Yorkshire and Humber SHA plan TPP-based EPR

17 Oct 2007

Yorkshire and Humber Strategic Health Authority has adopted a new IM&T strategy that explicitly plans for the possible non-delivery of Lorenzo, the strategic software the NHS IT programme is meant to provide to three-fifths of the NHS.

Instead, the SHA now plans to base its delivery of electronic patient records on a primary and community care record system supplied by The Phoenix Partnership (TPP). Under the plan acute systems would be connected to a TPP core electronic record.

E-Health Insider has learned that Yorkshire and Humber SHA is pushing its primary care trusts to adopt TPP’s SystmOne software as the foundation for shared electronic records. As well as providing an alternative should Lorenzo fail to be delivered, or be further “descoped”, the approach should enable the SHA avoid having to pay penalties to local service provider Computer Sciences Corporation (CSC), under the contracts it was committed to by central NHS IT agency, Connecting for Health (CfH).

Yorkshire and Humber SHA says the mass-migration to the TPP route offers a way to achieve the benefits of shared electronic records to deliver better healthcare, while avoiding the SHA becoming liable for penalty payments to local service provider CSC.

The SHA says its plan mitigates the risk of further delays in the delivery of the Lorenzo system to be supplied by CSC, already running three years late. Each SHA has been committed by CfH to take a certain number of implementations from the LSP or pay penalties, irrespective of whether the Lorenzo software is available.

EHI understands that although Yorkshire and Humber has so far been the most explicit about its preference for the TPP-option other SHAs in the North of England are also developing similar strategies.

Although potentially offering a pragmatic route to electronic records using off-the-shelf software the Yorkshire and Humber strategy runs counter to the government’s commitment to GP Systems of Choice. Instead it is predicated on the SHA forcing a mass migration of all its practices and PCTs to TPP.

As part of the strategy the SHA intends to treble the number of further GP practices migrated to TPP SystmOne - from the 100 it is contractually committed to by the end of 2008/2009 to over 300. The aim would be to move 100% of PCTs onto TPP by the end of 2009.

In addition, by over-delivering on the contract, Yorkshire and Humber’s additional 200 installs would be used to offset the implementation deficits in other SHAs covered CSC, specifically in the North West and West Midlands.

Yorkshire and Humber SHA document states: “TPP could therefore form the basis of an electronic patient record. Our target would be to have deployed the TPP system to 50% of GPs, 75% of PCTs and 100% of prisons in Yorkshire and the Humber by March 2008 and 70% of GPs and 100% of PCTs by March 2009.”

Individual SHA's contracted commitments to take a set number of systems - or find an SHA willing to make good the shortfall - applies despite the continued delays in the availability of Lorenzo. Instead deploying TPP SystmOne to hundreds more sites is being seen as a 'get out of jail free' card, offering a way for SHAs to avoid penalties, while also enabling CSC to get paid under the CfH-negotiated contract.

The document also stresses that one of the key objectives, and part of the rationale of the TPP route, is to avoid incurring penalties to the LSP.

It says the TPP-based strategy “Ensures that the SHA delivers the NHS’s contractual commitments and thereby mitigates the risk of contractual default and the application of penalties.” The level of these penalties is not specified.

Because TPP is the current system GP and community system offered by CSC, the LSP would earn money from further implementations and the SHA could avoid contractual penalties. “All of the deployments planned under the strategy are still NPfIT deployments and therefore count towards the delivery of the programme by the SHA,” explains the Yorkshire and Humber paper.

A September board paper from Yorkshire and Humber says “By accelerating the deployment of the primary and secondary care system the SHA will actually over-deliver on the NHS’s contractual commitments in Yorkshire and Humber both this year and next.”

This contrasts with the position in the North West and West Midlands, which has a “significant gap in its contractual commitments.” Yorkshire and Humber says it is being asked “to help them by over-delivering on our contract.”

Setting out the benefits of the strategy the SHA document says: “It expedites the delivery of the National Programme for IT in Yorkshire and the Humber”. In addition, it says the plan will “mitigate the risk of further delay to, or non-delivery of, the strategic solution (Lorenzo) from CSC”.

“In the event of delay to, non-delivery of or a change of scope of Lorenzo we would seek to link the secondary care systems to the TPP systems,” says the IM&T strategy document. “This would effectively create a Yorkshire and Humber-wide electronic patient record enabling us to achieve the vision of a shared clinical record.”

If, however, Lorenzo is delivered the strategy argues that the drive to TPP would provide a helpful enabling step. “If Lorenzo is delivered then migrating existing users from standardised hosted systems such as TPP will be easier than trying to migrate them off a plethora of different systems as is the case today. Therefore at worst this is an enabling strategy.”

In the continuing absence of Lorenzo the SHA says that CSC’s product set for secondary care “is a package of separate software applications” – iPM patient administration system (PAS), iCM clinical management system for orders and reports, departmental systems (theatres, maternity and A&E), and integration solution and a management information system.

