Scale of NHS

1. Delivering 21st Century IT for the NHS : as at 11.05and Beyond!Jean Robertsjean@hcjean.demon.co.ukCredit to various sources : BCS, IMIA, DH, NPfIT, commercial players

2. 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 Uni Manchester November 2005

3. 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 Scale – Largest in Europe Uni Manchester November 2005

4. To represent all this activity is a challenge 133 People to take care of the patient The Patient Uni Manchester November 2005

5. Organisational cycles • 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 • 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) Uni Manchester November 2005

6. NHS Chronology (selected) Uni Manchester November 2005

7. Structures interworkingRef. NHS Explained from NHSIA Uni Manchester November 2005

8. 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 - n3@nhsia.nhs.uk Uni Manchester November 2005

9. 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 Uni Manchester November 2005

10. 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 Uni Manchester November 2005

11. Principles Increase IT funding dramatically - target IT spend National direction and performance management of IT National standards and specification Partnership with IT Industry - deliver compliant systems & clinical applications - National, Regional, Local Electronic transfer of prescriptions • Integrated Care Records Service • Phased portfolio inc • clinical tools and functionality • National services • Local applications Electronic appointment bookings Backbone IT infrastructure - accelerate connecting the NHS with secure Broadband Uni Manchester November 2005

12. What the NHS will see July 2004 Jan 2005 Jan 2006 Jan 2007 Jan 2008 Choose and Book (2004 on) NHS Care records Service (Security, messages, personal demographics) PLANS HAVE SLIPPED, WATCH THE PRESS AND CfH WEBSITE GP IT (QMAS) PACs (phase 1) (phase 2) (phase 3) LSP bundles (NE and E) Electronic Transfer of Prescriptions GP to GP transfer LSP bundles (North West/West Mids) LSP bundles (London and Southern) NHS Care Records Service - clinical records start Uni Manchester November 2005 NCRS - future releases

13. Concerns • prescribing, dispensing or prescriptions • numbers of solutions - choice and competition • scale of local investment • timescales • other pressures • Competency and capability • context and usefulness Uni Manchester November 2005

14. 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 …. Uni Manchester November 2005

15. 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 Uni Manchester November 2005

16. Promotion Prevention Screening andsurveillance Respite / Palliative Investigation / Assessment / Diagnosis Treatment, including rehabilitation Maintenance Care components supported by NCRS Integrated Programme of Care for a Population or Patient Group Care Settings Primary Intermediate Tertiary Secondary / Acute Uni Manchester November 2005

17. NHS Care Records Service A 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 Uni Manchester November 2005

18. 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 Uni Manchester November 2005

19. 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 Uni Manchester November 2005

20. Financial Affordability NPFIT Programme structure NISP N3 NPFIT Central Budget NASP ICRS, e-Booking, e-Prescribing LSP implementation of NASP LSP Local ICRS Components ? 30 – 40% of costs LSP Local ICRS Components ? Local Implementation Costs Local Resources 60 – 70% of costs Uni Manchester November 2005

21. 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 Uni Manchester November 2005

22. Clusters CSC - Accenture Accenture CCAlliance(BT) Fujitsu Spine PACS Choose & Book N3 ETP CONTACT email Uni Manchester November 2005

23. Value This 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. Uni Manchester November 2005

24. 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 Uni Manchester November 2005

25. 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’ Uni Manchester November 2005

26. 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 Uni Manchester November 2005

27. 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 RS Recommendations • 2004 : establish • open, empowered, collaborative, committed workforce in well-defined roles • recognise mechanisms to harness existing experiences, and solutions, and make space for innovation Uni Manchester November 2005

28. 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 Uni Manchester November 2005

29. 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 Uni Manchester November 2005

30. 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 Uni Manchester November 2005

31. 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 Uni Manchester November 2005

32. 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? Uni Manchester November 2005

33. 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) Uni Manchester November 2005