 2009, suggested a newdirection for NHS IT towards a more localised approach based on a clear interoperability framework. Inresponse to this, the Conservative Party set out high level policy in terms of a move away from the currentcentralised model to one where local health organisations drive the IT that they require4. Likewise the LiberalDemocrats 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 infrastructureagainst a background of economicpressuresto enable the transformation of the way public services run.

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 Governmentin 2010) in forming a view on the best way forward.

2.2 Governments responsibility for Health IT

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

Health, and health IT, is uniquely complex and requires expert leadership and interpretation. There is no suchthing 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.

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

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 theNHS. The net result has frequently been additional cost, failure to meet the critical business needs, andsometimes new islands of technology.

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In 2006, the Royal Society commissioned a policy report on Digital Healthcare7. Its views resonate well fouryears later:

Information and communication technologies (ICTs) have the potential to transform radically the delivery of healthcare and to addressfuture health challenges. Whether they actually do so will depend on the design and implementation processes sufficiently accountingfor the users needs, and the provision of adequate support and training after their introduction.

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

The single most important factor in realising the potential of healthcare ICTs is the people who use them. The end users of any newtechnology must be involved at all stages of the design, development and implementation, taking into account how people work togetherand 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 healthcareshould play a role. The following summarises them.

3.1 Electronic Health Records

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-economicimpact of interoperable EHRs and ePrescribing systems in Europe and beyond8. The case studies representedprojects 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 theirnet financial boostthe results of the EHR IMPACT study give grounds for optimism in the success, value and deployment ofinteroperable EHR and ePrescribing systems across Europe.

While these reports reference developments on cross-sector records sharing, many of the opportunities andchallenges also remain valid in planning for the implementation of care record solutions within healthcareproviders, typically referred to as Electronic Patient Records (EPRs). Essential organisational ingredients toimplementing 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 gatewayreviews; 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.

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03 Where can Healthcare ITOffer most Opportunity?

The remainder of the report is structured as follows:

Section 3 WheredoeshealthcareIT offerthe most opportunity? building on best practice nationallyand internationally as context.

Section 4 NHS IT / NPfIT in Overview describes the key NHS requirements of IT, describeswhat NPfIT was intended to address, the current situation and proposes guiding principles for the future.

Section 5 Localised NHS IT describes the current situation around the delivery of systems byLocal Service Providers (LSPs) and what alternatives exist, especially in the delivery of IT to support theclinical operational needs of hospitals and local health communities.

Section 6 National Infrastructure & Organisation considers the way forward for the NPfITnational 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.

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

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02 Introduction

7. http://royalsociety.org/General_WF.aspx?pageid=10771&terms=nhs+ict

8. www.ehr-impact.eu

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3.2 Telemedicine

In 2008, the EC sent a Communication 9 to European organisations including the European Parliament ontelemedicine for the benefit of patients, healthcare systems and society. Appendix C also provides a summaryof key conclusions of the Communication. It concluded that

Telemedicine can improve access to specialised care in areas suf fering from a shortage of expertise, or in areas where access to

healthcare is difficultTelemedicine will only realise its full potential if Member States engage actively in integrating it into theirhealth systems.

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

While evident that Telemedicine can offer a great potential, it does create challenges, especially in terms of itsfunding and impact on current reimbursement schemes. There are also important legal and ethical issues tobe addressed. These issues aside, by extending the reach of physicians into the domestic care setting, there isconsiderable 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 withouttaking advantage of common national infrastructure.

Recommendation 3.A: an incoming Government needs to establish a national framework on how best to exploitthe potential of telemedicine, based on best practice in t he 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.

3.3 Collaboration and Communication Technology

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

The Internet Protocol (IP) network provides a platform to deliver collaborative applications that can improveproductivity, mobility and be a foundation for business transformation. By this is meant a variety of app licationsidentified in Ciscos 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.

19

Figure 3.1- Organisational Challenges affecting the CRS

18

03 Where can Healthcare ITOffer most Opportunity?

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 inimplementing its EPR in the 1990s:

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.

