DH carrying out 'confidential' review of CfH

Tags: A Accenture BCS CfH DH HIS Informatics Information iS London NAO Nicholson NPfIT Quality SHA Strategic

15 Nov 2006

E-Health Insider has learned that an urgent 'confidential' review of the NHS IT programme and structure of Connecting for Health, the agency responsible for its delivery, has been launched by the new chief executive of the NHS David Nicholson.

The new boss of the health service has commissioned a review of the £6.2bn NHS digitisation project as one of his first actions since taking up post in September.

The CfH review, which has already begun taking evidence, is understood to be focusing on reviewing how to re-structure CfH to make it and the programme it is charged with delivering more locally responsive.

Described to E-Health Insider as a 'confidential rapid review', suppliers have already been called in by a CfH study group to answer questions on the state of the programme with sessions being held this week.

But some industry figures contacted questioned how thorough it would be and suggested the terms of reference were too limited. "It’s a rush job," said one senior industry figure. "It appears to be very short and a not very thorough job."

Those involved indicate that this is a review that dare not speak its name. "CfH are insisting this is not a 'review', and is nothing to do with the past but all about the future," explained one senior industry source.

One CfH source stressed that the review was not being undertaken by CfH but by DH: "It’s a review that's being done to us". However, several of the key figures conducting the review are understood to be senior executives from CfH.

Despite the well-documented delays and significant difficulties in delivering the core clinical and care records systems at the centre of the project the Nicholson review is believed to exclude technical questions and performance to date. Instead the review is being cast as strictly forward looking, focusing on how to improve future prospects for success through re-configuration.

The DH confirmed to EHI that the review has been 'commissioned' by Nicholson. A spokesperson said a review was timely given "the re-structuring of the NHS and the recent transfer of responsibilities from Accenture to CSC".

The DH spokesperson added that the review was linked to CfH "preparing for Executive Agency status". Health Minister Caroline Flint recently confirmed that CfH would be a time-limited agency with a lifespan of no more than a further five years.

The spokesperson said the review also took in a new programme of work - "the NPfIT Local Ownership Programme" - which in line with the summer NAO report on the IT programme aims to achieve "a shift in ownership to the local NHS to ensure it is an essential part of normal NHS business in supporting the delivery of better quality and safer care".

NHS Connecting for Health declined to offer any comment on the review.

One of the most likely outcomes of the 'NPfIT Local Ownership Programme' is that much of CfH's work and responsibilities will be devolved to the nine new strategic health authorities, rather than be concentrated centrally in Leeds.

An indication of the likely direction of travel is provided in the person of Kevin Jarrold, who as well as being the CfH regional implementation director for the London cluster is also the chief information officer for London Strategic Health Authority. Nicholson was chief executive for London SHA immediately before taking up his new post.

Two weeks ago CfH staff were notified in a letter from chief operating officer Gordon Hextall that re-structuring plans were being drawn up, and sources within the agency indicate these will be based on moving a significant number of staff out to structures aligned to SHAs.

Calls for a review of the project, including calls from both the British Computer Society and from a group of 23 eminent computer academics, have all previously been rejected.

Just three weeks ago health minister Lord Warner rejected the academics call for a review stating: "I want the programme's management and suppliers to concentrate on implementation, and not be diverted by attending to another review." DH thinking appears to have since moved on.

Dr Glyn Hayes, vice-president of the BCS and chair of its health informatics forum said: "If this review is designed to refocus CfH towards a more local implementation approach we are all in favour as we want those successes that have been achieved to be built on."

Dr Hayes added that a local implementation approach potentially provided the way to address a lot of the very real anxieties around confidentiality.

The BCS is itself due to publish a full review of the technical architecture of the NHS IT programme within the next two weeks.

Readers Comments

Ask the question... Ask the question !

15 Nov 06 09:57

Can the 'terms of reference' of this review ever get beyond examining the business logic governing the programme? That is, should we have a supra-system measuring activity or a patchwork of locallly controlled systems to do this?

This debate is ultimately sterile and misses the essential point that neither scenario will get clinical staff to move to electronic clinical notation. NPfIT's core vision is to get meaningful clinical data, currently on paper, into an electronic format. Health benefits accrue from this and not from a debate on Lorenzo vs. RiO vs. Millenium, etc.

Calling in the suppliers to explain themselves is at best a side-show and will confuse the DH even more. The focus needs to be at the level of clinical specialties and services, for example, what is needed to support the West Midlands in a diatetes screening and management programme? The ultimate arbiters of this question will be the people providing West Midlands diabetic services themselves.

