Scale of NHS

Delivering 21st Century IT for the NHS : as at 11.05and Beyond!

Jean [email protected]

Credit to various sources : BCS, IMIA, DH, NPfIT, commercial players

Uni Manchester November 2005

Scale of NHS

Population : 55m people in England.

Transaction load (02/03) approximately :

– 325m consultations in primary care ( 6 times / year to GP)

– 13m outpatient consultations pa

– Almost 5.6m planned admittances to hospital

– Nearly 13m people attended A&E

– 4m emergency admissions to hospital

– 617m prescription items issued


Scale – Largest in Europe

• 0.56 Billion turnover

• 15,500 staff

• 3,150 beds

• 531 clinical consultants

• 7 campuses

• 2 major sites

• regional and tertiary centres of excellence

• 5.5K PCs

• 57 network servers and 62 application servers

• Arrangements with 60 HAs

• 3 PAS systems

• 2 ways of coding

• 212,000 FCE per annum

• 900,000 OP attendances

• 17,000 A&E per month


To represent all this activity is a challenge

The PatientThe Patient133 People to take care133 People to take careof the patientof the patient


Organisational cycles• 1948 Formation of NHS

• by 66 - GP Charter, nurses stronger, DHSS formed

• By 74 – AHA formed

• 1978 - WHO Alma Ata PHC

• 1982 - AHAs abolished, DHAs formed

• 1982-84 Korner Information Use Reports

• 1983- Griffiths - DGMs replaced consensus mgt

• 1986 - Resource Mgt using DRGs

• 1987 – Promoting Better Health

• 1988 - Griffiths 2 - SS purchase care for locale

• 1989 - DH and DSS split

• 1990 - GP Contract (minor surgery, IT sys)

• 1990 - FPC to FHSA

• 1991 - Patients Charter - standards for services

• 1991 - GP Fundholding

• 1992 - The Health of the Nation - lifestyle & public health

• 1992 - Getting Better with Information - IM&T

• 1994 - Making IT Work1997 - The New NHS : Modern, Dependable. Our Healthier Nation

• 1997 - Caldicott - governance

• 1998- Information for Health - info triangle

• 2001 - Building the Information Core -HOW

• 2002 - Wanless1. Delivering 21st Century IT

• 2004 - Wanless2. NCR elements (SS again)

•1948 NHS formed

•68 - DHSS

•82 - Korner Information reports

•86 - Resource Mgt with DRGs etc

•89 – DH & Dss split

•91 - GP fundholding

•92 - Getting Better with IT

•94 - Making IT Work

•98 – Information for Health

•02 - Wanless 1 and Delivering C21

•04 - Wanless 2 and social care converging


NHS Chronology (selected)

1998 Information for Health2002 Delivering 21st Century IT

2002 Wanless (funding) 2003 Wanless II (Public Health)

2000 NHS Plan : a plan for investment and plan for Reform

1997 The New NHS : Modern, Dependable

Protti evaluations

Readiness Reviews


Structures interworking Ref. NHS Explained from NHSIA


New National Network (N3)• A combination of Broadband connections and network services to

link all NHS organisations in England with specialist applications and wider Internet applications

• Orders already placed for the first 3,300 Broadband connections for the NHS

• NHS will represent 10% of all Broadband usage in Britain

• In longer term data circuits will provide voice services to make phone lines redundant and increase savings

• Over the next 7 years new contract will save an estimated £900m compared to previous NHSnet contract

• Reference material - [email protected]


21st Century IT for the NHS

• within e-government agenda, under close Treasury scrutiny

• central Budget - £2.3 billion (03-06)

• central activity - procurement, standardisation, economies of scale, programme management

• Local management responsibility for implementation to support service improvement

• person / service user focused rather than on organisations

• Seamless, consistent support for care of service users across all care settings – equity of access

• migration to common solutions across all care communities


Aims of NPfIT• Support the delivery of care and services around each patient’s

choice, quickly, conveniently and seamlessly

• Support staff through :

• electronic communications

• better knowledge management and support

• faster access to essential information (notes, test results)

• routine access to specialised expertise

• Improve the management of services by providing good quality data to support :