Theyrequirethe Chief Executivespersonal 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 deep-

rooted clinical/operational processes being

redesigned which must therefore be ChiefExecutive 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

staffhaveno choiceasto whether ornot touse 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 andpatient thatcomesintocontact withthe

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

advancethat hasthe potential toboth do great harm

anddo greatgood:they needto 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).

9. COM(2008) 689

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support solutions available today. The Audit Commission report A Spoonful of Sugar in December 2001offers some interesting statistics:

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

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

70% of these errors could be eliminated by the use of computerised prescribing andclinical information systems;

1,200 lives per year can be saved.

The Electronic Prescription Service (EPS) will enable prescribers - such as GPs and practice nurses - to sendprescriptions 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 enablesubstantial back-office savings as well as providing a rich source of connected prescription information at anational 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 clinicaland administrative benefits in a timelier manner.

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 thebenefits that can be secured by changes to both front-line and administrative processes.

3.5 Document & Record Management

If the widespread adoption of EHRs represents tomorrows vision, then todays reality in hospitals is papercase notes, the legacy cost of which will be with the NHS for many years to come. Many new hospital buildshave no capacity for the storage of physical records.

The key driver on the path towards being paperless or paperlite, is the role of Electronic Document RecordManagement (EDRM) solutions in respect of the paper case notes. EDRM provides a way to scan, digitise andstore the paper records, so that the clinician not only can see the electronic information from the point ofimplementation through the EPR but also an integrated scanned view of the historic record. It is essential thatEDRM solutions fit well with clinical practice and must meet patient safety and information governancerequirements.

EDRM solutions were not included as a core LSP service at the outset. The view of some we spoke to is thatthe 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 benefitsare significant around clerical and clinical productivity for notes that are regularly accessed, as well as the patientcare benefits from the avoidance of cancelled appointments due to lost notes, and the savings in the spaceneeded to store paper files.

Recommendation 3.D: A review is needed of EDRM experience to-date, to establish both the maturity of thetechnology solutions and the associated business case, with a view to accelerating its adoption in hospitals.

21

Through rigorous analysis of current business processes, the technology can be exploited in line with neworganisational design and practice to make dramatic clinical productivity and patient satisfaction improvementspossible.

Appendix D references a report just published (see www.accaglobal.com) on the audited evidence of the benefitsgained 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 reports foreword that it providesa persuasive account ofthe huge impact the new communications infrastructure deployed at NUH has had on re-engineering the day-to-day working processesof its emergency department. In particular, it shows a reduction in the patient journey time of 23% for adult patientsand 33% for paediatric patients, and an increase in clinical productivity of 12%.

The report makes a compelling case to exploit IP-based communications and collaboration technology on awider basis beyond busy A&E departments, e.g.:

in acute hospitals, where process times are dependent on human-human, ungoverned processes thatcan be accelerated, made visible, repeatable and reliable. For example, the discharge of in-patientswhere 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.

Recommendation 3.B: a new Government would need to establish a national framework on how best to exploitthe potential of collaboration and communications technology, based on best practice in the UKand 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-offarrangements linked to favourable NHS-wide pricing. However, as always the emphasis must not be ontechnology but instead on the realisation of benefits through more efficient working practices linked in turn toa sound business case.

3.4 Prescribing Value Chain

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

Experience from other countries such as the US, where the prescribing valuechain management is more mature,

is that IT has the potential to: address the significant levels of fraud; help reduce drug wastage; improve controloverprescribinghabits (e.g. use of generics); and improve patientsafety througha reduction in medication errors.

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 forreconciliation and a local shared medication record would have an immediate and dramatic impact both uponacute sector patient safety and improved medication management and outcomes across the continuum.

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

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Self-evidently, IT needs to respond to the business and clinical needs of its users and not be an end in itself. Inthis section we introduce some of those needs, describe what NPfIT was intended to address, what the currentsituation now is and propose what should be guiding principles for the future.

4.1 The NHS Needs for IT

Sincethe advent of NPfIT, sadlythere hasbeen no published,overarching healthinformaticsstrategy10 that sets outclearly the clinical and business objectives that IT needs to support, and explains how the different elements of theIT architecture fit together nowand in the future in supportof these objectives, providing a realisticexpectation offutureplans. Crucially anactive linkis needed betweenNHS policymakersand thoseresponsiblefor informatics11.