Joined up governance

15 Nov 06 10:26

It is essential that NPfIT Governance and wider NHS Governance are seamless. To me that means a significantly reduced role for the Clusters and an increasing role for SHA’s & PCTs. If this happens this should enable the sharp end of the NHS to be joined up with the CfH team - which should in theory help bridge the current reality gap between CfH and the service. The big issue here is putting sufficient resources in the SHA's & PCTs to make this happen - not currently within their planned 'lean organisations'.

It may also be helpful to senior CfH staff including Granger to get out more – go visit sites either live or planned to go live with NPfIT deployments. More – he should do this quietly and get to speak one to ones with CEOs, Lead Clinicians and Programme Leads and ask for honest views on where we are at. I think this is the only way he will get to see reality, given the level of filtering out detail that must take place when dealing with a programme of this size. In my experience staff at a cluster level do not understand or feed up detailed big issues that the sharp end of the NHS are experiencing with the programme.

In other words why wait for this ‘review’ Mr Granger – why not go find out for yourself and be prepared.

The Customer is Always Right

15 Nov 06 14:59

One thing that this not-review needs to bring out is the shameful way that from the beginning the "customer" has felt left out of designing and delivering a system for their needs.

CfH is NOT the customer for NPfIT - the clinical staff who deliver healthcare to this country are, CfH is only the salesman / agent. Any project of this size is bound to be complicated and dificult to deliver, and so it should be. But what should not be acceptable is the seeming lack of input and guidance from the clinical element of the healthcare team. The management and IT bods may well know how to put the system together, but only if they are told wha the system is to provide.

The only people qualified to design a system to deliver clinical benefits are clinical staff, and until they are fully confident that their needs and requirements are being put first there is no way that the Programme will work.

So CfH get out there and ask your customers what they want, and then deliver that to their satisfaction and maybe healthcare IT will be something we can all be proud of.

The beginning of the end ?

15 Nov 06 21:51

A review ! No doubt the conclusion will be all is hunky dorey and "rather than dwelling on past problems we need to forge ahead at an increased pace" completely ignoring the fact that there is close to zero clinician involvement/enthusiasm/engagement/knowledge or appetite for the system.

The Great NHS Boat Race

15 Nov 06 23:05

This reminds me of the great NHS boat race.......

".....Once upon a time it was resolved to have a boat race between an external consultancy team and a team representing the NHS. Both teams practiced long and hard to reach their peak performance. On the big day they were ready as they could be. The external consultants won by a mile.

Afterwards the NHS team became very discouraged by the result and morale sagged. Senior management decided that the reason for the crushing defeat had to be found and a working party was set up to investigate the problem and recommend appropriate action.

Their conclusion was that the external consultants' team had eight people rowing and one person steering, whereas the NHS team had eight people steering and one person rowing,

Senior Management immediately hired a consultancy company to do a study on the team structure. Millions of pounds and several months later they concluded that “too many people were steering and not enough rowing".

To prevent losing to the consultants next year, the team structure was changed to three “Assistant Steering Managers", three "Steering Managers", one "Executive Steering Manager" and a "Director of Steering Services". A performance and appraisal system was set up to give the person rowing the boat more incentive to work harder.

The next year the external consultants won by two miles. The NHS laid off the rower for poor performance, sold off all the paddles, cancelled capital investment for new equipment and halted development of a new canoe. The money saved was used to fund higher than average pay awards to Senior Management."

....so what do we think?

NHS Boat race

16 Nov 06 10:12

I thought the external consultants won because they borrowed the NHS's boat to find out what rowing involved and returned it full of holes and with a rudder that took the boat in the wrong direction.

NHS Boat Race

16 Nov 06 12:03

Well, after 2+ years inside an LSP despairing at the headless chickenry, the most hilarious thing about that NHS Boat Race tale is the idea that the external consultants would have had one person steering and eight actually doing something.

Who is accountable?

16 Nov 06 15:17

I think most people would welcome more local control of the the programme but I am intrigued by the notion that the London model of a joint RID and SHA CIO might be a model for NPfIT programme governance. The recent letter from David Nicholson makes SHA CEx's responsible as SROs. But the ability to deal with LSPs sits with the cluster. Under the joint RID/SHA CIO model who exactly is accountable to whom? On a positive note it might enable SHAs to hold LSPs to account - but it might work the other way; the cluster continues to deal with the LSP but the SHA can't holds the cluster to account as they are one and the same at the top.