• NSFs, clinical audit, governance and management information


Integrated Care Records Service -Phased portfolio inc clinical tools and functionality-National services -Local applications

Electronicappointmentbookings

Electronic transfer ofprescriptions

Partnership with IT Industry - deliver compliant systems & clinical applications - National, Regional, Local

National direction and performance management of ITNational standards and specification

Increase IT funding dramatically - target IT spend

Backbone IT infrastructure -accelerate connecting the NHS with

secure Broadband

Principles


What the NHS will see

Choose and Book (2004 on)Choose and Book (2004 on)

PACs (phase 1) (phase 2) (phase 3)PACs (phase 1) (phase 2) (phase 3)

GP IT (QMAS)GP IT (QMAS)

LSP bundles (NE and E)LSP bundles (NE and E)

Electronic Transfer of PrescriptionsElectronic Transfer of Prescriptions

GP to GP transferGP to GP transfer

LSP bundles (North West/West Mids)LSP bundles (North West/West Mids)

LSP bundles (London and Southern)LSP bundles (London and Southern)

NHS Care records Service (Security, messages, personal demographics)

NHS Care Records Service - clinical records startNHS Care Records Service - clinical records start

NCRS - future releasesNCRS - future releases

July 2004 Jan 2005 Jan 2006 Jan 2007 Jan 2008

PLANS HAVE

SLIPPED, WATCH

THE PRESS AND

CfH WEBSITE


Concerns

• prescribing, dispensing or prescriptions

• numbers of solutions - choice and competition

• scale of local investment

• timescales

• other pressures

• Competency and capability

• context and usefulness


Patient data may come from anywhere

• Visits the dentist / therapist ...

• Has home visit from GP, nurse, care worker, midwife …

• Visits a Walk-in Centre

• Calls OOH service

• Uses a Home Healthcare Guide

• Calls NHS Direct or NHS Direct Online

• Visits OP

• Attends A&E

• Visits GP / Practice nurse

• Goes to pharmacy / self-medicates

• Attends as IP and has interventions ….


Integrated Care Records Service

• Ensuring interoperability

• Focusing on the patient journey

• Implementing electronic records

• Providing a national service

• Issues of completeness, context, confidentiality, usefulness, timeliness, robustness and cost


Care components supported by NCRS

Promotion

Investigation / Assessment / Diagnosis

Treatment, including rehabilitation

Maintenance

Primary Intermediate Tertiary

Integrated Programme of Care for a Population or Patient Group

Secondary /Acute

Prevention

Screening and surveillance

Respite / Palliative

Care Settings


NHS Care Records ServiceA single electronic health care record for every individual in

England:

• a comprehensive life-long history of patient’s health and care information, regardless of where and when any by whom they were treated

• immediate access to summary of care encounters and clinical events held on a national data repository, for professionals

• support to the NHS to collect and analyse information, monitor health trends and to make the best use of clinical and other resources

• retain essential information held at local level where most care is delivered


Key priorities from DH

• Providing central direction and managing local implementation

• Engaging stakeholders

• Targeting increased funding (24-48 Bn in total in 10 years)

• Streamlining procurement

• Establishing standards


Issues

• DESIGN ------ and get buy-in to requirements specified

• BUILD --------- and ensure fitness for purpose

• OPERATE ---- and establish mechanisms for sustaining service, keeping up to date and including innovation


Financial Affordability

NPFIT Programme structure

NISP N3

NASP ICRS, e-Booking, e-Prescribing

LSP implementation of NASP

LSP Local ICRS Components ?

LSP Local ICRS Components ?

Local Implementation Costs

NPFIT Central Budget

Local Resources

30 – 40% of costs

60 – 70% of costs


LSP delivery in bundles – e.g. covering -

• Maternity bundle

• Theatre management bundle

• Patient Administration System bundle: - Master Patient index - Clinical data repository - A & E tracking - Registration, admissions, discharges & transfers - Bed management etc

• Clinical support bundle - Results reporting - Order communications - Clinical noting and correspondence - Discharge summary


