NPfIT: The NHS National Programme for Information Technology. A Sociotechnical Systems Perspective
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1 NPfIT: The NHS National Programme for Information Technology A Sociotechnical Systems Perspective Ken Eason Emeritus Professor - Dept of Human Sciences, Loughborough University Senior Consultant, The Bayswater Institute k.d.eason@lboro.ac.uk Part 1: The Programme and its Implementation Part 2: Evaluation from a Sociotechnical Perspective Part 3: A Sociotechnical Way Forward
2 The NHS National Programme for Information Technology (NPfIT) A 10-year programme to create electronic patient records from the cradle to the grave for every citizen of England The biggest commercial computer programme in Europe Brennan 2005
3 The Rationale for the NPfIT Previous NHS computer projects: local Trust developments, limited data interchange, not-invented-here culture Government priority to modernise the NHS Decision to adopt national, centrally-driven IT applications to ensure: National exchange of patient data Getting all parts of NHS up to a common standard Getting all Trusts to common best practice in health care information Connecting for Health (CfH) created to deliver National Programme for IT (NPfIT) Contracts let to Supplier Consortium to get best industrial practice and deliver well established healthcare IT applications
4 Progress Dates NHS/CfH Service Providers 2002 Launch of NPfIT 2003 Define Applications Start Bidding Process Announce Winners Create consortia Submit bids 2004 Detailed negotiation of contracts Negotiations Implement Choose and Book NHS Trusts End Users Consultations Consultations Pilot Implement - ations of standard applications General support for the concept of electronic records
5 The Initial Contracts Application Consortium Leader Main Supplier Value National National network British Telecom 530,000,000 National spine British Telecom CSW 620,000,000 Choose and Book Atos Origin Cerner 645,000,000 North East Cluster Accenture isoft 1,099,000,000 London Cluster BritishTelecom (Capital Alliance) IDX 996,000,000 East & EM Cluster Accenture isoft 934,000,000 NW & WM Cluster CSC Alliance isoft 973,000,000 Southern cluster Fujitsu Alliance IDX 896,000,000 Region Totals 6,112,500,000
6 2002/04 The Initial Plan Government/DH CfH Roll out of standard applications across 500+ Trusts in 10 year period Consortia NHS Trusts Healthcare teams Patients
7 2003: The real costs? 2005: Delays in delivery 2004: Implementation of Choose and Book 2005: Registering users
8 Problems as Trust s assimilate NPfIT applications Response to Implementation Trusts/Application Issue Rejection Royal Marsden Care Records will not support research Rejection London Mental Health Trusts Care records not fit for mental health - interim system needed Rejection Wirrell New system means a step back in sharing records Rejection GP Surgeries New system would replace current system widely used and nothing would be gained. Stress and Breakdown Nuffield Orthopaedic Out patient records lost Stress and Breakdown St. Mary Sidcup Slow system delaying patient care
9 NPfIT Evaluation(1) National Audit Office May 2008 National Infrastructure Projects Project Purpose Deployment Adoption N3 The National Network To provide fast,broadband connections between all trusts Target: connect all sites by March 2007 Achievement: 2 months before schedule Not relevant NHSmail To provide a secure service for all trusts Achievement: delivered on time in Oct 2004 take up has been slow May % of NHS users using NHSmail The National Data Spine To provide the architecture for the national databases Technical delivery achieved in a number of releases from May 2006 Not relevant
10 NPfIT Evaluation (2) Specific Applications Project Purpose Deployment Adoption The summary care record (SCR) To mount limited care records of all patients in England on the Spine Deferred by 2 years Early adopter for technical reasons pilots in March and consultations on 2007 patient confidentiality Choose and Book To enable GPs to help patients choose referrals and to make electronic bookings Deployment target: to 95% GP clinics by March 2008 Target: 90% of referrals by March 2007 Achievement: 31% referrals by March 2008 Picture To store and share Archiving and electronic images Communication (X-rays etc) System (PACS) Brought into NPfIT 2004 Fully deployed by Dec 2007, 3 months ahead of schedule No details but case study reports of rapid take-up in radiography practice
