NHS IT loses key contractor

Trying to eat the Elephant in one bite gives you indigestion

I think "my mate dave etc etc" is more than likely correct in his analysis. I am nether an IT person nor a Health service person, but as a taxpayer I want best value and as a health service user I was a slick and effective system.

So free from the constraints of reality this is what I would do.

1) Do a piece of work to rank the trusts level of systems competence (both IT and non IT) - we are not going to publish the results, we are going to be honest and fair. There are no prizes, but.....

2) pick the three best (geography and possibly other factors may play a part) and keep the better 10..20 on board with regular updates and be open to comments and suggestions. Keep all the others informed of progress at 6 monthly intervals.

3) using the contractor's expertise married to the key trust's expertise and nicking good ideas from where ever you can build a system, keeping in mind the requirement for scalability.

4) Make the thing out of industry standard components, ensuring that compatibility with all potential devices is supported in a standard way. Where an equipment supplier tries to insist on a prop interface try not use them unless you really have to.

5) All equipment supply and installation effort is reversed auctioned off against a tight spec - ensure you are not necessarily committed to the lowest bid. Although in practice you will take this unless there is a good reason why not. Performance criteria must be specified and applied fairly - suppliers must be aware that this will be taken into account in further auctions. Part of the process is a risk assessment of the supplier.

6) When you have an operating system and have done the initial bug fix / minor redesign bring those trusts on the best 20 list into the process.

7) Upscale the project and continue to enhance.

8) open it up to all trusts who wish to buy in to the process.

Key points

Trusts are not forced to use the system

Trusts buy into the designed system (which of course incorporates best practice)

Funds are available it implement the approved system

Valid suggestions for improvements (IE developing best practice) are accepted and welcomed from anywhere at anytime

So you avoid fighting negative battles and when you have a demonstrably good system people will queue at your door voluntarely, especially as there is money to fund it.

Paris cos she takes it one at a time

GP viewpoint..

The things that have been delivered (from an end-user viewpoint) are fairly straightforward and were well developed as systems prior to NPfIT - broadband network (N2 - we were connected in 1998), PACS being adopted because it is useful (some Trusts were forced to cancel contracts with non-approved suppliers) and NHSMail (RG cancelled the contract with ?EDS - haven't noticed any improvement - still clunky.. ;-<).

The Big Idea - the SSEPR - Single Shared Electronic Patient Record - or Detailed Care Record - is much more difficult. (I'm a GP so won't comment on PAS).

Annonymus Coward talks of 240 million GP appointments: like Richard Granger, he doesn't seem to have noticed that GPs were already working with EPRs before NPfIT: why do you think the BMA signed up to a performance related pay structure - the Quality and Outcome Framework - totally dependent on keeping all your patient records electronically?

In Lorenzo level 4, CSC is hoping to install a true SSEPR: I assume this means the abolition of paper-based records everywhere. There are problems with the clinical governance ( http://shorterlink.co.uk/14383 ) and also with confidentiality. Who *is* the data controller, and how, in a single record, do you prevent the chiropodist seeing that you are a regular attender at the sexual disease clinic? Let alone, how do you prevent the secondary use of marketing direct to the patient?

AC said "93C3. Just remember: get 93C3 on your records."

This stops the creation of a Spine record of any sort, and patients in areas where the Summary Care Record is being piloted have been informed about their options.

I am not clear - and would welcome information - how this would work for a SSEPR, and whether patients in practices where an SSEPR (primary care version) such as SystmOne is installed are being informed that the latest upgrade - to implement smartcard access - will give them this option to set their NCR (National Care Record) to share, share with consent or no spine record. The default is implied consent for sharing.

This is actually off topic: AFAIAA, Fijutsu and Cerner thought a Detailed Care Record was a Trust wide EPR - not an SSEPR at all!

(technical content alert because if no-one had spotted the problems until I brought it up in December 2007, why should all of you?)

@my mate dave

You are 100% correct in your writing there.

Whilst most in this discussion thread work in IT, some of us only have a server and four users to look after and others have just a little more complex environment, demanding customers, complex projects and even more complex contracts.