The customer is not the customers

16 Nov 06 19:04

NPfIT will claim "customer" engagement from early on - some clinicians mysteriously had time to go to far away places and consult and sit on committees. Most clinicians are too busy doing medical care to go away. Imperative was that those who went away knew and understood how they worked themselves (we often have so little insight into how we work, when we are busy working) AND insight into how the other clinician customers work. Orthopaedic consultants work in very different way from neuropsychiatrists, dermatologists from paediatricians. One customer is not the customers. It would have required some very smart clinicians and very smart systems analysts to identify core requirements that would make all areas of practice more efficient and more safe. It would have been immensely straightforward to get it wrong! It seems we took the straightforward track to get it wrong. To get it right needs the very cleverest systems analysts to meet and observe the many varied customers, and find a core system that helps. The BMA publication today claims that an early phase will be to list the patients current active health problems and diagnoses and recent and previous medications and allergies. SO simple, so useful, so far from what we are getting in the Southern Cluster!

The review must concentrate not on why clinicians did not go to meetings, but on why the providers did not go to see the clinicians at work, and come to understand the most complex work environment in human endeavour and find ways to make it less complex.

Tell 'em how it is Glyn

roger@safescript.org

17 Nov 06 09:04

Glyn Hayes was unusually taciturn in his comment or did you only quote the bland bit? We at the coal face (GP land) want the whole juggernaut of centralised care records stopped and the powers that be to recognise that we already have the care record safe and well cared for in every GP surgery in the country for every patient in the country. What is going to be gained by downloading parts of these records to the black hole of the spine?(Meds, allergies, diseases, lab tests?) -answer nothing for patient care. What will be massively lost will be patient privacy. As most clinicians know you can correctly guess most diagnoses from Meds - sealed envelopes - PAH - a time consuming conjuring trick. Interestingly politicians and prominent people will not take part. I say if its not good enough for Blair and Becks its no good for Joe Public. Roger Weeks GP

Why clinicians don't go to meetings

17 Nov 06 09:34

First, although the programme pays lip service to it, remuneration for travel and backfill for the 'day job' is not forthcoming. po not only do clinicians have to agree to go, but their trusts also, who end up footing the bill. Not too likely in the current financial climate, methinks.

Secondly, in the early days there was no cognition of how busy clinicians are, and the notice required for attendance - 6-8 weeks. Whilst this has improved latterly, it certainly reduced clinician engagement in the early days.

It's a great shame, because the NHS must be one of the most complex 'organisms' ever, and a huge challenge to systems analysts/domain experts.

What is going to be gained?

17 Nov 06 10:38

What is going to be gained is that often forgotten benefit of patient care.

GOVERNANCE ALIGNEMENT IS DESPARATELY NEEDED

17 Nov 06 10:45

Being at the "sharp" end with a complete lack of guidance and more importanly leadership is very frustrating. This review will hopefully address the key issue of governance and accountability at a SHA level, where there is signficant lack of key resources and skills necessary to move the programme forward strategically.

PCTs need sound leadership and support, and from my own experiences the lack of capable people within the SHA CIO teams is compounding delivery. In their defence they are small teams and cannot cope with the demands on their time with such a wide customer base. PCTs do want to take ownership, but need to be included in the overall scoping of the delivery approach and not just told to do things all the time and then be performance managed against something they have no control over.

One of my own major concerns is that IT seem to be leading on what is a major change programme in its own right, and in my view CfH should be an executive function in its own right in every organisation, with clear goverance and accoutability. It should not be aligned to the traditional IT mavericks who see this as an opportunity to get themselves noticed and not always to the benefit of the overall vision and intent.

Like every programme activity, there is a point in time when people really understand what they are doing and the impact and this is when it really should be owned by the business with recognition that it is not just deploying hardware and software. We all know that it will enable a whole series of service re-design and unique opportunities for the NHS to work in different ways to the benefit of patient care and effective service delivery.

confidence and trust

tim.llewellin@glos.nhs.uk

17 Nov 06 11:03

CfH has lost the confidence of not only many clinical staff, but also those of us who already work across the boundaries of I.T. and the clinical arena.

As a relative newcomer to the NHS about 3 years ago, I found that even with more than 20 years experience of working within the IT sector, I was apprehensive of decisions that I would make that could have implications for the care of any patient. I therefore took the time and effort to liaise with nursing staff, pharmacy staff, admin staff as well as the doctors and consultants, in an attempt to understand the nature of the work they do, and then use my knowledge of I.T. to implement technical solutions in a manner that was sympathetic (often replicated) the existing ways tasks were achieved.

This “base line understanding” of what goes on in the real world of GP surgeries, clinics and hospitals seems to be missing within the CfH program. If they understood this, then they would appreciate how difficult it is to marry real world practice to the conceptual aims put forward by external systems consultants. Consultants who may understand the concept of “core data structures”, but who have little understanding of clinical practice or the needs and priorities of those who are the real stakeholders.

Of course some consultation has taken place, but that was probably after the framework had already been designed. This replicated the process that occurs within many Public Sector IT projects, most of which also go way over the forecasted costs, and often fail to provide systems that do what needs to be done.