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

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

Reinforced by the economic constraints facing the UK, and in the context of an ageing population, futurehealthcare 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 publichealthcare and self-care.

For example, the Transforming Community Services Programme aims to improve community services so thatthey 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, forexample, 130 poly-systems around polyclinics are being developed, which will radically change not onlyprimary and community care, but remove substantial parts of current care provision from acute hospitals.

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

The full IT implications of this shift in care provisioning priorities are difficult to predict. As the plurality ofproviders grows, IT becomes a vital prerequisite to enable patient-centric, joined up healthcare services at thepoint 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 processes

12

.

23

04 NHS IT / NPfIT in Overview

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 onthe necessary front-line and back office process changes needed to secure the associated benefits.

3.6 Shared Services

The NHS itself has a highly varied estate of data centres and computer rooms. At the top end, the NPfiT-provided services come from highly resilient, state-of-the-art Data Centres. At the other extreme, byextrapolation there are at least 500+ local NHS computer rooms, some of which would fail rudimentary healthand safety checks (e.g. we heard of one centre with rat infestations).

The NHS has examples of IT-related shared business service programmes. The most noteworthy are theElectronic Staff Record (ESR) which provides a single NHS-wide HR and payroll system, and the SharedBusiness Services (SBS) which delivers a finance and accounting shared service to about 120 trusts. While eachis rightly regarded as a success in its own right, at a local IT level, there are complaints because they operateseparate engagement and service delivery models to NPfIT. Although both run on Oracle platforms, there isminimal 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 SHA-wide shared service provision. In many cases these organisations are below critical mass in scale and unable toattract/retain the range and depth of IT skills required. However local knowledge, accountability andownership 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 aheadof where many are now.

Recommendation3.E: Assess what economies and improved service can be gained from consolidating NHS datacentres and local IT staffing:

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

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

where appropriate, and if agreed to by affected Foundation Trusts, IT staff should be organised intoshared services aligned to the natural health communities that they serve. i.e. county or at most SHAlevel. 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 aleading role in the implementation of front-line systems, following national guidance. They should workunder the local clinical leadership of IT-enabled change programmes, reducing time, cost and local

variability in selecting clinical systems locally.

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03 Where can Healthcare ITOffer most Opportunity?

1.

2.

3.

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 20102015: from Good

to Great - DH December 2009

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Other key components or work streams within the NPfIT are:

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 t o GP record transfer.

4.3 The Situation now

A constant feature over the last 20-30 years has been that NHS Informatics has struggled with organisationalalignment in two senses:

between a remote, central function and sub-scale IT departments in Trusts (except now in larger FTsand 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.

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

If each provider now had an integrated EPR system as intended through the LSP Programme, the informationcollection could flow as a by-product of the operational systems. Instead, the problem of IT silos has if anythinggot 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 enablersfor joined-up care the NHS) and to fix the local operational IT problem, especially in hospitals, community andmental health services.

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 theroll-out of PACS across the country; in improving the professionalism of IT services in the NHS; in assuranceprocesses to warrant systems connecting in with the national infrastructure; and in the delivery of IT solutionsin 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 toimpose IT (especially in that clinical engagement was limited initially). There was a collective failure to getNPfIT positioned as an enabler for transformation of services. (During our work, we met with UK SpecialistHospitals Limited, which operates four independent treatment centres in the South West. Although on a muchsmaller scale, their approach started by developing the Integrated Care Pathways (ICPs) for each procedure to

25

To that regard, any single organisation providing NHS care services cannot have a monopoly over its patientinformation. Its reimbursement must be based not only on adhering to quality metrics but in its adherence tonationally agreed record sharing standards, subject to confidentiality and privacy constraints.

As individuals become more information aware and empowered through the web 2.0 revolution, the desire formore 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 samecondition, they want to connect with their GPs and other clinicians13.

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

The future Government needs to give early priority to setting a clear direction of travel for informatics and ITin the NHS and so give clarity to all stakeholders, within the context of its aspirations for the NHS and newpolicy environment. The resulting strategy must support the policy and clinical agenda with due regard totransformational change and overall cost of ownership. This needs to be consistent with and support the recentlypublished Government ICT strategy.