Clusters

North West

North East

Yorkshire & The Humber

East Midlands

West Midlands

South WestSouth East

East of England

1 1

2

2

34

4

2

3

1

7

56

12

3

32

1

4

2

34

6

1

5

1

12

3

2

456

34

5South West1. Swindon

2. Bristol

3. Bournemouth

4. Exeter

5. Plymouth

South East1. Oxford

2. Reading

3. Guildford

4. Brighton

5. Portsmouth

6. Southampton

West Midlands1. Wolverhampton

2. Birmingham

3. Coventry

East Midlands1. Nottingham

2. Derby

3. Leicester

4. Northampton

East of England1. Norwich

2. Peterborough

3. Cambridge

4. Bedford

5. Ipswich

6. Luton

North West1. Carlisle

2. Blackpool

3. Liverpool

4. Manchester

North East1. Newcastle-upon-Tyne

2. Middlesbrough

Yorkshire & The Humber1. York

2. Leeds

3. Wakefield

4. Barnsley

5. Sheffield

6. Rotherham

7. Hull

LONDON

Choose & Book

N3 ETP PACSCONTACTemail

Spine

CSC - Accenture

Accenture

CCAlliance(BT)

Fujitsu


ValueThis will be achieved by:

• Avoiding multiple procurements

• Significant reduction in time taken on procurement and acquisition costs

• Reduced unit costs for applications and systems e.g. PACS

• Ensuring that multiple national suppliers maintain on-going post award competitive pressures at the time of any change, extension or renewal.


Key local priorities

• Localisation - customisation and standards

• Facilitation - local investment and flexibility

• Empowerment - staff training & management of change

• Ownership - by whom and with what obligations

• Innovation - inclusion, negotiation, synergy


RISK : various aspects

• Adverse events within 10% of all admissions

• 850,000 adverse events per annum in NHS

• 5% potentially preventable (~50,00 per annum and 5% of NHS Budget

•1974 – cost £1m >>>>>>>>> £446mill in 2001

•‘every near-miss is a free lesson’


BCSHIF & RADICAL STEPS position

• enhance the likelihood of best possible outcomes from £2.3Bn (and the rest) investment in NHS IT

• seek the views of the widest community

• focus on issues around key themes e.g. confidentiality

• generate position paper and follow-up actions expressing expert commentary

• Promote constructive criticism to the community, decision influencers and decision makers


RS Recommendations

• 2002 : Looking for -

– early returns on investment

– minimisation of risk

– securing long term futures

– Quick Hits for positive change

• 2003: Looking for actions -

– best coordinated at national level

– to increase the understanding by and empower the workforce

– addressing information governance

– deliver benefits asap

• 2004 : establish

- open, empowered, collaborative, committed workforce in well-defined roles

- recognise mechanisms to harness existing experiences, and solutions, and make space for innovation


2005 residual issues

Preserve and share learning from existing (legacy) situations

Regularly explain the why, how, where and by whom

Minimise risk, make selected specific expertise available on call off basis rather than tolerate ad hoc amateur activities


Concerns - retain information in its context

• data is at risk if extracted inappropriately and misunderstood

• privacy issues are significant

• minimise potential for corruption during transition to new era

• experience of practitioners is necessary to establish importance of data, or functions and of local priorities and previous operation


Risks

• Current NHS developments may deliver operable but not operational systems

• Social care applications may be blighted

• Cultural barriers be reinforced by parallel developments

• Professionals may be de-motivated

• Another Shipman, Bristol babies or Climbie may prompt knee-jerk reaction

• Citizens may take things into their own hands


Sticky issues - ethics come into the equation

• Life threatening situations

• Genetic engineering / genotyping

• Reproductive selection / genetic predispositions

• Medical research

• Long-term care situations

• ‘Life to years’ or ‘Years to life’

• Mental health situations

• Making decisions for and about Children

• Respecting patient choice : dying with dignity


Consent must be ‘fit for purpose’

• in language that the subject understands

• given by a subject that is competent to consent

• for explicit purposes, not just ‘do what you need to’

• not given under duress

• When might the conditions for apparent agreement be questionable?


Reference sources

• Developing 21st Century IT support (DH website)

• CfH National Programme for IT (www.connectingforhealth.nhs.uk)

• Health & Social Care Information Centre

• Department of Health site

• (More) Radical Steps etc (www.bcs.org/BCS/Forums/Health)

Documents

Scale of NHS