Inside e-health on moving the goalposts

In the latest of his regular columns, IT journalist Jon Hoeksma reflects on how policy can move faster than the IT that is supposed to support it: and wonders whether the promised new era of fewer targets will make things better.

When asked what represented the greatest challenge for a statesman, British Prime Minister Harold Macmillan famously replied: “Events, my dear boy, events.”

If NHS managers and clinicians were asked a similar question, the answer might well be: “Targets, government targets.” And for those responsible for providing their information systems, it would surely be: “Changing and disconnected requirements.”

Delivering complex health services can be made more difficult by the need to simultaneously meet national targets and collect reporting data, when it isn’t generated as part of routine operations or planned for by new IT systems.

A new era for targets

After a ten-year period in which myriad targets have come down rapid fire from Richmond House and No. 10 on everything from clinical standards to efficiency savings, and hospital food to environmental sustainability, NHS professionals have been promised a new era. “Politicians who don’t want to be held responsible for every bed pan dropped in the health service must resist the urge to develop bed-pan droppage reducation strategies, with associated annual targets.”

On top of balancing the books and maintaing national standards of care, there are just two “must do” targets that NHS managers are being told to focus on – healthcare associated infections and achieving the 18-week referral to treatment (RTT) objective. It is the second of these that Prime Minister Gordon Brown is said to ask NHS chief executive David Nicholson about at every meeting.

18 weeks, now counting

It is just a year until the NHS must deliver on the 18 week wait, although some deadlines come earlier. By March, NHS organisations must ensure that 85 per cent of admitted and 90 per cent of non-admitted patients wait less than 18 weeks. Meanwhile, the reporting targets come much earlier: by January, trusts must have data on RTT completion for all admitted patients.

Achieving the 18 week target requires NHS trusts and primary care trusts to make fundamental changes to their processes and care pathways. It also creates huge challenges for data capture and reporting, particularly when the care pathways involves multiple specialists and agencies.

In most cases, the new 18-week RTT reporting requirements are not met by current systems. And because the target was introduced after the beginning of National Programme for IT in the NHS in 2002, they are not met by its systems, either.

As a result, trusts are having to work on solutions with IT partners, develop their own solutions or put in paper systems and hire extra people to manually do the work.

Disconnects between policy and IT

At the level of data and reporting, 18-week RTT is a prime example of disconnected policy. NPfIT bought a bunch of IT systems to do certain things - and almost immediately the government decided it wanted to do different things.

For the NHS, this is a huge pain; for the IT consulting industry, responding to changed requirements, known as changed control notices, is how they meet their margins. The problem is by no means unique to the NHS, but it is one of the main reasons that NPfIT has sought to enforce rigorous standardisation; it prevents every local trust racking up costs by asking for their own revisions to software.

“Ruthless standardisation” has proved a double-edged blade, however, since it also means that changes have to be negotiated and agreed nationally through a highly bureaucratic process. And almost every time the NHS has to go back to its IT suppliers and say “we said we wanted our computer to do this, but now we’d like it to do that as well”, there can be a lengthy delay followed by a very large bill.

This is unfortunate because, predictably, a lot of new requirements have come into scope that just weren’t around five years ago. Further huge new information requirements are being created by the move to Payment by Results and Practice Based Commissioning. Both policies were introduced after the NHS IT programme was first concieved; yet trusts and PCTs risk losing revenue unless they can succesfully capture data and report on patient flows and treatment. “The challenge that NHS Connecting for Health is now struggling with is how to get economies of scale from purchasing a handful of systems nationally, while also delivering the flexibility needed to ensure they can meet changing demands.”

Meeting the patient “choice” agenda, with its associated reporting on clinical outcomes, creates further demands on trusts and PCTs. To promote choice to patients, the DH is tendering for an £80 million NHS Choices website: a new initiative outside NPfIT and other existing channels such as NHS Direct.

Adapting to events

The need to accomodate such emergant requirements was recognised at the beginning of NPfIT, and in certain discrete areas - including Picture Archiving and Communications systems, NHSMail, the QMAS GP quality and payment system – this has been done successfully.

But areas linked to the core NHS Care Record systems have fared less well. As delivery delays have lengthened, the programme has become squeezed. The later its suppliers are in delivering systems, the more those systems fall behind changed requirements. If delays go too far, systems can be obsolete before they are ever installed.
The challenge that NHS Connecting for Health is now struggling with is how to get economies of scale from purchasing a handful of systems nationally, while also delivering the flexibility needed to ensure they can meet changing demands.

Part of the answer must lie in the National Local Ownership Programme (NLOP) that is already showing signs of leading to a greater local say in setting priorities and configuring systems to meet local needs. It remains to be seen, however, how local ownership can be squared with a nationally-specified and determined programme; and with the need to respond to changing national demands.

About the author: Jon Hoeksma is technology journalist of the year, and co-founder and editor of the industry portal, e-Health Insider.