4.2 What NPfIT intended to do

The aim of NPfIT was to assist the NHS in providing better, safer care, by delivering modern computer systemsand services that improve how patient information is stored and accessed. CFH was formed in 2005 as aDepartment of Health (DH) Directorate charged with delivering NPfIT.

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

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

The detailed background and chronology behind the creation and execution of NPfIT has been welldocumented 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 uniquereference point for patient demographic and summary clinical information, and the security and access controlsto central patient based data. LSPs are responsible for the delivery of care records locally, which connect intothe Spine.

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04 NHS IT / NPfIT in Overview

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

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,

intervene early to prevent deterioration and avoid hospital admissions. NHS 20102015: from Good to Great - DH December 2009

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

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

the NHSs 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

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,

and increase the rate of take-up of advanced IT (NAO report on NPfIT 2006)

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One aspect that NPfIT has successfully addressed was the historic low level of investments in IT, averaging lessthan 2% of NHS revenue. The most recent survey conducted by CFH shows a projected NHS IT spend in2009/10 (revenue and capital) totalling 4bn, of which NPfITs share is 1.8bn 17. This represents 3.15% oftotal NHS revenue spend, and 25% of NHS capital spend.

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 usefulcapability maturity tool used for benchmarking local IT infrastructure services. Additionally, the LSPProgramme set a useful mandate to ensure Trusts invest sufficiently to create a warranted technical environment.

Incontrast,it waspointedout to usthat inthe South,wherethere isnow noLSP, thisonushas been lostand someTrusts are reluctant to invest in a sufficiently professional approach. In many areas outside the Programme, ICTremains highly fragmented and variable, with many home grown solutions remaining supported by a man in a

van,a longwayfromthe aspirationsset outin theGovernmentICT strategyof hostedsolutions inthe G-Gloud.

4.4 Guiding Principles for the Future

In 2020healths view, a national approach should only be taken when one or more of three guiding principlescan be met:

there isan overwhelmingcasefor doing something onceandonce onlyacross theNHS to avoid redundantvariation and provide a baseline modelfor localbusiness 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 typicallyback office or infrastructure related, leaving the wider NHS to select and implement front-line systemsapplying available national guidance and interoperability standards;

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

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

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

Outside these, and respecting any nationally agreed contracts, 2020health believes that the principle should bethat local NHS should be free to decide on its own approach to IT, consistent with the needs of its organisationand to support the delivery of joined-up care locally and nationally.

Recommendation4.B: a new Government should test the existing activities of the centre, with respect to NHSIT & NPfIT, against these principles, which in turn will inform the future scope of national IT Programmesand organisation(s).

27

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 governancetowards NHS ownership over NPfIT, with CFH acting more in a supporting role. However, these arrangementsare neither fully centralised (with authority to match) nor fully decentralised (local responsibility) and representa half-way house which lacks clear responsibilities and accountability.

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 needa collaborative, opt-in approach (with local responsibilities), and others purely local. We return to this inSection 4.4 below.

Insummary, thedeliveryof theoverall visionfor theCareRecordsServiceremainsat least5 years away, based aroundsome major failures, especially in the LSP arena around the delivery of modern EPR-like capability in hospitals.

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

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

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

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

In the meantime, many hospitals continue to rely on core Patient Administration Systems (PAS) that emanatefrom the 1980s, with a limited amount of integration between the core and departmental systems, and islandsof information, especially in more automated parts of the hospital such as Intensive Care Units (ICU) andtheatres. Many hospitals have been in wait and see mode since the Programmes inception, in some instancesfor 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.

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04 NHS IT / NPfIT in Overview

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

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

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

n ee ds, a s w el l a s t ak in g a dv an ta ge o f m ar ke t d ev el op me nt s t o m ak e m or e u se o f t he i nf or ma ti on t he y h ol d. 1 7. S ou rc e: h tt p: // ww w. co nn ec ti ng fo rh ea lt h. nh s. uk /r es ou rc es /i mt st af f/ su rv ey

1.

2.

3.

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5.2 Why have there been such Difficulties?

Much has evolved since the LSP contracts were signed in 2003/04, changing the baseline NHS environmentand so affecting the IT requirements.

