Examination of Witnesses (Question Numbers
16 June 2008
Q60 Geraldine Smith: Can I also ask
what sort of support they will get? They are obviously one of
the first of three early adopters. What sort of help and support
is there? It is a massive exercise for them in staff training.
Mr Hextall: It is. They have support
from CSC, as the supplier, and iSOFT, who are keen to make sure
that the product works. So they are getting a substantial amount
of support. Connecting for Health has a deployment support team
helping, and the way that the early adopters are doing it in the
North, Midlands and East, the two who are next are going to be
helping in the Morecambe Bay area so that they can learn the lessons
from Morecambe Bay, for Bradford and South Birmingham, who are
the next ones to go.
Q61 Geraldine Smith: I hope there
are not too many lessons to be learned.
Mr Hextall: There are always lessons
to be learned.
Q62 Geraldine Smith: I hope they
get it right first time, because it does have such serious repercussions
for patient care. Most of the problems we have had in the past
in our area are down to poor administration so I think it is essential
that we get it right. Is three months enough of a time gap before
you start rolling it out to all the trusts? That does not seem
very long to me.
Mr Hextall: If everything went
well, it would be enough time. Again, we need to be quality-driven
rather than date-driven as far as that release key milestone,
that then will sign off the release for the remainder of the trusts
to be able to take. If everything goes according to plan, the
three months will be okay. It will be clearly monitored on a weekly
basis during that period.
Q63 Geraldine Smith: From the demonstration
last week, it did look very good. I hope it works as well as it
appeared to in that demonstration. Can I ask, is it just going
to be the hospitals that hold this information or is there that
link with the GPs, or is it going to be gradual?
Mr Hextall: It will be gradual.
There are four releases currently planned of the Lorenzo software
and that is one thing that was a change, one of the lessons from
the review that Mr Bacon enquired about that we commissioned last
year. The four releases have increasing levels of functionality
and the GP integration is in the fourth release, so it is right
at the end.
Q64 Geraldine Smith: What sort of
time delay is that? How long are you talking about?
Mr Hextall: I think it is 2010.
I would need to check.
Mr Nicholson: Spring 2010.
Q65 Geraldine Smith: One of the things
again from the demonstration that I found very useful was that
there appeared to be an alert system as well, so there was a lot
of information available for GPs who may be prescribing a drug
that may interfere with someone's condition that they may not
be immediately aware of.
Mr Hextall: They certainly have
elements of prompts and decision support built into the system
to try and prevent people doing the wrong thing, yes.
Q66 Geraldine Smith: Can I ask about
security of data, because, of course, everyone is concerned about
that. Can you reassure me?
Mr Hextall: Yes. As with all the
Connecting for Health systems, patient confidentiality is ensured
by anybody using the system having to access the system with a
smartcard, and you can only get a smartcard on production of evidence
of identity, typically a passport, and evidence of residence,
typically a utility bill. Your smartcard would then contain details
of your role-based access, and there are different roles that
can be set into the card so you would only be able to use it for
the purpose that it was given to you, and again, only if you have
a legitimate relationship with the patient. That is the same kind
of level of security which is known as e-GIF level 3 in government
terminology, which is the highest that we could aspire to.
Q67 Geraldine Smith: Mr Nicholson,
can I ask you, just changing the subject slightly. We touched
on trusts doing their own thing, having different systems. I do
not think they should be able to. We still have a National Health
Service and I think if you have an IT system it should be linked
nationally. One of the problems is if you have a great many different
systems operating. That is bound to cause problems, I would have
Mr Nicholson: The way that we
are trying to operate is that they will all take the same system
in a particular LSP area. I personally have a different constitutional
relationship with foundation trusts than I do with NHS trusts.
I cannot direct NHS Foundation trusts to take it but what I can
do is to make sure that the processes are in place to make it
much more likely that they will.
Q68 Geraldine Smith: Do you think
you should be able to direct them?
Mr Nicholson: All I would say
on it is that the only place I have been where they have seriously
looked at this is Bradford. They went through a process of looking
at the alternatives and came to the conclusion that the national
system was by far the best one for them, and they are absolute
advocates for it now. By telling them to do something, you would
not have got the kind of advocacy and the commitment they have
to implementing that they have now. So I think if they come to
it under their own conclusion, that is a much more powerful way
of taking it forward.