I don’t believe anyone believes there is a simple solution, we need to improve the provision of information, we need to share information between not only organisations within the NHS but also to partners that also provide care. We need to do this within a framework that we trust. That trust must exist on many levels, first we need to trust that the information we provide to any system is secure and only available to appropriate persons. Secondly we need to trust the information that we receive from any such system. That’s a significant step forward not only in terms of technical provision, but also in terms of culture.

Send Mr Nicholson all of this

18 Nov 06 23:37

It is time for e-health-insider to assume a Governance role - send all these brief comments on CRS (going back for months) to the CE of the NHS, Mr Nicholson, with copies to the CMO, Sir Liam Donaldson. I have done my bit with letters to both - come on now - your chance to influence the NHS and save us from binary fission!

Jogging DH's corporate memory ...

19 Nov 06 17:54

Rather than commissioning a review, perhaps David Nicholson should have sought reassurance from his acting predecessor - Sir Ian Carruthers - who didn't give the impression that there was much amiss when giving evidence - as CfH's Senior Responsible Owner Number 6 - to the PAC in June of this year:

Q49: Sir Ian Carruthers: First of all, it [NPfIT] is not going wrong.

Q50 ...... Sir Ian Carruthers: Apart from the care record everything is going right ....

Q91 Sir Ian Carruthers: The benefits of the programme are clear.

Or perhaps things have gone rapidly downhill since 26th June?

Oh me oh my

19 Nov 06 19:46

I can't believe I got to the bottom of the comments list and no one mentioned the NHS Information Authority, the regionalised body that used to do........................................

NHSIA - correcting the omission!

20 Nov 06 10:02

The regionalised body that use to do ....... quite a lot actually in terms of value-for-money: services (e.g. Exeter system, Read Codes, datasets etc, NeLH; NHS mail); implementation projects (e.g. Pathology messaging, Numbers for babies); development projects (ERDIP, SNOMED, dm+d).

NHSIA or CFH

20 Nov 06 13:30

I worked for both the IA and more recently for CFH. These days it is difficult to tell the difference

Re: NHSIA and CfH

20 Nov 06 15:26

Given the amount of funding being channelled through CfH (compared with the NHSIA's relatively modest £200 - 300m p.a.) there ought to be a striking difference. It would be interesting to use the NHSIA's performance over its 6 year existence (costs versus benefits) as a benchmark against which to evaluate its successor.

Confidential?

20 Nov 06 22:52

Who has any idea that this is confidential? The IA versus CfH debate is a complete waste of time. It would be useful if the terms of reference for the review(s) can be made available. A more open view of participants and how they have been made participants would do much to alleviate the general pissed-off-ness of those that need to respond to initiatives.

Sorry

Waste of time?

21 Nov 06 10:55

I don't fully agree with the previous commentator that the NHSIA versus CfH debate is a complete waste of time. The DH has adopted a series of delivery models for its IT ambitions for the NHS over the past 15 years: IMG - NHSIA - CfH. It's clear to many (if not most) people that CfH is approaching the end of "life as it knows it" and that a further restructuring is going to happen. In attempting to understand where CfH has gone wrong - and IMHO it's been the least effective and efficient delivery approach to date - comparison with other approaches could yield useful ideas for shaping whatever "initiative" is to follow.

Fudge

22 Nov 06 15:36

There are several strands to the comments here that are interesting.

These maverick local IT people have often implemented real systems in busy hospitals, listened acutely and sometimes painfully to clinicians in their own setting, and speak from a degree of knowledge of what would work within an NHS setting in a busy hospital.

Barriers to sanity of NPfIT progress have been many, from the LSP, and the software provider, but also from Cluster NPfIT, or blamed on decisions at 'CfH Leeds'. All are guilty of passing the buck for unpopular or illogical decisions to others.

The Clinical engagement was poor, almost exclusively Consultant level, and from few specialties that could get cover, or nearly retired grandees. The administrative and management engagement was worse, and NHS IT professionals often made to feel unwelcome.

A number of us have tried to get CfH and LSP to 'come to the people', but even on-site demonstrations are far less flexible and user focussed than anything I have organised before. (Won't work over lunchtime, won't do free-form or hands on sessions, won't split over more than one location..we tried all of these).

The NHSIA/CfH debate is interesting because the IA did at least only concern itself with items that were better done centrally, or relatively harmless to end users and patients.

The real problem with CfH is there is nothing between the policy excesses and the pragmatism that local implementation could achieve. And the demise of the agency will leave us with impossibly expensive contracts to deliver half a solution. The idea of LSPs is an equal problem in my view.