The strategy says that only one acute trust covered by the SHA, Bradford Teaching Hospitals NHS Trust, has yet received a secondary care product from CSC, the iPM PAS, plus integration and management information. It concludes though this has been successful but adds: “The system is still bedding in and it therefore too early to tell whether this would form a suitable platform for other trusts.”

Neither Yorkshire and Humber SHA or CSC had responded to questions put by EHI at the time of publication.

Jon Hoeksma

Reader's Comments

incipient amnesia

17 Oct 07 12:24

Didn't I read something recently about GPs having some sort of 'Choice' about the systems they used? Or was that a choice of GP's socks?

No Amnesia

17 Oct 07 12:53

You miss the point. GPSoC gives GPs choice. The target is 70% of GPs. This means the strategy is predicated not on forcing GPs but on pursuasion. This relies on providing a GP system at least as useful as their existing one for their own work plus high levels of integration with other clinical information such as community nursing, child health and therapies. If the 70% is acheived it will raise questions about the 30% of practices who priorities the convenience of staying as they are over the benefits to patients of modernised, integrated information systems.

Faith-ware

director@doctors.org.uk

17 Oct 07 14:04

"This relies on providing a GP system at least as useful as their existing one for their own work plus high levels of integration with other clinical information such as community nursing, child health and therapies." ... which implies bringing a very large number of people to believe a lot of things about the proposed solution for which there is currently no evidence.

amnesiac

17 Oct 07 14:47

I do think it is comments like this that make GPs so nervous. It is (just) possible that integration with other primary and community care systems could bring clincial benefit, although in my experience of them they are primarily bean counting systems.

Set against that is the inevitability of upheaval in a practice of change, and the consequent (albeit perhaps temporary) discomfort adn clinical risk associated with a change of system. This is why GPs fought so hard for GPSoC, and i think to dismiss their concerns as a matter of 'convienience' is to miss the part that these systems play in the treatment of patients

Further, talk of 'pursuation' and questions being raise over those who are not 'pursuaded' would make GPs ver nervous indeed

Faith but not blind faith

17 Oct 07 14:56

30% of GP practices in Yorkshire and Humber have already moved to the TPP system. Most PCTs are currently implementing plans for community nursing, community therapies child health, prisons. If you are not based in Y+H you may not see the speed of progress.

The big point is that this is based on systems which are not perfect but are at least as good as the alternatives. It is based on pursuasion not compulsion.

If this is faith it is faith in a realisable vision not in a pipe dream.

re: Faith-ware

17 Oct 07 16:53

>>a GP system at least as useful as their existing one for their own work<<

Each to his own (or at least we wish it was). The TPP GP solution is elegant from both technical and interface viewpoints - and already servicing a decent percentage of GP practices nationally, albeit not the same proportion as EMIS.

However we would do well to remember that EMIS supports a range of legacy applications which are not always fully intercompatible. TPP System One users are all kept on the same version of the same application which is already centrally hosted.

Having the GP system support a cluster level shared record seems to be the direction BT are heading towards in London too. However there must be reasonable doubt that hypertrophied GP systems will support secondary care better than Millenium, Lorenzo or Carecast (RIP) would have supported general practice.

Money versus my patient care.

angus.goudie@GP-A89021.nhs.uk

18 Oct 07 12:46

What concerns me is that LSP income and SHA penalties seem to be driving a central agenda in many areas where there is no immediate benefit to may patients. Changing system from one in which most GPs are happy would lead to 12months of reduced function and inevitably loss of data quality and some data contentext. In addition to this years of cross community work, honing of templates/ audits and expertise etc. would be thrown away. This taken with reduced efficiency for a year would have a major impact on patients. With so much to lose, especially in areas with 70-100% EMIS use the equation seems easy until all the high commerce is added to the equation.

Am I missing something? Strategy based on avoiding SHA fines..

maryhawking@tigers.demon.co.uk

19 Oct 07 11:14

"As well as providing an alternative should Lorenzo fail to be delivered, or be further “descoped”, the approach should enable the SHA avoid having to pay penalties to local service provider Computer Sciences Corporation (CSC), under the contracts it was committed to by central NHS IT agency, Connecting for Health (CfH)."

So we have an interesting situation here. !. LSP is contracted to supply a secondary care system - Lorenzo - to acute trusts. 2. LSP unable to supply this secondary care system. 3. *However* the contracts say that the NHS has to take up a certain specified number of LSP systems, and will be financially penalised if it fails to do so. 4. Result? the only place that the NHS can find sufficient uptake (as admitted by the SHA) is to force general practices to migrate to the system which now appears to be owned by the LSP, CSC (at any rate, CSC is listed as the supplier in GPSoC: is there a conflict of interest? CSC as GP system supplier as well as service provider?).