Q69 Geraldine Smith: Can I just ask
about how the Choose and Book system is going? It appeared a bit
mixed in my own area. I think people like the booking part. I
am not so sure they think there are real choices there or that
they want the choice. I am getting into policy areas. How is the
actual IT system going?
Mr Nicholson: The IT system itself
works well. In fact, 90% of GP Practices at one stage or another
use it. So it does work. I think some of the operational ways
that people work underneath it are sometimes quite difficult.
For example, if you want to book a date, the implication is that
there is a clinic there for you to book, so the hospital has to
be absolutely on top of the way that they manage and pre-book
clinics. That is not absolutely in place everywhere and it just
takes time to make that happen, but it does give you the opportunity,
whether you take it or not, to have the kind of choice that people
now have through free choice. As you know, people can now choose
secondary care, can choose any hospital that will do services
at NHS quality for NHS tariff in the country when you are making
a referral. So whilst we do not force people, if they do not want
to make that choice, it is available and increasingly I think
people will take it up.
Q70 Geraldine Smith: In my experience,
people just want their local hospital to be good. They do not
want six choices or three choices. They just want their own hospital
to be good. That is the priority for them.
Mr Nicholson: Yes, I agree.
Q71 Geraldine Smith: Finally, with
Choose and Book, what is the feedback from GPs? Are they satisfied
with it? Do they think it is going reasonably well?
Dr Braunold: From my understanding
from my colleaguesand I have spent a lot of time talking
to my colleagues about Choose and Bookthere are those of
us who are lucky enough to work in areas where our configuration
of our services, our computers on our desks, are working well.
Choose and Book is working well for us and I scream blue murder
when it is down actually, because I do not like going back to
the old system. I like the fact that I know about the different
hospitals in London and the different services that are there,
and my vulnerable patients, who do not speak good English, are
able to leave the room with the date of their consultation with
the clinician. We do not have any of that coming back to me, "When
is my appointment coming?" There are other colleagues for
whom it is not working as well. The local configuration of their
computers is not working so well or they have some kind of real
objection to doing some of the extra work that I personally believe
I advocate to do in my consulting room. I have spoken to a colleague,
for instance, a friend of mine, who was actually very anti doing
the work, but he was totally transformed by the relationship improvement
with his patients of enabling them to get their appointment. So
he feels that, even though it takes longer, he prefers to do that.
It takes time to move the population of GPs along but the tool
is working, the tool is deployed and it works.
Q72 Keith Hill: Mr Nicholson, this
is obviously a fabulous and very exciting programme, which will
presumably confer hugely valuable benefits on patients in England.
Is it being attempted anywhere else in the world?
Mr Nicholson: I do not know whether
it is. Certainly there is lots and lots of interest in it from
Australia, from Spain, from the rest of Europe. We recently had
some people over from France. There are lots of people very interested
in the way we are doing it but I do not know whether there is
actually anywhere else doing it in exactly the way that we are.
Mr Hextall: From the discussions
we have had with other countries, I am sure that everybody is
doing the same thing but nobody is doing it on the same scale.
Typically, Australia and America are doing it on a state-based
system and Switzerland is doing it on the canton-based system
but the same functions of having patient information available,
electronic booking and the electronic prescriptions ...
Q73 Keith Hill: It is the sheer scale
and centralisation of the National Health Service which makes
Mr Hextall: Yes.
Q74 Keith Hill: Personally, it seems
to me very difficult to think of what else would be a more compelling
thing that you would want to do for the National Health Service
going forward into the 21st century.
Mr Nicholson: An interesting thing
to me is if you take something like picture archiving, which is
digital x-rays and all the rest of it. Four or five years ago
we were quite behind the rest of Europe in terms of implementation
of picture archiving. Now we are the first G8 country to have
it completely implemented across the whole of the country, enabling
digital x-rays and images to be moved between departments, between
hospitals, and between services. We were able to do that because
of the nature of the system, because of the way we were implementing
it. We would never have been able to do that if we had left it
to individual organisations to decide when to do it and how to
Q75 Keith Hill: When I asked the
question first, I deliberately referred to patients in England
but we are a United Kingdom and we do still have reasonably porous
borders. What are the opportunities going to be for Wales, Scotland
and Northern Ireland?