Without seeking to attribute blame, it is evident that there have been difficulties on both sides. In our view, themain reasons include:

while the CRS Programme was conceived as a change project, it quickly was repositionedand driven as a large scale IT deployment challenge, with change management reduced in priority;

clinical engagement and leadership were lacking at the outset, and although clinicians locallywere 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 provedvery challenging;

there has been limited local ownership over the solutions, in part because Trusts have had nochoice in the solutions they receive (in four out of five clusters, LSPs had exclusivity);

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 productspecialists. Ensuring all parties remained aligned proved very difficult;

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

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

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

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

Many of these points are understood and accepted by all parties involved, and there has been a gradualapproach to address t hem over recent years through successive contract resets, with some improvement.

For example, the iSOFT 7 (seven Trusts in London and the South who already had iSOFT systems) is oneexample of a contract variation from the standard LSP mode. Here the framework allowed for aligned opt outwhich carried forward the broad thrust of the Programmes aims but is less prescriptive about how. In another

29

This section looks in more detail at the LSP delivery of solutions to the local NHS, where and why there havebeen difficulties and what the way forward ought to be. It also considers how to move forward outside the LSPenvironment, notably the South, in terms of interoperability, procurement and shared care records.

5.1 The Original LSP Model in Concept

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 functionalityin an integrated fashion across a whole health community.

The country was divided into five clusters, each with a LSP acting as prime contractor for the delivery of thefull ICRS scope. Each LSP would have exclusivity around a core set of functionality.18 There was also anadditional services catalogue allowing Trusts to call off other services.

Requirements were defined by the CRS Output-Based Specification (OBS). (There was a crucial assumptionthat requirements could be standardised across the NHS, leading to a standardised process model.)

Although specialist healthcare application software would underpin the service, as leading global IT serviceproviders, the LSPs were selected to act as prime contractors and orchestrate the heavy lifting, e.g. programmemanagement, hosting, software configuration, environment management, systems integration, large scaledeployment.

The on-going responsibility of LSPs in this regard was recently reaffirmed by Ministers19,

The role of national Programme local service providers (LSPs) is to deliver information technology (IT) systems and services acrossthe National Health Service within defined groups of strategic health authorities. LSPs ensure the integration of existing localsystems and, where necessary, implement new systems so that the national applications can be delivered locally, while maintainingcommon 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 weredelivered and benefits realised:

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 deliveringthe NHS Care Records Service, the suppliers have borne the cost of overcoming difficulties in delivering the software and not thetaxpayer.20

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

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05 Localised NHS IT

18. as defined in the 2003 OutputBased Specification (OBS)

19. Mike OBrien, Health Minister - Hansard 21 May 2009

20. NAO 2006 report On NPfIT

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However, the early releases of Cerner in the South were problematic, with gradual improvements with successivedeployments. However, when contract reset terms could not be agreed with Fujitsu about t he future deploymentand configuration models, CFH terminated the contract in May 2008. A termination settlement has yetto be reached.

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 teststhat both products should meet by 30th November 2009 .

Theremainingtwo LSPs (BTforLondonandCSC forNME)areagainin contract reset.As healthministerMikeOBrien MP confirmed on 2nd March , the resets have in part the objective of achieving 600M savings alreadyannounced 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 somecommon features across the current contract resets. For example, both are considering options such as: somelevel of Trust opt-out (i.e. local choice, to a degree); revised delivery models; greater inter-operability aroundthe prescribed solutions; and some reductions in functionality with a view to the suppliers saving cost througha reduced scope and associated risk.

5.4 The LSP way forward

By the time a new Government is in place after the Election, the LSP contract resets may or may not have beensuccessfully 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.

As a starting point, a new Government must test the LSP contractual arrangements and baseline plans againstkey criteria such as the following:

are the future deployment plans credible and realisable? Do they match up to the evidence of recentdeployments? Have the products and deployment approach been fully stress tested?;

where necessary and demanded by the Trusts, is there a satisfactory direct customer relationship betweenTrust and application supplier? (So that the specific expertise of the application provider is directly andreadily 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 arrangementsequitable?;

do the arrangements represent value for money, benchmarked against other UK and internationalprocurements?;

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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case, to speed up delivery of solutions, the enterprise-wide approach to ICRS was broken up, replacedby organisational-centric solutions and a level of prioritisation - at least within the acute space - aroundthe Clinical 521.