11 NPfIT Evaluation (3) Full Electronic Care Record Systems Project Purpose Deployment Adoption The London Programme for IT To deliver common and full electronic care records to all London NHS Trusts Programme proved impracticable Revised plan from 2007 To deliver common The Southern and full electronic Programme for IT Programme proved impracticable Main contractor (Fujitsu) left the programme in June 2008 To deliver common and full electronic care records to all NHS Trusts in the North,Midlands and East of England Originally three separate clusters. The programme was impracticable in all cases. Main contractor (Accenture) for two clusters withdrew in Sept 2006 and all three were merged. In the place of the adoption of the original standard record systems there has been patchy adoption of: Interim solutions -products that better fit local conditions and PAS solutions that do not contain clinical information care records to all NHS Trusts in the South of England The North, Midlands and East Programme for IT
12 The NPfIT from a sociotechnical perspective The goals are sociotechnical not technical It is a technocentric project that: Does not allow for the diversity of healthcare practices Does not support the development of new healthcare practices that make use of electronic records Deployment of technology is making progress but adoption is problematic
13 The diversity of existing sociotechnical systems CfH Suppliers Diversity of Trusts Type Size Healthcare practices Installed technical systems Location
14 2006: Guys Hospital boss criticizes one size fits all
15 Adoption: when a technical system is introduced to an existing healthcare sociotechnical system TRUST Performance Improvement The Healthcare Task Patient ill Diagnose Treat New Digital Technical System Systems NPfIT Application Discharge Social Systems Patient well
16 Healthcare delivery as a sociotechnical system:emergent behaviour TRUST The Healthcare Task Patient ill DiagnoseWork- Treat Arounds NPfIT Application Benefits Discharge Stress New Technical And Failure Social Digital Systems Systems System Partial Usage Patient well
17 Clinical information in electronic care records Perceived Issues Entry at source? Consequences of entries Output records (tick boxes) or working documents? Role-based access Emergent Behaviour Admin not clinical information in record Irregular access practices Mixed electronic and paper records
18 1-08: Implementation and Disruption to Linear Implementation Process Government/DH Challenge CfH Breakdown Suppliers Media Variation Reject Plan in Plan Trusts A-S Delay Trusts T-Z Implement Usage Healthcare teams Patients
19 2006: Suppliers responses
20 The Way Forward 1: A technical problem? 2006: An open letter from 23 IT Professors
21 The way forward 2: A sociotechnical problem? A local sociotechnical systems design strategy Turning push into pull Treat IT implementation as a sociotechnical design process The social system implications are not fixed: there are local design opportunities Help local staff to: identify specific benefits they can realise (develop a pull ) local design plans to realise the local benefits/minimise the costs and risks find an evolutionary path to achieve progressive exploitation of new technical capability Eason K.D. (2005) Exploiting the potential of the NPfIT: a local design approach BJHC&IM
22 Towards Decentralisation and Sociotechnical Development? Connecting for Health Local ownership Trusts can find their own suppliers Competence and capabilities in local implementation More General Lord Darzi - local clinician-led quality care Health care and social care No national records?
23 The NPfIT: A Continuing Story It has to be a sociotechnical project to be successful How far will it move from being a technocentric project? Papers Eason K.D. (2008) The National Health Service National Programme for Information Technology (NPfIT): A Socio-technical Systems Perspective To be published in Wendy Currie and David Finnegan (eds) Integrating healthcare with information and communications technology Radcliffe, Oxford, 2009 Eason K. D., Clegg C. and others (2008) A future strategy for information technology in the NHS, health and social care in England: A submission from the BCS Sociotechnical Specialist Group to the review being conducted by Glyn Hayes on behalf of the BCS Health Informatics Group
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