Mr Hextall: Certainly Wales and
Scotland have similar schemes. They were given an opportunity
when we placed the adverts for the contract for procurement in
2003 to join in with the national programme for IT, and either
were not able to respond quickly enough or had their own ideas.
Certainly Wales and Scotland are doing very similar initiatives
about making patient information available where it is needed
and we are collaborating with both of those jurisdictions at the
Professor Thick: I attend a European
forum of those who are developing electronic records, and I think
the general observation is that boundaries are very dangerous
places because you go across, you get ill and how are your records
going to follow? We are putting a great deal of effort into making
sure that the standards that we implement are international, that
the summary records that we develop are inter-operable precisely
in order to make patient safety the prime issue.
Q76 Keith Hill: This is all good
Mr Nicholson: I was recently,
for a completely different reason, visiting the Armed Forces in
Afghanistan. I was in a hospital in Helmand province where they
were able to send digital images from the middle of Helmand province
right into the University Hospital Birmingham, so that by the
time the injured member of the Armed Forces got into the hospital
all the images and all the details were with the doctors, which
I thought was fantastic.
Q77 Keith Hill: It is fantastic.
It is very sad about the individual soldier of course, but this
is very impressive stuff. Let me take you into slightly more detailed
questions now, because as the NAO remarks, this will only succeed
if you can engage the support and enthusiasm of clinicians and
other NHS staff. There are obviously issues which emerge from
the NAO report about a certain dissatisfactionI think you
may have alluded to it earlierabout the realism of progress
reporting and communications. How can you make progress reporting
and communications about the programme more open and realistic
Mr Hextall: I must admit I was
puzzled when I saw that comment originally in the report but I
now understand it, because we have a plethora of information to
be able to manage the programme, so from a programme management
perspective there is not anything we do not know. What we are
not particularly good at is making that available in lay terms
so that the public can understand how individual trusts perhaps
are progressing. It typically takes 12 months for a trust to prepare
and then implement a patient administration system as part of
the national programme. There is a lot of preparation, a lot of
data migration that needs to happen. We have not been very good
at being able to measure that to make it visible. For the future,
taking that recommendation on board, we are looking at being able
to turn the plethora of information that we use to manage the
programme internally into external facing information for the
Q78 Keith Hill: That is for the public
but let me just put you an issue which is raised by the NAO about
the surveys you do with staff and ask you if there is any significance
in the fact that in the latest survey you carried out you decided
not to ask staff about how favourable they were towards the programme.
Mr Hextall: That was the MORI
survey, I think. We have done the MORI survey in three waves.
In the first couple we asked the same questions virtually, I think.
What happened between the first two waves and the third one was
that we went through an NPfIT local ownership programme where
we were putting more ownership and accountability on the NHS so
that they felt they could pull the systems and they owned them
rather than feeling that perhaps they were being delivered to
them. As part of that process we consulted with the strategic
health authorities on what they wanted out of the survey by way
of stakeholder engagement and communication to inform their engagement
and communications. So the questions were actually formed out
of discussions with the strategic health authorities and shaped
in that way. So if there was a question dropped, that would be
why it was dropped.
Q79 Keith Hill: Let me turn to something
which has already been raised, which is the issue of clinical
functionality. How can you convince staff of the benefits of the
programme given the limited clinical functionality currently available?
Professor Thick: You are quite
right. In the first implementations in the south it has been disappointing
perhaps that there is such a limited amount of clinical functionality
in the Cerner product that was deployed. I think that has resulted
in great expectations in the clinical community there which have
been let down, so they feel cross. Also, if you put in a new PAS
system into a hospital you necessarily change the processes of
the way people work and, as far as the clinicians were concerned,
they saw their everyday work being changed around in a way that
they did not understand, and perhaps with a limited amount of
consultation. So their perception inevitably was that the system
did not work because it did not do what they normally do. We are
going to have to turn that around considerably by accelerating
the amount of clinical functionality that goes into particularly
the south. It is not quite so true in the North because the clinical
functionality is there in the first place. We are putting a great
deal of effort into making sure it becomes available before then
very quickly and in particular, order communications.