Paris because she has just one server and four users to look after too and also could probably "knock up a system for the NHS in five minutes"

Advice

"mad enough to employ the likes of Accenture/Fujitsu/IBM/BT/EDS/TCS etc"

Who are also all 'consultants' whose function in life is change/bugger up everything. When did you ever hear a consultant say: "That bit's working OK, let's leave it as it is"?

The irony is that the NHS has in-house IT depts who could draw up a sensible spec for this sort of thing, but this government always gives preference to people who charge ten times as much.

Huh?!

Um, actually I can't see what scale or integration has got to do with it.

A web client in .Net or Java and a well designed Oracle database in a cluster will do the job rather well. Integration with systems? Um, it's a DB. It's got as much "intergration" as any DB will have FFS. It's up to the trusts to get their systems in order to communicate via some simple standard (XML anyone?).

Can't see what more is needed actually... big fucking firewall and a fat pipe into the cluster?

Yeah, it's not a lunch-time job, but anything more that 2 years including full consultancy is a fucking joke. £5mill including all hardware. Bargin.

What they actually need is a bit more of a dictatorship from the head of IT for the whole NHS and a single supplier for the app, a single supplier for the network and a single supplier for infrastructure. (App can be any dev company worth their salt, network can be C&W/BT etc and Infrastructure can be Cisco or Juniper with software from RHEL or Win2k8)

Mines the one with the "consultancy" invoice in it....

@my mate dave...

While I certainly agree on the general contrariness of doctors and the difficulty of getting them on board, I don't think they could be accurately described as stake-holders in the NPfIT project. Certainly none of the other, non-doctor, staff who have to use the systems can be.

I know people who have to use some of these systems, newly installed, daily. The previous systems worked, people could do their jobs and everything was not awful. The new system seemingly has been designed according the "patient-centric" mantra by people who have absolutely no idea what people using the system would need to do. Patient-centric must sound wonderful unless you actually know what secretaries, booking clerks and the like need to do. They need to do things based on clinics which are associated with specific doctors, doesn't fit into a system apparently having the patient as the primary thing available to search by.

There is partitioning so that certain people can be given certain privileges but managers with no clue about how actual work gets done have used these to prevent access to essential tasks for certain workers. Secretaries do need to check/book appointments in the real even if in theoretical management-world they don't.

NPfIT/CfH is for clueless managers by clueless managers to meet political targets. It is definitively not about giving staff the tools to improve patient care, not about involving the real stakeholders (doctors, nurses, secretaries, all the folks who try to do the real work of the NHS) to see how they work to make it easier. The only glimmer of a silver lining is that this debacle might give the big players reason to think about not bidding on the ID card system. No bidders because of excessive risk would sink it faster than any amount of campaigning by No2ID (Fine work though they do :))

Anon, obviously :P

not simple at all

I agree with the AC who pointed out that these systems cannot be written for beer and a pie. These systems are not trivial. The systems in question use various esoteric protocols for data feeds to push and pull the data from each other. If you're lucky, they will talk HL7 or DICOM (look them up on google, they are pretty well documented) if youre unlucky, they will use some proprietary protocol which is a total ball-ache to implement. For example, connecting to a site's ftp server, downloading messages as text files, and parsing all these with no comeback on any errors, or system specific XML files and other such nastiness. The difficulty in the implementation is usually therefore not the issue of writing the program itself but getting the program to cooperate with the rest of the hospital, rest of the trust or even the rest of the NHS ("Spine", anyone?)

It is/was bloody awful software anyhow

The product they were hawking is win95 code, adapted (badly) from the american market and the list of modules and functions that simply do not function is immense.

of course we, the NHS, wanted them fixed according to the specification -however Fujitsu wanted major cash to do this.

Simple reason -they did not author the software, maintain it or correct it -Cerner do, They have no contact with the NHS at all -so Fujitsu have to pay them to do it and of course according to NPfIT rules, the main contractor does not get paid until the damn thing works.

So they dumped us, Ba$t@rds