I really don't see that the apparent incompetencies in writing the original contracts with the LSPs *and* in the inability of the super-efficient LSPs (after all, this was why they were selected - proven ability to deliver) form a valid reason for strategically planning to flout GPSoC (surely GPSoC is now government policy?) and "persuade" GP practices with systems they consider to suit their needs better than TPP to change systems with all the risks to patient care (and loss of legally valid medical records) which this involves.

Am I missing something blindingly obvious here? Such as the only real remit for the SHA is financial, and patient care has to be subordinate to this?

The Obvious

19 Oct 07 15:34

The obvious thing that our esteemed GPs seem to be missing is that the SHAs strategy is about integrated care records supporting improved patient care. GPs can choose to be part of that strategy or can choose not to be. So far 30% of the GPs in Yorkshire and Humber have ***chosen*** to do so and as part of that strategy have got a highly functional and useable GP System.

I must be missing something blindingly obvious because that seems to be a strategy that is about patient care.

According to the SHA Board papers..

maryhawking@tigers.demon.co.uk

19 Oct 07 17:46

Check what the Yorkshire and Humber SHA IM&T strategy actually says. http://www.yorksandhumber.nhs.uk/reports-and-publications/BoardMeetings/4_september_07.asp (you want enclosure E) They are disarmingly open about the reasons for planning 100% adoption of TPP - including helping out other SHAs! No discussion of any advantages over existing systems or acknowledgment that GPSoC is not optional for SHAs..

As the SHA itself states that their strategy is to avoid the risk of financial penalties for failure to deliver the quota of CSC installations, who am I to argue with their stated reasons? ;->>

". However sufficient projects have been identified to ensure that contractual commitments for 2007/08 can be met.

CSC Alliance’s existing primary/community system is TPP SystmOne. TPP SystmOne is deployed to GP, Child Health, Community and Prison services, additional modules will be deployed as they become available e.g. diabetes, palliative care and drug dependency." "Benefits of the strategy

It expedites the delivery of the National Programme for IT in Yorkshire and the Humber

• All of the deployments planned under the strategy are still NPfIT deployments and therefore count towards the delivery of the programme by the SHA." "It ensures that the SHA delivers the NHS’s contractual commitments and thereby mitigates the risk of contractual default and the application of penalties

• By continuing to support the delivery of existing secondary care products the SHA will ensure that the NHS’s contractual commitments are met in 2007/08. In 2008/09 the majority of the contractual commitment centres around the delivery of the first iteration of Lorenzo

• By accelerating the deployment of the primary and community system the SHA will actually over-deliver on the NHS’s contractual commitments in Yorkshire and the Humber both this year and next. For example the NHS in Yorkshire and the Humber is contractually committed to deliver 42 GP systems in 2007/08 and 62 GP systems in 2008/09, this strategy plans to deliver 350. The NHS in the North West and West Midlands already has a significant gap in its contractual commitments and we are being asked to help them by over-delivering on our contract."

shared records dont need systemone

22 Oct 07 14:00

I am an Emis using GP and we shared records with our district nurses on Emis. Then they were told they had to change to Systmone as it would be wireless enabled and they would use it in patients' homes. Several years later, our poor nurses now use 4 separate record systems. Paper in the homes as Systmone never has been wireless enabled for them, Systmone, the social care system, and Emis to communicate with us. It works but it's inefficient. What we had before was shared and worked well. The agenda for the SHA is about control and finance and nothing to do with shared care records, which are nice but not crucial. (Post edited by EHI)

Is Mary missing something?

nhstechie@btinternet.com

23 Oct 07 00:37

I guess this raises a bigger question - what are the SHAs there for?

The NHS Operating Framework charges SHAs with promoting NPfIT, ensuring PCTs do the same and ensuring the NHS complies with the terms of the LSP contract.

Rather than kow-towing to the demands of the LSP to buy £Xm per year of products (never mind the quality or effectiveness) perhaps ensuring LSPs comply with the requirements placed on them by the LSP contracts would be more appropriate? Back in 2004 at the ASSIST National Conference Richard Granger hailed the start of a period of "pro-active supplier management", whatever happened?

NLOP was supposed to devolve supplier management to the local NHS, not devolve demand management from the LSPs to the SHAs. The only thing which will stimulate demand for LSP products is the timely delivery by them of fit for purpose software which meets current and future frontline requirements and is integrated across the health and social care (remember them?) spectrum of services.

NLOP (No Longer Our Problem) is fast becoming an all too true joke with the SHAs set to take the flak.

EPR Boundaries

23 Oct 07 10:56

Interesting fall-out of the strategy will be that if all GP Practices move to TPP and Acutes move to Lorenzo then CSC will have met their contractual commitment. Will they then develop Lorenzo GP ? My guess is not so we will have 2 EPR's and a bun fight as to where Community should go. Should they integrate with GP's or Acutes ? CSC will probably offer something along the lines of increased integration - but with integration comes summarisation and aggregation and depreciation in the value of the electronic patient record and all of the wonderful things that were promised become - scaled back.