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

Finally, it is difficult to determine whether the LSP model is delivering value for money (compared to a morelocalised procurement approach). It needs more consideration, particularly in terms of the unit prices forsoftware licence and deployments as compared to similar procurements elsewhere 22. We return to this point later.It needs to be benchmarked against the costs of Trusts who have opted out of the Programme, and againstother UK and international pricing.

5.3 LSP Progress and Recent Developments

[The history of developments around the LSP Programme has been documented in detail elsewhere. Whatfollows is our interpretation on events].

Initially, in 2004, two of the four winning LSPs (BT in London and Fujitsu in the South) relied on hospitalsoftware from a leading US provider, IDX, while the other two (CSC and Accenture) planned to use solutionsfrom 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 thanplanned so that both LSPs chose to deploy working interim solutions: in CSCs case around iSOFTs legacyiPM and iCM products (PAS and enterprise clinical solutions) in the acute space; in Accentures case, primarycare and community software from TPP.

As a result of these changes, significant numbers of large scale product deployments of interim solutions intosecondary, community & mental health have created a platform for shared care, and enabled improved workloadand case management.

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

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 withanother US clinical software provider, Cerner, also a rec ognised leader in the US market. Thi s was on the basisthat an as is version of the Cerner system already deployed in the Newham and Homerton hospitals wouldbe taken, which could be readily deployed as Release 0 elsewhere. A design process would be followed to meetthe full ICRS requirements through subsequent releases of Cerner.

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05 Localised NHS IT

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

and sophisticated reporting; (2) Order Communications and Diagnostics Reporting (including all pathology and radiology tests and tests ordered in primary care); (3) letters with

coding (discharge summaries, clinic and A&E letters); (4) scheduling (for beds, tests, theatres etc.); (5) e-Prescribing (including To Take Out (TTO) medicines).

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.

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Architecture

In outline, a hospital-wide EPR solution must meet the following broad requirements: rich functionality; deepintegration; fast response times; a full view of all relevant clinical information as a basis for intelligence /decisionsupport; an intuitive user interface; and the use of IT-supported ICPs. It must also be able to drive out andreport on the NHS quality agenda and other key information needs.

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

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

The Cerner solution is an example of the single database approach and clinicians we spoke to saw it as beingwell ahead of alternatives in terms of the depth of its functionality and its ability to generate task lists andprompt alerts across the enterprise.

There is also an emerging view that an alternative surround and replace strategy is viable, based on progressin other countries. This is discussed more in Appendix G. It potential ly represents a more flexible, perhaps lowercost way of meeting the requirements. On the other hand, it is not proven in the NHS. In our view, the approachis worthy of closer research and validation.

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

Recommendation5.B: more research is needed, and potentially pilots, into the viability of other local integrationtechnologies and approaches such as surround and replace, and the resulting impact on business cases. Itshould endeavour to address the circumstances when such approaches may be more fruitful than a traditionalapproach of rip and replace.

Interoperability, Standards and Open Source

The EU usefully describes interoperability as:the ability to exchange, understand and act on patient and other health information and knowledge, among linguistically andculturally disparate clinicians, patients and other actors, within and across jurisdictions, in a collaborative manner.

Separately, the EU has identified that:

Full record sharing requires at least two levels to be achieved:

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

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.

Semantic interoperability is essential for automatic computer processing to underpin real value-added EHR clinical applications, suchas 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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what flexibility exists in the implementation roadmaps and integration of existing systems? Can Trustschose a model that meets their own capability and maturity? Does it provide an open, low-cost platformthat other specialist application providers can readily leverage?;

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

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

If the view is taken that the revised LSP arrangements do not pass these criteria, the LSP contracts would needto be deconstructed in a carefully planned fashion retaining what is best and transferring the hospital EPRelements into a catalogue.

Whatever emerges, those LSP elements that work well (e.g. delivery of primary, community and mental healthCRS solutions; PACS; resilient hosting services) should continue in one form or another.

In the hospital EPR area, much has been invested in time and money, some sites are operation