Insider View: Jon Hoeksma

The Conservative Party-commissioned review of NHS and social care IT is likely to focus the need to accelerate the delivery of local clinical systems. Three months after local service providers BT and CSC were given new deadlines to deliver, E-Health Insider editor Jon Hoeksma wonders whether they will make it.

The delays in the National Programme for IT in the NHS have been well documented. Most recently, the Public Accounts Committee found that although it has been a success in some areas, its Achilles’ heel is still its failure to deliver fit for purpose rich local care record systems.

Delays to the two ‘strategic’ systems – iSoft’s Lorenzo and Cerner Millennium – now stretch to four-plus years. The Secretary of State for Health, the chief executive of the NHS, and the Department of Health’s chief information officer, Christine Connelly, have all said that the two remaining local service providers must show they can deliver them. Otherwise, alternatives will be sought.

The clock ticks

In April, Connelly set a six month deadline for progress. She said she wanted to see one more deployment of Millennium in a London acute trust by November; one more Lorenzo deployment in any care setting by the same date; and full Lorenzo deployment into an acute trust by March 2010.

Speaking in Harrogate, Connelly said: “If we don’t see significant progress by the end of November 2009, then we will move to a new plan for delivering informatics in healthcare."

At the end of July, it looks as though that new plan will needed before the end of the year, since the prospect of substantive progress by Connelly’s deadlines looks to be slipping away. One well placed source reports that the requirement for “significant progress” by November is being diluted.

Kingston Hospital NHS Trust, the next London trust due to take Millennium, reports good progress but problems with reporting – something every trust working with Cerner has struggled with since 2006. The planned September go-live is now under review until reporting issues are worked out.

At best, this may be a near miss, with a fair prospect of at least one Cerner implementation in London this year. If it happens, it will be the first by LSP BT in 18 months. But with all RiO community and mental health implementations on hold until September, progress on clinical systems in London has all but ground to a halt.

Against this backdrop, it’s not surprising that some trusts are looking at alternatives. NHS Wandsworth is now exploring whether EMIS Web can take the role intended for Cerner Millennium at Queen Mary’s Hospital in Roehampton.

Looking for the right note in the NME

Wandsworth is not alone. Nationally, there is an emerging picture of suppliers that have served the primary and community care arenas looking to extend into the acute sector. EMIS, CSE-Servelec and TPP have all developed plans to either link into or offer products to smaller acute trusts.

NHS Yorkshire and the Humber has also continued to successfully deploy an integrated care record system, covering all care sectors, by standardising on TPP SystmOne. Meanwhile, the prognosis for a number of large-scale Lorenzo installations in the North, Midlands and East of England looks doubtful in the next 12 months.

University Hospitals of Morecambe Bay NHS Foundation trust is the reference site for Lorenzo, although it is also in small-scale use in Birmingham and Bradford. Pennine Care NHS Foundation Trust, which provides mental health services, looks set to begin to implement Lorenzo soon, so the November deadline should be met.

Yet although Morecambe Bay is well prepared and well motivated, it has taken nine months to get the system live on three wards. All involved in the project are justly proud of the progress that has been made with what is still a brand new system, but the Lorenzo product remains far short of being ready to roll out to a string of further sites.

This makes it hard to see how ‘significant progress’ is to be made in another acute trust by end of March. If it was going to happen, work would need to be well underway by now, and Kettering General Hospital NHS Foundation Trust, which is thought to be the trust in question, will only say it is to adopt the system.

Another source, an enthusiastic supporter of the programme, said in his view the full Lorenzo product was two years away from being ready to deploy. To make even the PAC’s latest estimate for the end of the programme, this would mean an improbable number of implementations in 2012-14.

No news is not good news

Given the current situation many trusts, if they are able to, are playing safe and staying put. East Cheshire NHS Trust, for instance, has just decided to stick with its current version of iSoft’s Clinicom and update the ageing hardware on which it runs.

And in London, Epsom and St Helier University Hospitals NHS Trust recently rejected Millennium, deciding instead to stick with iSoft’s iPM and iCM. The trust said the £4-5m cost of a switch was “untenable” and that London trusts that had taken Cerner had been “damaged”.

Many other trusts will have to stick with their current supplier. The 23 trusts using McKesson Totalcare and Star PAS systems – which were meant to have been replaced five years ago – now look certain to need yet another extension beyond March 2010, the date on which they are currently due to have support switched off.

By contrast, three foundation trusts – Royal Berkshire, Newcastle and Wirrall – have now selected Cerner at the end of an open procurement and dug deep to find the money to pay for it. A successful go-live at Newcastle, a big bang across four hospitals, would do a lot to restore confidence in Millennium, but raise some searching questions about where BT adds value as an LSP.

But change won’t be easy

In June, Connelly told EHI that the South will be the proving ground for ‘acute systems of choice’, with a procurement to be carried out to see whether there are existing systems that offer better options to trusts than Lorenzo or Millennium.

“One thing that it will tell us is ‘do better products exist?’ That will inform our options as we get to the end of November,” Connelly said last month. But any attempt to rekindle a battered supplier market will take time and will almost certainly not lead to any new implementations from alternative vendors before 2010.

In 2010, we are likely to see a new Conservative government, one committed to abolishing NPfIT. In reality, a new set of ministers will almost certainly have to work with the LSP and NASP contracts they inherit. The DH’s decision to resign revised contracts with CSC and BT cannot be wished away.

The experience of Accenture and then Fujitsu is that the contracts may cost as much to cancel as they do to see through. The challenge remains to get good quality clinical systems delivered from them and not just further enrich the lawyers and management consultants.